What is postnatal depression?
Postnatal depression is characterized by feelings of hopelessness, agitation, sadness, despondency, suicidal ideation, and a perceived inadequacy in caring for the infant (Born, Zinga, & Steiner, 2004). It is defined by the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a major or minor depressive episode affecting women within four weeks after childbirth (American Psychiatric Association, 2013). However, this definition is often expanded by clinicians and researchers to occur anytime within the first year postpartum (Stowe, Hosetter, & Newport, 2005).
The burden of postnatal depression
Research (meta-analyses) that examine the prevalence of postnatal depression estimates rates of 20% in low- and middle-income countries compared to 13% in high-income countries (O’Hara & Swain, 1996). Women who experience postnatal depression without receiving adequate treatment are at a greater risk of suffering chronic and recurrent depression throughout life, which can be profoundly disabling (Patel et al., 2012). For example, suicide as a result of postnatal depression and other mental disorders is a leading cause of death among women in the postpartum period.
Not only the women who experience postnatal depression suffer its consequences. This disorder is associated with weak maternal-infant attachment and delays in children’s cognitive and emotional development. It is also associated with early cessation of breastfeeding, which contributes to malnutrition and diarrheal diseases in infants, especially in low- and middle-income countries (Cooper, Murray, & Stein, 1993).
A closer look at research on postnatal depression in Mexico
Over the last few years we have led several studies focusing on epidemiological, health systems and policy aspects related to postnatal depression in Mexico. These studies have been carried out by the Mexican National Institute of Public Health in collaboration with the University of South Carolina in the USA. Postnatal depression is not uncommon among Mexican women. One community-based study estimated prevalence to be 14% among adult women and 16% among adolescent women who received postpartum care in an urban, public-sector hospital (deCastro et al, 2011). Risk factors for postnatal depression in Mexico include lack of social support, lower levels of education, reported fear during labor, lack of a partner, unplanned pregnancy, and even giving birth to a baby girl compared to a baby boy (Lara et al., 2012; deCastro, 2011). Previous episodes of depression, anxiety, and stress during pregnancy, history of trauma, and feelings of incompetence in mothering have also been significantly associated with postnatal depression among Mexican women (Alvarado-Esquivel et al., 2010; Navarro et al., 2011).
Early identification of risk factors is an important strategy to prevent onset of postnatal depression. In fact, results from an analysis of predicted probabilities among a hospital-based sample of Mexican women indicate that postnatal depression could be reduced to 5.5% if the risk factors of low social support, unplanned pregnancy, and exposure to intimate partner violence (IPV) during pregnancy were eliminated (deCastro et al, under review). IPV during pregnancy, in particular, is a significant risk factor for postnatal depression. Results from one study we conducted among a sample of women from Mexico City indicated that one in five women experience IPV during pregnancy, which includes emotional, physical, or sexual abuse. Compared to women who did not report such violence, the women who reported IPV during pregnancy were significantly more likely to develop postnatal depressive symptoms (deCastro et al, 2014, in press).
Due to the substantial negative effects of postnatal depression and the importance of effectively addressing it, we have focused our research on how healthcare providers detect and treat postnatal depression in primary, secondary and tertiary-levels of care in Mexico (Place et al, 2013; deCastro et al, under review). Consistent with evidence suggesting the influence of psychosocial risk factors on postnatal depression, a sample of healthcare providers likewise expressed an understanding of how social and behavioral antecedents, including extreme poverty, high expectations for women as mothers, and IPV have an impact on the occurrence of postnatal depression. These same providers often viewed any symptoms of distress as representing a possible case of postnatal depression with the potential to affect women’s responsibilities associated with motherhood (Place et al, 2013).
Notwithstanding healthcare provider awareness about postnatal depression, we found that overall, detection of postnatal depressive symptoms and care for women experiencing postnatal depression are not systematically included in women’s healthcare throughout their pregnancy and postpartum. Nationally, less than half of obstetric units are routinely detecting (37%) or treating (40%) postnatal depression (deCastro et al , under review). Lack of hospital guidelines and official norms are among the reasons providers reported to account for the poor rates of detection and treatment (deCastro et al, under review).
Notably, one psycho-educational intervention to prevent postnatal depression among high-risk women was implemented in one public-sector hospital in Mexico. There was a trend suggesting that participants in the intervention group had a larger reduction of depressive symptoms at 6 weeks and 4-6 months postpartum compared to participants receiving usual care in the control group (Lara et al, 2010). These results suggest that postnatal depression in Mexico has the potential to be successfully prevented, detected, and treated.
As part of our research, we decided to investigate what formal direction existed in Mexico regarding the detection and treatment of postnatal depression, if anything at all. We conducted a comprehensive review of national health plans, national action plans, federal and state laws and regulations, clinical practice guidelines, and public-sector healthcare facility policies examining whether they included a statement of intent and/or actions related to the care and management of women who experience or who are at risk of experiencing postnatal depression. Postnatal depression was noticeably absent from maternal health, pregnancy care and mental health policies and guidelines. Even when mentioned, actions relating to the care and management of women who experience or who are at risk of experiencing postnatal depression were generally not included (Place et al, 2013).
What can be done?
The World Health Organization (WHO) and the United Nations Population Fund (UNFPA) highlight education and training for healthcare providers and the development of a policy framework as core strategies to address maternal mental health in low- and middle-income countries.
Materials that build on providers’ existing conceptualizations of postnatal depression need to be developed and incorporated into professional training so that women’s full range of needs can be addressed throughout pregnancy as well as postpartum. Policy makers should consider expanding existing mental health policies by identifying actions that prioritize the care of women who experience postnatal depression, as well as establishing clinical practice guidelines that specifically address maternal mental health problems. The intersection of mental health with maternal health needs to be recognized by health professionals, who play a key role in the well-being of women, children and families.
Do you know if postnatal depression is addressed as part of the health system in your country?
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Jean Marie Sims Place, PhD is a faculty member at the Department of Physiology and Health Science at Ball State University in Muncie, Indiana, USA.
Deborah L Billings, PhD is an adjunct faculty member at the Department of Health Promotion, Education and Behavior at the University of South Carolina in Columbia, South Carolina, and the Gillings School of Global Public Health at the University of North Carolina in Chapel Hill, North Carolina, USA. She serves as the Director of the South Carolina Contraceptive Access Campaign.
Filipa de Castro, PhD is a professor and researcher at the Reproductive Health Unit at the Center for Population Health Research of the National Institute of Public Health in Mexico City, Mexico.
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