UNC Health Talk

The Maternal Bond

When Alison Stuebe, MD, was an undergraduate, she learned how the things we see as children affect the development of our brains in profound ways. She was immediately hooked on early-childhood development and decided to dedicate the rest of her life to fostering the bonds between mothers and their babies. Her work earned her a Jefferson-Pilot Fellowship from the UNC School of Medicine.

We sat down with Dr. Stuebe to discuss her work as a researcher and Director of Lactation Services at UNC Health Care, including her most recent grant to study the connection between postpartum depression and the critical bonds of attachment that mothers need to form with their newborns.

What was the driving force behind your decision to major in biology at Duke and pursuing an MD at Washington University?

I’ve always enjoyed science and how things work. I took a fabulous neurobiology class my freshman year at Duke, trying to understand how the brain works. We looked at this one study that found that if you cover one eye of a kitten during a critical period of development and then take off the eye patch, the kitten will never see through that eye. But that’s not because the eye didn’t develop properly; it’s because the areas in the brain that receive input form the eye grow or shrink depending on whether or not they get a signal.

To me, this was evidence of why early development and the things we do with young children are so important. So I thought I’d end up as a pediatrician. Then, in medical school, I realized that I really loved talking to the moms. So I landed in obstetrics, and now I do research that looks at the early relationship between moms and babies.

What motivated you to conduct research in maternal health?

I always loved the clinical piece of taking care of women and helping them navigate pregnancy, childbirth, and the early postpartum years. A woman’s first pregnancy is often her first significant contact with the health care system as an adult. When we offer really good prenatal care, help women understand what’s happening to their bodies, and help them through pregnancy and birth feeling like they’re active participants – that they’re the stars, honestly – then this impacts how they think about the health care system, how they access health care, and whether they’ll come in for annual exams. It also impacts their entire families. So we have this enormous opportunity to impact all these interactions with the health care system if we provide really good care.

Yet, there’s this gap right after birth because, in the United States, we stop caring about what happens to moms in the immediate postpartum period. Kids get regular checkups. Moms get one six-week checkup, but they often don’t keep that appointment because they’re so busy looking after their babies. We, as a society, don’t offer a lot of support during that period.

My interest in lactation and postpartum depression grew out of this. It’s all about understanding how things can come undone for some moms in the weeks after birth. I’m interested in how to create a system that gives moms real support so they can foster their own development as moms – and that development directly impacts the development of their children.

During your research, you found that women with a family history of breast cancer were 59 percent less likely to develop breast cancer themselves, if they breastfed their children. Why do you think breastfeeding is so important when it comes to cancer and other health issues?

First, there are different kinds of breast cancer. It’s the aggressive, triple-negative basal-like breast cancer that seems to be reduced by breastfeeding more so than is ER/PR positive breast cancer, which is more treatable. The current data suggest that the more times you’ve been pregnant, the lower the risk of ER/PR positive breast cancer. With the more aggressive basal-like breast cancer, the duration of breastfeeding plays more of a role.

So, in our paper, we theorized that if mothers don’t breast feed at all, there are all these cells that have just started figuring out how to make milk, and they’re just getting ready to differentiate. And if that system is shut down – if those cells never get used to make milk – then it could be that this leaves more cells at risk of going rogue and turning into breast cancer. But that’s a theory. We haven’t researched that.

However, in the Black Women’s Health Study, researchers found that women who had two or more pregnancies – but didn’t breastfeed – faced a much higher breast-cancer risk than did those who had two pregnancies and did breastfed. I’m working with Melissa Troester in the school of public health to try to understand how breastfeeding changes the breast microenvironment to reduce breast cancer risk.

When we upset the normal physiology – when new moms don’t breastfeed – we expose moms and babies to risk that they wouldn’t face otherwise.

