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The Role of Social Isolation as a Predetermining Factor for Postpartum Depression Development: A Literature Review

By

Caroline-Grace Hawes

Senior Honors Thesis School of Nursing

University of North Carolina at Chapel Hill

April 14, 2020

Approved:

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Abstract

Postpartum depression is a globally prevalent, widespread issue among women following childbirth that primarily causes severe, distressing reverberations in the mother. Additionally, these afflictions endured by the mother can further impact the infant, spouse, and other individuals in the household. Research has identified numerous risk factors for postpartum depression; however, the role of social isolation in the development of postpartum depression is underrepresented in literature. The purpose of this literature review is to identify the role of social isolation as a predetermining factor for the development of postpartum depression. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to conduct and guide a systematic search of available literature. A total of 22 articles that were specific to the development of postpartum depression and that primarily focused on social isolation in regard to development of postpartum depression were included for review. After a thorough review of the literature, four key themes emerged. The four key themes identified included a lack of support, individuals or groups who have commonly become

marginalized or isolated in society (i.e. immigrants, refugees, etc.), a loss of identity, and the fear of being an unfit mother. These themes correlated directly with the relationship of social

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The Role of Social Isolation as a Predetermining Factor for Postpartum Depression Development: A Literature Review

Introduction

Postpartum depression among mothers following childbirth is a globally prevalent, widespread issue. In 2018, research conducted by the Center for Disease Control (2020), estimated that postpartum depression affects one in nine women nationally. According to the National Institute of Mental Health (2020), postpartum depression can be defined as a mood disorder affecting women after childbirth, causing mothers to experience feelings of extreme sadness, anxiety, and exhaustion, making it difficult to complete daily activities for both themselves and for others. Up to 80% of women following childbirth experience at least some symptoms of what is referred to as “baby blues.” “Baby blues” is defined by The National Institute of Mental Health (2020) as “short-term dips in mood caused by all of the changes that come with a new baby” (para. 3). The short-term diminishments in mood are commonly attributed to changes in hormone levels following delivery, in combination with isolation, increased levels of stress, sleep deprivation, and fatigue. Women experiencing “baby blues” commonly report feeling tearful, overwhelmed, and/or emotionally fragile within the first few days following delivery (NIMH, 2020). “Baby blues” typically peak around one week of

postpartum and normally taper off by the end of the second week. Postpartum depression differs from “baby blues” in severity and lasting a longer time period (NIMH, 2020).

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irritability (Smith & Segal, 2019). While “baby blues” typically taper off by the end of the second week following delivery, postpartum depression symptoms continue and increase in severity. These symptoms can include an inability to care for the newborn, withdrawal or distance from their partner, an inability to properly bond with their newborn, extreme anxiety, insomnia, poor nutrition due to the inability to eat, feelings of guilt or worthlessness, and suicidal thoughts or ideations (Smith & Segal, 2019). All of these symptoms are considered warning signs or alarming indicators for postpartum depression.

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developing into a chronic depressive disorder (D’Amelio et al., 2006). Additionally, postpartum depression can influence and affect the mother’s ability to parent due to inadequate levels of energy, difficulty focusing on the baby’s needs in addition to their own, inability to properly care for her baby, and having suicidal thoughts or ideations (March of Dimes, 2019). Furthermore, postpartum depression can have a dispersion effect, causing an emotional strain with anyone close to the baby. The spouse of a new mother with postpartum depression also has an increased risk of developing depression (Mayo Clinic, 2018).

In addition to the complications experienced by mothers and those close to the baby, postpartum depression can also have a significant impact on the newborn. Many of these complications and impacts can be avoided if postpartum depression is addressed early and treated promptly (March of Dimes, 2019). If postpartum depression is left untreated, mothers may skip their postpartum checkups and/or regular well-baby visits, or they may not follow instructions from the healthcare provider regarding care for the newborn. This can lead to the infant not receiving necessary medical care and places the newborn at risk for experiencing adverse health effects. It can also cause interferences with newborn-mother bonding and cause difficulties with breastfeeding (March of Dimes, 2019). Researchers also have a widespread belief that postpartum depression can have long-term effects throughout childhood for the newborn. The possible long-term effects include a delay in language development, behavioral problems, complications with mother-child bonding, experience of increased crying or agitation, learning difficulties, troubles dealing with stress, and difficulty adjusting in school or other social situations (Mayo Clinic, 2018).

