Postpartum depression

Postpartum depression is a serious disorder that affects many women globally. Studies have
shown that cultural factors play a significant role in postpartum depression; they may trigger
postpartum depression as well as contribute to the alleviation of its depressive symptomatology.
The cultural aspects of the postpartum period have been described in the literature; however,
the impact of cultural factors upon postpartum depression has been less investigated, and studies
that looked at this association have yielded oppositional conclusions. In addition, the literature
is inconclusive as to whether there are significant differences among various cultures in the
prevalence of postpartum depression.
Criteria for Major Depressive Episode Five (or more) of the following symptoms have been
present during the same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note:
Do not include symptoms that are clearly due to a general medical condition, or mood-
incongruent delusions of hallucinations. Depressed mood most of the day, nearly every day,
as indicated by either subjective report (e.g. feels sad or empty) or observation made by others
(e.g. appears tearful) Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day (as indicated by either subjective account or observation made
by others) Significant weight loss when not dieting or weight gain (e.g. a change of more
than 5% of body weight in a month), or decrease or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every
day (observable by others, not merely subjective feelings of restlessness or being slowed down)
Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or
guilt about being sick) Diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others) Recurrent thoughts of death
(not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt
or a specific plan for committing suicide The symptoms do not meet criteria for a Mixed
Episode The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning The symptoms are not due to the direct
physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical
condition (e.g. hypothyroidism) The symptoms are not better accounted for by Bereavement,
i.e. after the loss of a loved one, the symptoms persist for longer than 2 months or are
characterized by marked functional impairment, morbid preoccupation with worthlessness,
suicidal ideation, psychotic symptoms or psychomotor retardation. Postpartum onset
specifier: Onset of episode within 4 weeks postpartum

The term postpartum depression refers to a nonpsychotic depressive episode that begins in the
postpartum periodAs previously stated, screening for postnatal mood disturbance can be
difficult given the number of somatic symptoms typically associated with having a new baby
that are also symptoms of major depression (Nonacs et al., 1998). Distinguishing between
depressive symptoms and the supposed normal sequelae of childbirth, such as changes in
weight, sleep, and energy is a challenge that further complicates clinical diagnosis (Hostetter &
Stowe, 2002). For example, although it is difficult to assess sleep disturbance in new mothers,
the clinician may ask about the mothers ability to easily rest or sleep when given the
opportunity. Many women with postpartum depression often have such high levels of anxiety
that they are unable to rest or return to sleep after getting up with the infant at night.
With a few notable exceptions, most of the relevant research into psychiatric disorders
associated with childbearing has been confined to developed countries, mainly in Western
Europe and North America (Kumar, 1994). The physiology of human pregnancy and childbirth
is the same all over the world, but the event is conceptualized and structured, and hence,
experienced by the mother and by her social group very differently (Kumar, 1994). It has been
purported that postpartum depression simply does not exist within certain cultures. Stern and
Kruckman (1983) wrote that a review of the anthropological literature revealed surprisingly
little evidence of the phenomenon identified in Western diagnoses as postnatal depression. This
conclusion was lent some support by anecdotal observations in Nigeria (Kelly, 1967), South
Africa (Chalmers, 1988) and India (Gautam, Nijhawan, & Gehlot, 1982) that nonpsychotic
depression after childbirth is rare in such societies. However, higher maternal morbidity rates
may result in under-reporting. It should be noted that these conclusions were based on
observational data, and not all studies combined ethnographic field observations with formal
diagnostic testing. One should also be aware of the danger of cultural stereotyping, and of the
possibility that the presence of disorders such as postpartum depression in particular cultures
may go unrecognized (Kumar, 1994).
Stern and Kruckman (1983) draw attention to the fact that the defining criteria for depression
may vary greatly across different cultural settings, so the problem cannot simply be resolved
by applying a Western concept of depression to other cultures.

It is well established that there are marked cultural differences in the way that
psychiatric symptoms are presented to health professionals (Kleinman, 1996) with some groups
more likely to somatize symptoms.

