postpartum

Postpartum depression

Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual prevalence rate unclear. Among men, in particular new fathers, the incidence of postpartum depression has been estimated to be between 1% and 25.5%.^[4]Postpartum depression (PPD), also called postnatal depression, is a type of clinical depression which can affect women after childbirth. Symptoms include sadness, fatigue, changes in sleeping and eating patterns, reduced desire for sex, crying episodes, anxiety, and irritability. Although a number of risk factors have been identified, the causes of PPD are not well understood. Many women recover with a treatment consisting of a support group or counseling.^[1][2] The Edinburgh postnatal depression scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression.^[3] If the new mother scores 13 or more, she likely has PPD and further assessment should follow.^[3]

Contents

Signs and symptoms

Symptoms of PPD can occur any time in the first year postpartum.^[5] These include, but are not limited to:

• Sadness^[5]
• Hopelessness^[5]
• Low self-esteem^[5]
• Guilt^[5]
• A feeling of being overwhelmed
• Sleep and eating disturbances^[5]
• Inability to be comforted^[5]
• Exhaustion^[5]
• Emptiness^[5]
• Anhedonia^[5]
• Social withdrawal^[5]
• Low or no energy^[5]
• Becoming easily frustrated^[5]
• Feeling inadequate in taking care of the baby^[5]
• Decreased sex drive^[6]

Onset and duration

Postpartum depression usually begins in the first few months after childbirth. In Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, it is defined as depression with onset within four weeks after childbirth. Postpartum depression can also affect women who have suffered a miscarriage.^[7] It usually begins around two weeks after delivery.^[8] It may last several months or even a year.^[9]

Psychosis

Main article: Postpartum psychosis

Postpartum psychosis is a separate mental health disorder which is sometimes erroneously referred to as postpartum depression. It is less common than PPD, and it involves the onset of psychotic symptoms that may include thought disturbances, hallucinations, delusions and/or disorganized speech or behavior. The prevalence of postpartum psychosis in the general population is 1–2 per 1,000 childbirths, but the rate is 100 times higher in women with bipolar disorder or a previous history of postpartum psychosis. Bipolar disorder and, to a lesser extent, schizophrenia, have elevated prevalences in postpartum psychosis.^[10] Previous research looked at the relationship between childbirth and postpartum psychosis. Using data on 54,000 births over a 12-year period, researchers found that psychiatric admissions were seven times more likely in the first 30 days after childbirth than in the prepregnancy period, and among women who developed postpartum psychosis after childbirth, 72%–80% had bipolar disorder or schizoaffective disorder and 12% had schizophrenia. Indicators of a possible bipolar diagnosis include a history of missed or misdiagnosed mood episodes, any previous mania or hypomania, and a family history of bipolar disorder or postpartum psychosis.^[10]
Treatment for postnatal psychosis is essential; it will not go away without medical attention.^[5]

Effects on the parent-infant relationship

Postpartum depression may lead mothers to be inconsistent with childcare.^[11] Women diagnosed with postpartum depression often focus more on the negative events of childcare, resulting in poor coping strategies.^{[citation needed]} The four groups of coping methods are divided into different styles of coping subgroups. Avoidance coping is one of the most common strategies used.^{[citation needed]} It consists of denial and behavioral disengagement subgroups (for example, an avoidant mother might not respond to her baby crying). This strategy, however, does not resolve any problems and ends up negatively affecting the mother’s mood, similarly of the other coping strategies used.^{[citation needed]}

• Avoidance coping: denial, behavioral disengagement
• Problem-focused coping: active coping, planning, positive reframing
• Support seeking coping: emotional support, instrumental support
• Venting coping: venting, self-blame

Security

Multiple factors must be considered when evaluating the capacity of a seriously depressed mother to provide a safe-enough caregiving environment that can support the healthy development of her baby and her relationship with that baby.^[12] Such factors, including maternal attachment history, present social supports, insight, and ability to accept help, are often best considered by an interdisciplinary professional treatment team that includes infant mental health specialists or other mental health practitioners with experience in working with children and families.

Causes

The etiology of PPD is not well understood. It is sometimes assumed to be caused by a lack of vitamins.^[13] Other studies tend to show the more likely causes are the significant changes in a woman's hormones during pregnancy.^[14] Yet other studies have suggested no known correlation between hormones and postpartum mood disorders,^[7] and hormonal treatment has not helped postpartum depression victims. Further, fathers, who are not undergoing profound hormonal changes, suffer PPD at relatively high rates.^[15] Finally, all mothers experience these hormonal changes, yet only about 10–15% suffer PPD. This does not mean, however, that hormones do not play a role in PPD.^[16] For example, in women with a history of PPD, a hormone treatment simulating pregnancy and parturition caused these women to suffer mood symptoms. The same treatment, however, did not cause mood symptoms in women with no history of PPD. One interpretation of these results is that a subgroup of women are vulnerable to hormone changes during pregnancy. Another interpretation is that simulating a pregnancy will trigger PPD in women who are vulnerable to PPD for any of the reasons indicated by Beck's meta-analysis as summarized above.
Profound lifestyle changes brought about by caring for the infant are also frequently claimed to cause PPD, but, again, little evidence supports this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child.^[17] Plus, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.^{[citation needed]}
In 2009, researchers at the University of California, Irvine, reported the levels of placental corticotropin-releasing hormone (CRH) during the 25th week of pregnancy may help predict a woman's chances of developing postpartum depression.^[18]