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include the absence of emotional, practical, or social support (NIMH, 2020). Social isolation can be defined as “a state in which the individual lacks a sense of belonging socially, engagement with others, has a minimal number of contacts, and they are deficient in fulfilling and quality relationships” (Nicholson, 2012, p. 137). The role of social isolation in the development of postpartum depression is underrepresented in literature with no current systematic reviews available. In addition, it is particularly important to look further into the role of social isolation and its effects following childbirth given the current state of affairs. Amidst the current global COVID-19 pandemic, several precautionary measures have been instituted. These interim actions include substantial safety precautions, implementation of stringent hospital visitation policies, closure or limited operations of several supportive services, social distancing or

isolation, and quarantine upon possible exposure. These interim actions have heightened the risk of developing postpartum depression among laboring mothers and those who have recently given birth (Lieshout, 2020). The purpose of this literature review is to examine the role of social isolation as a predetermining factor for the development of postpartum depression.

Methods

This literature review was conducted and guided by a systematic search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The aim of this literature review was to gather a comprehensive collection of published studies and literature reviews exploring the role of social isolation as a predetermining factor for the development of postpartum depression. Articles were selected from searches conducted on PubMED, CINAHL, and PsychINFO databases. The preliminary search terms included

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articles, with 97 being from PubMED, 63 from CINAHL, and 68 from PsychINFO. For the purpose of this literature review, inclusion criteria were created for selection of pertinent articles. The criteria included written in English language, specific to development of postpartum

depression, and a primary focus on social isolation with regard to the development of postpartum depression. Based on this criterion and the removal of duplicate articles, 157 articles were included to be utilized for this review. After further review, a total of 22 articles were included for examination. These articles include eight qualitative studies, five cross-sectional studies, four randomized controlled trials, two quantitative studies, two longitudinal studies, and one meta-data analysis.

Results

A synthesized table of the 22 articles studied are displayed in Table 1. These articles

focused on unique aspects and effects of isolation in postpartum women that led them to develop or experience symptoms of postpartum depression. From these articles, four key themes emerged that significantly influenced social isolation in the postpartum period for women. The themes found included a lack of support, being an immigrant, loss of identity, and fear of being an unfit mother. In this section, the four main themes will be examined as predetermining factors for development of postpartum depression.

Lack of Support

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2017; Barclay & Kent, 1998; Eastwood et al., 2013; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014; Lumley et al., 2006; Mauthner, 2002; Ward, 2014).

Immigrant

Immigrants experience a wide range of variables that have been linked with the experience or diagnosis of postpartum depression. One of the most influential variables found was suffering in isolation. Eleven studies examined how refugee, migrant, or immigrant new mothers experience postpartum depression (Eastwood et al., 2012b; Tobin et al., 2018; Ahmed et al., 2008; Dennis et al., 2009; Alhasanat et al., 2017; Barclay & Kent, 1998; Eastwood et al., 2013; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014; Ward, 2014). Of those studies, nine reported lack of social support due to a lack of proximity from family members and friends as being a significant factor for their experience of postpartum depression (Eastwood et al., 2012b; Tobin et al., 2018; Ahmed et al., 2008; Alhasanat et al., 2017; Eastwood et al., 2013; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014; Ward, 2014).

Another major theme found was suffering in solitude (Tobin et al., 2018). One article recognized this pervasive sadness new mothers experienced being significantly impacted by their lack of social support. This sadness was further exacerbated by the “loss of a safe and secure family network” due to distance between them (Tobin et al., 2018, p. 1). Another study reported a lack of practical support being a recurrent theme among their participants (Gardner et al., 2013).

