The Influence of Culture on the Development and Detection of Postpartum Depression

1. The Influence of Culture on the Development and Detection of Postpartum Depression Cindy-Lee Dennis, RN, PhD Assistant Professor, Faculty of Nursing CIHR New Investigator Career Scientist, Ontario Ministry of Health

2. What are immigrant mothers at increased risk for postpartum depression? • Why does postpartum depression often remain undetected? • What is screening? • What tools can health professionals use to detect postpartum depression? • Recommendations for detecting depressive Symptoms

3. Childbirth represents for women a time of great vulnerability to become mentally unwell, with postpartum mood disorders representing the most frequent form of maternal morbidity following delivery

4. These affective disorders following childbirth range in severity from the early maternity blues to postpartum psychosis, a serious state affecting less than 1% of mothers

5. Within this group of disorders is postpartum depression, a condition often exhibiting the disabling symptoms of dysphoria, emotional lability, insomnia, confusion, anxiety, guilt, and suicidal ideation. • Frequently exacerbating these indicators are low self-esteem, inability to cope, feelings of incompetence, and loneliness.

6. The inception rate is greatest in the first 12 weeks postpartum with duration frequently dependent on severity and time to onset of treatment • Postpartum depression is a major public health issue for many women from diverse cultures

7. Longitudinal and epidemiological studies have yielded varying prevalence rates, ranging from 3% to more than 25% of women in the first year following delivery • These rates fluctuate due to sampling, timing of assessment, differing diagnostic criteria, and whether the studies were retrospective or prospective (6- to 10-fold higher)

8. A meta-analysis of 59 studies reported an overall prevalence of postpartum depression to be 13% • It is noteworthy that the absolute difference in estimates between self-report assessments and diagnostic interviews was small

9. Risk Factors (Beck, 2001) • Prenatal depression • Childcare stress • Life stress • Lack of social support • Prenatal anxiety • Maternity blues • Marital dissatisfaction • Previous history of depression • Low self-esteem • Low socio-economic status • Marital status • Unwanted/unplanned pregnancy

10. However, preliminary research suggests that immigrant mothers from diverse cultures may be at higher risk to develop postpartum depression

11. Postdoctoral Research Fellowship • UBC, Faculty of Medicine, Dept. Health Care & Epidemiology • Population-based study - 645 mothers completed questionnaires at 1, 4, and 8 weeks postpartum

12. Edinburgh Postnatal Depression Scale (EPDS) • 10-item self-report instrument • Designed specifically to assess depressive symptoms in new mothers • Cut-off >12 =confirmpostpartum depression • Cut-off > 9 =community-based screening • Translated into diverse languages

13. Sample Characteristics • Mean age was 28.5 years (SD = 5.0) • 89% Caucasian • 90% married or common-law • 39% high school or less, 38% college/trade education, 21% university degree • Income: 36% < $30,000, 31% > $80,000 • 44% primiparous • 74% vaginal delivery • 69% discharged home within 48 hours

14. Question Who is at risk for depressive symptoms in the immediate postpartum period? • A multifactorial predictive model was developed using sequential logistic regression analysis • The outcome was an EPDS score > 9 at 1-week postpartum

15. Socio-Demographic Factors • Marital status • Age • Education • Ethnicity • Immigration during the last five years • Household income • Ability to manage with income • Access to transportation • Suitable housing

16. Biological/Psychological Factors • Vulnerable personality • Self-Esteem • Premenstrual symptoms • Maternal psychiatric history • Family psychiatric history • History of postpartum depression

17. Pregnancy Factors • Infertility problems • Planned pregnancy • Mother’s feelings about pregnancy • Partner’s feelings about pregnancy • Pregnancy complications

18. Life Stressors • Life events (past 12 months) • Job stress • Worrying about returning to work • Satisfaction with job

19. Substance Abuse and Violence • Use of alcohol and drugs by the mother or her partner • History of physical or sexual abuse • Fear of partner • History of physical abuse as a child • Physical abuse directed towards the subject’s mother by her father • Interaction with child protection services

