This Is It

RUNNING HEAD: RISK OF POSTPARTUM DEPRESSION IN LATINA WOMEN
Risks of Postpartum Depression in Immigrant Adolescent Latina Women

Leslie Lina Sigala
May 4, 2011
Submitted as the Culminating Experience requirement in partial fulfillment for the degree of
Master of Science in Psychology, concentration in Clinical Psychology at San Francisco State
University
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Acknowledgement
It is with immense gratitude that I acknowledge the support and help of my Professor Dr.
Julia Lewis, PhD for her support in writing my thesis. As well as thanking my parents Vicente
and Clementina Sigala and my siblings, classmates, and the McHardy family (Eamonn, Lisa,
Liam and Zara) who are a family away from home.
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ABSTRACT
Postpartum depression is a mental health issue affecting almost 10% of new mothers
annually. Due to a myriad of cultural and socio-economic factors, Latina women are underserved
with regard to mental health issues and consequently, postpartum depression can go undiagnosed
within the community. This study addresses the risk of postpartum depression among recent
immigrant, adolescent Latina women. The factors considered are age, socioeconomic status,
education, acculturation, and obstetrics complications, as well as the impact on the mother and
her infant. This examination proceeds first with a relevant literature review, a case study, and
finally, provides recommendations for various treatments that can help young Latina mothers
cope with postpartum depression.
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TABLE OF CONTENTS
I. Cover page 1
II. Acknowledgement 2
II. Abstract 3
IV. Table of Contents 4
V. Introduction and Overview 6
VI. Application to Theory 10
VII. Relevant Research 14

