Mental ill health during early motherhood, or ‘perinatal mental illness’, is a serious public health issue with potentially serious consequences for women’s life-long mental health and the health and wellbeing of their children and families (Hayes, et al, 2001). Although difficult to estimate, there are also economic and social costs associated with the cognitive and behavioural impact of postnatal depression. As of 2008, the national economic burden of this condition to public services is estimated at £35.7 million per annum. The mean estimated cost for maternal care in the community for those with postnatal depression is 55% higher than for those without (Petrou et al, 2002). It can also herald the onset of long-term mental health problems for the mother and is associated with increased risk of maternal suicide (Oates, 2003). Postnatal depression has also been linked with depression in fathers and with high rates of family breakdown (Ballard, 1994). There is also evidence that children born to depressed mothers do less well educationally, experience higher levels of behavioural problems and are more likely to develop psychological problems in later life (Oates, 2002).

Social support is a flexible concept – so broad that its meaning can easily be assumed, or bent to different purposes, rather than overtly attended to. This produces problems in researching social support since the underlying assumptions or theoretical frameworks of the work are not always clear. Postnatal depression has been associated with a lack of social support (Bebbington, 1998). The risk of PND has been found to increase when the level of social support is low or absent (Morse et al 2000; Pederson 1999). Beck (1992) states that social support not only provides practical help, but can aid the mother emotionally by hindering the common experience of rumination.

There are three common forms of postnatal illnesses: the baby blues, postnatal (or postpartum) depression and puerperal psychosis, each of which differs in its prevalence, clinical presentation, and management. Postnatal depression is the most common complication of childbearing (Wisner, et al 2002), affecting 10-15% of women (Cooper et al, 2008). According to the National Institute for Clinical Evidence (NICE, 2007) postnatal depression (hereafter also known as PND) has been defined as non-psychotic depression occurring during the first 3 months following the birth of a baby. The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) defines the perinatal period as commencing at 22 completed weeks (154 days) of gestation and ending seven completed days after birth (WHO, 1992). In the fourth edition of the Diagnostic & Statistical Manual (DSM-IV), the American Psychiatric Association makes no mention of perinatal mental illness although postnatal depression is included, but only if the mother is diagnosed within four weeks of the birth (American Psychiatric Organisation, 1994).

The interest and motivation for exploring the topic of postnatal depression is due to professional experience of working in this field. This dissertation seeks to explore the variety of approaches for treating PND, focussing on the role of social support. Current national policy and frameworks will be examined, together with current practice of interventions.

Evaluating Mental Health Policy

There have been many discussions about whether depression during the early postnatal period is either quantitatively or qualitatively different from depression at other times (Stoppard, 2000) and has been the focus of much policy and research since the 1960s (Brockington, 1998). In 2004, the National Institute for Clinical Evidence (NICE) asked the National Collaborating Centre for Mental Health (NCCMH) to develop a clinical guideline on the treatment and management of mental health problems in the antenatal and postnatal period (NCCMH, 2004). Before this, the Department of Health published a 10 year agenda for improving mental health care in England, known as the National Service Framework for Mental Health (NSF, 1999) which set priorities for the way that services were to be provided. The NSF proposed protocols to be implemented for the management of postnatal depression, anxiety disorders and those needing referral to psychological therapies. The NSF recognised the role of Health Visitors with training who could use routine contact with new mothers to identify PND and treat its milder forms. Furthermore, the NSF related to actions to reduce suicides, by ensuring that staff would be competent to assess the risk of suicide among individuals at greatest risk. This standard was relevant to Health Visitors, as maternal suicide was cited as the largest cause of maternal death in the first postnatal year.

