research and studies

Culturally Induced Postpartum Depression A Theoretical Position STl iART C. TENTONI, PhD, and KATHLEEN A. HIGH, RN, BSN

A three fartor theory, based on an independently conducted survey of 49primigravidas, is portulated lo explain thP potential that rxistr /or cultural attitudts toward pregnancy to become precipitating a p t r in the portpartum depresston syndrome Changes in body proportions, public attitudes, and the soctal h e r of expectant women 5re ureuied prrmarib as negattue experiences which retull in a iors of seIJesteem A meanc of redurinq cognitrue dissonance by inrreasing interaction w i th thore al to pregnant is proposed

Pregnancy requires a woman to cope with the pregnancy itself, la- bor, delivery, and the subsequent childrearing, in addition to the de- mands of everyday life.’.’ A variety of emotional changes can occur. In- creased introversion and passivity may be evident near the end of the first trimester and increase during the third trimester. Mood swings, mixed feelings, restlessness, nervous- ness, irritability, preoccupation, un- due worries about personal health, and depression are all evident to some degree. When these distur- bances reach a severe level after de- livery and cannot be resolved the re- sult is postpartum depression, which can be distinguished from transitory de- pression in terms of duration and se- verity of symptoms.

Transitory depression (maternity blues) can occur during the first few days after delivery,‘ and symptoms include tearfulness, despondency, poor concentration, forgetfulness, and anxiety. This syndrome usually subsides after the milk-letdown re- flex occurs and hormone levels re- turn to the pre-pregnancy state.’ While transitory depression is brief in duration, postpartum depression may not be.

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Postpartum depression is most evi- dent on the return home from the hospital, and general symptoms in- clude tearfulness, despondency, feel- ings of inadequacy, and inability to cope with the infant.4 The syndrome has been described as consisting of three stages.’

The first stage is very similar to the maternity blues; however, fright- ening dreams/fantasies and suicidal ideation can occur due to emotioaal letdown following the excitement of deli very.

In the second stage, which may last one to three months, the mother tries to incorporate the infant into the family structure, to meet the in- fant’s needs, and to cope with her own physical changes a n d h e r changing role as a mate. The most debilitating aspect of this period is interrupted sleep, which results in a loss of rapid eye movement (REM) sleep.” ’”

The third stage, which may ex- tend to one year postpartum, in- volves the mother trying to cope with the long-term adjustments of becoming a parent. Common feel- ings during this period are lethargy, being vaguely upset, and ambiva-

lence toward the role of mother- hood.” ’’

There is no dispute over the possi- bil i ty of postpar tum depression being a physiological phenomenon caused by endocrine changes, hor- monal imbalance, and blood loss. However, little consideration has been given to the possibility of pre- disposing cultural factors. Changes in the primigravida’s attitude, which occur long before the infant’s birth, may be cul tural ly induced a n d could be the precursors of later post- partum depression.

Method The sample consisted of 49 primi-

gravidas, 18-30 years of age (average, 24.6), from middle to upper-middle socioeconomic a n d educat ional backgrounds. Subjects were ob- tained with the cooperation and per- mission of the International Child- b i r th Educat ion Association of Milwaukee. Subjects were not ran- domly selected for two reasons: 1) the main interest of this investiga- tion was the primigravida; 2) many attending obstetricians at the five major hospitals with obstetrical units in the Milwaukee area denied permission or access to their pa- tients.

Subjects were asked to complete a 10-item questionnaire (see Appen- dix) prior to attending their first CEA class. Three of the ten ques- tions were innocuous and used as a means to “break the ice”. Answers were to be short essay and a follow- up interview to elaborate on their re- spective responses was conducted by a clinical psychologist. Subjects were not informed of the exact nature of the study but were told that atti- tudes about pregnancy were being studied.

Results All of the primigravidas reported

that their pregnancies were planned

and wanted. Despite this fact, only 30 (61%) really felt positive about being pregnant. Thirty-four (69%) exhibited a positive view toward the role of motherhood. Thirty-one (64%) reported that friends and rela- tives had told them primarily the negative aspects of labor and deliv- ery. Twenty-eight (58%) reported feeling good about having to buy maternity clothes, and all 49 re- spondents had negative feelings about seeing their figures in a mir- ror. All reported their main concerns as getting their figures back, fears over stretch marks, or having a cesa- rean section. Only five (10%) added as a secondary concern anxiety about their babies’ health upon de- livery. Thirty (61%) reported that their social lives had changed due to their pregnancies. This change con- sisted of a reduction in social con- tacts and quitting work.

