User:Escadar Alemayehu/Postpartum Depression

Risk factors
While the causes of PPD are not understood, a number of factors have been suggested to increase the risk. These risks can be broken down into two categories, biological and psychosocial:

Biological Risk Factors

 * Administration of labor-inducing medication synthetic oxytocin
 * Chronic illnesses caused by neuroendocrine irregularities
 * Genetic history of PPD
 * Hormone irregularities
 * Inflammatory illnesses (irritable bowel syndrome, fibromyalgia)
 * Formula feeding rather than breast feeding
 * Cigarette smoking

The risk factors for postpartum depression can be broken down into two categories as listed above, biological and psychosocial. Certain biological risk factors include the administration of oxytocin to induce labor. Chronic illnesses such as diabetes, or Addison's disease, as well as issues hypothalamic-pituitary-adrenal dysregulation (which controls hormonal responses), inflammatory processes like asthma or celiac disease, and genetic vulnerabilities such as a family history of depression or PPD. Chronic illnesses caused by neuroendocrine irregularities including irritable bowl syndrome and fibromyalgia typically put individuals at risk for further health complications. However, it has been found that these diseases do not increase risk for postpartum depression, these factors are known to correlate with PPD. This correlation does not mean these factors are causal. Cigarette smoking has been known to have additive effects. Some studies have found a link between PPD and low levels of DHA (an omega-3 fatty acid) in the mother. A correlation between postpartum thyroiditis and postpartum depression has been proposed but remains controversial. There may also be a link between postpartum depression and anti-thyroid antibodies.

Psychosocial Risk Factors

 * Prenatal depression or anxiety
 * A personal or family history of depression
 * Moderate to severe premenstrual symptoms
 * Stressful life events experienced during pregnancy
 * Postpartum blues
 * Birth-related psychological trauma
 * Birth-related physical trauma
 * History of sexual abuse
 * Childhood trauma
 * Previous stillbirth or miscarriage
 * Formula-feeding rather than breast-feeding
 * Low self-esteem
 * Childcare or life stress
 * Low social support
 * Poor marital relationship or single marital status
 * Low socioeconomic status
 * A lack of strong emotional support from spouse, partner, family, or friends
 * Infant temperament problems/colic
 * Unplanned/unwanted pregnancy
 * Breastfeeding difficulties

The psychosocial risk factors for postpartum depression include severe life events, some forms of chronic strain, relationship quality, and support from partner and mother. There is a need for more research in regard to the link between psychosocial risk factors and postpartum depression. Some psychosocial risk factors can be linked to the social determinants of health. Women with fewer resources indicate a higher level of postpartum depression and stress than those women with more resources, such as financial.

Rates of PPD have been shown to decrease as income increases. Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing risk of PPD. Women with fewer resources may also include single mothers of low income. Single mothers of low income may have more limited access to resources while transitioning into motherhood.

Studies have also shown a correlation between a mother's race and postpartum depression. African American mothers have been shown to have the highest risk of PPD at 25%, while Asian mothers had the lowest at 11.5%, after controlling for social factors such as age, income, education, marital status, and baby's health. The PPD rates for First Nations, Caucasian and Hispanic women fell in between.

Migration away from a cultural community of support can be a factor in PPD. Traditional cultures around the world prioritize organized support during postpartum care to ensure the mother's mental and physical health, wellbeing, and recovery.

One of the strongest predictors of paternal PPD is having a partner who has PPD, with fathers developing PPD 50% of the time when their female partner has PPD.

Sexual orientation has also been studied as a risk factor for PPD. In a 2007 study conducted by Ross and colleagues, lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample group. It was found that lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale scores than did the heterosexual women in the sample. These higher rates of PPD in lesbian/bisexual mothers may reflect less social support, particularly from their families of origin and additional stress due to homophobic discrimination in society.

There is a call to integrate both a consideration of biological and psychosocial risk factors for PPD when treating and researching the illness.

North America
 United States 

Within the United States, the prevalence of postpartum depression was lower than the global approximation at 11.5% but varied between states from as low as 8% to as high as 20.1%. The highest prevalence in the US is found among women who are American Indian/Alaska Natives or Asian/Pacific Islanders, possess less than 12 years of education, are unmarried, smoke during pregnancy, experience over two stressful life events, or who’s full term infant is low-birthweight or was admitted to a Newborn Intensive Care Unit. While US prevalence decreased from 2004 to 2012, it did not decrease among American Indian/Alaska Native women or those with full term, low-birthweight infants.

Even with the variety of studies, it is difficult to find the exact rate as approximately 60% of US women are not diagnosed and of those diagnosed approximately 50% are not treated for PPD. Cesarean section rates did not affect the rates of PPD. While there is discussion of postpartum depression in fathers, there is no formal diagnosis for postpartum depression in fathers.