Upadhyaya et al. (1989) found no marked differences in rates of depression or level of

somatic and psychological symptoms between groups of indigenous white and Asian women
presenting to clinics in India. However, when their reasons for consulting their doctors were
examined, the Asian women consulted exclusively for somatic symptoms whereas the white
mothers were more likely to present with depression.

This may be linked into womens reluctance to admit to symptoms of depression

because of cultural expectations of motherhood.

The rituals adopted within some cultures following childbirth have been purported to
protect against the development of postpartum depression. For example, Okano et al. (1992)
have drawn attention to the Japanese custom of Satogaeri Bunben in which the new mother
stays with her own mother for several weeks after giving birth. They have suggested that there
may be a link between the onset of depression and having to leave the maternal home. Therefore
a perceived, or actual, lack of social support may contribute to the onset of the illness.

There are no major differences in the rates of postnatal depression in the few cross-
cultural comparisons that have so far been reported. Differences rather than similarities in
incidence rates might have been expected and these important studies need replication and
extension in other settings.

Some of the rituals practiced within cultures may be protective against postnatal
depression because they provide social and practical support for the new mother.

Psychiatric disorders are heavily stigmatized within many cultures, and women and
their families may be reluctant to seek help from health professionals, preferring to try and
manage the illness with no outside help. Health professionals may only be consulted when the
woman is so severely ill that the family can no longer cope.
Although the focus of the meta-analyses focused on non-biological risk factors it is necessary
to provide an overview of biological theories of postpartum depression. The rapid decline in
the levels of reproductive hormones that occur after delivery has been proposed as a possible
aetiology of postpartum affective disorders (Wisner et al., 2002). Following childbirth,
progesterone and estrogen levels fall rapidly, returning to prepregnancy levels within 3 days.
When estrogen falls after birth, prolactin, which has risen during pregnancy, is no longer
blocked and lactation is initiated. Suckling by the infant stimulates the secretion of oxytocin.
The usual cyclical variation of androgens is absent during both pregnancy and lactation. Plasma
corticosteroids reach a peak during labour and decrease significantly within 4 hours postpartum.
Thyroid function returns to prepregnancy levels approximately 4 weeks after delivery
(Robinson et al., 2001). There is no conclusive evidence for a relationship between the various
neurotransmitter systems, free or total tryptophan levels, or cortisol levels and symptoms of
postpartum depression (Llewellyn, Stowe, & Nemeroff, 1997). However, Harris (1996) showed
a minor association of postpartum depression and thyroid dysfunction in thyroid antibody
positive women. Although it has been suggested that postnatal depression is caused by low
levels of progesterone or estrogen or high levels of prolactin, no consistent relationships have
been found ( Harris, 1994; Hendrick, Altshuler, & Suri, 1998). Pregnancy and birth are often
regarded as stressful life events in their own right, and the stressfulness of these events may
lead to depression (Holmes & Rahe, 1967Social support, as it is manifest during pregnancy, is
a relatively potent risk factor for postpartum depression, particularly in the form of high levels
of depressive symptomatology. Studies have consistently found differences between perceived
and received social support in women with postpartum depression. These differences may be
accounted for, in part, by the fact that depressed individuals tend to view everything more
negatively, including their perceptions of level of support.

