Department of Social Medicine, Harvard Medical School, Boston, Massachusetts, USA, and Department of Psychiatry, Chinese University of Hong Kong, Hong Kong
Department of Obstetrics and Gynaecology, Chinese University of Hong Kong
Department of Psychiatry, Chinese University of Hong Kong
Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Hong Kong
Correspondence: Dr Dominic T. S. Lee, c/o Department of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong. Fax: (617) 812 0077; e-mail: tak_lee{at}hms.harvard.edu
Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To investigate the sociocultural risk factors of postnatal depression using ethnographically informed epidemiological methods.
Method A total of 959 women were assessed at their first ante-partum visit (baseline), in the third trimester, immediately after delivery, and 3 months postpartum. Six domains of risk factors were examined. The dependent variable was postnatal depression (as defined by the Edinburgh Postnatal Depression Scale) at 3 months post-partum.
Results Conflict with mother-in-law, marital dissatisfaction, past depression and antenatal depression independently predicted the occurrence of postnatal depression. The cultural practice of peiyue a Chinese post-partum custom of mandated family support was associated with better social support and a slightly lower risk of postnatal depression.
Conclusions Sociocultural aspects of the immediate puerperium shape maternal emotional well-being. In-law conflict is an important source of household distress in many Asian societies. The findings have implications for clinical practice and future studies.
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INTRODUCTION |
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METHOD |
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Study design
After a complete description of the study to the participants, their
written informed consent was obtained. We recruited the participants at the
first antenatal assessment (baseline) and reassessed them in their third
trimester (3032 weeks of gestation), immediately after delivery and at
3 months post-partum. At baseline, the research nurses collected
socio-demographic, medical, obstetric and psychiatric data from the
participants in a semi-structured manner. Putative risk factors of postnatal
depression were examined at baseline as far as possible. Risk factors that
could not be assessed at baseline were measured in the earliest feasible
assessment.
Putative risk factors
We examined the risk factors that are commonly reported in previous studies
of postnatal depression. We also assessed ethnocultural risk factors of local
importance. Six domains of risk factors were included:
A number of sociocultural risk factors have been proposed for postnatal depression. One focus of attention has been the dissolution of traditional cultural rites and values in modern motherhood. In preindustrial societies the post-partum period is patterned by elaborate customs and rituals, many of which mobilise social support and call attention to maternal vulnerability. In modern culture, such customs and rituals rarely exist (Pillsbury, 1978; Stern & Kruckman, 1983; Cox, 1996).
A commonly cited example of socio-protective post-partum custom is mandated family support. In most contemporary Asian societies, recently delivered women are still regarded as vulnerable, and are exempted from their usual household duties for an extended period (Pillsbury, 1978; Grace et al, 2001). Such exemption is generally made possible by the continual presence of a designated elder female kin, most commonly the womans mother or mother-in-law. This practice, called peiyue in the Chinese culture, consolidates and formalises post-partum support, guarantees passage of child-rearing knowledge, and protects the mother from exhaustion and sleep deprivation. Social anthropologists and cultural psychiatrists have long suggested that peiyue, as a socio-moral custom that mothers the mother, may prevent social isolation and postnatal depression (Pillsbury, 1978). On the other hand, these post-partum support practices bring in extended family members, such as in-laws, who may not be welcomed by the new mothers. For centuries, tense relationships between women and their mothers-in-law have been a source of household disharmony in Chinese and many other Asian societies (Chen, 1999). A qualitative phenomenological study conducted by our group found that the enriched social contact ritualised by peiyue is not necessarily perceived as supportive (Chan et al, 2002). There were also reports of mother-in-law problems in postnatal depression of other cultures (Barrows & Barrows, 2002; Chandran et al, 2002). Hence, the emergence of the mother-in-law in the puerperium as the peiyue kin can be double-edged.
Thus far, the epidemiology research has overlooked the role of conflict between mother-in-law/daughter-in-law in causing postnatal depression. Besides, the hypothesis that specific cultural practices can preclude postnatal depression which can have profound public health implications has not been subjected to empirical testing. These omissions are but examples that reveal the divide between ethnographic and epidemiological research. Ethnographic hypotheses are rarely tested empirically, and epidemiological studies seldom draw on ethnographic insights. We want to show that this divide is unnecessary, and can be overcome.
Assessment tools
Most risk factors were ascertained by direct inquiry with the participants
or examination of case records. Psychometric rating scales were used to assess
the following risk factors: marital relationship (Index of Marital
Satisfaction), perceived social support (Medical Outcome Study Social Support
Survey) and antenatal life events (Social Readjustment Rating Scale).