20. Social Support • Global Support • Relationship-Specific Support from: • Partner • Mother • Mother-in-law • Other women with children

21. Obstetrical Factors • Induction of labour • Mode of delivery • Satisfied with pain management • Control during labour • Labour complications

22. Maternal Adjustment • Ready for hospital discharge • Infant feeding method • Satisfaction with infant feeding method

23. In the multivariate analysis, significant variables were tested and retained in the model if the p-value for the beta-estimate was 0.05 or less • Variables were entered into the model in the following chronological order: socio-demographic, biological/psychological, pregnancy, life stressors, substance abuse/violence, social support, obstetric, and maternal adjustment.

24. Risk Factor Beta OR 95% CI Immigrated within last five years 1.60 4.94 1.00-24.8 History of depression before pregnancy 0.60 1.82 1.05-3.16 Vulnerable personality 0.20 1.21 1.13-1.31 Life stressors 0.12 1.12 1.01-1.24 Pregnancy-induced hypertension 1.28 3.62 1.05-9.74 Global support -.04 0.96 0.93-0.99 Satisfaction with infant feeding method .83 2.29 1.13-4.64 Ready for hospital discharged 1.33 3.78 1.40-10.19

25. Dennis, C-L., Janssen, P., & Singer, J. (2004). Identifying Women At-Risk for Postpartum Depression in the Immediate Postpartum Period: Development of a Multifactorial Predictive Model. Acta Psychiatrica Scandinavica, 110, 338-346

26. Among the few studies that have examined immigration, most have also found this variable to be a significant factor • Danaci, A. E., Dinc, G., Deveci, A., Sen, F. S., & Icelli, I. (2002). Postnatal depression in turkey: epidemiological and cultural aspects. Social Psychiatry & Psychiatric Epidemiology, 37(3), 125-129. • Dankner, R., Goldberg, R. P., Fisch, R. Z., & Crum, R. M. (2000). Cultural elements of postpartum depression. A study of 327 Jewish Jerusalem women. Journal of Reproductive Medicine, 45(2), 97-104. • Glasser, S., Barell, V., Shoham, A., Ziv, A., Boyko, V., Lusky, A., et al. (1998). Prospective study of postpartum depression in an Israeli cohort: prevalence, incidence and demographic risk factors. Journal of Psychosomatic Obstetrics & Gynecology, 19(3), 155-164. • Zelkowitz, P., & Milet, T. H. (1995). Screening for post-partum depression in a community sample. Canadian Journal of Psychiatry, 40(2), 80-86.

27. Unfortunately, scant research has been conducted as to why these women are at-risk postpartum depression

28. Why are immigrant women at risk for PPD?

29. Investigations with general non-postpartum immigrant populations have clearly demonstrated a link between the acculturation process and psychological problems

30. When individuals interface with a new host society, they confront many challenges, including adjusting to a new language, different customs and norms for social interactions, unfamiliar rules and laws, and in some cases extreme lifestyle changes (e.g., rural to urban)

31. Acculturation refers to the process of adjusting to these life modifications, and depending on the disparity between the two cultures, acculturative stress is a common outcome resulting frequently in an increased risk for depression

32. While considerable attention has been paid to the importance of acculturative stress ondepression among non-postpartum immigrant populations and stressful life events on maternal mood, the relationship between acculturative stress and postpartum depression has not been explored

33. Research also suggests factors may have a protective effect on acculturative stress, including the provision of social support and socio-economic status • This is particularly salient for postpartum depression, given that studies clearly suggest social deficiencies increase the risk of postpartum depression

34. In addition to enhancing social support, another factor that may have a protective effect on the development of postpartum depression is traditional postpartum rituals • For example, in many cultures special practices and customs serve to impose structure and meaning in the perinatal period and promote the successful transition to motherhood(Stuchbery, Matthey, & Barnett, 1998)