Six of the 11 studies reviewed reported cultural differences in their new place of living as being a precursor to postpartum depression (Tobin et al., 2018; Ahmed et al., 2008; Alhasanat et al., 2017; Barclay & Kent, 1998; Gardner et al., 2013; Ward, 2014). Cultural differences

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provided in Africa as opposed to the United Kingdom was discussed. In Africa, family members assisted with household chores, caring for the newborn, and helping cook for the new mom, which alleviated the stress and pressure being placed on this new mother (Gardner et al., 2013). Another study emphasized the feelings of postpartum depression among Arabic immigrants being intensified by their deprivation of traditional post-birth cultural practices. In Arabic culture, after birth, there is a forty-day postpartum recovery period that is a cultural norm (Alhasanat et al., 2017).

Another widely experienced factor described within these eleven studies was barriers to formal support (Eastwood et al., 2012b; Tobin et al., 2018; Ahmed et al., 2008; Barclay & Kent, 1998; Eastwood et al., 2013; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014). Access to support services was complicated by a lack of language proficiency within their new country of living (Tobin et al., 2018). Barriers to support were further manifested by immigrant mothers’ lack of knowledge about how the health system operates in their new country. This lack of knowledge is worsened by new mothers’ fears of stigmatization and the potential possibility of their newborn being taken into care by the state (Ahmed et al., 2008; Alhasanat et al., 2017; Eastwood et al., 2013; Hanley & Long, 2006; Ward, 2014).

Loss of Identity

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for feeling this loss of identity can be attributed to many women caring for their newborn without any additional help along with keeping up basic everyday tasks, including household chores, cooking, etc. (Ahmed et al., 2008; Barclay & Kent, 1998; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014; Naphas & Amasheh, 1999). Without the help from a spouse, extended family, and/or close friends during the day, new mothers found motherhood to be extremely overwhelming and intimidating, which further exacerbated feelings of loneliness. This lack of help also contributes to exhaustion experienced by mothers. This exhaustion is caused by the mothers’ lack of sleep, the demands of caring for a newborn, and the disruptions in a newborn’s sleeping schedule (Eastwood et al., 2013). One study described this combination of feelings as “the superhuman demands of dealing with a new, frighteningly small human being without help and limited, or no previous experience, compounds the physical exhaustion” (Barclay & Kent, 1998, p. 6). These new mothers often “yearn for old familiar routines before the baby was first born”, and they find themselves mourning the loss of the person they once were, which further increases the risk of experiencing postpartum depression (Gardner et al., 2013, p. 760).

Fear of being an unfit mother

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being clean and with all the chores performed by the new mom, and her husband is the only other one involved in the care of this healthy newborn. Though this image is broadcasted to the world, it is inaccurate and fails to represent the reality of bringing home a newborn. When a new mother does not fit this glamorized image of motherhood or fails to have a smooth adjustment to motherhood, our society is quick to assume there is a problem on her behalf. Society is quick to label the mother as a “misfit mother”, as if this new mother could have prevented the

development of postpartum depression. (Barclay & Kent, 1998, p. 7). This label of being a “misfit mother” contributes to the stigmatisms around postpartum depression, which creates fear among many mothers. All nine of the articles identified this fear of failure as a mother and not living up to expectations of society as a significant barrier to seeking help from their healthcare provider (Tobin et al., 2018; Knudson-Martin & Silverstein, 2009; Ahmed et al., 2008; Alhasanat et al., 2017; Barclay & Kent, 1998; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014; Naphas & Amasheh, 1999).

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depression (Tobin et al., 2018; Knudson-Martin & Silverstein, 2009; Ahmed et al., 2008; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014). Two articles documented that some mothers’ failure to seek help was attributed to the idea that “this was a condition that happened to other women” (Hanley & Long, 2006, p. 151).This idea caused them to have reluctance in talking openly about their personal struggles with new motherhood (Alhasanat et al., 2017; Hanley & Long, 2006). Many mothers failed to seek help due to embarrassment, which contributed further to their postpartum depression (Tobin et al., 2018; Knudson-Martin &

Silverstein, 2009; Ahmed et al., 2008; Hanley & Long, 2006; Kathree et al., 2014).

Discussion

After a thorough review of the literature, four key themes emerged from the articles researched. These four key themes correlated directly with the role of social isolation and its relationship of being a predetermining factor for the development of postpartum depression. The four key themes studied included lack of support, individuals or groups who have commonly become marginalized or isolated in society (i.e. immigrants, refugees, etc.), the loss of identity, and the fear of being an unfit mother.