The Index of Marital Satisfaction (IMS) is a 25-item self-report scale designed to measure the degree of problem a spouse encounters in the marital relationship (Hudson, 1982). It has been shown to have excellent internal consistency, testretest reliability and concurrent validity. A score of 31 or above is commonly used to define marital problems. The psychometric properties of the Chinese IMS are comparable to the original version, and the validation data are currently under review for publication.
The Social Readjustment Rating Scale (SRRS) is a self-administered scale that has been widely used to examine 43 significant life events in the near past (Holmes & Rahe, 1967). The Chinese version was developed for the Hong Kong context: items irrelevant to local context were removed, and life events of indigenous importance were added (Shek & Mak, 1997). The Chinese SRRS contains both threatening and rewarding events, as well as major and minor life events.
The Medical Outcome Study Social Support Survey is a 20-item self-administered questionnaire developed by the Rand and Medical Outcomes Study teams to measure social support; it has good reliability and validity (Sherbourne & Stewart, 1991). The Chinese version has been validated, showing satisfactory psychometric properties (Yu et al, 2002).
The peiyue ritual was assessed with a semi-structured interview that focused on the content, context and duration of the practice. The semi-structured interview, developed by the research team, also assessed the knowledge and practice of other traditional post-partum customs. The first part of the assessment enquires about the respondents knowledge of the contents of post-partum customs, i.e. whether the respondents are aware of the different taboos and rituals. The second part asks about the actual practice of various rituals and taboos after the delivery. The duration of, and the degree of adherence to, different rituals were recorded. This section also examines where, by whom and for how long the peiyue was observed. The participation of the father in child care and household duties in the peiyue period was also assessed.
The mother-in-law relationship was assessed with a modified five-point Likert measure, as no specific scale has been developed to measure this dyadic relationship. Our pilot test showed that framing an appropriate statement for the in-law relationship was difficult. A statement such as I am on poor terms with my mother-in-law often attracts defensive responses, whereas the reverse statement I get on well with my mother-in-law tends to attract socially approved answers. Hence, instead of asking the respondents to rate the level of agreement or disagreement with a statement, we ask them to rate the relationship with the mother-in-law, using one of the following responses (5 very good, 4 good, 3 average, 2 poor, 1 very poor). The respondents replied with a number instead of the corresponding adjective which has more explicit meaning. We also enhanced the veracity of the report by putting the question near the end of the interview when there was generally better rapport. In debriefing the respondents of the pilot study, we found this modified Likert measure to be superior to the conventional agreement approach. The poor and very poor responses were able to capture nearly all participants who had significant or serious problems with their mothers-in-law. Hence, we combined these two responses into one category, comparing it with a second category comprising the very good, good and average responses, in the statistical analyses.
Assessment of depression
Postnatal depression was assessed using the Edinburgh Postnatal Depression
Scale (EPDS; Cox et al,
1987). Numerous studies have demonstrated the reliability and
validity of the EPDS in identifying depression, and it has been widely applied
in both research and clinical settings. We validated the Chinese version of
the EPDS and found that its sensitivity (0.82) and specificity (0.86) were
comparable to the original scale. A lower cut-off score (9/10) was desirable
for the Chinese population (Lee et
al, 1998). Since the EPDS was originally designed to screen
for rather than to diagnose postnatal depression, the EPDS
high scorers are referred to as probable postnatal depression
hereafter.
We also used the EPDS to assess level of depression in the third trimester. We did not use this scale to define probable depression in the third trimester because our previous analysis had shown that antenatal depression was rare in the study sample (Lee et al, 2001). Based on informed clinical experience, we categorised the third-trimester EPDS scores into three levels: 09, nil or insignificant depressive symptoms; 1014, mild to moderate depressive symptoms; and >14, severe depressive symptoms. These groupings were decided before data were collected.
Data analyses
The socio-demographic and psychosocial characteristics of the participants
were summarised using descriptive statistics. The characteristics of the
participants who were not included in the 3-month assessment were compared
with those who were assessed using the chi-squared test for categorical data
and the t-test for ordinal data. Because nearly 20 hypotheses were
tested in checking for potential biases introduced by 3-month attrition, a
conservative threshold for significance (P<0.01) was used instead
of the conventional P<0.05.
The 3-month probable postnatal depression status was used as the dependent
variable for univariate and multivariate analyses against putative risk
factors. The risk of caseness according to the presence or
absence of risk factors was first assessed in a univariate manner, and risk
ratios calculated with 95% confidence intervals. Statistical associations
between caseness and individual putative risk factors were tested using
2 tests for dichotomous and categorical variables, and
independent Students t-test for continuous variables. Because
more than 30 hypotheses were tested in the univariate analyses, a conservative
threshold for significance (P<0.01) was used instead of the
conventional P<0.05.