Subsequent policy statements and guidance have since been supplemented to the framework, including the National Institute of Clinical Evidence (NICE, 2007) guidelines for antenatal and postnatal mental health (NICE-CG45, 2007). The NICE guidance identifies the need for emotional and social support for new mothers, whilst the National Service Framework aims to deliver a high quality standardized service. In 2007, the in-depth guidance was published where the standards for postnatal mental health needs were summarized as:

All professionals involved in the care of women immediately following childbirth need to be able to distinguish normal emotional and psychological changes from significant mental health problems, and to refer women for support according to their needs

All professionals directly involved in the care of each woman who has been identified as at risk of a recurrence of a severe mental illness following the birth, including the family, are familiar with her relapse signs

Each woman who has been identified as at risk of a recurrence of a severe mental illness has a written plan of agreed multi-disciplinary interventions and actions to be taken

The Department of Health issued guidance in 2009, called the ‘Healthy Child Programme: pregnancy and the first five years of life’ and is an update to the National Service Framework for Children, Young People and Maternity Services (2004). The programme emphasises the NICE guidelines, including the need for the woman to be asked sensitive and appropriate questions to help identify depression. Additionally, the programme states the need for parent-infant groups, baby massage, listening visits, cognitive behavioural therapy and interpersonal therapy.

In February 2011, the Government published its new Mental Health strategy ‘No Health without Mental Health’ which acknowledges that mental health is a public health issue that needs co-operation from many different agencies, including education, social care, housing, employment and welfare.

According to NICE (2007), various psychosocial and psychological treatments are recommended for the management of depression in the postnatal period:

Social support – can be defined in terms of sources of support (e.g. spouse, friends and relatives, support groups), or in terms of the type of support received, (e.g. informational support, emotional support, practical support).

Non-directive counselling – an empathic and non-judgemental approach, listening rather than directing but offering non-verbal encouragement. This approach is usually offered by health visitors.

Self-help strategies:

Guided self help

Computerized cognitive behavioural therapy (C-CBT)

Exercise

Brief psychological treatment

Structured psychological treatment:

Cognitive behavioural therapy

Interpersonal therapy

NICE guidelines clearly state that PND services are subject to local variation due to locally existing services. To ensure the effective provision of high quality clinical services, it is essential that there is a clear referral and management protocol for services with a well defined pathway. Furthermore, NICE guidance states that services should develop clinical networks to improve access for women to specialist perinatal mental health services.

In a report published in March 2011 by the Patients Association, it was found that 64% of Primary Care Trusts (PCT’s) do not have a specific strategy in place when commissioning services specific to PND. World Class Commissioning (www.icn.csip.org.uk) clearly states that PCT’s should have services that accurately reflect the needs of the local population. The report also shows that 44% of PCT’s are failing to implement the NICE guidance due to not being part of a clinical network or not having a lead clinician for perinatal mental health.

Is there a problem?

What is it?

Why does it need to be solved?

What is your hypothesis (hunch)?

Who will benefit from your investigation?

In what sense will they benefit?

In what sense will my contribution add to what is already known?

How in general terms are you going to solve the problem, e.g., collect data, analyse data?

By what methods? E.g., a case study approach.

What are the constraints or limitations of the study?

Methodology (<1000)

The title of this dissertation is postnatal depression and the role of social support from a feminist perspective.

A systematic literature review was conducted

The search methods used for the literature review were as follows:

Databases searched included: MEDLINE, CINAHL, DAWSONERA, PsychLit, EBCOHOST, CENTRAL and DARE.

Published books as listed in the References.

Published articles in hard copy journals.

Key terms were: postnatal depression, postpartum depression, isolation, social support, stigma, mental illness

The searches were designed to be as inclusive as possible

The searches were limited to articles between 1985 and 2011.

An additional google search was conducted

Overall, a total of ( ) abstracts were identified by the literature searches, over ( ) papers were assessed resulting in the final reference list of ( ) papers.

Methodological limitations

Ethical limitations

The overall aim of this study is to understand postnatal depression and the objectives are as follows:

Explore the different sources of social support for new mothers in the year following childbirth

To evaluate the effectiveness of different models

To examine the evidence of efficacy of social support

To consider the findings in relation to policy and practice interventions and guidance of perinatal mental health

Theoretical Perspective

Brewer (2000) states that theory is a ‘set of interrelated abstract propositions about human affairs and the social world’. While much of the research on postnatal depression has been subjective, it may provide a political and ideological commitment to supporting the development of health services specifically targeted at women’s health needs. Such a political process is consistent with the drive of feminist concerns that the health care system has failed to distinguish the particular needs of women (Najman, et al, 2000). This dissertation will attempt to look at the role of social support role from a feminist perspective.

