I. Introduction
II. The Phenomena of Postpartum Illness
A. Historical Perspectives
B. Definitions, Symptoms, and Complaints
C. Complaints and Symptoms
Figure 1. Common Complaints of New Mothers and Fathers
Figure 2. Reported Symptoms for Postpartum Depression
III. Etiology/Cause
A. Biological Theories
B. Psychological Theories
C. Anthropological Perspective
D. Summary
1. Personality Variables
2. Demographic Variables
3. Interpersonal Variables
4. Obstetric Variables
IV. Treatment and Prevention
A. The Role of Social Support
1. Social Support and the Postpartum Period
2. Postpartum Self-help
3. Social Support and Postpartum Disorders
B. Psychosocial Interventions
Figure 3. Prevention Strategies for New Parents
Figure 4. Prevention Strategies for Health Professionals
C. Psychopharmacologic Treatment
D. Screening
V. Summary
VI. References
VII. Acknowledgements
VIII. Disclaimer
An Introduction to Postpartum Illness
- Laurence Kruckman and Susan Smith
I. Introduction
One clearly negative outcome of the perinatal period is postpartum depression. However, the nature of this phenomenon - as a disease and as an illness - and its relationship with behavioral and structural variables remains unclear. The following narrative reveals the personal and clinical complexity of postpartum illness:
When our daughter was born it was the happiest moment of my life. Everything was so perfect. But then without any reason I became so sad. I lost my energy and I felt that it was all my fault that it was happening. Then I got these feelings of hurting myself and kept asking myself, “Why?” I felt stupid having these feelings and didn’t want anyone to know because I thought I could fight it on my own. It was like there was something going on inside of me which I had no control over. I didn’t want these feelings but they came up when least expected. Inside I would say, “You might as well give up, something is telling you to. There is no use in going on.” These thoughts terrified me and I would shake my head and say, “What the hell are you saying! This isn’t what you want.” But I also felt that nothing would straighten me out and I would never feel like me again. And then I became panicky for fear I would harm my daughter. I know I won’t do anything extreme, I haven’t even attempted anything. But these thoughts are ruining me inside. I see terrible visions and can’t seem to shake them off completely. I have been remaining silent because of being ashamed, guilty, and isolated. I don’t feel I’m insane. I also had thought that they would take me away to a mental hospital if I admitted what I was feeling and I definitely don’t want that. But I do need some help to recover. I can’t seem to do it myself (Herz 1992: 65).
The very term used to describe the disease - `depression’ - has deep experiential and emotional meanings in Western culture, and has been applied rather imprecisely to both mild, temporary forms of depression which are quite common in the first postpartum days, as well as to the more severe psychotic reactions which are quite rare. Typically, the syndrome is characterized by feelings of sadness in the new mother, extreme emotional instability, weeping, irritability and fatigue.
While there is great interest in the shorter, more temporary form of postpartum illness- commonly referred to as ‘Baby Blues’ or postpartum `blues’ - in the popular culture as reflected in articles in women’s magazines and in ‘folk’ knowledge (Gazella 1981), the medical and psychiatric literature reflects a preoccupation with the more severe postpartum psychosis. According to some, the postpartum ‘blues’ are so common and seemingly harmless that they have often been judged unworthy of serious study (Yalom et al. 1968). Even less well studied or defined is a phenomenon which some researchers view as between postpartum baby blues and psychosis in terms of its duration and severity and which may be a separate form of postpartum depression (Paykel 1980).
Most of the research on postpartum depression has looked to biological and/or psychosocial causes such as hormonal shifts, maternal age and birth order, psychiatric history, marital relationship, etc. At this time little consideration has been given to the impact of the cultural patterning of the postpartum period as a cause in postpartum depression - factors such as the structure, organization of the family and social group, role expectations of the new mother and significant others, etc.
Interestingly, a review of the anthropological literature reveals little evidence of the phenomenon identified in Western psychiatric diagnoses and in popular notions as postpartum depression. This view will be discussed briefly under the heading Anthropological Perspective, below.
In the following section a review of explanations concerning the cause of postpartum illness in medical and psychological literature is presented, followed by a summary of current theories regarding prevention and treatment. An examination of the anthropological literature on childbirth suggests that there are some common elements in the social structuring of the postpartum period cross-culturally. This information is provided to support the idea that while there is no doubt a continuum of physical changes/processes post-natally, the experience of postpartum depression in its non-psychotic forms is probably both exacerbated and cushioned by socio-cultural factors (Pillsbury 1978).
Compared to many rural, non-western cultures, in the US we recognize no formal social structuring of the postpartum once the mother has returned home. There is a popular, informal or folk notion of this period as being emotionally draining, stressful and fatiguing - between 60-80% of U.S. mothers express this experience in terms of ‘baby blues.’ Some have suggested that the ‘baby blues,’ and possibly mid-levels of depression may represent a culture-bound syndrome of the West resulting in part from modern birthing practices and the lack of clear role definition and provision of social support to the new mother.
Since 1994 research on the following topics has begun to blossom: pharmacological treatment in breast feeding mothers, the role of infant temperament, sleep deprivation, self-image, e.g. weight gain, universal screening and depression scales, e.g. EPDS, cross-cultural patterns of the postpartum, and environmental stress. Still, a quick review of journal research from the past five years reveals that most articles focus on biological cause (hypothalamic-pituitary-adrenal axis, gonadal hormones, thyroid, etc) or pharmacotheraphy linked to a fairly strict biological etiological view (34%). Strict psychological factors dominant about 18% of the publications, with related research on prediction, risk, screening scales comprising another 20%.
While research is increasing on this topic since 1994, little is known about the social environment surrounding birth especially once the mother leaves the hospital.
II. The Phenomena of Postpartum Depression
A. Historical Perspectives
Postpartum emotional problems, especially psychosis, were one of the few clearly recognized psychiatric entities during the 19th century. This awareness reflected the much earlier writings of Hippocrates, who in 700 B.C. described the emotional problems of the postpartum woman in detail, as well as the writings of Galen, Celsus and others. By 1858, Marcé had published a definitive study, Traits de la Folie des Femmes Enceintes, linking negative emotional reactions with childbirth.
The status of postpartum psychosis treatment after 1860, however, illustrates the power of diagnostic criteria to affect attitudes and research foci: Kraepelinian criteria, which did not include a category for postpartum depression, were in effect. Afflicted women, it seemed, were `manic depressive,’ or suffering from `dementia praecox,’ `toxic confusion’ or `neurotic states.’ As a result, many early psychiatrists concluded, as had Kraepelin, that `post-partum psychosis’ did not exist as a separate syndrome (Brockington 1978). By 1940, Jacobs stated that “every reaction type may occur during the puerperium,” hence, “Puerperal psychosis as a clinical entity does not exist” (Jackson et al. 1943). Foundeur et al. were even more insistent: “the results would not appear to justify terming the post-partum illness as a separate illness any more than one might term those young patients who react unfavorably to college as sufferers from a `college psychosis’” (Foundeur et al. 1957).