Depressive Symptoms in Latina Women 15
Low Income and History of Depression Latinas during Postpartum 17
Adolescents 18
Obstetrical Complication 18
Immigrant Status 19
VIII. Case Study 22
Introduction and Referral 22
History 23
Observation 25
Summary/Conceptualization 26
IX. Recommendation for Treatment 30
Support Groups 30
Individual Therapy 31
Medication 32
Related Issues 33
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X. Conclusions 34
XI. References 36
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Introduction and Overview
Postpartum depression (PPD) can affect a new mother at a vulnerable time for herself and
her new born. The prevalence of postpartum depression and the impact on young mothers and
their newborn is an increasing problem. PPD is a mental health illness that afflicts an estimated
400,000 women in the United States per year; a likely 10% prevalence of all pregnancies in the
United States. According to the U.S. Census, in 2006 Latinos were 14.8 % of the total U.S.
population (44.25 million people) and the largest ethnic minority group. Latinos are a rapidly
growing population; in fact Latinas have more women under 39 years of age than any other
ethnic group, an age where most are becoming or are already mothers. Many of these Latinas
who are also immigrants are at risk of suffering from PDD. This paper will include an
assessment and discussion of current literary resources on the subject. Particular focus is on
factors and risks that predict PPD and their impact on recently immigrated Latina women and
their infants. Their entire experience will be explored through a thorough literature review and an
individual case presentation. The unique risks of an individual immigrant Latina woman possibly
suffering from PPD and how it may affect both her and her new born infant during this critical
time after birth will be presented in detail. Analyzing this cumulative experience will inform
clinicians of the importance of effective treatments, and explore the supportive role that
clinicians should play.
The prevalence of postpartum depression and the impact to young mothers is an
increasing problem. According to the Institute of Mental Health depression is a mood disorder
where a person may have symptoms of feeling sad, anxious, empty, hopeless, helpless,
worthless, guilty, irritable or restless. A loss of interest in activities, a loss of appetite or
overeating, problems concentrating, remembering details or making decisions, and suicidal
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ideation are all linked to this disorder. When discussing postpartum depression it‟s the same
symptoms, but the syndrome mostly affects women who have recently given birth, usually
occurring in the first few months after birth but sometimes lasting up to several months or even a
year.
Giving birth can be simultaneously an exciting and a traumatic event for a woman. Many
things are happening to the mother, including an influx of hormonal changes, physical body
changes; in short, a complete change of life. According to Beck‟s Cognitive theory of
depression, low self-esteem, childcare stress, prenatal anxiety or not having prenatal care can all
contribute to postpartum depression, while socioeconomic factors such as low or no social
support, a poor marital relationship, single parenthood, and unplanned/unwanted pregnancies can
also cause the illness (Beck, 1995).
Recent immigrant women from Latin countries can struggle to settle into their new life in
the U.S. and feelings of helplessness and having to be dependent on their partners or relatives
often add more to their struggle. Also, language limitations and being unable to speak English
can further establish isolation and lead to depression symptoms. A recent study (Milan, et al.
2007) showed that adolescent Latinas are at a significantly higher risk of poor mental health,
specifically depression and anxiety, due to lack of support and education, hindering the ability to
access support.
In considering this issue, it is important to examine both the women affected by PPD and
the infant‟s development as part of the mother –infant relationship. In the article “Postnatal
depression and infant development” by Murray, Copper, and Stein (1991), of concern is the
consequences of PPD on infant development in the postnatal months. This study suggests that
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depressed mothers are typically unresponsive to infant cues, being either withdrawn with flatness
of affect or else intrusive and hostile. In response infants can become withdrawn from maternal
contact and emotionally disconnected from their environment. In a follow up study of PPD
entitled “The impact of maternal depression on infant development” (Murray 1992) it was found
that the mother-infant relationship and the cognitive development of children were adversely
affected. Women with PPD were found to be more insecure when assessing their relationships
with infants then non-depressed mothers. PPD mothers helped their children less during playtime
and infants behaved more negatively towards their mothers. These findings strongly indicated
the necessity for the early detection and treatment of PPD.
Women diagnosed with PPD have a tendency to focus more on the negative aspects of
childcare, which can result in poor parenting strategies (Murray, 1996) which can in turn affect
the mother-infant relationship, an aspect that will be explored further in this paper. PPD can
make it difficult for a mother to provide proper ongoing childcare and since a strong infant-
mother relationship, a sense of security and attachment are essential for infant development,
these developments are all jeopardized by the illness.
Children need a balance between the outside world and the love and support of a parent.
In his attachment theory John Bowlby (Bowlby, 1969) suggests that infants learn about their
environment while keeping their caregiver close. If a young mother is dealing with significant
stresses, such as those mentioned earlier commonly confronting Latina immigrants, such stress
can directly affect the infant‟s emotional well-being by disrupting the attachment relationship.
There are specific reasons why Latinas, above other females around the world, are
especially susceptible to PPD. Cultural beliefs can cause many Latinas to interpret depression in
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a reductive way, which can be problematic. Anxiety and sorrowfulness, for example, are
sometimes seen as something normal, especially when Latinas describe their symptoms as “un
estar mal de los nervios” („an ailment of nerves‟) or just being plain tired. This normalization can
mask considering the mental state as a serious situation especially if present over a period of
time. In the Latino culture depression is often viewed as something temporary that will go away
without needing medication or therapy treatment. This view can make it difficult for Latinas to
identify if they are suffering from PPD, while also making it difficult for a them to seek direct
help from a mental health professional on their own.
According to an article in Maternidad Latina (2007), a prominent idea existing in the
Latino culture is that “Ser una buena madre” („being a good mother‟) should be the main role of
a female. Everything else is considered secondary, including her own health and state of mind.
With PPD, feelings of guilt and shame for not being able to care for one‟s children and home can
impact the intensity and length that a Latina will be depressed.
Another factor increasing risk for PPD is that immigrant Latinas are at a higher risk of
being in an abusive relationship. Limited medical resources and lack of knowledge of support are
risk factors. Having a partner who drinks heavily or has a poor socioeconomic status can also
play a role in domestic violence. Clearly, being in an abusive relationship can further increase a
Latina‟s depression.
Additionally, cultural displacement can have a severe impact on the dilemmas of
motherhood, according to Tummala-Nara, (2004). Akhtar (1999) cites various psychological
factors, including motivations and circumstances for immigrating, the age of migration, pre-
immigration character organization and the reason of leaving the country behind, which can
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affect a new mother and her mental capacities. When looking at young teenage girls who travel
far away from home, it is significant to consider whether they have made the decision to leave
voluntarily alone or an have been forced by family, other people, or even war. This circumstance
can seriously affect young Latinas how they may react if they find themselves in a vulnerable
situation such as a pregnancy.
Application to Theory
When a woman is diagnosed with PPD, most clinicians will immediately recommend
therapy and support as treatment. When an infant is born, there is always an adjustment to the
mother‟s established daily life and family system, which can include children who are already in
the home and her daily routine. Winnicott described the need for maternal sensitivity in this
situation in his paper, “The Observation of Infants in a Set Situation” (1941), and repeatedly
referred to it throughout his work. His statement, “there is no such thing as a baby,” implies that
without a mother, an infant cannot exist, since they are intrinsically linked. Essentially, the
infant is an important element of who a mother is; it‟s what makes a mother, thus the baby can be
the most affected when mother is dealing with PPD. For women who have PPD, in addition to