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2006; Shorey et. al., 2018; Zaidi et al., 2017; Kerstis et al., 2016). Though the EPDS is very beneficial in diagnosing these mothers, there are varying opinions on when the questionnaire should be performed. Further research needs to be done in order to determine the optimal time for screening individuals at risk for postpartum depression in relation to social isolation. Additionally, research has supported the use of a phone call intervention program during the postpartum period to mothers who recently gave birth. Telephone-based support intervention programs have been used as an additional resource for support with these mothers at risk for postpartum depression due to social isolation individuals (Denis, 2003; Dennis et al., 2009; Shorey et. al., 2018). Upon feedback on these programs, many mothers voiced that they preferred to have individuals calling them who had been through postpartum depression or a very similar experience themselves, which was helpful in allowing them to fully relate to what that mother was currently going through. Similar to the EPDS, the phone call intervention programs need additional research to determine the ideal time to begin the program and the time frame for how long the program should continue (Denis, 2003). Another suggested intervention for clinical practice includes the implementation of support groups within the community for mothers in the postpartum period to share their experiences and feelings. Several of the articles reinforced that many women following birth found it extremely helpful to talk to others who are or had been in similar situations. This provides these mothers with reassurance that they are not alone in the feelings they are experiencing (Ahmed et al., 2008).

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Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014; Lumley et al., 2006; Mauthner, 2002; Naphas & Amasheh, 1999; Shorey et. al., 2018; Ward, 2014; Zaidi et al., 2017; Kerstis et al., 2016). Some studies focused on specific cultures or individuals from specific backgrounds (Eastwood et al., 2012b; Denis, 2003; Tobin et al., 2018; Ahmed et al., 2008; Alhasanat et al., 2017; Barclay & Kent, 1998; Eastwood et al., 2013; Gardner et al., 2013; Hanley & Long, 2006; Kathree et al., 2014; Naphas & Amasheh, 1999; Ward, 2014). The translation of these findings may differ. Another limitation in this review of research is that there were several articles used that had small sample sizes, which could affect the validity and reliability of the study’s findings. In one of the studies reviewed, a set of individuals was included in the study even though they violated the participant study requirements (Kerstis et al., 2016). This could have caused the results to be biased. The findings of the study may have also been influenced by the lack of blinding to the type of support the patients were receiving (Eastwood et al., 2013).

Conclusion

Social isolation can play a significant role in the postpartum period and has been

identified as a substantial risk factor for the development of postpartum depression. This review has identified major themes and a number of methods to be used within future studies for the evaluation of social isolation as a predetermining factor for postpartum depression. While many studies have shown that social isolation has an impact on the development of postpartum

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[ISRCTN03464021]. BMC Public Health, 6, 37. https://doi.org/10.1186/1471-2458-6-37 Mauthner, N. S. (2002). Postnatal depression the significance of social contacts between

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Shorey, S., Chee, C., Chong, Y. S., Ng, E. D., Lau, Y., & Dennis, C. L. (2018). Evaluation of technology-based peer support intervention program for preventing postnatal depression: Protocol for a randomized controlled trial. JMIR ResearchProtocols, 7(3), e81.

https://doi.org/10.2196/resprot.9416

Smith, M., & Segal, J. (2019). Postpartum Depression and the Baby Blues. Retrieved from https://www.helpguide.org/articles/depression/postpartum-depression-and-the-baby-blues.htm

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Ward, C. (2014). Migrant mothers & the role of social support when child rearing.

Contemporary Nurse, 16(1-2), 74-85. https://doi.org/10.5172/conu.16.1-2.74

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Figure 1. PRISMA Diagram

Full-text articles excluded due to not meeting inclusion criteria

(n = 22)

Studies included in qualitative synthesis

(n = 22)

Full-text articles assessed for eligibility

(n = 44)

Records excluded (n = 66) Records screened

(n = 110)

Records after duplicates removed (n = 157)

Additional records identified through other sources

(n = 0) Records identified through database

searching (n = 228)

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Table 1. Included Manuscripts