Three-Factor Theory Three distinct theoretical factors

emerged from responses to the ques- tionnaires and interviews. These three factors, all related to a loss of self-esteem, are changes in body pro- portions, changes in public attitudes, and changes in social life.

Changes in body image become a threat to self-esteem due to a pri- migravida’s deteriorating self-con- cept.R,’r’ Many women begin to gain weight and start to show in approxi- mately the first trimester. While a woman may be secretly elated about her pregnancy, weight gain is not desirable in our society. It is diffi- cult, and possibly harmful, for a pregnant woman to continue to “think thin”. Loss of self-esteem be- gins when a woman can no longer fit into her regular clothes. Weight gain, facial skin breakdown, and stretch marks-normal occurrences in pregnancy-become real fears in light of societal attitudes toward being overweight, blemished, or scarred.

Public attitudes toward the preg- nant woman seem negative for the most part. Reeder feels that society is primarily organized for families with children,’’ yet while there may be societal pressure to have children, the parent role itself is not highly valued.” Parenting is not considered

to be a career, although it is more difficult to succeed at than an occu- pational career. With the changing economic conditions and social V a l -

ues it is often necessary, or seems necessary, for women to work, and society gives a negative connotation to the word “housewife”. The role of being a housewife can lead to feel- ings of low self-esteem and worth- lessness.R*2”

A woman receives no special treatment from the public during the first trimester, since her body has not changed significantly. Then, during the second and third trimes- ters, the pregnant woman, due to her expanding shape, becomes a novelty when out in public. People glance or stare a t the pregnant woman’s abdomen; some giggle or point. These actions serve to remind the woman of her condition and could lead to a loss of self-esteem.

Changes in social life are also cul- turally imposed, but usually on a more subtle and covert basis- th rough overprotect ion. (Some changes in social life are expected, such as refraining from smoking and drinking alcoholic beverages.) The primigravida becomes fearful of en- countering those who overprotect her. This fear can lead to a with- drawal from social si tuations. Today’s attitude toward the role of motherhood may not have advanced much beyond that held in the early 1900s when pregnant women were basically sequestered at home during their term of pregnancy. This lim- ited social life may be the most diffi- cult aspect from which to recover.

These three factors are inter- dependent. Changes in body propor- tion affect the public’s attitude to- ward the primigravida, which in tu rn determine her social life. Changes in social life can affect how a primigravida views herself and her pregnancy, which can lead to a loss of self-esteem and feelings of in- adequacy. It is quite conceivable tha t these three factors lay the groundwork for postpartum depres- sion. These factors come into play during the last six months of preg- nancy, and can have a gradual, in- sidious effect on a woman’s attitude toward herself, her pregnancy, and her baby.

Psychological Explanations Why these factors may influence a

primigravida’s attitude toward her- self or her pregnancy may be ex- plained with existing psychological theories.

Cognitive dissonance2’ appears to have a definite relationship to the mother role. A primigravida nor- mally receives a great deal of sup- port and encouragement from signif- icant others in her life. However, since the prevalent social attitudes toward motherhood are not positive, dissonance is created. The cognitive dissonance forces the primigravida to become unsure of herself and her impending new role. This can lead to a restructuring of cognitions about herself and her pregnancy in a negative direction.

Another theory involves com- parison levels.22 The comparison level for a given person is defined as the level of outcomes experienced to be fairly neutral in value. Better out- comes are greeted with a certain amount of satisfaction and are expe- rienced as being good in value. The amount of satisfaction experienced is contingent on how far the outcomes exceed the comparison level. The height the comparison level reaches depends on the person’s previously experienced outcomes, both those re- ceived personally and those known to be received by others. The com- parison level theory is used for anal- ysis of self-evaluation. How well-off a person feels depends on with whom the comparisons are made.