2. The Multicultural Literature Concerning Postnatal Depression

The literature on mental health illness addresses the fact that people from diverse cultural
backgrounds might display different constructions of mental health illness and, therefore,
various ways of handling and coping with it. For example, some studies on depression among
South Asian women, in particular Punjabis, have identified a cultural idiom called sinking
heart which they experience as a result of excessive heat, exhaustion, worry, or a feeling of
social failure [27]. Similarly, among women of African descent in America who had
experienced postpartum depression (PPD) in the past, a study reports that they described and
managed their depression in culturally specific ways, such as relying on their religious beliefs
and the counsel of family members as well as keeping the depression a secret in the family [21].
The women also believed that only white women experience postnatal depression, as postnatal
depression is considered a sign of weakness that does not represent a legitimate illness [21].
Some authors argued that the individual is bound by the rules of their culture which in turn
shape and influence their behaviour [28, 29]. Similarly, cultural aspects of ones social system
have a major impact on ones emotional life [28]. Major cultural differences influencing
depression are family structure and dynamics, social organization, socially-sanctioned defence
mechanisms, rituals, and social stresses [30]. Other cultural factors that may be important for a
general understanding of depression include a distinctive language related to depression, the
transmission of information among people about depression, and beliefs about healthcare and
the healthcare system.
Prevalence rates of postnatal depression vary widely from culture to culture. Studies in
developed countries report prevalence rates of 10% or more for postpartum depression [31]. In
developing societies the figures are variable. Postnatal depression is thought to occur three
times more in the developing societies than in developed ones [32], for example, in Khayelitsha,
Cape Town, in South Africa, the prevalence rate of major depression was reported to be 34.7%
at two months postpartum [32]. Other African studies that have looked at postpartum women
have dealt with the prevalence of psychological distress in general rather than focusing on major
depression or postnatal depression [3335], which looked at prevalence of major depression at
six weeks postpartum in Uganda, found a figure of 6.1%.
Similarly, the literature on mental health illness addresses the fact that aspects such as
perceptions and attitudes towards depression in different cultures may affect help-seeking
behaviour and access to treatment [10, 11]. Most studies in the literature regarding womens
health-seeking behaviour coincide, for example, in pointing out that BME women tend to rely
on family and religion as their main coping strategies. In the same way, for some women,
postnatal depression is not perceived as an illness, yet they recognise the need to seek spiritual
intervention. Equally, additional findings suggest that some black Caribbean women face
difficulties describing or talking about perinatal depression due to their tendency to underreport
their psychological feelings. Thus, barriers to health-seeking behaviour relate very much to the
reluctance of some BME women to discuss problems as well as the way in which problems are
dealt with [21, 27, 36, 37].
Another significant and controversial aspect of the literature, particularly in regard to the UK,
relates to the diagnosing of postnatal depression among BME women through the Edinburgh
Postnatal Depression Scale (EPDS). The EPDS is a psychometric measuring tool [38]. It
comprises a ten-item self-rating questionnaire which is administered by health visitors
approximately at eight weeks and at twelve months after childbirth. The EPDS is used by health
visitors in the community. Following its validation for use in the UK it was implemented across
the country by health visitors as a universal method of identifying mothers who were at risk of
postnatal depression [39] argued that EPDS was originally designed as a screening test and was
not intended as a diagnostic tool. However, many GP practices have continued to utilise the
questionnaire as a single psychometric diagnostic tool. Thus, the controversy in the literature
regarding the use of EDPS displays two positions: the one that considers this tool as culturally
insensitive for BME women [40, 41] and the one that argues that it is effective [42, 43].
The literature that considers the EPDS to be less culturally sensitive to the needs of women
from black and ethnic minority backgrounds states that it does not translate into other
languages, let alone cultures [44, 45]. These authors also cautioned against direct translations
of the tool, pointing out that some cultures do not have a word for depression, and suggesting
that other screening methods should be considered depending on ethnicity. It is argued that the
use of standardised Western methods and diagnostic classification systems, even by local-but-
Westernised investigators, may be culturally insensitive and could increase the risk of
practitioners missing symptoms or signs prevalent in non-Western cultures [46, 47]. Using
EPDS as the assessment tool for these women might result in them often being inappropriately
diagnosed or misdiagnosed, leading to omission. Additional arguments related to this position
in the literature claim that most research has been conducted in the Western developed countries
[31, 48] and has not taken into account the range of different psychosocial experiences likely
to be involved in childbirth, for example differences in rates of lone motherhood, the nature of
marriage, family kinship, and variations in the support new mothers receive in different
countries and cultures.
For those who consider EPDS an effective tool for diagnosing postnatal depression the main
evidence comes via some empirical studies that have screened women to check prevalence and
associated factors in two groups: Nigerian and Black Caribbean women reporting a significant
level of diagnosis [42, 43].
On the part of the health professionals, the literature addresses various factors that could
contribute to the lack of awareness, late diagnoses, undetected cases or, worse, excessive
medicalisation of symptoms. For example, [28] in a study investigating the influences of
cultural factors in relation to postpartum depression, found that mothers from different cultural
backgrounds may display culturally explicit behaviours and actions when suffering from
depression. Another author [49] argued that the way a person perceives and understands their
health is related to the subjective cultural experience in her or his society. [50] posits the idea
that all cultures are unstable and subject to daily variations, innovations and change. Similarly,
[51] clearly demonstrates this in a study on how women understood and responded to
depression according to their cultural understanding of the disorder. According to [30], culture
can be understood as shared beliefs, learned values, and attitudes which shape and influence
perception and behaviour. In other words, African women immigrants in the UK could be seen
as a group of people who share history, religion, language, thoughts and, overall, the experience
of being immigrants. Thus, how the cultural background of women is understood and
constructed by the providers of health services and how these providers and the women
communicate is a matter of great interest for researchers focusing on intercultural
communication in the context of health services in various multicultural societies.
Ultimately, although postnatal depression affects all women regardless of ethnicity or social
class, additional contributory risk factors include social exclusion, deprivation, and relationship
complexities [52]. Thus, despite all the attempts in the literature to explain the causes of this
illness, no single factor has been successfully identified as its cause. On the contrary, as
discussed above, several explanations have been put forward by the literature. This qualitative
study presented here [26] expects to add to this ample range of explanations in the literature on
postnatal depression particularly among African Women Immigrants in South East London.
From the womens narratives it was apparent that their African cultural background has a
bearing on their help-seeking behaviour. Although some of them felt sad, unhappy, and
stressed, they kept their feelings to themselves because, culturally, to admit having problems
coping with the after-effects of childbirth is probably a sign of failure or weakness in front of
the extended familyhusbands, mothers-in-law, and others. Thus, as [66] argues, the culturally
appropriate terminology for depression seems to be an issue for further research here.
Accurate estimates of the prevalence rate of PPD are difficult to obtain as cultural norms may
affect women's reporting of their symptoms, and lack of reliable screening tools may result in
underdiagnosis.34,35 Furthermore, the methods used to determine prevalence rates impact their
accuracy. For example, self-report measures can lead to larger estimates whereas longer periods
of evaluation (ie, length of the postpartum period) can indicate higher prevalence.36 Moreover,
ethnokinship culture, which defines social support rituals in the postpartum period, may yield
variability in rates (ie, wide range of prevalence) among countries and within countries.34