the risk to their own health and development, the attachment formation between the mother and
the infant can be affected immensely.
Newborn infants are especially sensitive to this mother-infant relationship, even from
their first moments of life. A recent study found that an hour-old infant can discriminate between
unfamiliar faces showing preference for a face that makes eye contact, and following a moving
face with its head and eyes (Farroni, Menon, & Johnson, 2006). DeCasper & Fifer (1980) found
that newborns will respond selectively to their mother‟s own voice, recognizing it from hearing
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her speaking while in utero and preferring it to the speech of strangers. Thus, from the day an
infant is born, mother and infant behaviorally interact with one another. The mother looks at the
baby and baby looks back; the baby cries and the mother soothes it. A good sign that a mother
and infant have a strong, healthy relationship is when characteristics are reciprocated between
the mother-infant dyad. Mothers who are in healthy dyads are responsive to their infant cries,
react to an infant‟s distress when hungry, cuddling them and reacting with other comforting
behaviors. A healthy infant response is to begin quieting down and being comforted by the
mother‟s embrace.
When a mother is suffering from PPD this bond of attachment can be severely affected.
Attachment between mother and infant is reciprocal, requiring both parties to interact with one
another. If a mother is suffering from PPD, she may be unable to maintain her side of the
development dyad. PPD can make the mother apathetic, emotionally withdrawn and
unresponsive to the infant, while even a mild depression can leave the mother sad, irritable and
fatigued. Even anxiety symptoms can interfere with the “relax flow” of the mother-child
interaction (Ross & McLean, 2006). Recent studies show women with PPD smile a lot less and
make less eye contact with their infant, and in response an infant can mirror this with a gaze of
avoidance and low level of positive affect (Field, et al, 1988; Reck et al., 2004). Reissland,
Shepard & Herrera (2003) found that mothers who are suffering from PPD talk less than mothers
who aren‟t depressed, and even their vocal patterns differ, which can distress the infant. Infants
of depressed mothers are held less, and spend more time “self touching”, an act that is thought of
as compensatory behavior (Herrera, Reissland, & Shepard, 2004). The overall effect is a
depressed dyad, which impairs the mother-infant bonding process.
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Another related theory is the one formed by Rene Spitz in 1946, which was based on
observations of 6 to 11 month old infants who had a formed a secure attachment in their first 6
months but who were then separated from their primary caretaker. The separation was not
something that was arranged or planned by the family, neither was it due to pure circumstance
such as through hospitalization or poverty. Spitz found that the infants became tearful and upset,
and the longer the separation, the more the infants would begin to shut down emotionally. They
became much quieter, lost their appetite, and their motor activity slowed down. Children were
also not responsive to social interaction, to the point where the infants would turn their faces to
the wall, and in some cases they even died (Spitz &Wolf, 1946). At times PPD can last up to 6
months after childbirth, during which time the mother-infant attachment has already taken place,
which can be devastating for an infant. Spitz found that if attachment figures aren‟t substituted
for the absent mother, the infant begins to withdraw from social interaction. Spitz noted that
appetite and activities levels drop, vocalization, eye contact and positive affect all decline; the
infants are in a less positive mood compared to secure, older infants.
Those infants, toddlers, and preschool children who fail to thrive and who fall below the
fifth percentile on growth curves as a result of either medical illness or, more specifically,
emotional deprivation, are known as non organic failure to thrive (NOFTT) cases. These children
who qualify for NOFTT status show more negative behavioral effects, less vocalization and
more gaze aversion (Steward, 2001). In a nationwide pediatric study of 5089 families in the
United States, maternal depression was correlated with less healthy feedings and sleep practices
in infants (Paulson et al. 2006), which can lead infants becoming malnourished which affect their
growth (Rahman, Iqbal, Bunn, Lovel & Harrington, 2004).
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The National Evaluation of Healthy Steps for Young Children analyzed parenting
practices of more than 5000 mother-infant dyads during the child‟s first three years of life. Self-
reported depressed mothers who participated were found to be less likely to communicate and
play with their children, show them books, keep a daily routine or limit television time. They
also were less likely to be up to date with their immunizations and more likely to have missed
infant medical appointments, but coincidently more likely to have more emergency room visits
(McLearn, Minkovitz, Strobin, Marks, & Hoa, 2006a, 2006b; Minkowitz et al. 2005).
Other studies show the effects of depression on the on health of the mother-infant
partnership. One report that found infant‟s risk of asthma was 6 to 8 times more likely to develop
if they had a depressed mother, as opposed to children whose mother wasn‟t depressed (Klinnert
et al., 2001). Infants of depressed mothers were also reported to have an increased frequency of
diarrhea in the first year (Rahman et al., 2004), and be more prone to colic (Akman et al., 2006).
All of these medical conditions can increase the infant‟s chronic crying, which in turn can
aggravate a mother‟s depressed mood, and unless carefully controlled is a proximate trigger for
abuse.
The long-term effects on infants who have a mother with PPD are not just physical, but
emotional and mental. Without emotional support or treatment for PPD during their infancy,
children will continue to show attachment insecurities as toddlers and become less interested in
both other children their age and adults, compared to other, securer toddlers (Cicchetti,
Rogosche, & Toth, 1998). There have also been studies that show diminished language skills and
cognitive development (Sohr-Preston & Scaramella, 2006) as a result of being brought up by a
depressed mother.
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There are continuous studies that demonstrate how a mother suffering from PPD will
affect an infant through when the infant becomes a child developing developmental and
emotional problems. In a longitudinal study of children with depressed mothers, children who
had been classified as having an avoidant attachment in their infancy were identified by their
teachers as being highly disorganized at the age of seven. Infants who were found to have
avoidant attachment in infancy were also more likely to show internalizing symptoms by the age
of seven (Lyons-Ruth, Easterbrooks, & Cibelli, 1997). Teens whose mothers experienced PPD
during their infancy are also more likely to act out behaviors (Pilowsky et al., 2006).
As shown, the infant‟s first months of life begins the development of a secure attachment,
but when mother suffers from PPD, it can be detrimental to an infant‟s physical, emotional, and
cognitive growth. An immigrant woman suffering from PPD can be damaged by a lack of
support or an inability to reach out to the community, or complicated by languages barriers. The
risks affecting an infant who is raised by a woman suffering from PPD can be devastating and
have long-lasting effects.
Relevant Research
Postpartum Depression (PPD) can affect a new mother at a very vulnerable time for her
and for her new-born infant. This literature review focuses on the unique risks of immigrant
adolescent Latina women suffering from PPD.
Most new mothers experience mood swings and mild depression, which can be expected
after the trauma of giving birth. Postpartum depression (PPD) occurs in the first few months after
birth, but sometimes lasts from several months to a year. Latina women, in particular those with
a history of depression or those at risk from the trauma of child birth, acculturation, immigration,
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and a lower socioeconomic status, have a higher likelihood of suffering from postpartum
depression.
Depressive Symptoms in Latina Women
The study entitled “Depressive symptoms in the immediate postpartum period among
Hispanic women in three U.S. cities,” by Kuo, Wilson, Holman, Fuentes-Afflick, O‟Sullivan,
and Mikoff, (2004) examined the rates of depressive symptoms in the immediate postpartum
period in 3, 952 Hispanic women across three cities: New York, San Francisco and Miami.
Results showed that 42.6% of those women had probable cases of depression. These cases
showed a correlation with lack of social support and health insurance coverage. Attributes of
acculturation and or immigration status also were related to PPD.
As this study is one of the largest and most relevant to this paper it will be explored in in
more detail. In this study women were recruited from the three urban centers from March 1999
to February 2001. The study selected women who were at least 17 years old at the time of
delivery and able to communicate in either Spanish and /or English. They were asked about their
immigration status, socio-demographic background, adequacy of prenatal care, and knowledge,