Risk factors

While the causes of PPD are not understood, a number of factors have been suggested to increase the risk:

• Birth-related psychological trauma
• Birth-related physiological trauma
• Elevated prolactin levels
• Oxytocin depletion
• Formula-feeding rather than breast-feeding^[19]
• A history of depression^[19]
• Cigarette smoking^[19]
• Low self-esteem^[20]
• Childcare stress^[20]
• Prenatal depression during pregnancy^[20]
• Prenatal anxiety^[20]
• Low social support^[20]
• Life stress^[20]
• Poor marital relationship^[20]
• Infant temperament problems/colic^[20]
• Maternity blues^[20]
• Single marital status^[20]
• Low socioeconomic status^[20]
• Unplanned/unwanted pregnancy^[20]

Of these, formula-feeding, a history of depression, and cigarette smoking have been shown to be additive effects.^[19]
These factors are known to correlate with PPD. "Correlation" in this case means, for example, high levels of prenatal depression are associated with high levels of postnatal depression, and low levels of prenatal depression are associated with low levels of postnatal depression. But this does not mean prenatal depression causes postnatal depression—they might both be caused by some third factor. In contrast, some factors, such as lack of social support, almost certainly cause postpartum depression.^[21] Anthropologists Kruckman and Stern tested the idea cross culturally, and their pioneering study determined six ways in which postpartum rituals, including the use of the postpartum ritual, la cuarentena, in Chicago Latina mothers, to protect or cushion the expression of mood disorders.^[22]
In addition to Beck’s meta-analysis cited above, other academic studies have shown a correlation between a mother’s race, social class and/or sexual orientation and postpartum depression. In 2006, Segre et al. conducted a study "on the extent to which race/ethnicity is a risk factor" for PPD.^[23] Studying 26,877 postpartum women, they found that 15.7% were depressed. Of the women who suffered from PPD, African American women suffered at a rate of 25.2%, American Indian/Native Alaskan women at 22.9%, Caucasian women at 15.5%, Hispanic women at 15.3%, and 11.5% for those reporting Asian/Pacific Islander. Even when "important social factors such as age, income, education, marital status, and baby’s health were controlled, African American women still emerged with significantly increased risk for…PPD".^[23]
Segre et al. also found a correlation between a mother’s social class and PPD. Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those with more financial resources. Rates of PPD decreased as income increased as follows:^[23] Women with fewer resources are also more likely to have an unintended or unwanted pregnancy, further increasing risk of PPD. Beck (2001) concurs with this, stating that these women are at risk for PPD because they may experience stressors such as financial difficulties. Single mothers of low income may have fewer resources to which they have access while transitioning into motherhood.

Income	PPD rate
<$10,000	24.3%
$10,000-$19,000	20.0%
$20,000-$29,000	18.8%
$30,000-$39,000	15.3%
$40,000-$49,000	13.7%
$50,000+	10.8%

Likewise, a study conducted by Howell et al. in 2006 confirms Segre’s findings that women who are not Caucasian and in lower socioeconomic categories have more symptoms of PPD.^[24]
In a 2007 study conducted by Ross et al., lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample. Ross et al. found that "lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale (EPDS) scores than the…sample of heterosexual women."^[25] The Ross study suggests that PPD may be more common among lesbian and bisexual mothers. From a study conducted in 2005 by Ross, the higher rates of PPD in lesbian/bisexual mothers than heterosexual mothers may be due to less "social support, particularly from their families of origin and…additional stress due to homophobic discrimination" in society.^[26]