Pakistan has a diverse ethnic and cultural background with some common features. Postpartum
customs include chila, a 40-day period of seclusion during which new mothers are required to
rest and are not permitted to cook or clean, as they are regarded as being dirty. Mothers of male
children are regarded as having high status. Child care decisions are complex, often involving
negotiations among the mother-in-law, other family members (eg, aunt), and the new parents
(Premji, Khowaja, Meherali, Forgeron, unpublished data, 2012). A hierarchical society exists
in which patriarchal joint family systems predominate, with the extended family defining the
social structure and individual identities (eg, marriage, roles) that marginalize women.37

Pregnant Pakistani women may be particularly vulnerable to stress, given the complex nature
and inequities in determinants of women's health (eg, economic, education, social support,
health services).38 Women's health needs are not given priority by the government, or the
people, including women themselves.39 In addition, changes in family systems or social
relations, specifically structures and practices,39,40 and pregnancy concerns such as reliance
on others to attend to daily roles and responsibilities, concern for the unborn child,40 and values
attached to birth of a male child,37 create social pressures that may influence mental health.
Urbanization is changing family structure (eg, nuclear family), authority patterns, relationships,
and the status of women. The social tensions associated with these changes, coupled with
hazards of urbanization (eg, poverty, unemployment, gender discrimination, lack of capacity of
health services) can have negative consequences on women's mental health.41