attitudes and beliefs regarding healthcare and immigration policies. Depression was measured by
the Epidemiologic Studies Depression Scale (CES-D), which contains 20 items assessing
depressive symptoms over a seven day period. The CES-D showed a high internal consistency
rate (α=0.86).
Acculturation was another independent variable measured using a twelve item
acculturation scale designed for Hispanics; factors considered were language usage, media use,
and ethnic social relationship. The measure had a high internal consistency (α=0.93).
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Immigration status was assessed through a self-declaration of either „U.S. citizen,‟ „legal
resident,‟ or „undocumented.‟ Another variable, social support, was measured on a twelve item
Multidimensional Scale of Perceived Social Support (MSPSS), which showed a high internal
consistency of (α=0.87). Health Insurance information was provided by the respondents,
including their use of Medicaid and other public or private insurance. Socio-demographics were
also reported by the participants, including age, education, marital status, monthly household
income, employment status and national origin.
The results showed that marital status, education and employment status were all
associated with level of depression. Women who were employed, had a higher education, and
higher incomes showed a significantly lower risk of depression. If a woman was divorced or
single she showed a higher risk of depression, which increased if she lived with her partner but
was not married. On the other hand, having some form of insurance was associated with a lower
risk of depression. Undocumented immigrant women with higher levels of depression also
showed issues of acculturation, but both variables (immigrant status and acculturation)
disappeared if there was a strong perceived social support for the women.
This study is one of the largest to research depression in Hispanic women, with 42.8%
showing signs of postpartum depressive disorder. The research directly examined the interaction
between PPD, socioeconomic status, acculturation issues, immigration status and social support.
The existence of social support turned out to be a very important factor in predicting if someone
would suffer from PPD. This review confirmed that, for Hispanic women, variables of
acculturation, immigrant status and social support can be indicators of risk for PPD. It is
interesting to note that, if social support was present there was decreased risk of PPD, even if
issues with acculturation and immigrant status existed.
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Another important study was done by Datta, Marquez-Ponce, Wilson, Du, and McGregor
(2008) who researched the prevalence of risk of PPD in an urban, mixed generation in the Latina
population. The subjects in this research were Latina women who received postpartum care
between September 2006 and September 2007 in various community health centers. Using the
Edinburgh Postnatal Depression Screen in Spanish and English, it was found that 47 of 255
women (18%) were identified as having PPD. The study also found women who had delivery
complications, neonatal complications or intervention for advanced maternal age, were at highest
risk of postpartum depression. The research concluded that urban Latinas had an 18% higher rate
of PPD in comparison to non-Latinas. The study recommended screening for PPD in the Latina
population as well as improving prevention intervention for postpartum women at risk,
especially those with prenatal complications. Unfortunately, the study did not identify the exact
age of the subjects; they just concluded older age as a risk. Various other variables such as
relationship violence and whether Spanish was their primary language were identified as
contributing to risk of PPD.
Low Income and History of Depression Latinas during Postpartum
Another variable that can heighten the risk of PPD is a woman‟s financial situation. The
study “Identifying risk for onset of major depressive episodes in low-income Latinas during
pregnancy and postpartum” by Le, Muñoz, Soto, Delucchi, and Ghosh Ippen, (2004) identified
those Latina women that are “more vulnerable” or “less vulnerable” to PPD. The study utilized
identified a sample of low-income, pregnant Latina women who were using public sector
prenatal services, finding 191 eligible women. 59.7% of these women were approached and
73.7% of that number agreed to participate. The sample was interviewed several times until 6
months postpartum. An MDE test was used, based on the Maternal Mood Screen, to see if there
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was any vulnerability to depression. Another tool used was based on their participants‟ self-
reported history and mood problems using the Center for Epidemiological Studies –Depression
Scale (CES-D). The findings supported the researchers‟ hypothesis that low-income Latina
women were at significantly higher risk of vulnerability to PPD. It was also restated that women
who had a history of major depression were also at a higher risk of PPD. The limitations to this
study were that it was a small sample size and lacked a clear definition of what is considered
„low-income,‟ in comparison to other income statuses.
Adolescents
The study, “Caregiving history and prenatal depressive symptoms in low-income
adolescent and young adult women: moderating and mediating effect,” by Milan, Kenshaw,
Lewis, Westdal, Schindler Rising, Patrikios, and Ickovics, (2007), measures prenatal depressive
symptoms in this vulnerable age group. Using attachment theory as the framework, this study
examined developmental differences in the interpersonal relationships and depressive symptoms
among young adolescents (age 14-19 years; n=352) and young adults (age 20-24 years; n=348),
including women that came from low income, single families of mostly African American and
Latina descent. They found that pregnant adolescents who also have maternal unavailability were
more likely to show depressive symptoms in the future, though paternal care-giving had a small,
independent association with depressive symptoms. This raised the concern about Latina women,
especially adolescent immigrant women, who come to America separated from their families,
particularly from their mothers. If an adolescent is pregnant and a recent immigrant, without
social support and the care of a mother; she is likely to be at a high risk of suffering from PPD.
Obstetrical Complications
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It is also important to review the likelihood of developing PPD caused by complications
at birth. “Obstetrical Complications and the Development of Postpartum depression Symptoms: a
prospective survey of MATQUID Cohort” by Verdoux, Sutter, Glatigny-Dallay, and Minisini
(2002) investigated the association between pregnant women, obstetrical complications (OC) and
PPD. 441 pregnant women participated in the research, which was carried out at the State
Maternity Hospital in Bordeaux. They were interviewed during the third trimester of pregnancy,
then at three days and six weeks after birth. The Edinburgh Postnatal Depression Scale (EPDS)
was used to access PPD. Data on a large range of pregnancy, delivery and neonatal somatic
adverse events were collected by interviewing the mothers. Data on obstetrical complications
were rated using the McNeil–Sjotrom scale. A dimensional definition of postnatal depression
(EPDS summary score 6 weeks after delivery) was used to explore the relationships between
OCs and early postnatal depressive symptoms. The results showed that severe complications
during pregnancy were associated with more intense depressive symptoms in the early postnatal
period, separate from those caused by martial adjustment, parity, and a history of depressive
anxiety disorder during pregnancy. Berk, M. & Schur, C (2001), found that 39% of
undocumented adult immigrants expressed fear about receiving medical services because of
undocumented status. Hence it can be concluded that concern about immigration status, which is
very common among young, often undocumented, Latina immigrants decreases the likelihood
of getting prenatal care that could potentially lead to obstetrical complications.
Immigrant Status
Immigrant status can also contribute to the risk of developing symptoms of depression for
a new mother. The study “Experiences of immigrant new mothers with symptoms of depression”
by Ahmed, Steward, Teng, Wahoush, and Gagnon (2008) looks at refugee, asylum seeking, non-
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refugee, and immigrant new mothers with depressive symptoms who were interviewed using a
qualitative method. In this study the Edinburgh Postpartum Depression Scale was given to
participants shortly after giving birth. Twelve to eighteen months after postpartum participants
were interviewed in a semi-structured interview which was tape-recorded. Many women
revealed that they felt that their depression was due to social isolation, physical changes and
feeling overwhelmed and financial worries. Other issues that mothers revealed in this study
included having embarrassment, language difficulties, fears of being labeled an unfit mother, or
concerns about of attitudes of some staff.
There were five categories in which the researchers found results: the experiences and
attributions of depression, the experience with health care providers and support services, what
barriers existed to asking for help, attributions of causes of recovery, and differences between