Evolutionary psychology

Research suggests that PPD is a functional component of human reproductive decision-making, research supports the notion that PPD caused mothers to decline investment in their offspring.^[27]
Human infants require an extraordinary degree of care. Lack of support and insufficient investment from fathers and/or other family members will increase the costs borne by mothers, whereas infant health problems will reduce the evolutionary benefits to be gained.^[27] If ancestral mothers did not receive enough support from fathers or other family members, they may not have been able to afford raising the new infant without harming any existing children, or damaging their own health (nursing depletes mothers' nutritional stores, placing the health of poorly nourished women in jeopardy).
For mothers suffering inadequate social support or other costly and stressful circumstances, negative emotions directed towards a new infant could serve an important evolved function by causing the mother to reduce her investment in an unaffordable infant, thereby reducing her costs. Numerous studies support the correlation between postpartum depression and lack of social support or other childcare stressors.^[20][27] Kruckman, using observations from anthropological field work, suggests that supportive rituals and knowledge, if projected to the mother in a meaningful and sincere fashion, can affect the hypothalamus, pituitary and adrenal function and the production of endocrine signal molecules, and reduce the expression of anxiety or panic in postpartum women.^[28][29]
Mothers with postpartum depression can unconsciously exhibit fewer positive emotions and more negative emotions toward their children, are less responsive and less sensitive to infant cues, less emotionally available, have a less successful maternal role attainment, and have infants that are less securely attached; and in more extreme cases, some women may have thoughts of harming their children.^{[20][30][31][32][33][34][35][36][37][38]} In other words, most mothers with PPD are suffering some kind of cost, like inadequate social support, and consequently are mothering less.^{[improper synthesis?]}
In this view, mothers with PPD do not have a mental illness, but instead cannot afford to take care of the new infant without more social support, more resources, etc. Treatment should therefore focus on helping mothers get what they need.^[27][39]

Prevention

Early identification and intervention improves long term prognoses for most women. Some success with preemptive treatment has been found as well. A 2013 Cochrane review found evidence that psychosocial or psychological intervention after childbirth helped reduce the risk of postnatal depression.^[40][41] These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy.^[40]
A major part of prevention is being informed about the risk factors, and the medical community can play a key role in identifying and treating postpartum depression. Women should be screened by their physician to determine their risk for acquiring postpartum depression. Also, proper exercise and nutrition appears to play a role in preventing postpartum, and depressed mood in general.
In the US, the American College of Obstetricians and Gynecologists recommends that the first prenatal visit include screening for depression, stress, support, and whether the pregnancy was planned.^[42] However providers do not consistently provide screening and appropriate follow-up.^[42] Currently, Alberta is the only province in Canada with universal PPD screening which has been in place since 2003. The PPD screening is carried out by Public Health nurses in conjunction with the baby's immunization schedule.

Treatment

Numerous scientific studies and scholarly journal articles support the notion that postpartum depression is treatable using a variety of methods. If the cause of PPD can be identified, as described above under "social risk factors", treatment should be aimed at mitigating the root cause of the problem, including increased partner support, additional help with childcare, cognitive therapy, etc. Non-professional interventions can be effective.^[43][44]
Women need to be taken seriously when symptoms occur. This is a twofold practice: First, the postpartum woman will want to trust her intuition about how she is feeling and believe that her symptoms are real enough to tell her significant other, a close friend, and/or her medical practitioner; erring on the side of caution will go a long way in the treatment of PPD.^[5] Second, the people in whom she confides must take her symptoms seriously as well, aiding her with treatment and support. Partners, friends and physicians may notice changes in a postpartum mother that she may not. Knowing that PPD is treatable with a variety of methods can make persistence in seeking treatment easier.^{[citation needed]}
Various treatment options include:

• Medical evaluation to rule out physiological problems
• Cognitive behavioral therapy (a form of psychotherapy)
• Possible medication
• Support groups
• Home visits/Home visitors
• Healthy diet
• Consistent/healthy sleep patterns

An experienced medical professional will work with a postpartum mother to develop a treatment plan that is right for her. This plan may include any combination of the above options, and might include some discussion or feedback from/with a partner. If a woman suffering from PPD does not feel she is being taken seriously or is being recommended a treatment plan she does not feel comfortable with, she will want to seek a second opinion.^[5] Other forms of therapy (like group therapy and home visitors) are also effective treatments for PPD.^[5]
A woman will want to discuss the various treatment options available with her physician and, if considering drug therapy, should speak about which medications are safe to take while breastfeeding.
Treatment for PPD can reduce the length of suffering and its severity. Untreated, the Baby Blues may go away on its own (and does in most cases). PPD may or may not go away without treatment. Speaking to a health care provider as soon as symptoms occur is the safest way to ensure prompt treatment and return to normal life.
According to The National Institutes of Mental Health, studies show that the childbearing years are when a woman is most likely to experience depression in her lifetime. Approximately 15% of all women will experience postpartum depression following the birth of a child.^[45] When the mental health of the mother is compromised, it affects the entire family.^[46]

Epidemiology

Postpartum depression are found across the globe, with rates varying from 11% to 42%.^[47]

Society and culture

The Malay culture holds a belief in a spirit known as Hantu Meroyan that resides in the placenta and amniotic fluid. When this spirit is unsatisfied and venting resentment, it causes the mother to experience frequent crying, loss of appetite, and trouble sleeping, known collectively as "sakit meroyan". The mother can be cured with the help of a shaman, who performs a séance to force the spirits to leave.^[48] Some cultures believe that the symptoms of postpartum depression or similar illnesses can be avoided through protective rituals in the period after birth. Chinese women participate in a ritual known as "doing the month" in which they spend the first 30 days after giving birth resting in bed, while the mother or mother-in-law takes care of domestic duties and childcare. In addition, the new mother is not allowed to bathe, wash her hair, leave the house, or be blown by the wind.^[49]