Postpartum depression, culture and African-American women

Postpartum depression (PPD) is defined as the development of mood disturbance two weeks to one year after delivery, with symptoms most often found during the third through ninth postpartum months (Steiner, 1990). Other investigators report that postpartum depression, also known as postnatal depression, develops from within two weeks of delivery to several months after delivery (Harding, 1989). It is also defined as a non-psychotic depressive episode that begins in, or extends into, the postpartum period (O'Hara & Swain, 1996). A review of medical records by Georgiopoulos, Bryan, Wollan and Yawn (2001) revealed a 10.7% estimated rate of depression in a population of 342 mothers. Prenatal depression, low self-esteem, childcare stress, and prenatal anxiety were identified as the strongest of 13 predictors with newly added predictors being single marital status, unplanned pregnancy and low socio-economic status (Beck, 2001).

Postpartum depression is defined by the American Psychological Association (2000) as a disorder with onset within four weeks postpartum and connected with a diagnosis such as (a) Major Depressive, (b) Manic, or Mixed Episode in Major Depressive Disorder, (c) Bipolar I Disorder, (d) Bipolar II, or (e) Brief Psychotic Disorder. Currently, there appear to be differences in the literature on the time of onset and the length of progression of postpartum depression. Postpartum depression is a moderate to severe mood disturbance, with at least four symptoms identified from a group of eight symptoms (Whiffen, 1991). These eight symptoms include appetite disturbance, sleep disturbance, agitation, loss of interest, fatigue, self-deprecation, indecisiveness or lack of concentration, and suicidal ideation. Terry, Mayocchi, and Hynes (1996) suggested that postpartum depression is characterized by symptoms of depression and anxiety, is a common postpartum condition, and is evidenced from 10 days up to 1 year after delivery.

Postpartum or maternity blues is much milder than postpartum depression and is a transient period of mild depression, mood instability, anxiety, and lack of concentration. It is also a period when the mother has increased concern for her and her baby's health (Harding, 1989). Beck, Reynolds, and Rutowski (1992) characterized the blues as consisting of symptoms of depression, tearfulness, anxiety, clouding of consciousness, irritability, headache, and variable mood. This condition occurs in about 50-80% of newly delivered mothers and lasts from 24-48 hours up to about ten days (Beck, Reynolds, & Rutowski, 1992; Harding, 1989).

Postpartum psychosis, on the other hand, is the most severe of the three affective conditions. It is a rare, acute psychotic reaction in women following childbirth (Whiffen, 1991). Characteristics of postpartum psychosis include hallucinations, delusions, and gross disorganization. It occurs in about 2 in every 1,000 women, and in most instances of postpartum psychosis, the postpartum mother will present with symptoms within two weeks of delivery (Harding, 1989).

The theory of maternal role attainment developed by Rubin (1967) and later extended by Mercer (1981, 1995) and others suggest that many factors affect a mothers' eventual acceptance and ability to be competent in her role as a mother. Postpartum depression is one of many factors, which have a negative influence on the transition to motherhood and thus successful maternal role attainment (Fowles, 1998). Postpartum depression is also thought to negatively influence maternal infant bonding and maternal responsiveness (Fleming, Flett, Ruble, & Shaul, 1988; Hart, Field, & del Valle, 1998; Coyl, Roggman, & Newland, 2002). The significance of exploring postpartum depression as a cultural variable becomes important as it may shed more light on the cause of this mental health disorder and thus its effect on maternal role attainment.

There has been an increasing focus on the etiology of postpartum depression, yet little focus has been directed toward the study of cultural dimensions of this devastating mental disorder. Cultural implications for postpartum depression can not be explained without first discussing the connection of culture and clinical depression. The purpose of this article is to discuss the connection between culture and postpartum depression with the primary focus on postpartum depression among African-American women. Implications for health policy are also presented.

CULTURE AND CLINICAL DEPRESSION

The role of culture and of gender in depression has been the focus of many studies as researchers try to unravel the origin, course, and management of this mood disorder. Culture is defined as the learned, shared, and transmitted values, beliefs, norms, and lifeways carried by a group of people, which guides their decisions, thinking, and actions in patterned ways (Leininger, 1991, p. 47). The individual in society is bound by the rules of their culture (Lazarus & Folkman, 1984). There appears to be some cultural variability, in the conditions under which it is appropriate to express one's feelings and in the patterns of outward expression such as crying and laughing (Lazarus & Folkman, 1989). It was suggested "the same events that may be fear-inducing in one culture, anger-inducing in a second, may be benign in a third" (Lazarus & Folkman, p. 228). In addition, Lazarus and Folkman suggest that cultural aspects of one's social system have a major impact on the individual's emotional life.