women who were still depressed and women who had recovered. The study found that many
Latina women attribute the experience of postpartum depression to the same factor as non-white
women, namely not having health care or continuous providers. The Latina situation of
immigrant women was more difficult than others, however, because of the lack of proximity to
their informal support system (i.e. family) and the barriers that existed to formal support, due to
their lack of knowledge or language deficiency. The interviews carried out in this study indicated
that the women were very sensitive to attitudes that could be interpreted as inattentive or
uncaring in social service workers, health care providers and receptionists. They also found that
at least half of the women were unaware of the services available to them to cope with
depressive symptoms. The study suggests that, for many immigrant women, their PPD may have
been caused or exacerbated by feelings of isolation, low social support and loss of autonomy
after giving birth (Nicolson, 1999).
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Tummala-Narra‟s article, “Mothering in a Foreign Land” (2004) addresses cultural
displacement and its impact on the dilemmas of immigrants and motherhood. The paper studies
various aspects of cultural displacement, including the adaptation of the immigrant process,
changing conceptions of gender roles and attachment, bicultural conflicts, and changing family
structure and social network. The article reveals that the experience of migrating to a new
country has a profound effect on a new mother, especially when considering the age of
migration, pre-immigration character organization, the reason why the person left their country,
the reception of the host population, the efficiency of their adaptation to their new country and
the birth of their children. For immigrant women, coming into a new country can be a stressful
event, especially if the reason for leaving was dealing with war-torn events, political violence or
difficult family relationships. For many women, coming to terms with redefining themselves in a
whole new country is very difficult. It can completely affect how they see themselves and at
times it can be difficult to accept many of the changes needed to assimilate effectively. The
article highlights findings of previous studies that even adopting a new language is a powerful
way of organizing cognitive and effective experience. But the emotional turmoil and stress that
an immigrant goes through when acculturating and the pressure of learning a new language in a
country where their own language is not understood can cause a person to disconnect from
dealing with and integrating emotionally painful content (Amati-Mehler, Argentieri, and
Canestri, 1993; Perez Foster, 1996). The article also discusses how physical and psychological
separation from one‟s own mother can cause a state of anxiety, especially if the immigrant‟s
mother is not available and not in her social support network.
In conclusion, while research has illuminated some issues there also areas of limitations
especially concerning predictors of risk of PPD for women and in particular for Latina immigrant
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adolescent women. It is important to identify who is at risk of PPD because, according the study
first mentioned (Murray, L. 1991), PPD can affect the infant-mother relationship and infant
development. The latter studies mentioned here identify risk indicators of ethnicity, age,
complication at birth, financial situation, acculturation, past history of depression and immigrant
status. Further research into the topic area is needed.
Case Study
Introduction and Referral
The U.C.S.F Infant-Parent Program based at San Francisco General Hospital provides
assessment and treatment when there are concerns about a child‟s development, or when
childrearing becomes a problem for parents and their children. The program focuses on the
infant-parent relationship and utilizes infant psychotherapy, a nondidactic guidance of infant
development through home visits, which make the service more accessible to the families.
The Client, identified henceforth as Ms. A., was referred to the Infant-Parent Program by
her Pediatrics‟ Health Nurse (PHN) who was concerned for her mental health. Ms. A. is a 17-
year-old monolingual Spanish-speaking immigrant from Mexico; she has a nine-month-old male
infant who was also referred to the Infant-Parent Program for services.
Despite a difficult birth the mother was initially described by the PHN as being „mature‟
despite her young age; she was considered a good mother in regards to her baby. The PHN
visited the mother and infant for monthly home checkups; during these visits the PHN found that
the mother‟s anxiety increased appreciably over several months. Mother began to experience
urges to hurt herself or her baby, which is why the mother and infant were referred to the Infant-
Parent Program.
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History
Ms. A. disclosed that she was 15 years old when she met her boyfriend in her small town
in Mexico. She said that her parents were very accepting of her boyfriend, and they seemed to
approve of him. He was from the same town she as she, and he had entered the United States at a
very young age. He had established himself in a good job in construction in San Francisco, and
was able to save enough money to build a house for his mother. When my client met him, she
was dating someone of whom her parents did not approve. After a short courtship, he asked her
to come to San Francisco. When Ms. A asked her mother for permission to marry him, the client
revealed that her mother told her that she didn‟t want to get in the way of her marriage. Ms. A.
said that her mother was always a friend, but she never saw her as a mother figure.
Ms. A. is a recent immigrant from Mexico. She arrived with her 22-year-old husband in
San Francisco at the age of 15 and was pregnant at the age of 16. The PHN indicated that the
mother had an unexpectedly difficult birth and her infant had a series of serious medical issues.
After several days of being in labor the mother had to have an unexpected cesarean, which can
be very difficult for any mother who especially these who had expected a normal childbirth. The
PHN indicated that another reason for the cesarean was that infant‟s heart beat was concerning.
Once the infant was born he went into cardiac arrest and was rushed to a trauma hospital that
specializes in pediatrics. The mother did not see the infant until three days after the birth when
she was transferred to the hospital where her child was getting infant cardiac treatment.
There were also complications from a mis-managed epidural administered while mother
was in labor after which Ms. A. lost sensation in the left side of her body for several weeks. Ms.
A. disclosed to a nurse who spoke fluent Spanish that the Spanish interpreter that was provided
23
to her while she was in labor didn‟t seem to understand her and was afraid to speak up when the
procedure was being done. Ms. A. said that she had tried to tell the interpreter that something felt
wrong, but they told her the feeling was normal. Since she didn‟t have her family there to
advocate for her, she didn‟t say anything else. After she had given birth the nurse came to take
her vitals and Ms. A realized she couldn‟t move her left side. After several neurological tests and
a small medical procedure, she was able to regain movement in her left side, but it took several
weeks.
The PHN noted that the mother had became much calmer since she was prescribed
medication for her depression, which had been given to her after she first expressed concerns for
the safety of her infant. Although she meets with a counselor at the local teen center, the mother
remains anxious and wants to be with her baby constantly to make sure that he is breathing. As a
result of this vigilance, the mother describes herself as constantly tired and unmotivated due to a
lack of sleep. The PHN described how Ms. A requires a lot of parenting help and remains
reluctant to leave her home. The mother has also declined many services in the past for fear of
having to leave her home. The Infant-Parent Program is thus an appropriate service for her needs
as it provides home therapy. The PHN suggested that having a Spanish-speaking therapist might
be useful for Ms. A. since she is monolingual speaker who has disclosed feeling frustrated not
being able to communicate with her medical providers. Ms. A. believes that this was the reason
why there were so many complications during the birth. She wasn‟t even aware that her infant
had been taken to another hospital until a social worker arrived to have her sign some documents
and explained to her where her infant was.
24
Observation
Since treatment began with Infant-Parent Program, Ms. A. has disclosed how difficult it
has been for her to leave her home, afraid that something bad will happen to her infant. Ms. A.‟s
social network is very small; most of her friendships are from her connection to her husband,
since he lived in San Francisco for several years before he met his wife. Her own friends are very
limited; when she when was ill, she only had one friend who was able to visit her during her stay
at the hospital.
The clinician‟s first of observation of Ms. A. was that she was a typical 17 year old who
was very excited to have someone coming visit her; she was eager to show off her infant and his
new matching clothing. As she spoke she described her feelings of fear and anxiety that her