This uncertainty regarding postpartum depression as a clinical entity continues today. The Diagnostic and Statistical Manual (DSM) II (1968) described a separated entity: “294.4 Psychosis with Childbirth,” but DSM III (1980) eliminated this category stating: “there is no compelling evidence that post-partum psychosis is a distinct entity” (APA 1968, 1980). According to Walther, “The Diagnostic and Statistical Manual of Mental Disorders still does not have a useful category for psychiatric disorders of the puerperium period” (1997:101). Interestingly, while US investigators suggest PP disorders are simply affective disorders occurring in the PP period, British investigators view the disorder as unique, e.g. symptoms coming in waves, etc.
B. Definitions, Symptoms, and Complaints
In the following sections, postpartum depression will be defined using the following three-part categorization adapted from Brown (1979) and others:
* Postpartum psychosis or puerperal psychosis - a relatively rare disorder following childbirth with symptoms similar to general psychotic reactions: confusion, fatigue, agitation, alterations in mood, feelings of hopelessness and shame, delusions or auditory hallucinations, hyperactivity and rapid speech or mania.
* Chronic depressive syndrome or moderate depression disorder - more debilitating than the `blues’ and more common than postpartum psychotic reactions, this still poorly defined syndrome is characterized by despondency, tearfulness, feelings of inadequacy, guilt, anxiety, irritability and fatigue. Researchers suggest that women experiencing this form of depression rarely seek treatment and are only recently being studied.
* Postpartum ‘blues’ or transitory minor affective disorder - the name most commonly used to describe the weeping and emotional instability which occurs during the first postpartum week. Descriptions of symptoms include frequent and prolonged crying, irritability, poor sleep, mood changes and a sense of vulnerability which may continue for several weeks.
Within the past five years a few researchers have suggested adding a fourth category, postpartum post-traumatic stress syndrome (PTS), linking the characteristics of PTS with birth (Fisher et al. 1997). In this regard, variables such as Caesarian birth, death of the infant, and other major stresses are viewed as triggering postpartum illness. Whether this fourth category will soon be generally linked to PPD remains to be seen.
Following is a list of common complains reported by both the new mother and father in western settings. These symptoms possibly are precursors to depression, but not necessarily. If the following complaints continue, professional advice should be sought: worsening of sleep disturbances, eating problems, intensity and duration of depressed feelings, withdrawal or social isolation, or lack of interaction with the new baby (Herz 1992:72).
At the very least they reflect the lack of social support, knowledge and information that many western parents report compared to individuals immersed in rural non-western cultures with extended families. These complaints might prove to be valuable insights for prospective parents, health care delivery professionals, and researchers:
Figure 1. Stress Factors Reported by New Mothers and Fathers
Self-reported Stress by the New Mother
Reduced sleep by the mother
Fatigue
Baby up every few hours for 6 weeks
On call 24 hours
Baby sleeps but constant vigilance is required
Loss of freedom
Unpredictable schedule
Physical pain/sore breasts/episiotomy
Increase work load, e.g. laundry
Self-reported Stress by the Father
Less sleep
Fatigue
Less Freedom
Increased work
Performance anxiety
Increased responsibility
Receives less attention
Limited support from colleagues
Figure 2. Symptoms of Postpartum Illness
The following table lists three types of symptoms (physical, mental states, behavioral reactions) for 1. Baby Blues, 2. Postpartum Depression and, 3. Postpartum Psychosis
BABY BLUES
Physical Symptoms:
Lack of Sleep
No Energy
Food Cravings or Loss of Appetite
Feeling Tired Even after Sleeping
Mental States:
Anxiety and Excessive Worry
Confusion
Great Concern over Physical Changes
Confusion and Nervousness
Feeling, “I’m not myself; this isn’t me”
Lack of Confidence
Sadness
Feeling Overwhelmed
Behavioral Reactions:
Crying more than Usual
Hyperactivity or Excitability
Oversensitivity
Feelings Hurt Easily
Irritability
Lack of Feeling for the Baby
POSTPARTUM DEPRESSION
Physical Symptoms:
Headaches
Numbness, Tingling in Limbs
Chest Pains, Heart Palpitations
Hyperventilating
Mental States:
Despondency or Despair
Feelings of Inadequacy
Inability to Cope
Hopelessness
Over Concern for Baby’s Health
Impaired Concentration or Memory
Loss of Normal Interests
Thoughts of Suicide
Bizarre or Strange Thoughts
Behavioral Reactions:
Extreme Behavior
Panic Attacks
Hostile
New Fears of Phobias
Hallucinations
Nightmares
Extreme Guilt
No Feelings for Baby
Over Concern for Baby
Feeling “out of control”
Feeling like “you are going crazy”
POSTPARTUM PSYCHOSIS
Physical Symptoms:
Refusal to Eat
Inability to Stop Activity
Frantic Excessive Energy
Mental States:
Extreme Confusion
Loss of Memory
Incoherence
Bizarre Hallucinations
Behavioral Reactions:
Suspiciousness
Irrational Statements
Preoccupation with Trivia
Although treatable, many women suffering from postpartum depression do not recognize that they have the illness. A study of postnatal depressed women showed that over 90% realized something was wrong, however less than 20% reported their symptoms to a health care provider. Of this sample, only one-third believed they had postpartum depression (Whitton et al. 1996). According to Walther (1997) it is estimated that only 20% with the disorder receive mental health treatment. The remaining individuals are either undiagnosed, misdiagnosed, or seek no medical assistance.
C. Frequency
While the descriptions of postpartum reactions at first glance appear precise, the `condition’ is a complex mixture of physical, emotional and behavioral changes. Studies of postpartum depression have suffered, too, from the problems troubling most psychosocial studies of disease: (1) differences in diagnostic criteria and (2) biased samples due to inconsistent referrals. As a result, many researchers suggest caution in interpreting the results of clinical studies, which represent the vast majority of postpartum research. With the advent of new depression scales specifically linked to birth, future research should be able to draw a more accurate picture of frequency.
