Culture and Pregnancy-related Depression

Although the cultural aspects of the pregnancy-related period have been studied extensively worldwide, the impact of cultural factors upon pregnancy-related depression ( also known as postpartum depression) has been less investigated. Most research into pregnancy-related depression has been conducted in Western, developed countries (see reviews by Kumar, 1994; O’Hara & Swain, 1996) which does not account for a full range of different psychosocial experiences likely to be involved in childbirth worldwide. Thus, while mothers and family members in most cultures describe morbid unhappiness after childbirth comparable to pregnancy-related depression, not all people conceive of this “unhappiness” as an illness, as pregnancy-related, or as being remediable by health professionals( Oates, 2004). It is hardly surprising that studies viewing this specific mental health problem through a cross-cultural lens tend to yield opposing conclusions, especially when seeking to compare the prevalence of pregnancy-related depression in different cultural settings.

Pregnancy-related Depression as Defined by Western Medicine

According to the American Psychological Association, it’s common for women to experience the “baby blues” — feeling stressed, sad, anxious, lonely, tired or weepy — following their baby’s birth. But some women, up to 1 in 7, experience a much more serious mood disorder — pregnancy-related depression. Pregnancy-related depression is a complex and challenging disorder that often takes women and their families by surprise. Unlike the baby blues, this depression doesn’t go away on its own. It can appear days or even months after delivering a baby; it can last for many weeks or months if left untreated. Pregnancy-related depression can make it hard for new mothers to get through the day, and it can affect care of the baby. It can affect any woman—women with easy pregnancies or problem pregnancies, first-time mothers and mothers with one or more children, women who are married and women who are not, and regardless of income, age, race or ethnicity (“What is Postpartum Depression & Anxiety?” 2014).

A Family Problem

This mood disorder commonly leads to marital problems and affects the psychological health of the partner (Ballard & Davies, 1996). Adverse effects on the cognitive and social development of the infant are also a serious risk (Murray & Cooper, 2003). Mothers with pregnancy-related depression commonly have thoughts of harming their children or themselves and are less emotionally available to their children. Thus, their infants are at risk of being less securely attached (Hagen, 1999). Though this disorder is clinically defined as “non-psychotic depressive episodes beginning within 4 weeks after childbirth” this form of depression has adverse effects on maternal–infant interaction during the first year of life and beyond (Beck, 2002). For the mother, this depressive episode can be the precursor for recurrent depression, and for her children, a mother’s ongoing depression can contribute to emotional, behavioral, cognitive, and interpersonal problems later in life (Miller, 2002).

Situational Factors Relevant Across Cultures

Despite the many different ways culturally diverse women and families conceptualize, explain, and report symptoms of depression, research studies have nonetheless identified a morbid un-happiness after childbirth comparable to pregnancy-related depression in many cultures (Oates, 2004). Research studies have shown that certain maternal and situational factors increase the likelihood a woman will experience symptoms of depression after the birth of a child (Callister et al., 2010). When screening for pregnancy-related depression in private practice settings, it is important providers be aware of factors shown to increase the likelihood of this depression. IMPORTANT SITUATIONAL FACTORS • Pregnancy intendedness • Parity and maternal age • Relationships with partner/extended family • Incidence of partner violence • Education, income, immigrant/refugee status • Past history of depression and anxiety • Self-efficacy in managing infant/household • Perceptions of birth experience/trauma • Physiological factors such as sleep deprivation hormonal shifts

Some additional factors unique to particular cultures:

• Sadness about gender of baby (China, India, some Islamic societies) (Goldbort, 2006) • Delays/problems in naming ceremony (some African countries) (Bina, 2008) • 40 days/”doing the month” & similar traditional practices (cultures worldwide) Perceived Emotional and Practical Support is Essential to New Mothers The very nature of marriage, family, and kinship vary a great deal across different countries and cultures. There are striking variations in the support new mothers receive across cultures (Oates, 2004). However, research has consistently shown that the single greatest deterrent of depression after childbirth is the perception a woman has of being given sufficient emotional and practical support from her spouse and family. A new mother’s expectations for support from spouses and extended family are very much culturally-based; where the expectations on the part of the mother were not met, women with new babies were found to be at greater risk for pregnancy-related depression. In multiple studies, women who had poor relationships with their partners were at higher risk for pregnancy-related depression, and family conflict, in general, increased the risk for pregnancy-related depression.