infant would get sick again. The mother described feeling overwhelmed and anxious for the last
several months, and that she was just so tired. Sometimes she would sleep for hours and would
leave her infant in the crib, a fact which was obvious when the infant was picked up and the back
of his head was found to be noticeably bald. When Ms. A. discussed her feelings she looked at
the clinician for approval, asking if it was good parenting to leave the infant in the crib for hours,
believing that he would be safe while she slept. Ms. A. revealed that she took naps of at least
four hours twice a day.
During the sessions the clinician observed that the infant constantly wanted to be picked
up and kept moving, which the mother commented on, mentioning that he is never still. The
infant seemed very anxious and kept trying to grab mother‟s breast as she tried to breast feed
him. After feeding the infant remained restless, starting to grab things and putting small objects
in his mouth as his mother looked on. He also seemed very squirmy and anxious when she tried
25
holding him. She described that he likes to bite and doesn‟t ever seem to be still, which made her
think that she was doing something wrong.
When the clinician asked Ms. A. when they could next meet, Ms. A. stated that she
tended to forget things, something that was very common for her, and that the clinician would
have to call the day before to remind her. Ms. A. mentioned that she tended to forget many
appointments, was not able to keep to her daily routines and often forgot what day it was. The
clinician asked her if she felt depressed, and she replied that she didn‟t consider herself
depressed, just sad and tired. Their feelings made it hard when she tried to cuddle her infant,
since she would be too exhausted or unmotivated to continue.
Another important observation occurred when the clinician was about to leave. Ms. A.
asked the clinician if they knew of a plastic object that would line the inside of a crib. She
pointed to the inside of the infant‟s crib where the infant had scraped his teeth against the crib.
The clinician observed that the entire inside had been scraped out. When asked if the infant liked
to chew on the crib, the mother responded that she thought he was mostly likely teething, and
figured that it must be normal. She had tried to distract him with teething toys that he didn‟t
seem to like, showing the clinician a large box of teething toys that had been untouched, since
clearly the infant preferred teething on his crib. The clinician asked Ms. A. if she had been
concerned about this, and she said that she was just worried that his teeth wouldn‟t grow out.
Summary/Conceptualization
The following are factors that contribute to Ms. A.‟s PPD. The first factor is her age,
since she was only 16 years old when she got pregnant. Ms. A disclosed during therapy that she
had planned her pregnancy and had wanted a child ever since she came into the country, because
26
she felt lonely. According to Milan (2007), a woman at her age is at a higher risk of PPD because
she doesn‟t have a social support network, specifically her mother, which could provide
emotional and physical support. The study identified pregnant adolescents with maternal
unavailability as having a high risk of depressive symptoms. Ms. A., a young mother, doesn‟t
have her own mother physically nearby or available to her, and only communicates with her by
phone. Due to her immigrant status she cannot return to her country, for fear of not being able to
return, especially since her son is a US citizen. It‟s also important to note her young age and lack
of social network in comparison to other girls her age.
For immigrant women such as this client, adapting to a new country can be a stressful
process, even if it was her choice to come in the first place. For many women, coming to terms
with redefining themselves in a whole new country can completely affect how they see
themselves. As cited earlier, Tummala-Narra‟s article “Mothering in a Foreign Land” (2004)
reveals that cultural displacement can have a negative impact on the dilemmas of motherhood,
the immigrant process, conceptions of genders roles and attachment, all of which are shown in
the case of Ms. A. As stated earlier, learning a new language is a powerful organizer of cognitive
and effective experience used to express, but can also cause an immigrant to repress and
disconnect from emotionally painful content because of the emotional turmoil and stress that
accompanies acculturating and the pressure of learning a new language to survive (Amati-
Mehler, Argentieri, and Canestri, 1993; Perez Foster, 1996). Ms. A. has demonstrated that even
though she is trying to learn another language and trying to adapt in this country, she doesn‟t
seem to understand simple emotional concepts, as she is stressed and overwrought with learning
a new language. We see this such as when her infant is displaying clearly anxious behavior and
27
mother seems to believe it is normal, she lacks understand that her infant is not functioning
normally.
Another contribution to her depressive behavior is the fact that Ms. A. had severe
complications during the birth process due to her unexpected caesarean and her infant‟s cardiac
arrest, which made it impossible for her to see her child after he was born. This traumatic
experience was compounded by the complications with the epidural that lead to the loss of her
physical movement. The difficulty of abandoning a birth plan and then transitioning into
immediate surgery can be very traumatic, a fact highlighted by Verdoux‟s (2002) study, which
concluded that severe complications during pregnancy are closely associated with intensely
depressive symptoms in the early postnatal period. The study determined that these events,
similar to what Ms. A. went through, are often far more damaging than problems caused by
martial adjustment, parity, and a history of depressive anxiety disorder during pregnancy.
Another complicating factor is Ms. A.‟s immigrant status, which increases her risk of
depression. This was investigated in the study “Experiences of immigrant new mothers with
symptoms of depression” Ahmed, Steward, Teng, Wahoush, and Gagnon, (2008), which looked
at refugees, asylum-seeking non-refugees, and immigrant new mothers with depressive
symptoms who were interviewed in a qualitative study. The study found that depression was due
to social isolation, physical changes, feeling overwhelmed and financial worries. Other factors
also included feeling embarrassed, language divides, a fear of being labeled an unfit mother, or
the negative attitude of some staff. In the case of Ms. A., she described the feeling of being alone
and unable to communicate to other people as a very difficult experience for her. She repeatedly
described her English language difficulties, not being able to talk to people, and feeling
embarrassed at not being able to communicate. The client shared that being monolingual, she felt
28
that she was at “a disconnect” from other young women her age, which can affect or even
increase her depressive symptoms.
This case also relates to another study, “Depressive Symptoms in the Immediate
Postpartum Period Among Hispanic Women in the Three U.S. Cities,” Kuo, Wilson, Holman,
Fuentes-Afflick, O‟Sullivan, and Mikoff (2004), which examined rates and depressive symptoms
in immediate postpartum in Hispanic women. This study found a correlation between these
women having a lack of social support and health insurance coverage, factors which made them
more likely to suffer depression. As emphasized throughout this thesis, social support is very
important for someone who is susceptible to postpartum, but due to her age and immigrant
status, Ms. A. also hasn‟t been able to find employment or insurance. The only thing she
qualified for was medical treatment, which was only was used for assistance in the birth of her
child. Lawyers who wanted to sue the hospital for the epidural incident approached her on
several occasions, but she declined for fear of bringing her immigrant status to attention.
This same study is relevant to Ms. A. in another way, since it showed that marital status,
education, and employment status are also associated with the risk of depression. Undocumented
immigrant women who had a higher level of depression also showed issues of acculturation, but
both concerns of having immigrant status and acculturation issues disappeared if there was
strong perceived social support for the women. The client, Ms. A., has no education, no
employment and no social support.
Currently, the treatment plan for Ms. A. and her son is still new, involving controlling her
depressive disorder through the use of an antidepressant prescribed by her psychiatrist, who
monitors her situation in weekly therapy sessions. Infant-Parent services are needed to respond to
29
the client‟s difficulties and to help her understand how her mental state impacts her relationship
with her infant. Some of the important factors to address during this process include the infant‟s
clear distress, his adjustment to stresses such as the traumatic birth, complicated by his mother‟s
misunderstanding of his needs and her ability to respond to them given her state of mental health.
Recommendations for Treatment
An image that tends to reflect Latina culture is the image of the Virgin Mary, a religious
icon to which many women aspire, representing the saint of all children and the perfect mother.
Becoming a mother for many Latina women is the “holy grail” of what a woman should
accomplish, and is often felt as her purpose in life. The message may subliminal, but it is very