35. These postpartum rituals have been examined in varying degrees among many cultures (e.g., Arabic,Chinese,Japanese, Malaysian, Taiwanese, Thai, etc. ) and frequently last between 30 to 40 days

36. While several studies provide evidence that traditional postpartum rituals are followed by the majority of women in their native country, limited research has been conducted related to the practice of these rituals post-migration

37. Current Research Initiative Systematic Review of Traditional Postpartum Practices • Dr. Cindy-Lee Dennis • Dr. Lori Ross • Dr. Sarah Romans • Dr. Gail Robinson • Dr. Ken Fung

38. Traditional postpartum rituals among indigenous/native mothers (including rationale for practices): • organized support (includes who, where, what activities, etc.) • dietary practices • restricted physical activities • hygiene practices • celebrations (e.g., naming baby) • other rituals

39. Example • Among chinese mothers the traditional rite of “Tso-Yueh-Tzu”, translated as ‘doing the month’, is concerned with beliefs and practices associated with the postpartum period • When doing the month, women are required to stay indoors and to follow specific dietary, hygiene, and physical activity restrictions for 4 weeks to promote recuperation • Additionally, someone (usually a female family member) assumes most of the infant care and household responsibilities

40. This traditional practice has been investigated in a number of studies and all suggest that many Chinese women still follow the practice and believe that it will improve their health (Cheung, 1997; Davis, 2001; Holroyd, Katie, Chun, & Ha, 1997; Lee et al., 1998) • However, resent research studying Hong Kong mothers found environmental constraints and difficulties in following the proscriptions of the traditional practices and questioned how women could adapt the ritual to fit with modern life(Leung, Arthur, & Martinson, 2005)

41. Similarly, one Australian study found that 18% of immigrant Chinese mothers felt ambivalent about traditional practices and that the reason they followed the practice was to please their in-laws (Matthey, Panasetis, & Barnett, 2002) • Furthermore, two studies suggest adherence to these traditional practices among native and immigrant Chinese mothers may not be protective against the onset of PPD (Leung, Arthur, & Martinson, 2005; Matthey, Panasetis, & Barnett, 2002)

42. While there are many variables involved in the practice of ‘doing the month’ that may have potential health benefits, research suggests that one salutary aspect may be the provision of organized support and that PPD may be prevented • However, it is unknown whether it indeed does have a potential protective effect or whether these rituals simply delay the development of PPD, as preliminary research with Hong Kong Chinese women suggests

43. Postpartum Practices and Depression Prevalences:Technocentric and Ethnokinship Cultural Perspectives • Posmontier, B., & Horowitz, J. A. (2004). Postpartum practices and depression prevalences: technocentric and ethnokinship cultural perspectives. Journal of Transcultural Nursing, 15(1), 34-43.

44. Technocentric • Cultures which use technology to monitor new mothers • The infant is the primary focus in the immediate postpartum period • Potential danger 24-48 hours • Maternal-infant separation • Mother discharged home to a social system that does not have formalized traditions or norms • Technology is valued over social networks • Canada, US, UK, Western Europe, Australia

45. Ethnokinship • Cultures in which the performance of social support rituals by family networks are the primary focus in the immediate and later postpartum period • While advanced technology is used to promote safe and optimum postpartum outcomes the family social supports retains primary importance • Korean, Chinese, Japanese, Hmong, Mexican, African, Arabic, Amish

46. Postpartum support structures • Mandated rest and assistance with household tasks • Maternal vulnerability • Social seclusion • Recognition of role transition

47. Cultural PPD Risk Factors • Acculturative stress • Traditional postpartum practices

48. Why does postpartum depression often remain undetected?

49. The lack of detection is not just a health professional issue that can be dealt with by just screening • Women do not proactively seek help • Dennis, C-L., & Chung-Lee, L. (submitted). A review of postpartum depression help-seeking behaviours and treatment preferences. Birth.

50. Maternal Barriers • Reluctant to obtain professional assistance • Unwilling to disclose emotional problems especially depression • Popular myth equates motherhood with happiness