Postpartum psychosis is reported to be a relatively rare disorder occurring on an average of 1 per 1000 births(.1%). Onset is severe and quick, usually within the first three months: 80 percent of all cases present within 3-14 days after a symptom-free period. It is interesting to note that the incidence rates of postpartum psychosis have remained unchanged since the 1850’s and that studies in various settings have produced similar estimates of rate. Even is we assume variations through time in diagnostic criteria and recording techniques, the above studies tend to indicate stable rates of postpartum depression for the past 130 years.
The incidence for postpartum depression is much more variable, ranging from 30 to 200 cases per 1000 births (3-20%), with an estimated 10-35% rate of recurrence. Depression may occur at any time after delivery, often after the woman had returned home from the hospital. The symptoms may last from a few weeks to several months: about 4% of the cases persist for as long as a year (Gelder 1978). Recent research by Righetti-Veltema et al. (1998) and Whitton et al (1996) claim the incidence of postpartum depression in its non-psychotic forms is approximately 10-15% for first time mothers.
Transitory `blues,’ like the more disabling postpartum psychosis, has a quick onset, usually 1-3 days postpartum. Incidence rates range from 500-800 cases per 1000 births (50-80%) depending on diagnostic criteria, time and location of the study.
III. Cause/Etiology
A. Biological Theories
The psychopharmacology revolution in the 1950’s stimulated a renewed interest in the relationship between postpartum depression and hormonal changes. It has been consistently noted that onset of symptoms on the third day postpartum corresponds strikingly to third day postpartum hormonal changes.
One striking and well-researched hormonal change during the postpartum period is the sharp drop in estrogen and progesterone. Estrogen and progesterone, the female reproductive hormones, increase 10-fold during pregnancy (Hytten and Leitch 1964) through the primary mechanism of synthesis by the feto-placental unit (Goddwin et al. 1976). Once the placenta is removed after delivery, estrogen and progesterone drop sharply to pre-pregnant levels. By three days postpartum, estrogen and progesterone are around pre-pregnant levels (Hytten and Leitch 1964). Nott et al. (1976) concluded after examining the hormone levels of 27 women before and after delivery that women with the greatest drop in progesterone levels after delivery were more likely to rate themselves depressed within 10 days of delivery. Handley et al. (1977), Livingston et al. (1978) and Stein et al. (1976) note a relationship between a rapid drop in estrogen levels at birth with a decrease in free plasma tryptophan levels to be correlated with depression.
A more recent research focus has been the area of prolactin activity during the puerperium. Prolactin levels form a reverse curve of the estrogen and progesterone levels during the postpartum period, with low levels occurring immediately after delivery and increasing to a high level plateau by the first week after birth. It is reasonable to assume a possible relationship exists between the decline of breast-feeding in the U.S., the rapid decline in prolactin in mothers who do not breast-feed and postpartum depression. This relationship is important and requires more research. By comparison, research on hospitalization prior to surgery, prolactin has been found to increase during episodes of emotional and physical stress.
Adrenal steroid changes in the postpartum possibly related to depression are: (1) changes in plasma cortisol which regulates the metabolism of fats, carbohydrates and protein; (2) an increase in aldosterone which results in an increased sodium and water retention and an accompanying decrease in potassium concentration; and (3) changes in glucose tolerance with a tendency toward low blood sugar (a change noted in depression in general). The role of cyclic adenosine monophosphete (AMP) in the transmission of nerve impulses has been linked to postpartum depression in some research based on assumptions concerning the lack of monoamine in the synaptic cleft and affective disorders. Ballinger et al. (1979) noted that cyclic AMP is more elevated during the puerperium than 2-3 months postpartum. They determined that women who most frequently experienced mood changes had large increases in cyclic AMP during the puerperium. Yalom et al. (1968) suggested that cyclic AMP might also be a key to the frequently noted relationship between a long, difficult labor and subsequent depression.
Current research indicates a relationship exists between premenstrual syndrome and postpartum depression. Chuong and Burgos (1995) reported higher rates of the disorder in women with PMS. Birth control, alcohol, and drug use was also found to be significantly greater among these women than control subjects. However, according to Herz (1992) data has not consistently supported the conclusion drawn regarding PMS and postpartum depression.
Another recent study revealed that women with obsessive-compulsive disorder (OCD) might be at an increased risk for developing postpartum depression. Those who suffer from OCD may experience an intensification of symptoms during the premenstrual and postpartum periods. Changes in gonadal hormones have been noted as a potential factor (Williams and Koran 1997).
Severe sleep disturbance and anxiety have also been noted as possible predictors of postpartum depression (Walther 1997). A recent study by Godfroid (1997), representing the first on EEG sleep profile during postpartum depression, showed that specific polysomnographic alterations exist during this period. The significance of these findings is difficult to explain and additional research is required, nevertheless it is clear that the EEG sleep profile during postpartum depression does differ from major depression of equal severity.
Although hormonal research has identified potential links with depression - estrogen, progesterone, corticosteroids and cyclic AMP - much of the research has been problematic. For example, various diurnal hormonal changes occur in late pregnancy, making research difficult. Also, there is a general lack of knowledge concerning individual variations in hormonal levels, the importance of hormonal synchrony, and the ability of individuals to adapt to changes.
Another difficulty with this research is that the primary focus has been on psychotic reactions: researchers have somewhat ignored hormonal studies on the larger phenomenon of the `blues’ or moderate depression disorders and as a result of utilizing psychotic patients, the sample sizes have been small.
Most researchers agree that hormonal research has not produced a direct link to postpartum depression. For example, a study by Harris et al. showed “no support for a direct association of progesterone with postnatal mood at 6 weeks postpartum” (1996:743). In addition, “Links between absolute or changing concentrations steroids such as cortisol and progesterone and maternity blues have not, so far, led to any positive associations with postnatal depression” (Gregoire et al. 1996: 930). Asch and Rubin suggested earlier that perhaps previous research has been measuring effect rather than cause based on their observations of depression in new fathers and grandmothers: ” . . . post-partum reactions in many cases are primarily psychogenic since the reactions occur in individuals who are not physiologically involved” (1974).
Evidence regarding the role of progesterone, estrogen, prolactin, cortisol, oxytoncin, thyroid, and vasopressin in postpartum depression remains contradictory. Therefore, only additional research will clarify any biological links to the origin of the illness.
Since psychological stimuli affect the neuroendrocrine systems, hormonal studies must be carried out in connection with psychosocial research. In an article reviewing the hormonal link to postpartum depression, Gelder states: ” . . . the balance of evidence points to social and psychological causes for these states” (1978). Two decades later, Hendrick et al. draw a similar conclusion: “The literature to date does not consistently support any single biological etiology for postpartum depression.” Additionally, “Future research on the biological factors that may underlie postpartum mood disorders should attempt to control for these (psychosocial) variables, as they otherwise are likely to confound the data (1998:98).”
