The Cultural Meaning of Postpartum Depression
Postpartum depression is a debilitating experience which affects anywhere from 7.1% to 25% of women¹. Although Postpartum Depression or PPD is classified under Major Depressive Disorder with a post-partum onset in the DSM-V, there are distinctive factors that set PPD apart. These include responsibility for the care of a child, sleep deprivation, and new tasks and roles such as breastfeeding, loss of independence, and primarily being bound to the home. Traditional measures for depression may miss or misconstrue important factors of postnatal distress due to these unique physiological and psychological demands.
Post-partum depression or PPD has been primarily conceptualized and treated as a medical problem situated within the individual or a psychosocial interaction between stress, vulnerability, and certain risk factors, including negative life events, prenatal depression, and marital conflict². The medical model views PPD as an individual illness linked to fluctuating hormones and previous psychiatric comorbidity. The medical model suggests that women experience enormous drops in estrogen and progesterone levels directly after childbirth that results in emotional dysregulation and depression⁵. Because there is no difference between estrogen and progesterone levels in mothers with and without PPD, researchers assume that certain women are more vulnerable to the effects of fluctuating hormones. However, many researchers believe the evidence of a hormonal cause for PPD remains inconclusive, as many studies provide insufficient or contradictory evidence⁶.
The psychosocial models conceptualize PPD in a stress-vulnerability context which focuses on certain risk factors including stressful life events outside of pregnancy, minimal social support, lower socioeconomic status, marital conflict, age, previous mood disorders, prenatal depression, complicated pregnancy or childbirth, infant temperament, unwanted pregnancy, or a negative attributional style⁷. Beck further proposed that incongruence between the mother’s perceived expectations of support and actual support offered were precursors to PPD. Others suggest that the medicalization of childbirth or the disruption between mother-child bonding due to pharmaceutical interventions increase the likelihood of PPD⁸.
Although these biopsychosocial factors shape the understanding of PPD, they fail to consider all variables. Both the medical and psychosocial model focuses solely on the individual mother and her immediate social environment, without taking into account subjective experiences or the socio-political context of mothers’ experiences. Qualitative research which prioritizes the subjective experience and lived reality of mothers struggling with PPD have revealed many emerging themes that are important to the understanding of PPD.
Some of those themes include the relational experience of isolation, the tension between cultural and personal expectations of motherhood versus the lived experience, the structural concerns of childcare in contemporary American culture, and the experience of invalidation and/or the overwhelming fear of invalidation from others.¹⁰ Because there is already extensive research on the medical and psychosocial factors of PPD, we will focus on unpacking what qualitative research tells us about the phenomenological and socio-cultural elements. The hope is that having a full understanding of the complexity of PPD will provide a framework for which to base effective treatments for mothers with PPD, as well as inform our grassroots efforts for increased cultural awareness and improved political policies around parenthood.
One of the most prevalent cultural themes which stood out in the research was the incongruence between socially constructed expectations of motherhood versus the lived experience of motherhood. According to research, for mothers with PPD, the childbearing experience often begins with an idolization of motherhood as natural, easy, and singularly fulfilling. The idea is reinforced through popular culture, parenting literature, and the media¹¹. Many women are taught that motherhood is the ultimate marker of success and being “a woman”, and thus construct their identity and self-worth around this image. Dominant, popular culture ideals are therefore what mothers expect. As a result, they may be unprepared for the reality of new motherhood. For many women, tasks of motherhood may not arise naturally and because of inaccurate expectations, feelings of incompetence may develop. According to a mother in one qualitative study, she explained, “I’d never changed a nappy. I’d never bottle-fed a baby; I’d never looked after a baby … I didn’t know what to do … I was in despair.”¹² Additionally, the fear of being a bad mother may result in exaggerated self-judgments in response to minor failures (e.g. “The floor is dirty, I am a terrible person.”)
Although experiences of motherhood are largely varied and neither wholly negative nor wholly positive, women in multiple studies expressed surprise at the difference between their expectations and their lived experience. In one account, a mother explained: “I thought…I wanted this baby, I’m going to be so happy, and everything’s going to be perfect. I’ll be baking cookies, and making soups, and the baby will be sleeping…I had this image that everything would be perfect. When it wasn’t, I was shocked.”¹³ Another woman expressed, “I always wanted to be at home with children and thought it would be so enjoyable and so rewarding, but I was just bored to death.”