Author Sample

Characteristics Study Design/Level of evidence

Variables/Measures Major Findings

Ahmed et

al., 2008 10 Refugee, asylum seeking, non-refugee, & immigrant new mothers with depressive symptoms who scored > 10 on EPDS

Qualitative Study - EPDS for

depressive symptoms - Semi-structured interviews which were taped, transcribed, & analyzed using a constant comparative approach

- Social isolation, as well as not having enough time to spend on oneself or with other family members, was identified as an important cause of depression

- Immigrant women appear to

attribute the experience of PP sadness & depression to many of the same reasons as

non-immigrant women, but their situation is made more difficult due to lack of proximity to informal support systems (family), & barriers to formal support due to lack of knowledge or language proficiency

Alhasanat , et al., 2017

50 women were recruited from an Arab community center for Economic & Social Services at the Women, Infants, & Children (WIC) program office in Dearborn, Michigan. Cross-sectional descriptive feasibility study - Demographic data collected - EPDS - Postpartum Depression Predictors Inventory-Revised (PDPI-R)

- Significantly related factors for PPD included cultural differences and social support.

- The strongest predictor for PPD

found in the study was the lack of social support.

- 36% of study sample reported

being at high risk for PPD with the EPDS. & 46% when assessed with the PDPI-R Barclay et al., 1998 This article follows an earlier discussion paper by these authors, that outlined high rates of misery exp.by most West. New mothers today are socially & culturally induced. This paper aimed to look into how Non-English Speaking Background

Review - EPDS is being

proposed as a screening tool for PPD among women with non-English speaking background women & all new moms in general

- Solution to the problem of these

women’s unhappiness/PPD as a new mother lies, in the family, community, & social networks they no longer have & find hard, if not impossible, to recreate

- Broad-based approaches that

address social isolation, women’s employment & child care, equity in partnerships where this is culturally possible/acceptable, & shared responsibility for parenting & household chores are needed by all families  no women should have to enter motherhood alone

- Need alternate images of new

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(NESB) women find the transition into motherhood in Western Society.

create realistic expectations & allow women/families to react to changes in their lives without being labeled as ‘depressed’

Dennis,

2003 42 mothers in British Columbia identified as high risk for PPD based on the Edinburgh Postnatal Depression Scale (EPDS).

Pilot randomized

controlled trial - Depressive symptoms determined by EPDS

- Maternal

self-esteem with the Rosenburg Self-Esteem Scale (SES) - Child-care stress, maternal loneliness, maternal perceptions of peer support, and peer volunteers’ perceptions of peer support.

- Peer-support intervention

significantly decreased depressive symptomatology at the 8-week. assessment.

- Mothers who received the

peer-support intervention were over 4x more likely to have decreased depressive symptoms compared to control.

- Telephone-based peer support may

significantly decrease depressive symptomology among some mothers

Dennis et al., 2009

Women were recruited from 7 large health regions & their corresponding public health departments across Ontario, Canada who were identified as high risk for PPD with their EPDS score (> 9 on EPDS)

Multisite randomized controlled trial

Intervention group = has access to all standard PP care in addition to being matched with a peer volunteer & receiving a telephone contact intervention

- EPDS for

depressive symptoms - State-trait anxiety inventory, the short version UCLA loneliness scale, & the health service utilization

- Indicated significant difference in the proportion of PPD between groups from baseline to 12 weeks.

- Women in the intervention group

were significantly less likely to have symptoms of PPD at 12 week. assessment compared to those in the control group

- Results suggested women who

received the peer support intervention were at ½ the risk of developing PPD at 12 weeks. PP than those in the control group

- There were no significant finding

at 24 weeks. Between intervention & control group

Eastwood et al., 2012a

Mothers of infants born in South Western Sydney Area Health Service (SWSAHS) from 2002 – 2003

Population-based cross-sectional study

- EPDS for

depressive symptoms

- Utilized the

Ingleburn Baby Information System (IBIS) database.