The Role of Culturally-Based Pregnancy-related Recovery Traditions

Few Western countries, including the U.S., follow a specific tradition for the pregnancy-related recovery period to the extent that many other cultures in the world do. A culturally-proscribed recovery period goes by different names in different parts of the world, but is commonly referred to as doing the month. Called peiyue in China, purudu in India, ansei in Japan, la cuarentena in Mexico and many Latin American countries, this cultural practice prescribes a period of rest and dietary restrictions intended to help women recover from childbirth. New mothers are typically exempted from household chores and religious rites for a month to 40 days. In some traditions, there are bathing and clothing restrictions, special infant feeding practices, and rules about sexual abstinence. In most cultures, female relatives take on care of the new baby and older children during the mother’s childbirth recovery. “Doing the Month” Traditions May Alleviate or Contribute to Pregnancy-related Depression Culturally-based pregnancy-related recovery traditions are mentioned by women worldwide as being extremely important in creating a sense of happiness and well-being after childbirth. In most cases, the lack of these traditions contributes to post-natal depression. However, in some circumstances, research revealed these traditions can actually contribute to unhappiness for a woman.

• Women who are trying to adhere to these practices in modernized societies often find there is no practical way of observing these important traditions. Women may live far away from their mothers and other female relatives. Economic realities may force some woman to return to work – even physically demanding work.
• The emotional dissonance of wanting to follow the rest month but not being able to do so was mentioned as causing upset by participants in several research studies, especially by immigrants and refugees. Often overwhelmed with their responsibilities, women mentioned feeling as if they had failed to be a perfect mother and wife and therefore became depressed (Bina, 2008).
• A woman may be very fearful that ignoring traditional practices puts her infant and herself at great risk (Waugh, L. J., 2011).
• Conversely, some women did not want to follow the traditional customs their families and communities insisted upon. In these cases, the period of “required rest” contributed to post-natal unhappiness.
• New mothers sometimes experience the support of family members as being interference. A woman might, for example, feel sad if she is not allowed to hold her new infant except to nurse. In general, the acculturation process for immigrants and refugees is a contributing factor in pregnancy-related depression whenever a women finds herself trapped between different value systems. After birth, a mother undergoes a shift in her identity. Especially if it is her first birth, her experience of her “self” becomes “self-as-mother.” At this critical juncture, cultural confusion may trap her between two mirrors. Which cultural reflection is more real for her personally?

Relationship with Mother-in-Laws

In some cultures, it is traditional for a new mother to live with her in-laws while she is recuperating from child birth. Studies of women in several such cultures found that new mothers often demonstrated higher depressive symptoms when the mother-in-law served as the key helper. Heh and colleagues (2004) explored the association between depressive symptoms in the pregnancy-related period of Taiwanese women and the social support aspect of the traditional Chinese rite of “doing the month.” Overall, support from the social network reduced the risk of pregnancy-related depression, especially if the support came from a woman’s own parents. By contrast, women who stayed at their in-laws homes and had their mother in-law serve as their key helper demonstrated higher depressive symptoms. In a similar study, Lee (2000) explored women’s subjective perceptions of cultural traditions. This study examined the prevalence and risk factors of pregnancy-related depression among Hong Kong women, including the effects of traditional pregnancy-related customs and in-law relationships on the psychological well-being of pregnant women. The peiyue care was found to influence depressive symptoms by improving the psychological well-being of the women. “On the other hand, negative relationships with the mother-in-law as well as not receiving peiyue care in-creased depressive symptoms.” Danaci and colleagues (2002) investigated the epidemiological aspects and cultural factors that may affect pregnancy-related depression in Turkey. One result indicated that the mother’s unconstructive relationship with her in-laws had a negative impact on her pregnancy-related depression. In Turkish culture, a couple often lives together with the husband’s parents. “The findings of this study were striking in light of most other studies which found the pregnancy-related cultural traditional support (i.e., “doing the month”) to be an alleviating factor for pregnancy-related depression. One reason for this opposite conclusion may be that more than twice as many women in this study lived with their in-laws as opposed to those who lived with their own parents, and the negative impact of in-laws is well documented” (Danaci et al., 2002).