B. Psychosocial Variables
1. Personality Variables
Psychological factors are thought by many to play a major role in postpartum depression. In many of the studies a major complaint reported by the new mothers was a feeling of `inadequacy’ regarding childbearing. Tentoni and High (1980) have suggested that postpartum depression is in part related to the explicitness of role expectations for females and mothers - roles which have changed dramatically in the past 50 years. In other research, role conflict has been identified as an important psychosocial variable predictive of emotional problems (Yalom et al. 1968; Brown et al. 1972; Markham 1961; Melges 1968). Using a large sample of postnatal women, the Maternal Attitudes Questionnaire (MAQ) was used to measure thoughts regarding role changes, expectations of motherhood, and expectations of the self as a mother. Results showed women with postpartum depression to be different cognitively than non-depressed mothers (Warner at al. 1997).
Closely related to notions of role conflict is the frequent finding that `attitude’ towards pregnancy, especially ambivalence, is a strong correlate of depression (Nilsson and Almgren 1970). `Sexual identity,’ another concept related to notions of role, has also been suggested as offering clues to the development of psychological symptoms following childbirth (Brown and Shereshefsky 1972). Specifically, Nilsson and Almgren (1970) found women who assessed themselves more `masculine’ than others reported fewer psychiatric symptoms during pregnancy but more during the postpartum.
Other studies have investigated the effect of weight retained after pregnancy on weight satisfaction, self-esteem and depression. Jenkin and Tiggemann (1997) found that a mother’s psychological well-being was determined by her weight following birth. Furthermore, research conducted by Walker (1997) showed women with greater weight gain reported symptoms of depression more often than those with lesser gains. Higher body mass indexes, weight gains, and symptoms of depression were also revealed in women who reported lowered self-esteem due to their weight. Both weight gain and the negative response to it is common following delivery. Women tend to be slightly heavier than they expect, “particularly in the case of the younger women” (Jenkin and Tiggemann 1997: 89).
The relationship between self-esteem and depression appears to be strong. Research shows that symptoms of depression are 39 times more likely to be seen in mothers with low self-esteem than in those who have self-esteem that is high (Hall et al. 1996). In a study by Fontaine and Jones (1997), self-esteem was associated with moderate depression two weeks postpartum.
2. Demographic Variables
Kendell et al. (1976) have correlated age with depression: either young or old first time mothers appear to be most vulnerable (Uddenbrug and Nilsson 1975). Yalom et al. (1968) concluded that age of first menstruation correlated more strongly with depression than age at first pregnancy.
It has been hypothesized for about two centuries that broad scale social change such as wars and economic depression played a role in postpartum depression. In 1814, Esquirol noted an increase in postpartum depression with the invasion of France and the fall of Napoleon; others have identified a similar increase in the U.S. during the 1930-1935 economic depression and during World War II.
Several researchers have tested variables associated with environmental conditions such as financial stress, socio-economic status (SES), geographic mobility, etc. Uddenberg et al. (1975), in a study of 95 Swedish women attending prenatal clinics, noted that the poorer the social condition, the higher the chances for depression.
Heitler (1976) linked depression to pregnant or recent mothers’ concern over financial matters and the reliability of their mates’ employment situation. Gordon and Gordon (1967) identified recent family `economic shifts’ as a factor in a new mother’s emotional adjustment. Davidson (1972), in his study of Jamaican women, observed an association between depression and low SES, but suggested that the real factors were a combination of low SES, large family size, and major responsibility for family support. Heitler (1976), in a study of 91 U.S. mothers, determined geographic mobility to be important: Gordon and Gordon (1967) concur and specify an unexpected or recent move as a key factor. In related research, Kendell et al. (1976) found a correlation between `psychiatric mortality’ and recent immigration.
3. Interpersonal Variables
Interpersonal factors such as family interaction, companionship and marital problems have also been suggested as important factors in postpartum depression. Douglas (1963), Heitler (1976) and Uddenberg (1975) isolated `mother-daughter interaction’ as an important variable: Uddenberg (1975) found a correlation between `rejection of mother’ and depression, while Heitler (1976) described similar results when a `hostile’ attitude exists between mother and daughter. Paykel et al. (1980), Pitt (1968), Nilsson and Almgren (1970) and Uddenberg (1975) found lack of meaningful social network support via family or friends related to depression: it may be that lack of support is also linked to the quality of mother-daughter interaction.
An inter-relationship between mother-infant separation, disturbed bonding and subsequent postpartum depression has been suggested (Righetti-Veltema et al. 1998). A meta-analysis conducted by Beck (1996) indicated a significant relationship between postpartum depression and infant temperament. Marital problems before and after childbirth have been correlated with depression by several researchers (Robson and Kumar 1980). Gordon and Gordon (1967) felt the probability of depression was increased if marriage partners differed in age and religion. Paykel et al. (1980), however, found `marital tension’ an important factor only if other stressful life events were present. It is important to remember that PP risk factors are difficult to identify and much of the research is conflicting.
4. Obstetric Variables
Among the most current research findings are those indicating the conditions surrounding the birthing process as risk factors for developing postpartum depression.
One such event is a traumatic obstetric experience, which has been linked to young mothers (Rona et al. 1998). More specifically, Fisher et al. (1997) concluded that operative intervention in first childbirth leaves a mother susceptible to grieving, posttraumatic distress, and depression. The mode of delivery was found to be the determining factor. “Those women who had spontaneous vaginal deliveries were most likely to experience a marked improvement in mood and an elevation in self-esteem across the late pregnancy to early postpartum interval. In contrast, women who had Caesarian deliveries were significantly more likely to experience a deterioration in mood and a diminution in self-esteem. The group who experienced instrumental intervention in vaginal deliveries fell midway between the other two groups, reporting neither an improvement nor a deterioration in mood and self-esteem” (Fisher et al. 1997:728).
Mothers of pre-term infants often become depressed which may, in turn, have a negative outcome on the health of their child. It was found by Locke et al. that “Maternal depression was related to the severity of the initial neonatal illness and was significantly related to intraventricular hemorrhage and bronchopulmonary dysplasia” (1997:145).
Research has also revealed that early discharge from the hospital puts women at an increased risk for developing postpartum depression, even when sociodemographic, obstetric and psychosocial risk factors are controlled for in statistical analyses (Hickey et al. 1997).
Birth order is frequently suggested as an associated factor. Davidson (1972), Yalom et al. (1968), Kendall et al. (1976) and Jackson and Laymeyer (1981) have concluded that the birth of the first child represents a unique stress and is correlated with depression more strongly than a second or third birth. Other studies have cited that “long and very short intervals between pregnancies may be potential risk factors for postpartum illness” (Herz 1992: 68).