- Strong association between lack of

support & maternal depressive symptoms

- Poverty & isolation identified as independent risk factors for maternal depressive symptoms

- Support the proposition that social

exclusion & social isolation are important determinants of maternal depression

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et al.,

2012b newborn infantsborn in Western Sydney Area Health Services (SWSAHS) from 2002-2003 cross-sectional

study (initiated in 1995; based on

the routine survey given out by SWSAHS too mothers who attended a 1st “well-baby” check at the clinic)

- Edinburgh

Postnatal Depression Scale (EPDS).

significant correlation with maternal depressive symptoms after birth  maternal

responsiveness, infant behavior, social exclusion, migrant social isolation, & family size

- Findings suggest that priority

should be given to providing support to mothers during pregnancy & after childbirth

Eastwood

et al., 2013 Migrant mothers delivering in 2002-2003 in South West Sydney, New South Wales, Australia

This article is part of an exploratory population-based cross-sectional study that researched aggregated rates of self-reported PPD symptoms in South Western Sydney Area Health Services from 2002-2003

- Binary outcome

variable = EPDS of > 9 or > 12  included under Ingleburn Baby Info. System (IBIS) – survey containing 45 items, both clinical (ex. Wt.) & parental-self report in nature

- Domains

assessed as measure at the suburb level = social networks, capital & cohesion; “depressed community,” health behaviors, access to services & ethnic segregation or integration

- Migrant moms were at higher risk

of having depressive symptoms if they were living in predominantly Australian-born disadvantaged community, with strong bonding/social network social capital  These findings suggest that migrant moms are socially isolated in these communities

- South West. Sydney region has a #

of multicultural home visiting services  implication of finding = multicultural home visiting support is also required for migrant moms living in more communities where they may have poor social networks

Evans et al., 2012

Total # of articles evaluated = 30

Criteria = examining optimism & PPD

12 review & 18 original research articles

- Framework used

to evaluate methodology of articles in review based on Polit & Beck’s hierarchy of research evidence

- Most common risk factors for

depressive symptoms during pregnancy = anxiety, perceived life stress, Hx of depression, lack of social support, unwanted pregnancy, low income, domestic violence, lack of education, smoking, & single marital status

- Lack of social support or

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as a dominant item among women who reported feeling depressed during & after pregnancy

- Evidence supports relationship

between optimism & depression as being a potent mitigating factor that might offset negative effects of stress or low social support, thereby, decreasing women’s risk for depression

- Optimism is a culturally

acceptable, easily accessible, & effective way to protect against development of depression during & after pregnancy

Gardner et al., 2014

6 West African moms (Nigeria = 3; Ghana = 3), who were experiencing low mood in the postnatal period

Manchester, England

Qualitative design - EPDS assess for

depressive symptoms

- SCID to assess

for depressive symptoms

- Semi-structured

interviews

-- Experiences of distress were

described through themes of isolation, a loss of identity, and issues of trust

- Relationships identified as a

protective factor

- Described PPD as largely d/t a

product of social stress  lack of practical & emotional support & on dysfunctional/difficult relationships

- Findings suggest that lack of

support & relationship difficulties have been found to be risk factors for PPD in general, in African women & other migrant cultures living in the UK

Knudson-Martin et al., 2009 Consisted of research reports from 9 studied published between 1999 & 2005  included women from. 7 European countries, Japan, Hong Kong, India, Uganda, & the United States

Meta-data-analysis of previous qualitative studies

Used 5 search engines to find the studies  Academic Search Premier, PsycInfo, PsychArticles, Health Source: Nursing/Academic , & Alt

HealthWatch

- Used a

systematic coding process to compare & contrast the experience of PPD in many different contexts & identify the relational processes involved

- Identified a common set of

relational processes within which PPD occurs

- PPD is experienced as a

cumulative struggle in which expressing negative feelings is not congruent with social

constructions of motherhood

- From study to study, they found

that though feelings of anxiety preceded PPD, it was the feelings of disconnection that appeared to precipitate & maintain the depression Hanleey et al., 2006 10 mothers participated in the study Wales

Qualitative - Case-study

method was chosen for this study

- Mothers were

interviewed in

- 9 distinct themes emerged =

previous knowledge of PPD, early traumatic life events,

(27)

great depth using a loosely structured format

relationships, support systems, valued experiences, prevention & lifestyles

- To some extent, PPD is a

consequence of social

deterioration rather than a purely physical reaction to motherhood

- Many moms are unable to cope

with the undue stresses & expectations of society

Kathree et al., 2014

This study was conducted in a community health Centre (CHC) in North West Province

53 women were screened over 2 months. The following criteria was used for participation: women greater than 18 years old, no previous diagnosis with depression, and had given birth to a live infant who was at the time of the study between 6 wks. & 12 m/o.

