Postpartum: diet and supplements after a spontaneous or operative delivery and the postpartum blues

VIDEO 15

The current rationale for women fasting during labor is to protect them from pulmonary aspiration should general anesthesia be needed for an emergency operative delivery. However, prolonged fasting in labor has never been proved to influence the incidence of pulmonary aspiration, and some clinicians and midwives consider that preventing food intake can be detrimental to the mother, her baby and the progress of labor. Postnatal depression is a medical condition that affects many women and the development of their infants. There is a lack of evidence on treatment and prevention strategies that are safe for mothers and infants. Certain dietary deficiencies in a pregnant or postnatal woman's diet may cause postnatal depression.

The postpartum period represents a critical phase of heightened vulnerability for women and offers a strategic opportunity to promote optimal nutrition and healthy lifestyle behaviors. Globally, women face a double burden of malnutrition, characterized by a high prevalence of obesity and metabolic disorders alongside significant nutrient deficiencies and anemia. In 2021, postpartum depression (PPD) prevalence in women was 17%, although prevalence rates vary widely, ranging from 6% to 61%. Healthy eating and supplementation of some nutrients is essential during this period to meet energy and nutrient requirements, prevent deficiencies and anemia, support the breastfeeding process and promote metabolic health, including the attainment of a healthy weight. Moreover, a healthy diet provides necessary nutrients and bioactive compounds that are involved in various physiological processes linked to mental health, including the prevention of depression.

A common belief during labor and postoperative delivery is the recommendation of fasting. The World Health Organization (WHO) advises that oral intake of fluids and food during labor should be recommended for women at low risk of requiring general anesthesia, as there is no substantial evidence suggesting this practice is harmful. Following a Cesarean section, guidelines advocate for the initiation of a regular diet within 2 hours post-delivery, supported by high-quality evidence indicating potential benefits and no associated risks.

The etiology of PPD is multifactorial, involving genetic predisposition, lifestyle factors and environmental, biological and psychosocial influences. A primary objective during the postpartum period is to promote optimal maternal nutrition and metabolic status, as numerous nutritional factors are associated with PPD. Metabolic disorders, particularly obesity, exhibit a bidirectional relationship with depression: women with obesity have higher risk of depression, and conversely, women with depression have an increased risk of developing obesity. Anemia, affecting 33.7% of women of reproductive age, is also a significant concern, with dietary iron deficiency being the most commonly reported cause. Studies have shown an association between low ferritin levels and an increased risk of PPD.

To mitigate these risks, it is recommended that all women in the postpartum period adhere to a healthy and sustainable dietary pattern, such as the Mediterranean type or the Dietary Approaches to Stop Hypertension (DASH) diets. These diets emphasize a high intake of vegetables, fruits, grains and legumes, and include fish and seafood, eggs, dairy and healthy fat sources such as nuts, seeds, specific oils (olive) and avocado. These foods provide healthy carbohydrates (high in fiber and with low glycemic load), high-quality proteins, healthy fats (including monounsaturated and omega-3 polyunsaturated fatty acids), multiple vitamins, minerals, polyphenols and other bioactive compounds. Many of these nutrients and bioactive compounds contribute to various physiological processes linked to the prevention of depression. For instance, anti-inflammatory and antioxidant activities, regulation of the microbiota gut–brain axis, neurotransmitter synthesis and modulation of the hypothalamic-pituitary-adrenal (HPA) axis are mechanisms that have been implicated in the pathogenesis of depression. A diet rich in fiber, phytochemicals and omega-3 fatty acids promotes the production of short-chain fatty acids in the gut, which enhance mucus secretion and antimicrobial properties, thereby supporting a healthy and functional intestinal barrier. This, in turn, is associated with reduced inflammatory responses, improved immunity and better metabolic outcomes. Gut dysbiosis, on the other hand, may disrupt brain activity, alter inflammatory cytokine levels, influence neuroinflammation and neurotransmitter release, and affect the HPA axis. Conversely, depression can exacerbate inflammatory cytokine production, negatively impacting microbiota composition, intestinal permeability and cortisol regulation.

Emerging evidence suggests that adherence to healthy dietary patterns may be associated with lower risk of perinatal depression. For instance, studies have demonstrated that adherence to the Mediterranean diet is associated with lower depression symptoms in adults diagnosed with depression.

In terms of specific nutrients, B-complex vitamins, iron, vitamin D and omega-3 fatty acids have been the most extensively studied in relation to PPD. Folate deficiency has been associated with depressive symptoms, and B12 deficiency is associated with inflammation, a mechanism implicated in the development of different psychiatric disorders. Women with inadequate intakes may require folate supplementation (400 μg/d) and B12 (2.6 μg/d, particularly in those following a vegan, vegetarian or plant-based diet). Iron supplementation may be necessary in postpartum women, particularly in areas with high prevalence of anemia. A review of studies revealed that in 4 out of 5 clinical trials, iron supplementation during the postpartum period was associated with lower risk of depression.

Vitamin-D deficiency (defined as 25-hydroxyvitamin D < 20 ng/ml) is highly prevalent during pregnancy and lactation, making the prevention or treatment of maternal vitamin-D deficiency a priority. Risk factors for deficiency include low sun exposure, living in high latitudes, low dietary intake, obesity and darker skin pigmentation. Although intake recommendations during breastfeeding vary (200–600 IU/D), recent evidence suggests that higher doses (1500–2000 IU/D) may be necessary to maintain adequate maternal vitamin-D status. A recent review of two randomized clinical trials from Iran, along with 18 observational studies, indicated that vitamin-D supplementation may be associated with a reduction in depression. In a review of eight trials in adults with diagnosed depression, five studies showed a positive association of vitamin-D supplementation and lower depressive symptoms. When considering the six studies with medium risk of bias, four studies confirm a positive association. However, the evidence remains inconclusive and further high-quality research is needed.

Omega-3 polyunsaturated fatty acids, particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are critical for mental health, yet global intake levels are often insufficient to meet the minimum recommended intake of DHA (200 mg/day). Fish, seafood and fish oils are the primary sources of active omega 3 (DHA and EPA). Omega-3 fatty acids have been associated with depression due to their role in antineuroinflammation, antioxidation, anti-neurodegeneration and modulation of the neurotransmitter system. While current evidence suggests that omega-3 supplementation during pregnancy and lactation may be associated with a reduced risk of perinatal and postpartum depression, quality of the evidence remains low, necessitating further research.

Breastfeeding should be strongly and supported from birth, as strong evidence has shown that breastfeeding exerts multiple health benefits for the mother and the infant. Studies have shown that breastfeeding may alleviate or prevent postpartum depression in women from low- and middle-income countries. Exclusive breastfeeding, compared to partial breastfeeding or non-breastfeeding, decreases the risk of postpartum depression.

In conclusion, ensuring that all women have access to and consume a healthy diet during the postpartum period is essential to provide an adequate amount of nutrients and bioactive substances that play a role in mental health. Comprehensive nutrition and lifestyle assessment will determine whether supplementation with specific nutrients is required to meet dietary needs and prevent deficiencies. Many women during this stage may need iron, folate, vitamin D and omega-3 supplementation to ensure adequate intakes and prevent deficiencies. Although, further research is needed to confirm the efficacy of specific nutrient supplementation in the prevention of PPD, omega-3 fatty acids and vitamin D show promise as preventive strategies.

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