C. Anthropological Perspectives: The Promise of Bio-cultural Research
Regarding postpartum illness, anthropology differs from psychiatry in two ways. First, anthropology envisions a more holistic, bio-cultural relationship between cultural patterns such as family structure, values, beliefs, roles, etc. and human biochemical action. Secondly, many anthropologists believe that mothers in rural, non-western cultures, characterized by large supportive kin groups, do not exhibit symptoms that are described as depression in the west.
The lack of PP depression (note: not psychosis) was noted before 1980 by many and summarized by Stern and Kruckman (1983). Recent research in the 80s and 90s by individuals better versed in comparative psychological research, and using more refined measuring devices have, in most cases, continued to support the hypothesis that PP depression is relatively unknown in non-western settings focused on kin based social systems:
Harkness (l987: 209) found that among Kipsigis in Kenya, where support and warm care are provided by husband, parents, and relatives, postpartum depression was uncommon.
Laderman (1987:98) reported that among a group in rural Malaysia that a particular “hantu” (disembodied spirit) linked to amniotic fluid can cause PP emotional problems. She reports the use of rituals to avoid such problems.
Macintyre (1992) while finding reports of severe PP mental disorders in south-east Papua New Guinea found no evidence of PPD.
Tseng et al. (1994) state that women practicing the Chinese rituals (”doing the month”) at home had significantly lower levels of PPD.
Stewart et al. (1996) researched PPD in a US population of Hmong immigrants and also found that mothers who had retained PP beliefs and rituals are better protected from PPD.
Stern and Kruckman (1983) suggest that the higher level of negative PP emotional outcomes in the U.S. result from the relative lack of (1) social structuring of postpartum events; (2) social recognition of a role transition for the new mother; (3) meaningful assistance to the new mother, including providing information regarding child and self care; and (4) some cultural rituals are unique in the manner in which the components are integrated into the social order.
Extending this argument, Kruckman (1992) states that postpartum rituals may cushion or prevent the experience for the following reasons: 1) postpartum rituals are a set of evocative devices for rousing, channeling, and domesticating powerful cultural emotions such as fear linked to birth, 2) postpartum rituals function to enhance and solidify social roles such as “motherhood,” 3) rituals serve as a learning process. Through ritual, the responsibilities, attitudes, and techniques of motherhood are revealed to the younger members of the group, and, 4) rituals are also a form of support. Rituals marshal regular, reliable, and predictable physical support from family members and the community, crucial to the new mother during birth and the postpartum. Task-oriented chores are defined and completed for the mother. Rituals also stimulate attention concerning the emotional needs of new mothers, reassuring them of their physical and emotional health and celebrating with them their new status.
Abnormality of the hypothalamic-pituitary-adrenal (HPA) axis has been one of the most consistently demonstrated biological markers of depression. In this regard there appears to be two truths: first, the birth process interacts with the HPA axis, and two, environmental events such as stress contribute to clinical depression (a recent large scale study by Brown (19 ) reports that 84% of clinically depressed individuals had a major stress event during the year before). Therefore, it seems reasonable to state that postpartum rituals that calm the mother, eliminate sleep deprivation (the number one complaint of western mothers), etc. can reduce PPD. Rituals, then, can not only change the hormonal flows but also identify the sensations that accompany birth in positive ways.
Kruckman (1998) feels that PP rituals can symbolically place a warm, secure blanket of emotional support around the mother, telling her through the rituals acts such as massage, special meal, poems, songs, etc., that her feelings, concerns, fears, and sensations are, while uncomfortable, normal, and will pass. Equally important, the group will see her through the PP. While western births are filled with rituals, they are often related to the medicalization of birth, e.g. wheel chair pick up and delivery, colored gowns, hospital bracelets, baby cards, etc. While known and anticipated, and at times desired by the mother, these rituals fail by their lack of “getting work done” and providing spiritual and emotional well-being.
Anthropologists believe that determining the behavioral sequences and social components which contribute to negative outcome, requires research from a combined biochemical and cultural approach. Here, the study of rituals worldwide can provide enlightenment, and groups practicing them could act as a control group to urban populations. In sum, many anthropologists see bio-cultural research, combining the biochemistry of birth and the cultural context of birth, as the most likely way to unravel the postpartum puzzle, discover causal factors, and initiate appropriate and effective prevention and treatment strategies.
D. Summary
The data presented in the studies described above suggest that there may be a more complex causal pattern or chain involved in the etiology of postpartum depression than biologically-based theories alone can explain. However, the psychosocial literature in general has been plagued by some methodological problems which deserve attention. For example, sample size has tended to be small and to utilize a clinical population of women who are still hospitalized postpartum which may skew the data because of the unique contextual and physiological factors. Frate et al. (1976) note that such methodology may confuse reactions caused by hospitalization with the finding of depression associated with the third or fourth postpartum day prior to release: “Due to the fact that most research has been hospital-based, little is actually known about post-partum reactions outside the institution.” His view still appears valid.
In addition, psychological studies have tended to focus on personality dysfunction as measured through such constructs as `depression,’ `anxiety,’ `tendermindedness,’ etc. Few studies have actually observed behavior or interpreted the results of psychological tests in the context of the wider social system of the family or community.
IV. Treatment and Prevention
A. The Role of Social Support and Self-help
1. Social Support and the Postpartum Period
The relationship between support and the expression of postpartum depression seems obvious given what we know in the West about depression and support apart from birth. During the past 20 years, scholars from several disciplines have suggested that social support promotes mental and physical well-being, especially in the face of stressful experiences (Jacobson l987; Cohen and Wills l985; Sarason and Sarason l985; Cassell l976).
The lack of social support (e.g. “natural support system”) and marital intimacy have long been linked with psychological distress (Caplan l974). Hirsch (l986) correlated lack of support with mental health problems among widows, and Lenz et al. (l986) found a relationship between “instrumental support” and physical illness, etc. It is puzzling why there has been so little research investigating the postpartum period, depression, and social support. Certainly the postpartum period represents a time of stress, a situation cross-culturally characterized by the need for immense physical and emotional support, and a period linked with high levels of depression.
Nuckolls et al. (l972: 431) found that mothers scoring high in “favorable psychosocial assets” had one-third the birth complications; O’Hara (l983) and Sosa et al. (l980) stressed the importance of a “confidant” during this time as a preventative to mental illness; and Robertson (l986) claims a relationship between the husband’s role and psychiatric illness. Cutrona (l982) and Paykel (l980) suggest life events and social support are in some way correlated and suggest additional research.
