The experience of postnatal depression occurs for approximately 10-15% of women within the first few weeks postpartum. Although often thought of as a biological depression, presumably because of the significant hormonal changes accompanying childbirth, postnatal depression is not characterised by so-called "endogeneous" features, and there is lower suicidal ideation than in other types of depression (Bhugra & Gregoire, 1993). From what little research that has been carried out, there appears to be a pattern emerging of a complex interaction of a number of factors (e.g., Boyce, 2003).
Childbirth itself is a significant life event that can range from being completely unwanted and seen as a tragedy, to the opposite extreme of being something wanted desperately and therefore extremely positive. Without knowing the circumstances, therefore, it would be possible, in theory, for the event to increase the likelihood of depression for some women, but considerably decrease the likelihood for other women. However, even when a pregnancy is planned or wanted, there are additional factors that may come into play including the impact of the transition to parenthood on other valued roles and goals and the degree to which the members of the mother's close social network provide good support with the extreme emotional and practical demands that follow (e.g., Nolen-Hoeksema, 2002). In terms of other roles and goals, if parenthood leads to the loss of ones that are valued, or leads to perceived conflict with these roles and goals, then depression is more likely to follow (e.g., Simon, 1992). In addition, the woman may approach the transition to motherhood with high expectations of being the perfect mother, even perhaps with the intention of making up for perceived weaknesses in how she herself was parented (cf. Markowitz, 2004). Moreover, as a mother there may be particular emotions that are not allowed towards the newborn baby, which, if they are experienced, may lead the mother to conclude that she is bad or to feel frightened of being left alone with the baby. In such cases, the spouse or partner may play a significant role. Thus, as in other types of depression discussed above, a poor marital relationship and low levels of social support have been the two factors most consistently found to be associated with the occurrence of postnatal depression (Bhugra & Gregoire, 1993; Kumar & Robson, 1984; Murray & Cooper, 2003).
In relation to the model that we have presented in this chapter, although there is much less research to draw on, there nevertheless seems to be some support for the SPAARS approach. If the occurrence of pregnancy and childbirth leads to the loss of or conflict with other valued roles and goals, then the mother will experience sadness because of those losses. This reaction will be exacerbated by a poor marital relationship. In addition, the ambivalent mother is likely to experience negative feelings towards the newborn child and towards her own reactions to motherhood. The physical and mental stresses involved in supporting a newborn child with little or no other support, will make the direct route to emotion more likely, as tiredness and exhaustion reduce the capacity for appraisal-based emotional responses. The mother may "catch herself" reacting in completely ego-alien ways, such as shouting at the newborn. These shame-disgust-based reactions to herself and to her child may provide the final part of the jigsaw that leads to postnatal depression.
One of the factors that makes parenting more problematic is of course the quality of parenting that the new mother and father themselves received as children (e.g., McMahon, Barnett, Kowalenko, & Tenant, 2005; Murray & Cooper, 2003). For example, in an interesting study of the partners of women with postnatal depression, Lovestone and Kumar (1993) reported that these men also had high rates of depression and other disorders themselves. The two factors that were predictive for depression in the men were, first, a past history of psychiatric problems, and, more interestingly, a poor relationship reported with their own fathers, but not with their mothers or with their wives. This finding was obtained on two different measures, one the Parental Bonding Instrument that retrospectively assesses childhood parental support, the other being the Significant Others Scale, which measures current levels of support. One can only speculate, as did Lovestone and Kumar, that if the schematic model of one's same-sexed parent is deficient as a parent, when plunged into that role oneself extreme feelings of self-inadequacy may result.
Two other disorders that are observed following childbirth are the "maternity blues" and the puerperal psychoses. Maternity blues are common within the first 10 days postpartum, typically lasting for 1 to 2 days. They occur in 50-70% of women and they seem to occur irrespective of the cultural practices surrounding childbirth (Bhugra & Gregoire, 1993). The frequency and timing of the problem suggests that it may be of hormonal origin and Kennerley and Gath (1989) have also shown that it is related to severe premenstrual tension. However, in their prospective study, Kennerley and Gath also found that the blues were related to anxiety and depression occurring during pregnancy, to anxieties about labour, and to the ubiquitous poor family and marital relationships. Therefore although there is a clear biological foundation for the problem, psychological and social factors are also significant. There does not seem to be any clear relationship between the occurrence of maternity blues and the occurrence of postnatal depression, although there is some suggestive evidence that their presence is a risk factor (e.g., Henshaw, Foreman, & Cox, 2004; Kumar & Robson, 1984).
The puerperal psychoses are much rarer than the maternity blues or postnatal depression with a prevalence of about one per thousand births (Brockington, 1996). From their large case-register study, Kendell, Chalmers, and Platz (1987) found that the highest risk was during the first 30 days postpartum, although some risk continued even after several months. Factors that increased the risk were being primiparous, a family history of affective disorder, obstetric complications, and, of course, a poor marital relationship. Kendell et al. (1987) did in fact conclude that most puerperal psychoses were actually bipolar disorders that had been triggered by childbirth, a conclusion that has been supported by more recent evidence (Chaudron & Pies, 2003). If true, then it is interesting evidence again that even in the most apparently biological of disorders one must examine the interplay with psychological and social factors as well.
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