According to Busfield (1996), feminism is a philosophy suggesting that women have been systematically disadvantaged. Durrheim (1999) argues that feminist theorists aim to change this by investigating the situations and understanding the experiences of women in society and in doing so, provide a better world for women. Feminist research is opposed to patriarchal societies, which attempt to understand the world in order to control and exploit its resources. Feminists also describe the male point of view as objective, logical, task-orientated and instrumental. It reflects a male emphasis on individual competition, on dominating and controlling the environment (Neuman, 1997). Further, by examining postnatal depression through a feminist lens, the mechanism of social structure that contributes to the pressure to find motherhood a perfect, happy time can be addressed.

Postnatal depression has been reported and studied since 1858 (Richards, 1990). In the nineteenth century, psychiatric disorders due to pregnancy and childbirth were common enough to account for 10% of all asylum admissions (Marland, 2003). Allen (1986) states that writer Chesler (1972) assumes that psychiatry sees women as “madder than men” and is perhaps rooted in the historical context of women’s psycho-pathology being linked with femininity (Showalter, 1987).

Taylor (1996), suggests that the dominant discourse surrounding postnatal depression overlooks the social construction of gender order and conventional gendered power dynamics. Furthermore, she stresses that the media play a role in blaming mothers, questioning appropriate behaviour and the choice of self-identity outside of motherhood. The structure of families in modern society creates problems of isolation and alienation (Taylor, 1996) as we move away from the traditional nuclear family unit and loss of close extended family ties.

Over the past decade, self-help, recovery, and support groups that draw upon the discourse of feminism have gained increasing importance as sources of emotional support and settings in which women seek to redefine the female self.

Models of mental illness

Postnatal depression is conceptualized as a “disease” or “illness” and research efforts have been devoted to describing, predicting, preventing, and treating it (Cox & Holden, 1994). Researchers have also endeavoured to uncover the underlying factors associated or correlated with postnatal depression, including biological variables such as hormones, other biochemicals, genetic factors; psychological characteristics such as personality traits, self-esteem, previous psychiatric history, family history, attitudes towards children, deficiencies in self-control, attribution style, social skills; a range of social variables, for example an unplanned pregnancy, method of feeding the baby, type of delivery, obstetric complications, infant temperament, previous experience with babies, marital relationship, social support, stressful life events, employment status, and socio-demographic characteristics such as social class, age, education, income, parity (O’Hara & Zekoski, 1988).

Mental illness can be difficult for people to understand or empathise with. Similarly, even mental health professionals can have difficulties in understanding what is going on for the patient, as there is no one diagnostic test that can be performed on the brain in an attempt to provide a simple answer or treatment. The effects of mental illness are made apparent in actions, feelings and thoughts, and therefore a model – or group of linked theories – is used to explain the cause and predict the best source of treatment. Doctors helping people with mental illness have models to guide them in both diagnosis and treatment. Most models of mental illnesses will nowadays acknowledge a combination of biological, psychological and social factors. Different models will, however, vary in which factors they rate as the most important. When advising a patient, a doctor tries to look at which interventions are likely to work best for that particular patient, taking into account the patient’s symptoms and circumstances. Models are the basis of every scientific belief.

The medical model and behavioural model of psychiatric illness differ in their assumptions about the nature of the illness and the appropriate treatment (ref), however many practicing psychiatrists use features from both in the ‘bio-psycho-social’ model (ref). Psychological models such as the learning theory, personal construct theory and psychoanalytic theory differ in the time-scale over which they try to produce explanations of behaviour.

A biological model of mental illness is based on the presumption that the illness has a physical cause and therefore requires a physical treatment. This model suggests that mental illness is caused by chemicals, genetics or hormonal imbalances and such, a biological intervention or treatment would be drugs to reverse the chemical imbalance.

