For birthing parents with pre-existing post-traumatic stress disorder, the road to breastfeeding isn't as smooth as you might have been led to believe, yet no one is talking about it. Here's what new parents should know.

By Katherine J Igoe
April 27, 2021
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An image of a mother breastfeeding her baby.
Credit: Getty Images.

Five days after I delivered my daughter, I realized how hard breastfeeding was going to be. I'd had an induced 52-hour labor and an unscheduled C-section. I was still in the hospital, hooked up to a painful, old-school breast pump that looked like a '70s fridge. No milk was coming. My chipper young nurse was undeterred—"Just keep at it!" she chirped. An on-call doctor said the opposite: "Your arduous delivery and history of trauma can mean your milk won't come in all the way," she mentioned offhandedly. I thought ruefully back to the online breastfeeding class I'd taken, in which a blonde woman had smiled and told me soothingly, "You'll make all the milk your baby needs." I wanted to track her down, knock on her door clutching my medical gown, and demand answers.

About half of all women experience some form of trauma and ten percent develop PTSD, but it can also go misdiagnosed, undiagnosed, or unrecognized. Up to 45 percent of mothers feel their birth experience was traumatic; since I have pre-existing PTSD followed by a traumatic delivery, it felt like a one-two punch. I'd been tackling my trauma for years, so I knew to have delivery resources: A supportive obstetrician who understood trauma. A husband who knew the signs of postpartum depression (PPD) and was ready to help, with four months' paid paternity leave. A trauma therapist on speed-dial. Yet the one thing I didn't factor into my plan was the connection between PTSD and breastfeeding.

Four lactation consultants later, I only experienced lactogenesis—my milk coming in—after ten days, and it wasn't all the way (ten to 12 ounces a day). I pumped for about three months before I stopped, feeling like I'd failed. I should have been able to breastfeed, I worried, but my body couldn't measure up. I didn't have PPD, so I felt like I'd fallen through the cracks.

If you've had a similarly challenging experience, you're not alone. A delay in production is possible, even though professionals can be hesitant to talk about it—and here's what you can do.

What's the Connection Between PTSD and Breastfeeding?

In theory, if you went through normal puberty and had a normal delivery, your milk supply should come in fully between two and five days postpartum. There are, however, several risk factors that could impact this. "Some people can make milk in the most extreme situations, while others struggle to make enough milk even when everything is 'perfect.' So trauma (both chronic and acute) is a risk factor for delayed lactogenesis, but it's not a guarantee," says Melissa Anne Dubois, RN, BSN, CCE, CLC, childbirth educator, home birth assistant and visiting nurse at Embrace Midwifery, and co-host of "The Babies in Common Show."

The missing link involves the Hypothalamic Pituitary Stress (HPA) axis and the Hypothalamic-Pituitary-Prolactin (HPP) axis, and oxytocin's impact on the HPA's response to stress. "There are two principal systems in the body: the stress system and the oxytocin system. We have to think about them like a light switch. When one is turned up, the other is turned off," says Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA, health psychologist, author, and fellow of the American Psychological Association in Health and Trauma Psychology. "If your stress system is activated, that turns your oxytocin system off, and that's what you need to have labor contractions and milk ejection."

Your providers might not speak about this for a variety of reasons; there's only so much they can teach prenatally and every person is different. But lots of medical professionals aren't trained in trauma, either, so wouldn't know to screen for conditions beyond PPD. Stress can also factor into the medicalized birth process, especially since many hospitals are still paid by the number of procedures they do (a.k.a. fee for service), and prenatal classes like the one I took can be focused more on the norms within the hospital than an individualized approach.

People with pre-existing PTSD may already experience invasive symptoms like hypervigilance, flashbacks, and a fight-or-flight response; touch, pressure, and pain can be triggers. All of this isn't helpful during birth, especially for releasing necessary oxytocin. Dubois makes the analogy: "Imagine you're being intimate with your partner. They're doing all the right things. And there's also a grizzly bear in your room."

What Does This Mean for Lactogenesis, Breastfeeding, and Pumping?