Of the 53 women screened, 20 women screened positive for postnatal depression

Qualitative - In-depth

face-to-face interviews, follow-up interviews & observations of participants in the home environment was adopted - Kleinman’s concept of explanatory models of illness was used to guide the interviews

- Focused

ethnography

- Key subthemes with causes of

depression included poverty & dependence, partner conflicts, unwanted pregnancies, and exacerbating factors

- Participants generally described

their experiences of depression as being the result of adverse circumstances & life events that caused feelings of pain & sadness

- Individual’s personal experiences

of social & economic factors may precipitate or exacerbate

depression Kerstis et al., 2016 Participants were Swedish-speaking parents of children born in the yrs. 2004-2006 from 8 Child Health Centers (CHCs)

Longitudinal

cohort study - EPDS with the cutoff point > 10 used

- Sense of

Coherence (SOC) – used Instrument SOC-3

- Swedish

Parenthood

- EPDS score was significantly

higher for the moms than fathers 3 months after childbirth with an

18% of mom’s with EPDS  10

- Results indicated that nearly 25%

of the children had at least 1 parent with depressive symptoms

- Mom’s estimated higher total

(28)

401 mothers & 396 fathers (393 couples) were included Vastmanland, Sweden Stress Questionnaire (SPSSQ) = measures parental stress & consists of 34 items with 5 sub-areas

- A baseline

questionnaire, 3 m/o

questionnaire, & 18 m/o

questionnaire were filled put by pt. and returned via mail to CHC.

- Parents were

informed that it was important to complete the questionnaires individually

- Both parents had their highest

level of stress in “role restriction” sub-area

- moms perceived higher levels of

stress than the fathers did in all sub-areas except for ‘social isolation,’ where the fathers perceived higher stress

- Social support (contact with

friends or relatives) had a + effect on SOC, therefore maintaining contact with friends & relatives can be important for new parents - Both mothers & fathers should

receive support & guidance during pregnancy & while bringing up their children to optimize the conditions for raising the child

Lumley et al., 2006

16 rural & metropolitan communities in Victoria, Australia were pair-matched & participated Cluster

randomized trial - Postal questionnaires mailed 6 m/o after birth to women giving birth from 07/02/00-05/08-01

- EPDS to assess

women’s health & well-being at 6 m/o

- PRISM drew on

social ecological theory with program development around existing high impact ‘leverage points’, encouraging both person-centered & environment-centered change

-- At 6 m/o, there was no imbalance

in major covariates between the 2 arms

- Women’s mental health or

physical health scores were not significantly different in the intervention & the comparison arm

- There was a real but small impact

on GPs taking part in educational programs

Mauthner ,

1995

40 mothers of young children living in England

Qualitative study - Semi structured,

in depth interviews

- “Voice-centered

- Study confirms that mothers’

(29)

18 of the 40 mothers experienced what they termed PPD relational method” was used to analyze the interview material from mothers in the study

nature of the many different relationships in which they are involved

- 2/3 explained that the most

valuable type of help they either wanted or received was to talk to another mother about their feelings.

- Honest friendships in which

mothers feel they can be open with each other can enable women to resist cultural norms of

motherhood & thereby prevent or overcome depression

- Self-help groups & befriending schemes, which allows mothers to share their experiences with each other, are very valuable

Nahas et

al., 1999 Setting = Western Sydney area in Australia

22 Jordanian Australian women were purposely selected with 9 key informants & 13 general informants

Ethnonursing research method – naturalistic, holistic, inductive, & qualitative research - Researchers evaluated themes & other findings by using Leininger’s 6 criteria for evaluating qualitative data

- Interviews with

informants were conducted in either English or Arabic

- 3 major themes were formulated

that focused on the care meanings & expression of PPD among Jordanian Australian women