Culture defines social support rituals, which may or may not mediate PPD.78,79 Traditional
rituals related to pregnancy, birth, and the postpartum period are believed to provide
psychosocial support to women and are thereby considered protective, as they decrease the risk
for PPD.78 For instance, the Chinese ritual of peiyue (ie, "mothering the mother" in that the
mother or mother-in-law takes responsibility for care of the baby and the house while the
mother rests), practiced by families in Hong Kong, is related to perceived availability of support
that can have a mediating effect on PPD (ie, lowered risk of PPD).80 However, in instances
where emotional support offered by mothers-in-law did not meet the new mothers' needs, social
support was negatively associated with PPD.81,82 High rates of PPD have also been reported
in other cultures where these traditional practices exist,83 such as Pakistan.

The literature examining the effects of cultural factors on PPD remains inconclusive as culture
has been noted to have a negative impact on PPD.78 Cultural beliefs held by women84 or
cultural traditions that shape support85,86 may not be protective against PPD. Mothers learn
about social norms in the way they are socialized through their various interactions,
observations, and communication among women within their family (eg, mother, aunts, and
grandmothers).87 A qualitative grounded theory study of PPD among African American
women found that women strived to be "strong black women," which in their perspective was
a culturally established norm. Furthermore, their belief that PPD could only happen to "white
women" precluded them from seeking care, as they were ashamed. They therefore relied on
prayer or faith to overcome their PPD. Consequently, cultural beliefs held by these African
American women were barriers to care and had a negative impact on their PPD.84 A
study88 examining the effect of gender bias situated in the Indian culture reported negative
consequences of culture on PPD. Hindu women residing in Mapusa, Goa, India, who gave birth
to girls were disheartened about their infant's gender, and this was a significant risk factor for
PPD. In addition, an interaction was reported between infant gender and other risk factors of
PPD, including marital violence and hunger.88 For example, mothers who experienced marital
violence were at an increased risk of PPD if they gave birth to a girl and were at lower risk if
they gave birth to a boy.88

Danaci et al85 examined epidemiological and cultural factors of PPD in Turkish women
residing in Manisa, western Turkey. An association was reported between the age of the baby
and the mean depression score of the mother. This relationship was attributed to Turkish
mothers seeking out and receiving support in the immediate postpartum period; however, this
support declined over time.85 Poor relationships with mothers-in-law, fathers-in-law, and
husbands were also identified as risk factors of PPD. Leung86 recruited Hong Kong Chinese
women to examine social support, stress, and PPD. The ritual of "doing the month" caused
stress for some women, as support from their in-laws was not valued, and thus was not found
to be protective against PPD. Nonetheless, the practice of "doing the month" was only partially
observed by women, which may partly explain the findings of the study.86 For example,
women who experienced PPD were less likely to embrace the child care practices of older
generations, perhaps due to differences in counseling received from healthcare providers and
support people. Postpartum depression was also related to less support being received from the
spouse, and viewing husbands as passive, not understanding, and, in some instances,
demanding.86

Although some studies examine the influence of culture on PPD, they are few in number and
provide varied conclusions with regard to the impact of culture on PPD.78 Culture influences
mother-infant interactions, and cultural practices may or may not reduce the risk for PPD.78

Mothers of preterm infants are at greater risk for PPD. Mothers of preterm infants express
feelings of greater parental stress,89 distress,17 and anxiety.57,90 Preterm infants exhibit
different behavioral characteristics10 than term infants,17 which may create challenges in
mother-infant interaction. Mothers who face difficulties with managing their preterm infants'
characteristics may develop parental stress. Therefore, mothers of preterm infants may be at
higher risk of developing PPD.76 Postpartum cultural practices of Pakistani women may or
may not mediate PPD. The higher rates of preterm birth could be one of the reasons for the high
prevalence of PPD in Pakistan. However, this needs to be validated through systematic research.
http://www.postpartumprogress.com/is-postpartum-depression-non-existent-in-other-cultures-
the-facts