Previous research has indicated that a majority of postpartum mothers are concerned about levels of support (Bull and Lawrence l985: 319) and that prolonged postpartum depression is “closely linked to lack of social support” (Cutrona l982: 487).
2. Postpartum Self-help
Given the current Western economic structure that reduces or eliminates the avenues for familial support, and a cultural system steeped in positivism, thus relying on the medical model, it is almost impossible to conceive of Western society either returning to extended family support systems or instituting postpartum support rituals. However, research on cause/etiology suggests that we must promote the idea of a social and physiological return from childbirth in research and prevention. Is there a solution to the problem at hand?
It is likely that mutual self-help (helping networks, intentional communities, or a variety of other names) is one realistic social answer, albeit a partial one. Mutual self-help is a volunteer organization that makes its own policy, especially regarding the kind of help offered. Members control the resources; the help offered is based on veteran member’s own experiences in solving particular problems; organizational structure is governed by consensus; and the group size is small and intimate. Basically, mutual support groups function to provide: information on how to cope; material help if necessary; and emotional and physical support and concern. This support has special meaning because it emanates from mothers who have had similar experiences. As new mothers realize that they share a common series of concerns and problems, they discover that what seemed unusual is common. Once they realize this, they no longer feel alone with their problems. If the above research is accurate, much of a new mother’s anxiety is based on the everyday problems of self-care and raising a healthy baby. These are not problems that always need medical intervention. Mutual self-help groups replicate many of the components concerning support found cross-culturally, and have the potential to cushion or prevent the expression of moderate level depression. A variant form of support group has more recently evolved, e.g. DAD, PEP, PSI, that is organized by trained professionals (Taylor 1996).
3. Social Support and Postpartum Disorders
Cross-cultural research reveals that birth is almost universally treated as a traumatic life event. As such, this period is everywhere a candidate for consensual shaping and social patterning. In most societies, including the U.S., birth and the immediate postpartum period are considered a time of vulnerability for mother and child. In order to deal with this danger and the uncertainty associated with birth, almost all cultures have produced a set of internally consistent and mutually dependent practices and beliefs, which are designed to manage the physiologically and socially problematic aspects of parturition in a way that makes sense in that particular cultural context. Cultures, over a period of hundreds or thousands of years, often have developed “policy” in the form of myth and rituals concerning the stressful event of birth.
In the U.S. many have argued convincingly that disruption of social support increases susceptibility to illness, including depression (Brown and Harris, l978; Miller and Ingham, l976). Several researchers have linked a lack of social support with postpartum depression (O’Hara, l983:336; Braverman and Roux, l978; Paykel et al., l980:345; Frate, l979:355). Not surprising, in one of the few studies of non-hospital environments, Paschall et al. found that only l8% of 90 mothers studied received more than 2 weeks of assistance with housework, and only 20% reported assistance with baby care beyond the first week (l976:750).
Stressful life events also have been suggested as a causal factor of mental problems (Brown and Harris l978). Stress related to family structure, marriage, occupation, housing, geographic mobility, have been correlated with postpartum depression (Sosa et al., l980; Heitler l976; O’Hara et al., l983; Paykel l980; Telles, l982). Associations between social variables such as support, stress and role conflict have been correlated frequently enough to suggest that there may be a more complex causal pattern, or chain, involved in the etiology of postpartum depression than biologically-based theories alone can encompass. The implications of this psychosocial research seem clear: the traditional social support in the U.S. that existed in the 1940’s when hospital births became the norm no longer exists. And, more importantly, the new early postpartum hospital discharge policy will, unless planned effectively, return the new mother “home” leaving her at risk for emotional stress due to the lack of social support.
A. Psychosocial Interventions
One method for preventing the occurrence of postpartum depression is attending to potential risk factors. Many studies have demonstrated that prenatal psychosocial interventions contribute to the transition into parenthood and, in turn, combat the development of postpartum depression.
In a prenatal prevention study (Herz 1992:73-75) experimental subjects found that following recommendations (such as those listed below) allowed them to experience less emotional upset than controls. It was shown that women developed less than half as many emotional problems when their husbands participated in classes with them. Also, “Instructed mothers had greater success with their babies: their six-month infants were significantly less irritable and had fewer sleep and eating disorders than the control’s babies.” In summary, Herz makes the following recommendations:
Figure 3. Prevention Strategies for New Mothers and Fathers
The responsibilities of motherhood are learned, hence get informed.
Get help from husband, dependable friends, and relatives.
Make friends with other couples who are experienced with child-bearing
Don’t overload yourself with unimportant tasks.
Don’t move soon after the baby arrives
Don’t be over concerned with keeping up appearances.
Get plenty of rest and sleep.
Don’t be a nurse to relatives and others at this time.
Confer and consult with husband, family and experienced friends, and discuss your plans and worries.
Don’t give up outside interests, but cut down on responsibilities and rearrange schedules
Arrange for babysitters early.
Get family doctor early.
In a related fashion, numerous studies have recommended the following objectives for health care providers:
Figure 4. Prevention Strategies for Health Care Delivery Professionals
Dispel the motherhood myth of the maternal instinct (i.e., an inborn knowledge of how best to take care of the baby), the myth of the unwavering limitless motherly love, and the myth of the total maternal fulfillment by the baby.
Strengthen the marital support by defining shared responsibilities and roles with realistic coping behavior during the parental adjustment.
Mobilize additional emotional support systems.
Reduce environmental stress factors.
Rearrange priorities.
Encourage a pregnant woman to become an apprentice to a new mother particularly if she has had no previous experience with an infant. (Herz 1992: 73-75)
C. Psychopharmacologic Treatment
As previously implied, a clear biological cause of postpartum depression is still unclear. Therefore, it is understandable that biochemical preventive measures in relation to physiological variables are controversial at this time as well. More research into the etiology of postpartum depression is still required.
However, based on our present understanding of potential risk factors psychological and medical practitioners attempt to prevent this disabling illness with psychopharmacologic interventions. It is suggested, however, that they be accompanied by psychosocial interventions, fitting the needs of the individual (Walther 1997).
Selective serotonin reuptake inhibitors (SSRIs) are frequently being noted as “the drugs of choice for first-line treatment of depression” These include fluoxetine (Prozac), sertraline (Zoloft), and Paxoxetine (Paxil). Among the advantages of these drugs are their low anticholinergic effects, their safety in overdose situations, and the fact that they are dosed once daily (Jermain 1995:36).