1. Care means carrying & fulfilling traditional gender roles as mother & wife

2. Care means strong family support & kindship ties during the postpartum period

3. Care is preservation of the Jordanian

childbearing customs as expressed in the

celebration of birth of the baby

- Factors influencing the

phenomenon of PPD are culturally situated & vary

- Family support & ties is essential & evident to help support the woman after birth to prevent feelings of loneliness & failure as a mother Rauccio et al., 2006 222 pregnant women between 28 – 40 weeks. of gestation

Exploratory Study

Investigated the role of the gynecologist in trying to predict PPD

- Submission of a

questionnaire based on the EPDS

- Results = 28.4% of the pt.’s

resulted + to the test (EPDS score > 12)

- Gynecologists must have a role in

helping to achieve an early diagnosis of the depression

Shorey et al.,

21 y/o or older can speak &

Randomized controlled, single

- Intervention

group receiving

- Results were not yet available to

(30)

2018 read English, own a

telephone & are willing to share their #, plan to stay in Singapore for the 1st 3 m/o post childbirth

73 new mothers were recruited, with 36 in the control group & 37 in the intervention group blinded experimental design Mothers were randomly allocated to 2 groups 1. Control group

= receiving only routine perinatal care from the hospital 2. Intervention group = receiving the peer support intervention & routine perinatal care from the hospital

the peer support intervention program & routine perinatal care from the hospital

- EPDS

- Pt. health

questionnaire = 9 item

questionnaire extracted from the full PHQ used to diagnose & measure the severity of major depression

- State Trait

anxiety inventory

- University of

California, LA Loneliness Scale

- Perceived social

support for parenting

-- Data collection continued past

publication

Tobin et al., 2017

Key words were used on each database, incl. = PPD, refugee & immigrant women, postnatal depression, experience of PPD, perceptions of PPD

36 articles were retrieved Of the articles found, 13 qualitative studies meet the inclusion criteria

A search of online databases was conducted, including the use of the following databases: CINAHL, MEDLINE, PsycINFO, Social Science Citation index, & PUBMed

- A systematic

comparison of the 13 qualitative studies that were utilized in this meta-synthesis

- Main goal with

this study - acknowledge our belief in the importance of effective screening, early detection, & treatment of PPD in order to minimize the harmful effects of this disease on the women & heir family

- Resulted in the emergence of 5

major themes that represent refugee & immigrant women’s experiences & perceptions of PPD & the perceived barriers & facilitators to help seeking 1. Suffering in solitude** 2. The invisible illness 3. Cultural conceptualizations 4. Barriers to help seeking 5. Facilitators of help seeking

Ward,

2003 93 women fromthe UK who relocated to

Cross-sectional

design - Semi-structured interviews

- 10-part

- Of the 40 women interviewed, 24

(31)

Australia Women were accepted as participants if they were born & grew up in the UK and had children

questionnaire was used to collect

quantitative data

with childrearing following migration

- 18 mentioned lack of support

when childrearing & over ½ of the 40 participants stated they were missing their mother or family in their homeland

- Lack of adequate social support,

life events, & financial stress are factors linked to depressive states following childbirth

- Lack of a positive support system

following childbirth was psychologically detrimental to some of the women

- The other participants who were

not diagnosed with PPD

mentioned that they felt they had suffered some of the symptoms of PPD Zaidi et al., 2017 149 antenatal women who completed the follow up screening for PPD at 6 weeks

Delhi

Longitudinal study - Kuppuswamy

Socio-Economic Status Scale - EPDS - Presumptive Stressful Life Event Scale (PSLES)

- Rosenberg Self

Esteem Scale (RSES

- De Jong

Gierveld Loneliness Scale - Questionnaires were given during antenatal & postnatal visits in the OPD & in the postnatal wards after delivery between 2nd 5tth PP day

- Previous stressful life events, loneliness, & low self-esteem were found to be significant precursors to PPD

- Low mean score of self-esteem & higher % of loneliness among depressed postnatal women

- Significant association between

young maternal age & birth of female child with developing PPD

- At 1st visit, 12.3% women scored

10 or more on EPDS. 2nd visit, 12.12% scored more than 10 on EPDS. Final screening at 6 weeks., depression was found in 12.75% of subjects

Figure

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