We entered factors that yielded risk ratios greater than 2 or confidence intervals that did not cross 1 on univariate analysis into logistic regression. Stepwise logistic regression analysis was first used to identify independent risk factors. When the best model was achieved, the regression was repeated using backward modelling to test for model stability. We computed unadjusted odds ratios and confidence intervals for each significant variable in the final model by the logistic regression. The adjusted odds ratios were computed by including all significant variables in the logistic regression.
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RESULTS |
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Peiyue support custom
Among the women included in the 3-month post-partum assessment, 626
participants (80.2%) received peiyue support in the first post-partum
month, most commonly from their mothers-in-law (35.3%; n=221), their
own mothers (34.3%; n=215) or other relatives (26.8%;
n=168). Women who received peiyue care reported better
social support than those who did not: t=0.49, d.f.=202.6,
P=0.013; mean difference 7.8 (95% CI 4.511.0), standard error
of difference 1.7.
Univariate analysis
A total of six putative risk factors were found to be significant in the
univariate analysis (Tables 2
and 3). Past depression,
marital dissatisfaction, inadequate social support, life events in pregnancy,
depressive symptoms in the third trimester and poor mother-in-law relationship
were associated with probable postnatal depression.
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Logistic regression analysis
The six significant variables were entered into the stepwise logistic
regression analyses. Because of theoretical interest, we also include
peiyue in the regression analyses. The final model had four
explanatory variables (Table
4). Backward stepwise regressions yielded the same model. The
final model indicated that probable postnatal depression was predicted by past
depression, depressive symptoms in late pregnancy, marital dissatisfaction and
poor mother-in-law relationship. A dose effect was also observed for antenatal
depressive symptoms.
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DISCUSSION |
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In-law dynamics in contemporary Asian families
Local cultural factors are also pertinent in shaping maternal
socio-affective well-being. In-law conflict was as important as spousal
discord in determining postnatal emotional adjustment in our population; this
confirms our ethnographic observation, and echoes the findings of other
researchers (Barrows & Barrows,
2002; Chan et al,
2002; Chandran et al,
2002). Adverse in-law relationship, especially between mother- and
daughter-in-law, is a centuries-old conflict in Asian societies. For instance,
a high percentage of Chinese couples considered the in-law relationships to be
difficult (Tseng & Hus,
1991). A Chinese national survey showed that trouble with the
mother-in-law was the third most common stressful life event among married
women (Zheng & Lin, 1994).
In another study in rural China, mother-in-law conflict was reported in nearly
a third of young women who attempted suicide
(Veronica, 2002). In Hong Kong
and India, mothers-in-law play a significant role in domestic violence
inflicted on married women (Fernandez,
1997; Leung et al,
2002). The mother-in-law relationship is also a common area of
conflict for urban Japanese housewives (Ago
et al, 1982). In Korea, nearly a third of abused married
women ascribed the problem to in-law troubles
(Kim & Shim, 1992).
The modern relationship between daughter-in-law and mother-in-law is embedded as much in the traditional patrilineal culture as in the growing economic independence of younger generations of Asian women. Traditionally in Asian societies, marriage means bringing in a daughter-in-law to join the family rather than composing a new household for the newly-weds. The daughter-in-law was commonly entrusted to the supervision and control of her mother-in-law, who was generally portrayed as tyrannical, if not abusive. The stereotypical representation of an oppressive mother-in-law and a submissive daughter-in-law, however, is rarely seen these days, as improved education opportunities and economic independence among younger women have remade the in-law relationships. These relationships are increasingly egalitarian, and family power has progressively been shifted to the younger generation (Rosen, 1978). This shift in power, however, does not necessarily reduce the tension imbued in the in-law relationship. The dissolution of archetypal hierarchy means that contemporary women now have to contest and negotiate for a new share of power. This negotiation is by no means easy: mother-in-law and daughter-in-law, brought up in different value systems, often have diametrically opposite views on the interpersonal issues of autonomy, respect, hierarchy and filial piety.
It is thus unsurprising that the intragender and intergeneration conflicts between daughters-in-law and mothers-in-law are difficult to deal with in the clinical context. The depressed daughters-in-law and their families may regard the conflicts as familial secrets that should not be disclosed to outsiders. Even when the daughters-in-law are willing to discuss the conflicts with therapists, most mothers-in-law would not come for assessment, let alone Western-style psychotherapy. So far, Asian psychiatry has treated in-law conflict as just one of many possible forms of interpersonal difficulties. As such, treatment (when provided) is usually eclectic and non-specific. In order for interventions to be culturally specific and appropriate, more research is clearly needed.
Rethinking maternal support and post-partum customs
We found that the absence of the post-partum support custom
(peiyue) was marginally significant (P<0.05) in the
univariate analysis, but not in the logistic regression. Given that more than
30 hypotheses were tested in the univariate analysis, it can be speculated
that the significant association of peiyue was a spurious one. If a
more conservative threshold of significance (P<0.01) were used,
the association would no longer be significant. On the other hand, a negative
finding for peiyue in the logistic regression should not be
unexpected, given that social support a major ingredient of
peiyue was adjusted for in the multivariate analysis.