A psychological model says that disruption or dysfunction in psychological processes lead to mental illness. Furthermore, personal experiences, social and environmental factors are important contributors to psychological distress. Taking anti-depressant medication would not be treating the cause of the problems; therefore treatment would be in the form of therapy such as psychoanalysis and cognitive behaviour therapy.

There are two social models of mental illness: the labelling theory states that behaviours disliked by society are labelled as symptoms of a psychiatric illness. Labelling a person as having a disease, particularly mental illness is to become that illness, for instance “she’s mental” and it is therefore easy to understand the concept of blame and stigma surrounding mental illness. Society believes that we can and should be able to control our psyche and emotions and thus the descent into mental crisis should be avoidable and controllable. Labelling, therefore, questions the very existence of mental illness and helps to maintain the imbalance of power between men and women (Taylor, 1996). Labelling a gendered illness provides society with a more palatable acceptance of the disease and its options for treatment. Szasz (1962) examined the concepts of stigma in mental illness and criticised the ways in which psychiatry made assumptions about those labelled as mentally ill.

Another theory is that social situations can lead to a mental illness. For instance poverty leads to situations that a person cannot control, which can lead the person to develop anxiety. Some researchers suggest that the availability of medical care and expectations of quality of life following the birth of a baby (Thurtle, 1995) lead to postnatal depression.

Feminist sociologists have looked at the impact of social factors on women’s mental illness from three different perspectives: societal causes, medical causes and the mother herself (Taylor, 1996). A typical feminist approach would be to question whether a historically patriarchal tradition, namely medicine, can realistically address the experiences and needs of women.

Medical perspectives consider that women’s unhappiness and discontent is framed in psychiatric terms and are therefore treated accordingly. The medical model has been the dominant theoretical perspective of postnatal depression and according to a feminist perspective this disempowers women’s individual experiences. While feminist researchers have criticized the medical model for the way it blames individual mothers for their difficulties, mothers themselves feel that the medical label and status, and the hormonal explanation, have the opposite effect of releasing them from blame and responsibility because the depression is something which is happening to them, their bodies and is therefore beyond their control. It is reassuring for some to know that they were not “going mad” but experiencing a medically recognized “problem,” shared by other mothers, and for which they were neither responsible nor to blame. Oakley (ref) suggests that pregnancy and childbirth are constituted as a disease by the medical profession.

In an article written for the British Journal of General Practice, Richards (ref) questioned whether giving the diagnosis of postnatal depression to tired, overwhelmed women, simply allows them to claim sickness benefit. Considerable effort has been put into research into the causes of postnatal depression from a biological or hormonal reason; however Richards (1990) believes that no consistent relationship has been found.

Dalton (1989) claims that there are endocrinology reasons for depression after childbirth, and that this could be treated by diet or hormonal treatment. However Oakley (1980) criticizes this view from a feminist perspective, believing this emphasizes women as reproducers. Despite Daltons (1989) opinion that postnatal depression is caused by hormones, she does believe that social and psychological support could benefit the mother.

Kitzinger (2006) believes that many women are wrongly labelled as suffering from postnatal depression because they are unhappy after the birth, when in fact their distress is the result of a medically managed but traumatic birth. Kitzinger (2006) argues that “the failure of the maternity services to give humane care can be ignored” when the focus is placed on the mother’s performance during childbirth. There are many theoretical perspectives that seek to explain the notion of postnatal depression and this dissertation will be focussing on the feminist perspective in a later chapter.

Chapter 2 – Postnatal Depression

The postnatal period is well known as an increased time of risk for the development of serious mood disorders. Many women feel exhausted, not just from the physical efforts from giving birth, but the emotional effects of adjusting to their new role as a mother. Although this dissertation is concentrating on postnatal depression, there are two other important conditions that can be diagnosed after the birth, which will be briefly mentioned as follows;

Baby blues

Baby blues is the term used to describe temporary feelings of tearfulness and lack of concentration either immediately following the birth or within a few days, sometimes coinciding with the mothers’ milk coming in. These feelings may come as a shock to the mother, as she may have expected to feel joy and elation. This condition is very common in up to 80% of new mothers, so is considered as normal, but generally passes after about ten days. There is no treatment for the baby blues, however practical and emotional support in these first few days would be helpful.

