Objectives: Postnatal depression (PPD) is a common health problem and it affects postpartum women. This is a brief note on its associated factors in women from different cultures.
Method: The literature review includes articles from MEDLINE, and Pubmed from 1991 to 2008. Additional articles and book chapters were referenced from these sources.
Results: The prevalence of postpartum depression reported 0.5% - 60% in the world, and in Asian countries ranged from 3.5% to 63.3% where Malaysia and Pakistan had the lowest and highest, respectively. One of the factors contributing to PPD in Asian societies may be that women may not have the empowerment to reject traditional rituals that imposed on them by their caregivers. Unsatisfactory pre-existing relationships between the mothers and their caregivers resulting in mothers experiencing difficulties during their confinement period may be another factor. Thirdly, some features of these traditional rituals, mainly the restricted practices, may be the cause tension, stress and disturbance. Finally, inevitable conflicts existing in the postpartum situation may sometimes disagree with the traditional rituals and therefore causes mothers mental and emotional breakdown.
What you wrote is different: Finally, conflicting psychological states caused by insistence on practice of traditional rituals existing in during the postpartum period may lead to mental and emotional breakdown
Conclusions: Health care professionals should be aware that the phenomenon is as prevalent in Asian cultures as in European cultures. Moreover, still further investigation needs to be done on about the global prevalence of childbearing women's experiences with depressive symptomatology.
Keywords: Postpartum depression; Risk factors; cultures
Article Outline
Introduction
Prevalence of postpartum depression
Culture element and postpartum depression
Recent changes of postpartum depression prevalence
Cultural elements in traditional societies
Conclusion
Introduction
Over the past four decades, many studies have emphasized on mood disorders after childbirth (Lusskin, Pundiak, and Habib., 2007).
Postpartum depression (PPD) is more frequent in women than thought otherwise (Clay, and Seehusen., 2004). Unfortunately, little attention has been paid to PPD in terms of identification, diagnosis, and treatment (Alici-Evcimen et al., 2003). Mothers at risk are seldom identified during pregnancy or at the delivery time (Nielsen. F et al., 2000 ). This occurs especially in developing countries where psychological issues are mostly ignored (Halbreich and Karkun., 2006). It should be noted that up to 80% of cases do not seek medical attention and thus are not diagnosed by respective specialists (Kelly et al., 2001).
Cultural dimensions play a significant role in the perception and experience of motherhood in variety of cultures. The diversity of prevalence of postpartum depression across the cultures help researchers to understand whether this disorder is primarily brought on by psychological or biological factors (Hoefliger, 2003).
Prevalence of postpartum depression:
Recently there appears to be a growing international recognition of postnatal depression as a significant public health concern (Oates. M. R et al., 2004). It has been noted that postnatal depression, particularly in western countries affect10-15% of postpartum women (O'Hara & Swain, 1996; Beck, 2001), but many researches and epidemiological studies have recognized the occurrence of increasingly high incidence of postpartum depression in diverse cultures in different parts of the world (Rahman et al., 2003). In a review by Halbreich and Karkun. (2006), of 140 past and related studies in 40 countries indicates, the reported frequency of PPD varied among countries between 0.5% to over 60%. These studies revealed that in some societies, namely, Singapore, Malta, Denmark, and Malaysia, the prevalence of PPD is quite low (0.5-9%), while, in other countries such as Guyana, Costa Rica, Italy, Chile, South Africa, Korea and, and Taiwan, PPD is very common (34-57.0%).
Halbreich and Karkun.(2006), reported frequency of PPD of 10-15% is unlikely to be an accurate global indication of this problematic issue. Their proposal observation mainly relied on two observations: firstly, it is based on a wide variation of cited prevalence which ranges from 0% to more than 60% of women. It is worthwhile to note that, this across inter-country variation does not completely cover all the within-country cross-cultural and diversified socio-economic situations, making the estimate meaningless. Secondly, most researches have used the Edinburgh Postnatal Depression Scale (EPDS) to measure PPD. The EPDS screening is focused on postpartum mood disorder which does not take into consideration anxiety, irritability and other symptoms that have been shown to be recurrent among the women, particularly during reproductive-related periods. Hence, EPDS will not provide a reliable instrument for detecting the considerable wide range of pre- and postpartum symptoms and disorders.
Another issue in the application of EPDS might be the variability of cut-off scores across countries, which in these examples range from 9 to 13. EPDS developers, who suggested a range of 9-10 to 13-14 for different populations, will also recommend culturally sensitive cut-off points. So, EPDS cut-off scores are different in different cultures and the sensitivity and specificity of the instrument, have been developed.
Errors in the estimation of the prevalence of PPD can be attributed to the inadequate sensitivity and specificity of the instrument ( Halbreich and Karkun., 2006).
Culture element and postpartum depression:
Since culture provides a significant context for all human experiences and is comprised of several shared ideas, perspectives, cognitive styles, and standards for emotional and behavioural responses, it can truly affect the way any individual comes to experience depression and consequently the way she/he asks for support--either physical or emotional. In this sense one cannot deny the role of culture as an important factor in pregnancy and postpartum adjustment. (Bashiri and Spielvogel., 1999).