The primigravida’s comparison level will be influenced first by her own direct experiences. If the pri- migravida feels good physically and emotionally, her comparison level might be relatively high, as the out- comes of being pregnant are viewed in a positive light. As the primigra- vida inevitably interacts with other women who have had children, she hears of their mildly negative experi- ences with respect to morning sick- ness, backaches, cravings, baby’s kicking, etc. These interactions serve to lower the primigravida’s com- parison level for her immediate situ- ation of being pregnant. Since later topics of discussion will shift to nega- tive experiences, e.g., labor, delivery, postpartum, the primigravida’s out-

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comes will diminish further. Her comparison level for pregnancy drops and so does the satisfaction of being pregnant. The vicarious expe- riences of others appear to influence the primigravida’s comparison level much more than direct experiences. This might be due to the primigra- vida’s anticipating the outcomes of pregnancy to be of increasingly less utility, resulting in fear, anxiety, re- sentment, and dissatisfaction. Dis- satisfaction is likely to occur due to the fact that there are no socially ac- ceptable alternative outcomes for being pregnant.

Since a great deal of the informa- tion a primigravida hears from other women about pregnancy is negative and anxiety-producing, the process of reproducing becomes a social trap,” where the woman has started in a direction that later proves to be unpleasant, with no easy way out. The unpleasantness of pregnancy rests with the woman and results in a loss of self-esteem, feelings of in- adequacy, loss or interruption of her career, and questioning her identity and purpose in life. This could lead to problems in the mother-infant relationship if the mother feels un- filled. The child would become the cause of the unfulfillment and be blamed for the mother’s in- adequacies.

Discussion Nearly 40% of the respondents ex-

perienced a loss of self-esteem, which resulted from changes in physical appearance, changes in social lives, and anticipatory fears of labor, de- livery, and childrearing. While this finding may be normal for American society, 40% seems high, considering the fact that all respondents re- ported that this was a planned and wanted pregnancy.

Ambivalence about motherhood is often common during pregnancy, but it seems feasible that a primigra- vida’s attitude toward herself and her pregnancy becomes altered vi- cariously by social interaction with women who have had children. The alteration of attitudes and cogni- tions about pregnancy produces feel- ings of uncertainty and dis- satisfaction. These feelings can take place for nearly six months prior to

delivery. In essence, “prepartum de- pression” develops and could natu- rally evolve into postpartum depres- sion. Prepartum depression is the eroding of self-esteem by societal factors and postpartum depression is the aftermath. Reduction or elimi- nation of the prepartum phase be- comes necessary if the primigravida is to cope effectively with her preg- nancy and baby.

The nurse and obstetrician be- come the vital first link in the chain of preventing the prepartum depres- sion phase. A great service could be provided to patients if the nurse and obstetrician could anticipate and dispel the myths surrounding preg- nancy. The nurse and obstetrician can counteract the negative infor- mation about pregnancy that pa- tients are likely to hear from others. The health care team might also ex- plore the possibilities of having pa- tients enroll in either the hospital’s maternity classes, or ICEA cla~ses.*~*~

Attendance of childbirth prepara- tion classes may be psychologically beneficial for three reasons: 1) The father becomes more involved in the birth process and can become the main source of support to the mother. 2) Classes will provide fac- tual information about pregnancy, labor, and delivery, dispelling any myths the primigravida may have heard. 3) Class involvement provides social interaction with other preg- nant women,’” allowing a more ac- curate, personal, comparison level. The primigravida can attain a more internal frame of reference, which should render her immune to the predisposing societal attitudes.

Primigravidas may be very in- secure over their pregnancies and impending role changes. This study suggests that societal attitudes are programming first-time mothers to- ward postpartum depression. Nurses who recognize this fact and take re- sponsible action could help reduce the impact of negative societal atti- tudes toward pregnancy. It would be impossible to change societal atti- tudes toward pregnancy as soon as is needed, therefore, more time must be spent in developing the primigra- vida’s internal frame of reference so her attitude can remain positive de- spite hearing negative informat ion.

If this can be accomplished, the pri- migravida may be able to feel better about herself and her infant.

Further investigation is needed in the area of the postpartum depres- sion syndrome. Before that can oc- cur, nurses and physicians will need to recognize the importance of the syndrome and the necessity to re- search any and all possible factors. Until this happens, it will be diffi- cult to interview and obtain follow- up information on primigravidas once they enter the hospital.