It depends on the person. In my case, my daughter was a week and a half late when I was induced. Dr. Kendall-Tackett speculates on my situation: "Your past trauma may have contributed—you might not have felt safe. The fact they induced you made it super-painful, and your body clearly wasn't ready. They could've tried to make you feel safe: keep you warm, increase wanted touch." It was a domino effect: trauma history and heightened stress led to a late, painful delivery, then to milk delay and supply difficulties.

Although no one told me at the time, a 10-day delay in milk production is significant. "It's a fine line you have to walk as a provider because you want to have people be confident, but somebody should have picked up that there was a problem," says Dr. Kendall-Tackett. Equally, the fact that a doctor mentioned lactogenesis delay may have planted a seed of doubt in my mind.

The good news is that supply depends on the pregnancy. If I have a second child, my experience may be better. But it's also true we need compassionate specialists to guide us through the minefield of complexity. I've listened to many moms struggle with supply, and the missing piece is often an empathetic response to our bodies' suffering.

"The pervasive cultural attitude of 'all that matters is a healthy baby' is a cancer of our collective consciousness," says Dubois. "It harms the most vulnerable among us and perpetuates trauma."

For someone with PTSD, breastfeeding challenges might be a symptom of deeper pain. If the underlying condition isn't being treated properly, "ending the breastfeeding relationship isn't going to fix what's wrong, and it might even spiral a person into more despair and grief. When your confidence is eroded, and judgment calls are made under duress, regret can follow, and more shame and guilt. It's a heavy load to bear," says Dubois.

Traumatic memories can sometimes pop up unexpectedly during the birth process, since it's such an emotional, vulnerable time. Having a baby is already tough. Add in triggers, flashbacks, and lack of support, and breastfeeding can be the first thing to go. It feels like having PTSD can put you at a disadvantage, but the failure isn't yours. There's nothing wrong with you—you just need more help.

What Can You Do to Address a Lactogenesis Delay?

Parents should know that such a delay is possible but not inevitable. Dr. Kendall-Tackett would've recommended I pump ten times a day through those first several weeks by "cluster pumping": a short burst of sessions, every hour for ten to 15 minutes, followed by a break to rest, then pumping again when I woke naturally from fullness. This would be a "bridge strategy" to ensure I'm encouraging lactogenesis, while also feeding my baby and getting some sleep.

"If you don't see milk by day four, increase the number of times the baby goes to the breast (as much as is comfortable)," says Dr. Kendall-Tackett. Also expect to continue supplementing with formula. "This is not forever. You're going to keep emptying your breasts, and your milk will come in. Keep yourself warm. Make yourself comfortable."

Getting a team of people who understand trauma is critical. If I were to do it over, before and after delivery, I'd consult with a private, International Board Certified Lactation Consultant (IBCLC) who understands cluster pumping and doesn't recommend getting up every two hours. I'd probably look into a midwife and doula, to have advocates who understand my unique needs in the hospital delivery room. I realize this is a privileged place: being able to afford resources and plan ahead. But I would have saved money compared to what I spent trying to get breastfeeding to work for me after the fact.

Addressing underlying PTSD through talk therapy, medication, or a combination of both is essential. The birth process may already feel like a lot, but without the work it may be harder. "We should educate all moms who have a history of trauma on the importance of thoughtfully planning for both her birth experience and breastfeeding if desired," says Samantha Meltzer-Brody, M.D., MPH, chair of the Department of Psychiatry at the University of North Carolina at Chapel Hill and director of the UNC Center for Women's Mood Disorders. There's an added layer of complexity, so it's vital to have increased supports in place and to work with supportive providers (obstetrical, mental health, and lactation specialists)."

And it's important to note here, too, that "some women with a history of trauma may find breastfeeding too intrusive, and this must be honored. It's a terrible thing for mothers to feel guilty for not breastfeeding if this is not in the best interest of the mother's mental health and particularly for those with a history of trauma," she says.

Go in knowing that we don't know everything about the complex, interconnected relationship between trauma and breastfeeding. Listen to your body, be tender to yourself, and determine the best option for your needs. And, at the end of the day, how you choose to feed your baby is up to you. You don't have to justify it to anyone. "Trust your gut," says Dubois. "You're the expert on your baby, and yourself."