Different Pathways to Care

In all cultures, social support from partners and family especially, but also friends, is consistently mentioned in research studies as the single most important deterrent to pregnancy-related depression. Thus, when screening for pregnancy-related depression in private practice settings, it is important that providers pay close attention to family and social dynamics. (Note: Though across countries the remedies for pregnancy-related depression were to be found in social support from family, partners, and friends, only in the U.S. did research participants mention anti-depressants. (Oates et al., 2004) Women from outside the U.S. may be very resistant to being medicated for depression after childbirth.

Talk Therapy

Across cultures, women who were identified in research studies as suffering from depression after childbirth mentioned the importance of having someone to talk to. Keeping in mind that mothers and family members in many countries may not conceive of unhappiness after pregnancy as an illness, as pregnancy-related, or as being remediable by health professionals, mothers in many cultures did seek some source of “talk therapy” – often from health care professionals. These pathways to care were different in different countries. For example, in the UK and Ireland mothers often sought out health visitors and midwives when they needed to talk. In Japan, women mentioned seeking out the support they needed from pediatricians and obstetricians. In one UK study of women across European countries, including UK Asians, unsympathetic maternity staff with little time to talk were specifically mentioned as contributors to unhappiness (Oates et al, 2004). Clearly, though the support of partners and family is paramount in preventing pregnancy-related depression, the perception of caring among health care professionals is also extremely important. The birth of a child can be over-whelming, and any sense of isolation is extremely harmful to a new mother.

Comparing Across Cultures – How Different Is It From America?

• In Germany women see midwives for their prenatal care. In fact, midwives are so respected that by law a midwife must be present at every birth, and a doctor is optional. (Schalken, 2014)
• Most expectant moms in Holland don’t see an obstetrician, but are instead referred by their family doctor to a local midwife practice. Doctors only intervene in high-risk cases or if complications arise during delivery. If a mother gives birth early in the day without complications, she and the baby may go home in as little as two hours. Then the unique Dutch system of kraamhulp (maternity home care) is set into motion. In this practice, for seven days a nurse comes to the home, a benefit covered by insurance. Not only does she provide medical care, but she also cleans, cooks, and gives instruction in basic parenting skills. (Schalken, 2014)
• In Japan, after leaving the hospital, mother and baby often stay at the mother’s parents’ home for a month or sometimes longer — it is a cultural tradition that women stay in bed with their baby for 21 days. During this time friends may drop by to greet the new baby and join the family in eating the celebratory food osekihan (red rice with red beans). (Schalken, 2014)
• In turkey, mother and baby stay home for the first 20 days after the birth. Friends drop by and drink a special beverage called lohusa serbeti. After this period, the mother and child make re-turn visits to gift-givers’ homes, where they receive a handkerchief filled with a single egg (for a healthy baby) and candy (for a good-natured baby). They also rub flour on the baby’s eyebrows and hairline, which is supposed to grant him a long life. (Schalken, 2014)

Summary/Key Points for Providers

Pay very close attention to family dynamics. In no situation can it be more crucial to find out:

• Who is living in the immediate household (is the mom with her own parents or her in-laws)
• Who is giving her the most support/advice after the new birth?
• Is she following any cultural traditions akin to “doing the month?” Show an interest in these!

As with any conversation about mental health in cross-cultural encounters, frame the problem and solution in the context of “family.” Baby blues affect the whole family. Be aware that the very concept of depression may not apply in non-western cultures and it is very ethnocentric to lack awareness of this key fact. Women from other cultures may be able to talk in terms of “unhappiness” after giving birth, but will not see this as:

• An illness
• Pregnancy–related
• Solvable by a health professional
• They may see this unhappiness as:
• A failure to be a perfect mother and wife
• Related to problems with “doing the 40 days”
• Related to interference from in-laws/mother-in-laws especially (this may be difficult to discuss in front of family however.)