References 1. Ziegel E, Van Blarcom CC: Obstet-

ric Nursing, Sixth edition. New York, Macmillan, 1972

2. Brenner AK: The blues. Am Baby 41(5):50-56, 1979

3. Pitt B: Maternity blues. Br J Psychi- atry 122:431-433, 1973

4. Pitt B: “Atypical” depression follow- ing childbirth. Br J Psychiatry 114:1325-1335, 1968

5. Boston Women’s Health Book Col- lective: Our Bodies, Our Selves. Sec- ond edition. New York, Simon and Schuster, 1976

6. Thompson RF: Introduction to Physiological Psychology. New York, Harper and Row, 1975

7. Heitler SK: Postpartum depression: A multi-dimensional study. Dissert Abstr Int 36(1 l-B):5792-5793, May 1976

8. Flamholtz-Trien S: Chasing those blues away. Am Baby 39(5): 26, 39, 1977

9. Mims-Jimenez SL: Beating the blues. Am Baby 41(17): 16, 24, 1979

10. Whelen EM: The “after-baby blues”. Am Baby 41(21): 16, 20, 1979

11. Davidson JRT: Post-partum mood change in Jamaican women: A de- scription and discussion on its signif- icance. Br J Psychiatry 121:659-663, 1972

12. Yalom ID, Lunde DT, Moos RH, Hamburg DA: Post-partum blues syndrome: A description and related variables. Arch Gen Psychiatry 18:16-27, 1968

13. Seward E: Preventing postpartum psychosis. Am J N u n 72:520-523, 1972

14. Wilson JE, Barglow P, Shipman W: Prognosis of postpartum mental ill- ness. Cornpr Psychiatry 13:305-316, 1972

15. Rosenwald GC, Stonehill MW: Early and late postpartum illnesses. Psychosom Med 34: 129-137, 1972

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16. Frommer EA, O'Shea G: Antenatal identification of women liable to have problems in managing their in- fants. Br J Psychiatry 123: 149- 156, 1973

17. Asch SS, Rubin LJ: Postpartum re- actions: Some unrecognized varia- tions. Am J Psychiatry 131:870-874, 1974

18. Roth N: The mental content of pue- peral psychoses. Am J Psychother 29:204-211, 1975

19. Mostow E, Newberry P: Work role and depression in women: A com- parison of workers and housewives in treatment. Am J Orthopsychiatry 45:538-548, 1975

20. Reeder LG: in Fitzpatrick E, Reeder SG, Mastroanni L: Maternity Nurs- ing, Twelfth edition. Philadelphia, JB Lippincott Company, 1971

21. Festinger L: A Theory of Cognitive Dissonance. Stanford, California, Stanford University Press, 1957

22. Thibaut JW, Kelley HH: The Social Psychology of Groups. New York, Wiley, 1959

23. Platt J: Social traps. Am Psycho1 2864 1-65 1, 1973

24. Neumann G Beyond pregnancy and childbirth: The use of anticipatory guidance in preparing couples for postpartum stress. Dissert Abstr Int 38(11-B):5582, May 1978

Address for correspondence: Stuart C. Tentoni, PhD, Clinical Psychologist, Waukesha County Unified Services, 500 Riverview Avenue, Waukesha, WI 53186.

Stuart Tentoni is a clinical psychologist wi th Waukesha Coung Communiy lJntf"d Services in Waukesha, Wisconsin. A graduate ( P h D ) of North Texas State Universiy, Dr. Tentoni has published extensively and made numerous presentations in the Jeld of clinical psychology.

Kathleen High attended Aluerno College where she earned her BSN. She has worked in prenatal classes and is currently an obstetrical nurse in labor and delivery at St. Francis Hos- pital in Milwaukee, Wisconsin.

Appendix: QUESTIONNAIRE

1. What is your present age? 2. Where do you shop for your personal and clothing items? 3. Where did you get your maternity clothes? 4. What were your feelings about needing maternity clothes? 5. What are your feelings about being pregnant? 6. How do you personally view the role of motherhood? 7. What do you think when you see yourself in a mirror? 8. What have others, either friends or relatives, told you about the role of motherhood? 9. What is your main concern or concerns about your pregnancy?

10. Has your social life changed in any way because of your condition? If so, what are you now doing dif-

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