There’s also very compelling data that not breastfeeding increases risk of ear infections, gastrointestinal illnesses, respiratory infections, obesity, leukemia, sudden infant death syndrome, and diabetes in children. And in moms, we’ve found that moms who don’t breastfeed have a higher risk of diabetes, hypertension, heart attacks, breast cancer, and ovarian cancer. When we upset the normal physiology – when new moms don’t breastfeed – we expose moms and babies to risk that they wouldn’t face otherwise.

So, now the hard part: how do we change the culture so the women who want to breastfeed can do it successfully? Simply saying that your baby will get ear infections if you don’t breastfeed doesn’t make it happen if moms don’t have paid maternity leave, supportive partners, or places to pump at work.

It’s not simple. But it’s also incredibly important. I think we all have a responsibility that if a mom says she wants to breastfeed, then we should do everything in our power to make it possible for her to realize that.

In March, the NIH awarded you a five-year, $2.9-million grant to focus on the potential link between post-partum depression and breastfeeding. Why might there be a connection and what were your preliminary findings that helped you secure the NIH grant?

Samantha Meltzer-Brody, Karen Grewen, and I did a pilot study with 50 moms with and without a history of depression. We measured hormones during their third trimester, and during breastfeeding at two weeks and eight weeks after birth. We found that moms with more anxiety and depression symptoms at eight weeks had lower levels of the hormone oxytocin when they were breastfeeding, compared with moms with fewer symptoms. So, with our grant, we’ll look at the role of oxytocin in postpartum depression, mom-baby interactions, and ultimately attachment.

As I’ve learned from our collaborator Cathi Propper at the Center for Developmental Science, one of the critical developmental tasks for infants is to form a secure attachment with a caregiver. When upset, the baby needs to be able to go to someone for support, feel better, and then go back to navigating the world around them. This has a substantial influence on the long-term psychological well-being of the child. But for that attachment to happen, the caregiver has to be sensitive to what the child’s needs are. Sometimes, babies want to be picked up, sometimes not. Sometimes they want to play, sometimes sleep. If the caregiver can understand and respond appropriately, then the child learns that the world works for them. They develop confidence and autonomy to do things on their own. We know that depressed women are not as good at understanding their babies’ cues. And our study found they don’t have as much oxytocin.

One possibility could be to give oxytocin to moms to help them facilitate appropriate interactions with their babies. But I’m not a fan of people inhaling oxytocin; I don’t want that to be my legacy. I want to see if we can find non-pharmaceutical ways of enhancing trust and reducing anxiety that would allow moms to have a more positive oxytocin trajectory so they could potentially mend that connection with their babies.

What is the most rewarding part of your job as a researcher and clinician?

What I love the most is helping moms see how amazing they are. I know that sounds cheesy. But it’s so important that when a mom gives birth she understands that there were things she did that were really fabulous. Sometimes, it’s easy for a mom to see that, like if she didn’t have an epidural and pushed out a 10-pound baby. But if a mom had a crash C-section and had to be intubated, and she managed to keep still and keep it together, she’s the one who saved that baby’s life.

It’s really easy for an obstetrician to swoop in and think, “I snatched your baby from the jaws of death.” But in fact, it’s usually the mom who realized something was wrong and came in. Then we saw the problem so we could intervene and take care of them.

A lot of my lactation patients have been to hell and back trying to get their babies to nurse. I start by saying, “You are amazing. And you have put far more effort into the three weeks of breastfeeding than have moms who’ve been breastfeeding for two years. You’re climbing up the steep side of the mountain.”

So much of our culture makes women feel bad about themselves and their bodies. I want to turn that around and help women realize what they can do and have done. When I see that light click – when I see that they get it – that’s really awesome.

Alison Stuebe is an assistant professor in the Departments of Obstetrics and Gynecology at the UNC School of Medicine and Maternal-Child Health at the Gillings School of Global Public Health. She is also Medical Director of Lactation Services for UNC Health Care.

Media contact: Mark Derewicz, 919-923-0959, mark.derewicz@unch.unc.edu