Dankner et al .(2000). declared that cultural elements, such as definition of roles, community support and rituals can explain the existing discrepancies in the postpartum depression. In some traditional, and cultural environments the range of postpartum depression is less than in other settings. This factor may highlight the significance of cultural patterns which strengthen the maternal role transition and as a result may reduce the physical and psychological tensions in the new mother. Dankner et al .(2000) researched on Jewish Jerusalem women in Israel showing a decreasing tendency in EPDS mean scores in cross secular, traditional, religious and orthodox families.
Asia as the largest and most populous continent of the world, containing four billion people, is categorised into six separate areas, naming: central region (including countries like Uzbekistan, Kazakhstan), eastern region (China, Hong Kong, Japan, etc.), south-eastern region (Thailand, Malaysia, Singapore, East Timor, Vietnam), and finally western Asia (such as Turkey, Israel, Unites Arab Emirates) (Wikipedia, 2008). These regions encompass a multitude of languages, socio-economic settings, cultural history, religious rituals, and varying status of mental health that inevitably affect the mother in the postpartum period (Wikipedia, 2008). Some cultures practice traditional rituals and helpful methods which are believed by their members to have an effective outcome in supporting and protecting women from the possible symptoms of depression (Halbreich and Karkun., 2006).
Klainin P, and Gordon Arthur.D. (2009), showed that the frequency of postpartum depression in Asian countries ranged from 3.5% to 63.3%. It is noteworthy that Malaysia and Pakistan had the lowest and respectively the highest frequency of occurrence. Accordingly, it had been shown that the traditional postpartum rituals cannot be considered as a promising factor and a psychological benefit for the new mothers. Various factors affect postpartum depression in Asian countries that can be classified into five main groups:
Physical/biological factors, namely: medical condition of the mother and premenstrual symptoms, body mass index (BMI) below normal, and food consumption with high levels of riboflavin (vitamin B2), and high dietary glycemic index.
Psychological factors, namely: symptoms of depression during the pregnancy, antenatal anxiety, past psychiatric history.
Obstetric/paediatric factors, namely: troubles during pregnancy, experience of abortion, previous loss of a baby, unplanned pregnancy.
Socio-demographic factors, namely: financial problems, experiencing the hunger in the past month, being a homemaker.
Cultural factors, naming: different habits of taking bath, washing one's hair, going out of the house, and even being blown by the wind (Klainin P and Gordon Arthur.D., 2009).
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Three of the first groups mentioned above were consistent with results to the previous meta-analytic researches which were mainly based on Western populations (O'Hara and Swain, 1996; Beck, 1998; Beck, 2001; Robertson et al .,2004; Klainin P and Gordon Arthur.D., 2009).
Important factors of PPD in those studies consists of prenatal depression, history of depression, psychiatric disorders during pregnancy, childcare anxiety, stressful life incidences, low self-respect, low social support, low marriage satisfaction, unintended pregnancy, difficult infant temperament, and low socioeconomic status (O'Hara and Swain, 1996; Beck, 1998; Beck, 2001; Robertson et al .,2004 ).
Anthropologists declare that the high frequency of PPD in Western societies is a justification for this claim that PPD is a "culture-bound syndrome." Interestingly, researchers proposed that the very absence of the birth rituals and the general decrease in domestic support (for instance, geographic space between the family and the increasing number of the close relatives which have outside occupations) will consequently result in the increasing amount of the depressions (Bashiri et al., 1999). Since Western culture has created individualistic responsibility for every member of the society and at the same time social isolation is basically the cause of urbanization and the economic restrictions, mothers as significant members of these communities are mostly subjected to higher rates of depression (Black, 2006).
In countries which have been influenced by the Western values, once the baby is borne all the attention and the care of family plus the health care providers would usually be cast upon the baby itself and the mother would be neglected. In quite opposite pole, other cultures put much more emphasis on the new mother and her physical and emotional needs, while certain parenthood rites supply special protection for her (Hoefliger, 2003). Furthermore, inadequacy of suitable role and lack of support for the new mothers may create a milieu for development of depression (Wile & Arechiga., 1999 cited in Black, 2006)).
By now, it seems rather significant to mention the results of the recent international study by Affonso, De, Horowitz, and Mayberry .(2000). which indicate lower mean scores of depressive symptomatology in Western European and higher mean levels from the Asian participations. The researchers point out that the improvement and prevailing programs for PPD besides the education and treatment programs in European societies may very effectively decrease the possibility of depressive symptomatology (affenso et al., 2000). Results demonstrated the rate of PPD in Sweden is in the lowest range (13% and 15.2%), USA is in middle point (37% and 29.5%), and Taiwan is in highest rate (73.7% and 60.8%) in 4 and 6 weeks postpartum respectively (affenso et al., 2000).