Canada
Since Canada has one of the largest refugee resettlement in the world with an equal percentage of women to men. This means that Canada has a disproportionate percentage of women that develop post-partum depression since there is an increased risk among the refugee population. In a blind study, where women had to reach out and participate, around 27% of the sample population had symptoms consistent with post-partum depression without even knowing. Also found that on average 8.46 women had minor and major PPDS was found to be 8.46 and 8.69% respectively. The main factors that were found to contribute in this study were the stress during pregnancy, the availability of support after, and a prior diagnosis of depression were all found to be factors. Canada has the specific population demographics that also involve a large amount of immigrant and indigenous women which creates a specific cultural demographic localized to Canada. In this study researchers found that these two populations were at significantly higher risk compared to “Canadian born non-indigenous mothers”. This study found that risk factors such as low education, low income cut off, taking antidepressants, and low social support are all factors that contribute to the higher percentage of these population in developing PPDS. Specifically, indigenous mothers had the most risk factors then immigrant mothers with non-indigenous Canadian women being closer to the overall population.

South America
A main issue surrounding PPD is the lack of study and the lack of reported prevalence that is based on studies developed in Western economically developed countries. In countries such as Brazil, Guyana, Costa Rica, Italy, Chile, and South Africa there is actually a prevalence of report, around 60%. In an itemized research analysis put a mean prevalence at 10-15% percent but explicitly stated that cultural factors such as perception of mental health and stigma could possibly be preventing accurate reporting. The analysis for south America shows that PPD occurs at a high rate looking comparatively at brazil (42%) Chile (4.6-48%) Guyana and Colombia (57%) and Venezuela (22%). In most of these countries PPD is not considered a serious condition for women and therefore there is an absence of support programs for prevention and treatment in health systems. Specifically, in Brazil PPD is identified through the family environment whereas in Chile PPD manifests itself through suicidal ideation and emotional instability. In both cases most women feel regret and refuse to take care of the child showing that this illness is serious for both the mother and child.

Asia
Previous studies have shown that the frequency of PPD in Asian countries ranged from 3.5% to 63.3% with Malaysia and Pakistan having the lowest and highest frequencies, respectively. From a selected group of studies found from a literature search, researchers discovered many demographic factors of Asian populations that showed significant association with PPD. Some of these include age of mother at the time of childbirth as well as older age at marriage. Being a migrant and giving birth to a child overseas has also been identified as a risk factor for PPD. Specifically for Japanese women who were born and raised in Japan but who gave birth to their child in Hawaii, USA, about 50% of them experienced emotional dysfunction during their pregnancy. In fact, all women who gave birth for the first time who were included in the study experienced PPD. In immigrant Asian Indian women, the researchers found a minor depressive symptomatology rate of 28% and an additional major depressive symptomatology rate of 24% likely due to different health care attitudes in different cultures and distance form family leading to homesickness.

In the context of Asian countries, premarital pregnancy is an important risk factor for PPD. This is because it is considered highly unacceptable in most Asian culture as there is a highly conservative attitude toward sex among Asian people than people in the west. In addition, conflicts between mother and daughter-in-law are notoriously common in Asian societies as traditionally for them, marriage means the daughter-in-law joining and adjusting to the groom’s family completely. These conflicts may be responsible for emergence of PPD. Regarding gender of the child, many studies have suggested dissatisfaction in infant’s gender (birth of a baby girl) is a risk factor for PPD. This is because in some Asian cultures, married couples are expected by the family to have at least one son to maintain the continuity of the bloodline which might lead a woman to experience PPD if she cannot give birth to a baby boy. Scholars have shown that there is a correlation between a decreasing risk of PPD and the availability of education and treatment programs in European and Australian societies, however there is an absence of such programs in Asian and South American societies that indicate PPD is not treated as seriously as a health concern in those regions.

Europe
There is a general assumption that Western cultures are homogenous and that there are no significant differences in psychiatric disorders across Europe and the USA. However, in reality factors associated with maternal depression, including work and environmental demands, access to universal maternity leave, health care, and financial security, are regulated and influenced by local policies that differ across countries. For example, European social policies differ from country-to-country contrary to the USA, all countries provide some form of paid universal maternity leave and free health care. Studies also found differences in symptomatic manifestations of PPD between European and American women. Women from Europe reported higher scores of anhedonia, self-blaming, and anxiety, while women from the USA disclosed more severe insomnia, depressive feelings, and thoughts of self-harming. Additionally, there are differences in prescribing patterns and attitudes towards certain medications between the USA and Europe which are indicative of how different countries approach treatment, and their different stigmas.