Puerperal psychosis

Puerperal psychosis is a terrifying and rare complication following the birth affecting between one in 500 and one in 1000 mothers. The symptoms are hallucinations and delusions and often the mother believes that the baby is evil, she hears voices and can be confused. The word ‘psychosis’ is simply a medical term, which means, according to the dictionary:

“any severe mental disorder in which contact with reality is lost or highly distorted”

The common treatment is anti-psychotic medication; however the mother may have to be admitted to a psychiatric unit for observation.

Symptoms of PND

The onset of postnatal depression can be gradual and difficult to distinguish either from the normal emotional sensitivity of recent childbirth, or because the mother is hesitant to disclose her true feelings. Many women feel that they may not need support or that they can manage on their own, whereas others may think there is a stigma attached to admitting feeling depressed. Some of the identifying symptoms of postnatal depression can be physical, however the majority are emotional and affect the everyday life of the mother. In order for a diagnosis to be made, at least five of the following symptoms have to be present for at least two continuous weeks;

Feeling unable to cope, loss of confidence, feeling inadequate

Panic attacks, excessive anxiety and obsessions about the baby, routines and cleaning

Negative thoughts, irrational thoughts, depressed mood

Feeling little/no love for the child, delayed/no bonding with the baby

Not enjoying motherhood and wondering what is wrong with them because of it

No interest or pleasure in anything, boredom, things seeming pointless

Suicidal thoughts

Constantly needing reassurance

Fear that if they asked for help their baby would be taken away

Feeling a burden to family and friends

Everything seeming negative, unable to remember positive times/things

Things getting out of proportion, being thrown by even small things

Tiredness, lethargy

Loss of appetite, weight loss

Loss of interest in sex, loss of libido

Risk factors

There is considerable discussion surrounding the cause of postnatal depression (Richards, 1990). In a report written by O’Hara and Zekosi (1996), their findings led to the conclusion that PND reflects the coincidental occurrence of the puerperium and depression, rather than reflecting a causal relation between childbearing and depression. However, Kumar et al, (1984) found that childbearing in itself has a damaging effect on the mental health of women. Martin et al (2001) conducted a comparison of women in a psychiatric mother and baby unit and concluded that puerperal depression has a distinct biological aetiology. This conflicts with Richards (1990) conclusion that there is no link.

According to Harlow (2003), any mother can be affected by postnatal depression, with no relation to age, social class, cultural background or educational status. However, research studies have consistently shown that the following risk factors are strong predictors of PND:

Poor quality social support

An unstable or unsupportive relationship

Depression or anxiety in pregnancy

Previous history of sexual abuse

Recent stressful life events

Labour/birth trauma

In addition to many factors on the mother’s side, there may be a relation between the behaviour of the infant that has an effect on maternal depression. In a study of 188 first time mothers, neonatal irritability and poor motor function was found to predict postnatal depression (Murray et al. 1996). There are few studies on the role of infant factors in the aetiology of postnatal depression, but it is possible that the babies react to parental mood and depression and vice versa.

Prevalence

According to Cox (1993) the incidence of women developing postnatal depression in the UK is between 10-12%. However, a study conducted in 2002, found that 27% of mothers aged between 15-44 years of age were found to be suffering from postnatal depression, of which half of them had contacted their GP within 4 months of the birth (Kaye, 2002). The rate of prevalence has varied due to different criteria (e.g, general practitioner’s or psychiatrist’s diagnosis, self-report questionnaire, clinical interview), different study designs and different time intervals (from few days up to several years) used. O’Hara (1987) suggested that the symptoms of postnatal depression can be relieved and diminished within one to six months, but sometimes depression can become chronic. Thus, it should be acknowledged that without effective treatment postnatal depressive symptoms may continue for as long as one to two years.