clear that Latinas believe they must be nurturing, devoted, and self-sacrificing. In short, they are
told that they should always put their children‟s needs before their own at all times. When these
aspirations are compromised by issues such as immigration, language barriers, depression and
trauma or compounded by their own familial development, it can be the most overwhelming
problem a new mother can go through. It is important to explore this particular issue with
immigrant Latina women who may be suffering from PPD, in order to provide them with
appropriate treatment and other useful resources.
Support Groups
According to Tummala-Narra, P.‟s Mothering in Foreign Land, support groups have
shown to provide relief to women with PPD. The goal of many support networks is to provide a
level of support that may help a mother feel she is being cared for. For Latinas, since a lack of
family support often contributes to their depression, this service can provide a much-needed
feeling of security that can assist them in working through their depression. One of the methods
30
used involves providing non-judgmental emotional support. The mother is assured that every
mother needs support, especially if a mother or her family is not well, and told that mothers
deserve care and are worthy of being the focus of society‟s attention. Another PPD support
strategy involves convincing the mother of three simple components: first that she is not alone,
second that she is not to blame, and third that she will get better; that her experience is real and
there is help for her especially. Having significant and culturally relevant emotional support can
be empowering and fruitful for a Latina mother who lacks this foundation.
Individual Psychotherapy
Another treatment approach that can be helpful for a woman suffering from PPD is a
psychodynamic, object relations approach. Object relations focuses on how early relationships
and experiences influence the way people feel about themselves and relate to others as adults.
The moment a female is born, her maternal identity begins. Her own mother‟s touch and voice,
the way she responds to cues and how her needs are met or not, all provide the foundation for
how she will be with her own child once she herself is a mother. Having traumatic experiences in
early life can make it difficult for new mothers to develop a secure happy relationship with their
child. Focusing on an immigrant woman‟s maternal identity when she develops PPD can be
helpful, especially if she feels that she is not meeting her infant‟s needs or feels that she is not
being what she things of as the ideal mother. According to Monk, Leight, & Fang (2007), when a
pregnant woman‟s overall concern is a fear about closeness and lack of security, she will
experience her pregnancy as stress-provoking. For some woman, the imagined experience of
motherhood and the fantasy of the baby turns out to be very different from the reality once the
infant is born. This discrepancy can be devastating as she not prepared for the feelings of
inadequacy and guilt that emerge when she realizes her fantasy has not come true. An immigrant
31
mother who is dealing with lack of support, precarious immigration status and other cultural
stressors previously mentioned, can begin to feel that she cannot fully support her infant. If she
has to return to work immediately after childbirth, which her own mother may not have done, she
may think that she cannot provide the same level parenting her own mother provided for her.
This feeling of inadequacy can have a dramatic influence on her own self-image and can further
feed into a feeling of failure to live up to the „perfect mother‟ image ingrained by her culture.
In the psychoanalytic approach, helping a mother work through her depression by
exploring her current and past relationships, in particular her familial relationships, can
positively affect her relationship with her infant. Helping a mother in therapy address these
issues can help her understand herself “childbearing requires an exchange of a known self in a
known world for an unknown self in unknown world” (Rubin, 1984). Having a therapist who is
culturally supportive and sensitive can provide a more empathetic role and a non-judgmental
relationship that creates a safe and nurturing environment in which a patient can explore past
patterns and work through any transference.
Medication
Another form of treatment for mothers with PPD is to provide medication along with
psychotherapy. Medication can be a difficult option if the Latina client is someone who has
never felt comfortable with medicine. There is a real risk of her not taking the medication. She
may be unable to understand the dosage. She may feel that the medication isn‟t working because
she may not understand the length of time it takes to start being effective. Having a physician
that can clearly explain the medicinal details and provide support will assist in the medication
process. For a new immigrant mother there are many concerns with taking medication and these
32
were present in the case presented here. A mother may want to control her own health care and
not let other people know that she is taking medication. For immigrants who may not have
financial support it may be easier to purchase medication that doesn‟t need a prescription, which
sometimes isn‟t as effective.
Another form of treatment for depression is the use of alternative treatments, including
long chain Omega-3 fatty acids (EPA and DHA), exercise and St. John‟s Wort. According to the
British Journal of Psychiatry, “there is good evidence that psychiatric illness is associated with
the depletion of EFA‟s (essential fatty acids) and crucially, that the supplementation can result in
clinical amelioration… The clinical trial data may herald a simple, safe and effective adjacent to
our standard treatments” (Hallahan & Garland, 2005). Exercise is also an inexpensive and
effective treatment. According to Daley et al (2007), the role of exercise in treating postpartum
depression is actually one of the most productive and safe ways of treating both mild and major
depression. They found that it works because it changes the brain‟s chemistry, specifically it
helps elevates serotonin and dopamine levels and release endorphins that relieve pain and help
create a sense of well being, helps release stress, all of which improve mood and the overall
quality of life. While studies show that St. John‟s Wort is an effective for treatment for
depression (Sarris, 2007), recent research has also found that it works as an anti-inflammatory,
which can be beneficial for a mother who has recently given birth (Balch, 2002).
Related Issues
One area that can be addressed is how education affects a mother‟s ability to find
treatment for PPD. Ian Bennett, from the University of Pennsylvania School of Medicine, studied
the link between women were unable to access prenatal services and literacy. He found “women
33
with low literacy faced added hurdles to the navigation of the health care systems for themselves
and their children. The stresses of poverty and an increased risk of depression further
complicated the challenges of getting services they need” (I. Bennett, personal communication,
2007). This is one area that requires further research, specifically in relation to immigrants who
are unable to find healthcare due to language and education barriers.
In another study, Dr Bennett found that among Latina prenatal care patients with limited
English proficiency, participants commonly also had inadequate literacy in Spanish, which
increased their already a high risk of maternal depressive symptomatology (Bennett et al., 2007).
A concern revealed from work by researcher Dr. Julie Gazmararian from Emory University
(Parkh et al., 1996) is that mothers with low literacy tend to have feelings of shame and thus are
likely to hide the fact that they cannot read or understand what their health care provider is
explaining to them. Another researcher, Dr. Lee Sanders, Associate Professor of Pediatrics at the
University of Miami Leonard M. Miller School of Medicine, found that maternal literacy is
connected to a higher likelihood that a child will be born prematurely and higher risk of infant
mortality (L. Sanders, personal communications, September 21, 2007). He stresses, however,
that there needs to be more research done internationally.
Conclusions
For many women becoming a mother is one of the most important transitions of her life.
This transition can be difficult and challenging especially if they are suffering from a mental
health disorder. PPD specifically can interfere in the development of an infant, as discussed
throughout this paper. As shown, recent Latina immigrated adolescent women confront a whole
34
set of factors that heighten their risk for PPD and these risk should be addressed with more
concern.
Although, PPD cannot be predicted or prevented with absolute accuracy, we can
appreciate the risks to specific vulnerable populations and try to protect future mothers who may
be susceptible to PDD. Helping medical professionals take these risk factors into consideration
when treating a Latina woman can help in identifying her symptoms and possibly even help the
client with a plan of care to help prevent PPD. By proactively preparing a mother for the
possibility that she might be at risk, and making her aware of the symptoms that may appear,
both mothers and medical professionals will be in better position to intervene effectively.
35
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RUNNING HEAD: RISK OF POSTPARTUM DEPRESSION IN LATINA WOMEN