In popular culture, breastfeeding is seen as the paradigm of the loving, peaceful bond between mother and child; signifying ultimate health and feelings of well-being. In reality, breastfeeding can be another complicated arena of sore and cracked nipples, limited milk supply, agonizing pain, and a heap of both internal and outside judgment. Popular culture does not typically acknowledge these varied and complex experiences of motherhood. A number of feminist researchers consider PPD a normative response to childbirth and as the period of bereavement that follows. Becoming a mother necessarily involves losses of occupational status, financial means, identity, body shape, leisure time, autonomy, sexuality, and relationships. PPD is therefore seen as a natural grieving period in a society where women represent the primary source of unpaid childcare labor. An alternative feminist perspective views woman not as “passive victims of societal structure,” but as agents actively negotiating their social and cultural context once they come into contact with the high and unrealistic expectations of motherhood.
In some studies, the mothers’ preconceived expectations that motherhood should be natural caused many to feel inadequate or ashamed if they needed to ask for advice or support, so they chose to stay silent. In one qualitative study, a woman explained: “It’s this difference between the facade you’re putting up and how you’re really feeling inside. And if it’s a feeling of that you can’t cope very easily and you don’t want people to know how you’re really feeling, you don’t want people to know you can’t cope because everyone does cope and nobody ever shows the side of not coping.”
Another study found that women were reluctant to seek out professional help, and when they were in a professional setting, more than 80% chose not to disclose their symptoms.¹⁴ These studies illustrate how the fear of being a “bad” or “unnatural” mother is a key factor in limiting help-seeking behaviors and, therefore, maintaining PPD. Research suggests that mothers who are able to adjust their expectations during the transition to motherhood are less likely to develop depression, whereas those who attempt to resolve the paradox through denial are more likely to develop PPD.
Hiding negative emotion and resisting support are directly related to the experience of isolation, another key qualitative theme that emerged. One study found that mothers’ inability to see their experience mirrored by the culture or within relationships created feelings of isolation and shame. Other research suggests that isolation is reinforced by the cultural idealization of motherhood and the gender inequity common in parenting. If fathers internalize the cultural belief that motherhood is natural and easy, then they may be more likely to give the primary childcare tasks to the mother, which only increases the mother’s isolation.
According to research, isolation prompted withdrawal from friends, family, and spouse. In many qualitative studies, mothers reported feeling alienated and emotionally distant from their old relationships, afraid to leave their own homes, disconnected from themselves, and distanced from their babies. The mothers asserted that this isolation stemmed from the belief that no one would understand their experience. The relational aspect of feeling alone, yet unable to reach out for help, was a common experience reported across all studies. One woman described it as “being imprisoned in my own prison.”¹⁵ The experience of self-silencing which was collective in women’s experiences of isolation was a key factor in maintaining the depression. Geographical isolation in terms of distance from extended family was also found to contribute to the lack of support, as it is common in the US for nuclear families to move away and raise their children independently.
Another major relational component to PPD was the experience of invalidation. Mothers described having direct experiences of invalidation where health professionals, doctors, spouses, or friends failed to show empathy or concern about their circumstances. Cultural ideologies and expectations of motherhood were often reinforced through interactions between the mothers and their community. For example, rather than feeling validated or heard, the mothers reported feeling judged. In one qualitative study, the mothers reported their experience being minimized through reactions such as, “everyone feels this way” or “you’re just a little down.”¹⁶ Mothers also frequently recounted the indifference or minimization of healthcare professionals. Researchers assert that similar to actual isolation, the inability to express ambivalent or negative emotions in a validating environment sustains the depression.
A cultural factor which also contributes to sustaining the depression is the general stress and exhaustion of practical concerns surrounding motherhood, one of the most frequently reported experiences in the data.¹⁷ The material nature of this concern is compounded by cultural and structural influences, such as the unequal division of reproductive and economic labor in most marriages. It is a common US practice that mothers are the primary childcare givers, while fathers provide the economic support. Despite changing gender roles and increased dual-earner households, studies in 2010 found that mothers still spent an average of 56 hours per week on childcare and household tasks, while men spent approximately 17 hours¹⁸. It was found that the mother’s employment status did not affect the amount of unpaid childcare labor.