The sixth report of the confidential enquiries into maternal deaths in the UK, Why Mothers Die, reported suicide as the most common cause of maternal death for women in the first year after childbirth. According to the Confidential Enquiries Report for Mothers and Child Health (Lewis, 2004) the number of suicides by women during the perinatal period has declined from 29 in 1997-1999 to 21 known suicides in 2000-2002. Depression can lead to more deaths from suicide each year than there are deaths from road accidents.

According to Gregoire et al (1996), if postnatal depression is left untreated, 25% of women will continue to suffer one year after delivery and one in twenty-one women will still have postnatal depression two years later (Lumley et al, 2003). The statistics also show that women with untreated PND are at least 300 times more likely to suffer again in subsequent pregnancies (Hamilton et al, 1992).

Detection

There are a number of rating scales used to measure and detect postnatal depression. In many countries, health visitors screen for PND using the Edinburgh Postnatal Depression Scale (EPDS), which is a 10-item self-reporting screening instrument to aid the detection of post-natal depression (Cox et al. 1987; Murray and Carothers 1990; Warner et al. 1996; Wickberg and Hwang 1996b). This is designed to assess the mother at 6-8 weeks after the birth by the Health Visitor at home (appendix). A threshold score of 12 has been used as an indication that correctly identifies at least 80% of mothers with major depression (Cox et al. 1987; Harris et al. 1989; Murray and Carothers 1990).

The NICE guidelines recommend the use of the ‘Whooley’ questions (appendix) as a simple screening method to detect postnatal depression. This screening technique is used by health visitors at the initial contact and offers the opportunity to screen without a formal assessment.

However, the EPDS and Whooley questions are not diagnostic tools in their self, and should always be used in conjunction with a clinical evaluation if necessary.

Consequences of postnatal depression

Different mechanisms have been proposed to explain the effect of postnatal depression to child’s psychopathology (Murray and Cooper 1997). Whiffen (1989) suggests that infant temperament and behaviour is related to postnatal depression, both as a consequence and a cause of it. Mothers with chronic depression have infants with more behavioural problems such as sleeping and eating problems and temper tantrums (Campbell et al. 1997), and severity of depressive symptoms associates with compromised cognitive and attachment security (Lyons-Ruth et al. 1986). A second effect might be the maternal interactional and parenting style, secondary to maternal depression. Mothers with postnatal depression may be emotionally unavailable for their infants and they may withdraw from interaction situations. In addition, they may respond in an inappropriate or unpredicted or even unreceptive manner to their child.

Paternal postnatal depression is rarely reported or studied, but estimated rates of paternal depression have varied from 4 to 13% (Ballard et al. 1994, Areias et al. 1996) in the early postpartum period.

Treatment and Prevention

If postnatal depression is left untreated, it can persist for many months with adverse consequences for mothers, children and families (Josefsson et al, 2001). There is the possibility of short and long-term consequences for the baby’s cognitive, social and emotional development. Depressed mothers make more negative and fewer positive responses to their babies and the infants learn a style of interaction that transfers to their subsequent interactions with other people (Field, et al 1988). Longer term adverse influences

have been demonstrated on children’s language development, IQ and social development (Coghill et al . 1986; Sharp et al . 1995; Murray et al. 1996; 1999).

Typically, mothers with postnatal depression go through silent suffering. Effective

treatments are available, but help is often not actively sought. Small and his group (1994)

found out that only one third of depressed mothers sought professional help. However,

these mothers often advised other depressed mothers to find someone to talk to.

However, the evidence for the effectiveness of interventions to prevent postnatal depression is conflicting. Stuart, et al, (2003) suggested that early intervention, even in the antenatal period is an effective way of tackling postnatal depression. Midwives counselling, given support and explanations about the childbirth prior to labour provided a better postnatal mental health of the mothers (Lavender and Walkinshaw 1998). The statistical power of existing studies is, however, very limited (Lawrie 2000). The provision