Antidepressant therapy has also been shown to significantly lower the rate of recurrence of postpartum depression (Wisner and Wheeler 1994). According to Jermain (1995) guidelines for the treatment of the disorder have not been clearly presented. The patient’s symptoms, the side effects of the drug, and the mother’s decision to breast-feed, determine which antidepressant will be implemented. Moreover, patients are advised not to expect an immediate response to therapy; on average it takes between one and three weeks before the drug begins to take action. The prescribed regimen must be followed and other medications and alcohol should be avoided in order to prevent the exacerbation of the disorder. Doxepin should be avoided as it has serious and potentially lethal side effects (Jermain 1995: 37).
Monoamine oxidase (MAO) inhibitors are prescribed less often. The concern with this class of drugs is that they interact with other medications, such as decongestants, SSRIs, venlafaxine, and meperidine. Also, a tyramine-restricted diet (no aged cheeses, red meats, red wines, or beer) must be followed while taking these compounds (Jermain 1995).
“Progesterone, with or without estrogen, thyroid and cortisone medications, bromocriptine, trytophan, and other drugs have been tried with varying results” (Herz 1992:75; Harris et al. 1996; Gregoire et al. 1996). Research by Gregoire et al. (1996) provided support for the use of transdermal estrogen as an effective treatment for postnatal depression. Mechanism of action, minimum effective dosage, and shortest necessary duration need to be determined.
For mothers considering breast-feeding, psychotropic drugs should be used with caution because most are excreted into breast milk (Jermain 1995). One of the most complete sources on the subject is Thomas Hale, Medications and Mothers’ Milk, 1989-99, Pharmasoft Medical Publishing,
(800-378-1317).
D. Screening
Generally, the symptoms of postpartum depression appear anywhere from three days to one week after delivery. Considering that the average length of hospital stays recently have been dramatically reduced as a result of early hospital discharge policy in the US, ” . . . to as brief a period as twenty-four hours following uncomplicated deliveries in some states,” health care professionals are not in an ideal situation for identifying the start of postpartum depression (Walther 1997:107). Therefore, according to Walther, “the four-to-six-week postpartum visit may be the ideal time to assess women for depression; and the first well baby appointment should not be a missed opportunity for assessment as well” (1997:107). Honikman (1994) reports that most health care providers are educated on PP illness, do discuss PP risk with prospective parents, but do not use formal questionnaires or depression scales. Further, health care providers, in their discussion with new mothers, focus on mild emotional reactions and not on the major mood and anxiety disorders.
Further, Walther believes, “the treatment of postpartum depression can be greatly enhanced by an ounce of prevention. With multifactorial causation, reducing any of the contributing factors may lessen the likelihood that a serious psychological problem will develop following birth. Sleep appears again and again as a key factor. New prospective studies have suggested that rates of depression during pregnancy are similar to those developed and diagnosed after pregnancy. Furthermore, prenatal depression has been found to be a predictor of postpartum depression. The incidence of postpartum depression may be reduced or may benefit from early interventions including parenting education and support, community resource referrals, psychotherapy of an individual, family, or group, and reassurance. When maternal anxiety and depression are reduced, newborns are also protected from the consequences of maternal deprivation which accompany postpartum depression” (Walther 1997:109-110).
Therefore, identifying women at high risk for postpartum depression is crucial. New mothers, “who appear excessively anxious, who have a history of past depressions, who are having marital or family problems or who have experienced other stressful life events should be referred for evaluation and early intervention planning. In addition, educating women in childbirth education classes or other antenatal forums about the real risk factors and early symptoms associated with postpartum depression and those resources available to help them cope with such an occurrence, can facilitate their ability to access appropriate preventive and early mental health care interventions” (Walther 1997:110).
V. Summary
As mentioned in the introduction, the largest percentage of the research and treatment of postpartum illness has focused either on the more psychotic reactions or biological-based variables presumed as cause. The consistently recorded low incidence rates for postpartum psychosis, historically and cross-culturally, suggest that it may represent a discrete clinical entity or illness. In contrast, very high incidence rates for milder forms of postpartum depression-in the U.S. popularly known as `baby blues’-have received little attention from researchers due to the perception that this phenomenon is `ubiquitous,’ `inevitable’ and self-limiting.
A review of the psychiatric literature on postpartum depression shows the overwhelming emphasis on biological explanations based on the global hormonal changes occurring postpartum. The precise mechanisms which would produce the clinical syndrome of psychotic depression or its milder forms have not been clearly identified. It may be that `baby blues’ may simply be the milder end of a biologically based continuum in which the severe end is psychosis. It may be that lumping the various forms of depression together at all is a conceptual mistake; e.g. perhaps psychotic postpartum depression is simply a form of manic-depressive illness with a postpartum onset. As with affective disorders in general, the relative etiological importance of biological, social, and psychological factors remains debated.
Research on the psychological correlates of postpartum depression has serious methodological limitations: many studies are based on an in-hospital sample and results are thus confounded by the effects of hospitalization. In addition, the lack of prospective or long-term follow-up studies makes reported mental status in the immediate postpartum a questionable measure. Finally, psychological studies have suggested correlates, such as maternal age, environmental stress, etc., but the specific mechanisms or interactions through which these variables relate to depression are unclear.
Despite the national concern with postpartum events such as child abuse and neglect, failure-to-thrive and sudden-infant death syndrome (SIDS), and with population that are perceived as `high risk’ such as teenage and/or single parents and parents with substance abuse or psychiatric problems, there is currently little field research on how people organize and experience their lives in this critical period. We know very little about what occurs after new mothers return home after giving birth in hospitals. It has been suggested that postpartum depression is linked to impaired cognitive abilities, social development, and children’s adjustment to school, especially in boys (Gregoire et al. 1996; Sharp et al. 1995, Sinclair and Murray 1998), crib deaths’ (Kukull and Peterson 1977), infanticide (Balchin 1975) and `bonding difficulties’ suggested as causally related to subsequent child abuse and neglect as are unrealistic parental expectations of infants (Steele and Pollock 1974). There are other suggestive statistics; for example, it has been estimated that 30% of the children who are subsequently abused or neglected were low birth weight or premature. The negative outcomes noted above typically occur during the first three years of life and are consistently correlated with the factors of economic stress, unemployment, and unwanted pregnancy (Gelles 1979). However, while there are strong correlation’s between perinatal events and negative outcomes, the causal factors and mechanisms remain unclear. Determining the behavioral sequences and social components which contribute to negative outcomes necessitates observational and ethnographic field studies worldwide, as well as prospective studies which follow women through the perinatal period.