Furthermore, our study showed that the mother-in-law was a common person to
provide peiyue. If the new mother and her mother-in-law did not get
along with each other, the in-law tension or conflict could offset the
potential benefit of the peiyue arrangement
(Steinberg, 1996). Thus,
mandated post-partum support, although well-intentioned, can be a mixed
blessing; and this may explain why in this study peiyue is associated
with only a slightly lower risk of depression. Future study should examine how
the new mothers perceive the peiyue relationship, and differentiate
between the helpful and unhelpful peiyue support arrangements in the
investigation.
Methodological issues
Our study has several limitations that deserve mentioning. First, the
diagnosis of postnatal depression was established with a self-report rating
scale rather than a clinician-administered structured diagnostic interview.
The EPDS was originally designed as a screening test, not a method for
diagnosing postnatal depression; thus, although it has been increasingly used
in large-scale postnatal depression studies to avoid burdening staff with
time-consuming diagnostic interviews
(Warner et al, 1996),
it is important to appreciate that its findings cannot be equated with
psychiatric diagnoses. The EPDS can at best be used as an estimate of probable
caseness; thus, participants with high scores on this scale received a group
label of probable postnatal depression in this report. Second,
almost a fifth of the participants failed to attend 3-month assessment.
Although these participants were essentially no different from those who
completed the study in terms of socio-demographic or psychiatric
characteristics, they were more likely to be later in their pregnancy at
recruitment. Third, about 40% of eligible women declined to participate in the
study, and only limited socio-demographic data were available from these
non-participants to evaluate the potential bias they might have introduced.
Furthermore, although we made the best effort to measure the risk factors
before the onset of depression, some factors could only be evaluated at the
3-month post-partum assessment. Besides, it is possible that
post-partum depression might actually begin as sub-syndromal
depression or even as depressive symptoms in pregnancy. Hence, in some cases
the risk factor assessment may not be entirely in advance of the outcome.
It is also important to note that our reported findings are associations rather than causations. The relationship between in-law conflicts and postnatal depression can be more complicated than is portrayed in our statistical model. Apart from exerting a direct effect on maternal post-partum emotional well-being, the mother-in-law conflict may also interact with the new mothers personality or affective state. Women with certain personality traits may be more susceptible to mother-in-law conflicts. Likewise, women who have developed substantial depressive symptoms during pregnancy may also be more sensitive to in-law conflicts. It is also probable that personality traits or antenatal depressive mood independently contribute to the postnatal depression. To unravel the complex relationship, more studies are needed.
The study did not consider whether the mother-in-law can also suffer from conflict with her daughter-in-law. As it has been shown that maternal and paternal postnatal depression are closely connected, future study should examine if mothers-in-law can develop depression in response to the stresses of grandparenthood in this cultural setting. Finally, the study was conducted in one particular Chinese society. Replications in other Chinese and other Asian societies are warranted.
Clinical implications
A recent study in east London showed that the in-law relationship remains a
powerful force in the local world of South Asian mothers living in the UK
(Bhopal, 1998). Since the
in-law relationship is essentially a peripheral one in Western family culture,
clinicians may not be aware that the extended family is the main form of
family life, and the in-laws are usually defined inside the family boundary of
Asian families (Chen, 1999). Psychiatrists and general practitioners should therefore routinely consider
the relevance of the mother-in-law and other elder female kin when working
with Asian families.
We hope this study will stimulate more research into the organisation of social support in the contemporary post-partum context. The myth that post-partum rituals and customs have largely disappeared in the industrialised world deserves examination. In many Western societies it is not uncommon for recently delivered women to be assisted by extended family members, some of whom may live in for a short period. More privileged families may even pay for a maternity nurse to support the new mother in the initial postpartum weeks (Morgan, 1996). A recent study in the UK reported that 41% of women practised some form of dietary proscription after childbirth (Huang & Mathers, 2001). Yet, in contrast to peiyue and similar rituals, post-partum customs in Western societies are generally unnamed, unstructured and unnoticed. More research is thus needed to fathom the submerged post-partum customs of the industrialised world. Understanding how practical, emotional and informational support of new mothers is structured in contemporary society can have profound public health implications, as it may lead to more effective interventions and prevention programmes.
Last but not least, our study shows that it is possible to combine rich ethnographic observation with rigorous epidemiological testing. The result is a multi-level pathway connecting cultural tradition, family institution, interpersonal experience and maternal emotional well-being. As our world becomes ever more globalised and multiethnic, psychocultural understandings of this kind will be of increasing relevance to Western psychiatric practice.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication May 6, 2003. Revision received August 27, 2003. Accepted for publication September 5, 2003.
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