Africa
Africa, like all other parts of the world struggles with a burden of postpartum depression. Current studies estimate the prevalence to be 15-25% but this is likely higher due to a lack of data and recorded cases. The magnitude of postpartum depression in South Africa is between 31.7% and 39.6%, in Morocco between 6.9% and 14%, in Nigeria between 10.7% and 22.9%, in Uganda 43%, in Tanzania 12%, in Zimbabwe 33%, in Sudan 9.2%, in Kenya between 13% and 18.7% and, 19.9% for participants in Ethiopia according to studies carried out in these countries among postpartum mothers between the ages of 17-49. This demonstrates the gravity of this problem in Africa, and the need for postpartum depression to be taken seriously as a public health concern in the continent. Additionally, each of these studies were conducted using Western developed assessment tools. Cultural factors can affect diagnosis and can be a barrier to assessing the burden of disease. Some recommendations to combat postpartum depression in Africa include considering postpartum depression as a public health problem that is neglected among postpartum mothers. Investing in research to assess the actual prevalence of postpartum depression, and encourage early screening, diagnosis and treatment of postpartum depression as an essential aspect of maternal care throughout Africa.

Legal Recognition
Recently, postpartum depression has become more widely recognized in society. In the US, the Patient Protection and Affordable Care Act included a section focusing on research into postpartum conditions including postpartum depression. Some argue that more resources in the form of policies, programs, and health objectives need to be directed to the care of those with PPD.

Role of Stigma
When stigma occurs, a person is labelled by their illness and viewed as part of a stereotyped group. There are three main elements of stigmas, 1) problems of knowledge (ignorance or misinformation), 2) problems of attitudes (prejudice), 3) problems of behavior (discrimination). Specifically regarding PPD, it is often left untreated as women frequently report feeling ashamed about seeking help and are concerned about being labeled as a “bad mother” if they acknowledge that they are experiencing depression. Although there has been previous research interest in depression-related stigma, few studies have addressed PPD stigma. One study studied PPD stigma through examining how an education intervention would impact it. They hypothesized that an education intervention would significantly influence PPD stigma scores. Although they found some consistencies with previous mental health stigma studies, for example, that males had higher levels of personal PPD stigma than females, most of the PPD results were inconsistent with other mental health studies. For example, they hypothesized that education intervention would lower PPD stigma scores, but in reality there was no significant impact and also familiarity with PPD was not associated with one's stigma towards people with PPD. This study was a strong starting point for further PPD research, but clearly indicates more needs to be done in order to learn what the most effective anti-stigma strategies are specifically for PPD.

Postpartum depression is still linked to significant stigma. This can also be difficult when trying to determine the true prevalence of postpartum depression. Participants in studies about PPD carry their beliefs, perceptions, cultural context and stigma of mental health in their cultures with them which can affect data. The stigma of mental health - with or without support from family members and health professionals - often deters women from seeking help for their PPD. When medical help is achieved, some women find the diagnosis helpful and encourage a higher profile for PPD amongst the health professional community.

Cultural Beliefs
Postpartum depression can be influenced by sociocultural factors. There are many examples of particular cultures and societies that hold specific beliefs about PPD. Malay culture holds a belief in Hantu Meroyan; a spirit 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.

Some cultures believe that the symptoms of postpartum depression or similar illnesses can be avoided through protective rituals in the period after birth. These may include offering structures of organized support, hygiene care, diet, rest, infant care, and breastfeeding instruction. The rituals appear to be most effective when the support is welcomed by the mother.

Some Chinese women participate in a ritual that is known as "doing the month" (confinement) 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 or shower, wash her hair, clean her teeth, leave the house, or be blown by the wind.

Media
Certain cases of postpartum mental health concerns received attention in the media and brought about dialogue on ways to address and understand more on postpartum mental health. Andrea Yates, a former nurse, became pregnant for the first time in 1976. After giving birth to five children in the coming years, she suffered severe depression and had many depressive episodes. This led to her believing that her children needed to be saved, and that by killing them, she could rescue their eternal souls. She drowned her children one by one over the course of an hour, by holding their heads under water in their family bathtub. When called into trial, she felt that she had saved her children rather than harming them and that this action would contribute to defeating Satan.

This was one of the first public and notable cases of postpartum psychosis, which helped create dialogue on women's mental health after childbirth. The court found that Yates was experiencing mental illness concerns, and the trial started the conversation of mental illness in cases of murder and whether or not it would lessen the sentence or not. It also started a dialogue on women going against “maternal instinct” after childbirth and what maternal instinct was truly defined by.

Yates' case brought wide media attention to the problem of filicide, or the murder of children by their parents. Throughout history, both men and women have perpetrated this act, but study of maternal filicide is more extensive.