The difficulty of abstracting universal components of postpartum activities, or of operationalizing notions such as `social support,’ relate to widely discussed concerns about the relationship between social organization and mental illness. Yet however one chooses to operationalize the concept of social support, it seems clear that as a society we pay astonishingly little attention to new mothers and that the lack of clear formal or informal social policies for this period contradict its importance in the life cycle.
VI. References
Beck, C.T. (1996). A meta-analysis of the relationship between postpartum depression and infant temperament. Nursing Research. 45(4):225-230.
Chuong, C.J., and Burgos, D.M. (1995). Medical history in women with premenstrual syndrome. J. Psychosom. Obstet. Gynecol. 16:21-27.
Fisher, J., Astbury, J., and Smith, A. (1997). Adverse psychological impact of operative obstetric interventions: A prospective longitudinal study. Australian and New Zealand Journal of Psychiatry. 31:728-738.
Fontaine, K.R., and Jones, L.C. (1997). Self-esteem, optimism, and postpartum depression. J. Clin. Psychol. 53:59-63.
Godfroid, I.O., Hubain, P.P., Dramaix, M., and Linkowski, P. (1997). Sleep during post-partum depression. Encephale. 23(4):262-266.
Gregoire, A.J.P., Kumar, R., Everitt, B., Henderson, A.F., and Studd, J.W.W. (1996). Transdermal oestrogen for treatment of severe postnatal depression. Lancet. 347:930-33.
Hale, Thomas. (1998) Medications and Mothers’ Milk, 1989-99, Pharmasoft Medical Publishing, Amarillo, Texas.
Hall, L.A., Kotch, J.B., Browne, D., Rayens, M.K. (1996). Self-esteem as a mediator of the effects of stressors and social resources on depressive symptoms in postpartum mothers. Nursing Research. 45(4):231-238.
Harris. B., Lovett, L., Smith, J., Read, G., Walker, R., and Newcombe, R. (1996). Cardiff puerperal mood and hormone study. III. Postnatal depression at 5 to 6 weeks postpartum, and its hormonal correlates across the peripartum period. British Journal of Psychiatry. 168:739-744.
Hendrick, V., Altshuler, L.L., and Suri, R. (1988). Hormonal changes in the postpartum and implications for postpartum depression. Psychosomatics. 39:93-101.
Herz, E.K. (1992). Prediction, Recognition, and Prevention. In J.A. Hamilton and P.N. Harberger (Eds.), Postpartum Psychiatric Illness: A picture puzzle. Philadelphia: University of Pennsylvania Press.
Hickey, A.R., Boyce, P.M., Ellwood, D., and Morris-Yates, A.D. (1997). Early discharge and risk for postnatal depression. Med. J. Aust. 167(5):244-247.
Jenkin, W., and Tiggemann, M. (1997). Psychological effects of weight retained after pregnancy. Women & Health. 25:89-98.
Jermain, D.M. (1995). Treatment of postpartum depression. American Pharmacy. 35:33-38.
Kruckman, L. (2000). “Rituals as Prevention: The Case of Postpartum Depression,” In The Nature and Function of Rituals, Ruth-Inge Heinze, Greenwood/Praeger Publishing.
_________ (1992). “Rituals and Support: An Anthropological View of Postpartum Depression,” in Postpartum Depression: The Picture Puzzle Disease, University of Pennsylvania Press, James Hamilton and Patricia Harberger (ed).
Locke, R., Baumgart, S., Locke, K., Doodstein, M., Thies, C., and Greenspan, J. (1997). Effect of maternal depression on premature infant health during initial hospitalization. J. Am. Osteopath. Assoc. 97(3):145-149.
Righetti-Veltema, M., Conne-Perreard, E., Bousquet, A., Manzano, J. (1998). Risk factors and predictive signs of postpartum depression. Journal of Affective Disorders. 49:167-180.
Rona, R.J., Smeeton, N.C., Beech, R., Barnett, A., and Sharland, G. (1998). Anxiety and depression in mothers related to severe malformation of the heart of the child and fetus. Acta Paediatr. 87(2):201-205.
Sharp, D., Hay, D.F., Pawlby, S., Schmucker, G., Allen, H., and Kumar, R. (1995). The impact of postnatal depression on boys’ intellectual development. J. Child Psychol. Psychiat. 36(8):1315-1336.
Sinclair, D., and Murray, L. (1998). Effects of postnatal depression on children’s adjustment to school. Teacher’s Reports. British Journal of Psychiatry. 172:58-63.
Steinberg, Susanne and L. Kruckman, (2000) “Reinventing Fatherhood in Japan and Canada,” Social Science and Medicine. Forthcoming.
Stern, Gwen and L. Kruckman (1983), “Multi-Disciplinary Perspectives on Postpartum Depression: An Anthropological Critique,” Social Science and Medicine, Vol. 17, 15, pages 1027-1041.
Walker, L.O. (1997). Weight and weight-related distress after childbirth: Relationships to stress, social support, and depressive symptoms. Journal of Holistic Nursing. 15(4):389-405.
Warner, R., Appleby, L., Whitton, A., and Faragher, B. (1997). Attitudes toward motherhood in postnatal depression: Development of the maternal attitudes questionnaire. J. Psychosom. Res. 43(4):351-358.
Walther, V.N. (1997). Postpartum depression: A review for perinatal social workers. Soc. Work Health Care. 24(3-4):99-111.
Whitton, A., Warner, R., and Appleby, L. (1996). The pathway to care in post-natal depression: Women’s attitudes to post-natal depression and its treatment. British Journal of General Practice. 46(408):427-428.
Williams, K.E., and Koran, L.M. (1997). Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum. J. Clin. Psychiatry. 58(7): 330-334.
Wisner, K.L., and Wheeler, S.B. (1994). Prevention of recurrent postpartum major depression. Hospital and Community Psychiatry. 45(12): 1191-1196.
Acknowledgements
This essay represents the views of the authors and not necessarily Postpartum Support International. Parts of the paper previously appeared in and article: Stern, Gwen and Laurence Kruckman, “Multi-Disciplinary Perspectives on Postpartum Depression: An Anthropological Critique,” Social Science and Medicine, Vol. 17, 15, pages 1027-1041, and a book chapter, “Rituals and Support: An Anthropological View of Postpartum Depression,” In James Hamilton and Patricia Harberger, Postpartum Psychiatric Illness, University of Pennsylvania Press, 1992, and a paper, “Rituals as Prevention,” presented at the 14th International Congress for Anthropological and Ethnological Sciences, College of William and Mary, July 1998.
Disclaimer
The above document is meant as a summary of research literature only. We are only stating what others have reported and we can not be responsible for their findings nor are we making any recommendations for treatment. We recommend that those suffering from postpartum illness seek care with a professional that is familiar with postpartum care.