Recent changes of postpartum depression prevalence
Scholars affirm that in Europe and Australian societies there is a close relation between the decreasing risk of PPD and the education and treatment programs provided for new mothers. Quite opposite to this results, higher mean levels of depressive symptomatology which have been reported from those Asian and South American societies , show that PPD in those countries is not considered as a health concern (Oates. M. R et al., 2004).
Furthermore, previous and recent studies challenge the hypothesis that geographic locales or westernized and industrialized societies mainly affect the frequency of PPD(I think it is true). In the three previous decades, societies in developing countries have experienced a rapid demographic and socioeconomic reformation, and the elimination of the traditional structure and their supportive practice of families may be an influencing factor in increasing the prevalence of postnatal disorders in women, although more research needs to be done in this area (Husain et al., 2006).
Another factor for the apparent diversity in the recurrence of PPD in developing societies may be the conflicting recommendations from the part of the family members and the professionals in health care. There may be sometimes quite different opinions and demands from the family regarding the care of baby and mother. Often it causes much trouble when mothers tend to follow the traditional structures while at the same time health care professional with their contradictory beliefs impose their own advice that seldom seems to be reasonable on the mothers and consequently put much more pressure on them to change their moods or behaviour that seldom seems to be reasonable (Nahas et al., 1999).
To name other remarkable cultural elements that may possibly have influential impact on frequency of PPD, one can refer to the lack of postnatal supportive equipments and services in many countries (Huang and Mathers, 2001) that eventually will affect the rates of PPD in mothers. It worth mentioning that despite these problems, in some cultures mothers choose to depend on the traditional treatments before taking the medical care, therefore their labour may be more difficult and painful and this may increase the risk of PPD (Rahim and al-Sabiae, 1991).
It should not be neglected that maternal depression is sometimes postponed to later stages of the postpartum period the mother's response to the. Accordingly, depression in the second and third month of postpartum period may be due to the mother's response to the withdrawal of postnatal support and the bitter acceptance of the realities of motherhood (Nahas et al., 1999).
In some cultures women experiencing depressive symptoms under-utilize healthcare services. This occurs finally because of the stigma these mothers undergo; Because of the possible stigmatization of PPD, mothers sometimes go into denial, while some of them assume that these symptoms are a common phenomenon of childbirth, or are momentary problems that eventually will be ameliorated (Chandran et al., 2002 citef in Halbreich.U, and Karkun. S et al.,2006).
Cultural elements in traditional societies
In Asian communities a variety of postpartum rites are practiced. Rituals such as the prescribed confinement periods which normally ranges from 30-40 days, controlled activities and diets, and practical/emotional support from family members, mother, and mother-in-law, traditional birth attendant, or female relatives. These cultural rituals have their own pros and cons and two opposite outcomes, on the one hand this kind of support can be effective in providing physical comfort, but on the other hand they act as significant sources of mental conflict and emotional disturbance. A number of researches indicate that postpartum rituals in Japan, Vietnam, Malaysia, Hong Kong, and Singapore could not by any means provide considerable psychological advantages for the new mothers (Halbreich.U et al.,2006).
The results of systematic review the role of traditional practice on decrease of PPD by Wong& Fisher. (2009), showed that confinement could not be assumed to be available to, welcomed by or effective for all Chinese popullation.
Klainin P, and Gordon Arthur. D. (2009). proposed that there are four probable reasons for such unpredicted results. Firstly, the women may not have decided to practice the traditional rituals by their own choice rather it was imposed on them by their caregivers' (e.g., mother-in-laws) recommendations. Secondly, due to unsatisfactory pre-existing relationships between the mothers and their caregivers, mothers may experience difficulties during their confinement period. Thirdly, some features of these traditional rituals, mainly the restricted practices, may cause tension, stress and disturbance. Finally, the inevitable conflicts(what is writhed as Some of these challenges....) existing in the postpartum situation may sometimes disagree with the traditional rituals and therefore causes mothers mental and emotional breakdown. Some of these challenges are cultural matters for instance, (gender preferences and the long for boy baby), baby's health conditions and temperament, new mothers' physical/psychological make-up, and economical and financial status of the family. Many cases have been reported of women who have higher levels of education and have experienced other forms of cultures are often resistant to their own traditional cultures.
Conclusion:
After all, one must notice that the variety in range of postnatal depression prevalence reported by researchers is surprisingly wide since it depends on different factors including, instruments which have been used for measuring, the translation of study materials from English to the source language, retrospective design, samples and sampling methods, the people who had applied them, differences in symptom definition and expression, the features of determining the symptoms and the time after the child birth when the depression is evaluated and, it may be not clear if the depression is presented as new occurrences. (Huang et al., 2000; Halbreich. U, and Karkun. S., 2006)
Finally it should be stressed health care professionals should be aware that the phenomenon is as prevalent in Asian cultures as in European cultures. Although, numerous studies have been conducted on PPD further research is needed on the childbearing women's experiences with depressive symptomatology globally.