Furthermore, limited parental leave policies and restricted structural supports such as affordable daycare increases the physical demands put on mothers. In cross-cultural studies of non-Western societies, high levels of family and community support were found after childbirth, whereas Western societies were found to have minimal postpartum support.¹⁹ Current models fail to take into account the cultural context and the effects of the emotional and physical exhaustion of mothering. The experiences reported in the qualitative data confirm this. In multiple studies, lack of practical support such as help with household chores and baby care were seen as the highest concern facing mothers with PPD. Chronic sleep deprivation was frequently cited as a primary stressor. In one study, over 70% of mothers identified exhaustion, lack of support, and isolation as being primary causes for their PPD and in another study, exhaustion was the most commonly endorsed factor for perceived cause of PPD with 62.1% of mothers reporting it. Over 20% recommended time away from their child as being the most helpful strategy.²⁰
The research above suggests that PPD has numerous cultural and relational factors which are not being addressed by standard psychotherapeutic treatment. Despite the varied and well-established research on both psychosocial and sociocultural influences, the medical model has been the leading method for understanding and intervening in PPD. Antidepressant medication is the most common treatment for PPD, regardless of the fact that there is scarce evidence that antidepressants achieve better results than placebo controls or psychotherapy.²¹ In fact, mothers have reported preferring talk therapy to medication, and many opt out of medication altogether over concerns about the possible health risks associated with antidepressants and breastfeeding. Psychotherapy represents an alternative to pharmacology, particularly for women who are breastfeeding, and it can more directly challenge the feelings of isolation and invalidation.
Including the cultural and relational data from qualitative research will increase the effectiveness of psychotherapeutic treatment for PPD. I believe, and the research shows, the medical and psychosocial experiences of PPD are valid, however, situated within a larger discourse of culture, values, and politics. Interventions to prevent and treat PPD should, therefore, focus on expanding options regarding how motherhood is constructed, create a supportive environment where ambivalent feelings can be validated, and increase relational connections to combat isolation and provide practical support.
Relational cultural therapy (RCT) is a psychotherapy which not only addresses the biopsychosocial components, but also the socio-cultural aspects of PPD. RCT is a talk therapy that validates the mother’s experience, as well as frames her experience in a relational-cultural context that focuses on healing shame, unpacking damaging cultural messages, and increasing mutual connection and empowerment.²² RCT has already shown promise in the treatment of PPD. A 2005 qualitative study examined the reactions of mothers who were visited by paraprofessional volunteers operating from an RCT perspective, and the mothers identified their volunteer home-visitors as important sources of connection and support.²³ Although RCT benefits the relational and cultural needs of PPD mothers, the services will remain ineffective if mothers are unable to access them or are unaware of their availability. The pervasive internal silencing of mothers influenced by cultural factors may affect help-seeking behaviors, as well as the physical barriers of primarily being bound to the home. Therefore, psychoeducation and community health outreach should be considered an important component of treatment. Access to psychotherapy through home-visits, distance counseling, and/or other alternatives would be important for this population.
Call to action
Become involved and join the movement for paid family leave by 2020.
If you know someone who is struggling, share postpartum resources and check-in with them as often as you can.
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[1] Beck, 1993; Miller, 2002
[2] Beck, 2001
[3] Choi et al., 2005; Dennis & Chung-Lee, 2006; Hall, 2006; Mauthner, 2010
[4] Beck, 1993; Coates, Ayers, & Visser, 2014; Knudson-Martin & Silverstein, 2009).
[5] Hayes, Roberts, & Davare, 2000; McMullen & Stoppard, 2006
[6] O’Hara & McCabe, 2013; Workman, Brummelte, & Galea, 2013
[7] Pearlstein et al., 2009; Sword, Watts, Kreuger, & Sheehan, 2002, O’Hara, 2013
[8] Hayes et al., 2000
[9] Hall, 2006, Nahas & Amashah, 1999, Woods, Thomas, Droppelman, & Meighan, 1997
[10] Coates et al., 2014; Knudson-Martin & Silverstein, 2009, McMullen & Stoppard, 2006; Wardrop & Popadiuk, 2013
[11] Hall, 2006; Mauthner, 2010; Paris & Dubus, 2005, Wardrop & Popdiuk, 2013
[12] Choi et al., 2005, p. 173
[13] Knudson-Martin & Silverstein, 2009, p. 152
[14] Dennis & Chung-Lee, 2006; Hall, 2006).
[15] Tatano Beck, 2002, p. 464
[16] Mauthner, 2010
[17] Hayes et al., 2000; Matthey, 2009; Roux et al., 2002
[18] Ussher, 2010
[19] Chen, Kuo, Chou, & Chen, 2007; Halbriek & Karkun, 2006
[20] Matthey, 2009
[21] O’Hara & McCabe, 2013
[22] RCT; Jordan, Kaplan, Miller, Stiver, & Surrey, 1991
[23] Paris & Dubus, 2005