Risks of Postpartum Depression in Immigrant Adolescent Latina Women

cope with postpartum depression.

IV. Table of Contents 4

V. Introduction and Overview 6

VI. Application to Theory 10

VII. Relevant Research 14

Introduction and Overview

clinicians should play.

The prevalence of postpartum depression and the impact to young mothers is an

worthless, guilty, irritable or restless. A loss of interest in activities, a loss of appetite or

overeating, problems concentrating, remembering details or making decisions, and suicidal

changes; in short, a complete change of life. According to Beck‟s Cognitive theory of

contribute to postpartum depression, while socioeconomic factors such as low or no social

also cause the illness (Beck, 1995).

the necessity for the early detection and treatment of PPD.

these developments are all jeopardized by the illness.

help from a mental health professional on their own.

According to an article in Maternidad Latina (2007), a prominent idea existing in the

impact the intensity and length that a Latina will be depressed.

Additionally, cultural displacement can have a severe impact on the dilemmas of

motherhood, according to Tummala-Nara, (2004). Akhtar (1999) cites various psychological

situation such as a pregnancy.

the infant can be affected immensely.

depressed dyad, which impairs the mother-infant bonding process.

infants are in a less positive mood compared to secure, older infants.

growth (Rahman, Iqbal, Bunn, Lovel & Harrington, 2004).

cognitive development (Sohr-Preston & Scaramella, 2006) as a result of being brought up by a

have long-lasting effects.

adolescent Latina women suffering from PPD.

Depressive Symptoms in Latina Women

acculturation and or immigration status also were related to PPD.

immigration status, socio-demographic background, adequacy of prenatal care, and knowledge,

Acculturation was another independent variable measured using a twelve item

consistency of (α=0.87). Health Insurance information was provided by the respondents,

income, employment status and national origin.

issues with acculturation and immigrant status existed.

population as well as improving prevention intervention for postpartum women at risk,

contributing to risk of PPD.

Low Income and History of Depression Latinas during Postpartum

„low-income,‟ in comparison to other income statuses.

The study, “Caregiving history and prenatal depressive symptoms in low-income

examined developmental differences in the interpersonal relationships and depressive symptoms

It is also important to review the likelihood of developing PPD caused by complications

at birth. “Obstetrical Complications and the Development of Postpartum depression Symptoms: a

prospective survey of MATQUID Cohort” by Verdoux, Sutter, Glatigny-Dallay, and Minisini

of getting prenatal care that could potentially lead to obstetrical complications.

were interviewed in a semi-structured interview which was tape-recorded. Many women

concerns about of attitudes of some staff.

after giving birth (Nicolson, 1999).

Tummala-Narra‟s article, “Mothering in a Foreign Land” (2004) addresses cultural

mother is not available and not in her social support network.

status. Further research into the topic area is needed.

Introduction and Referral

infant-parent relationship and utilizes infant psychotherapy, a nondidactic guidance of infant

and explained to her where her infant was.

four hours twice a day.

think that she was doing something wrong.

since she would be too exhausted or unmotivated to continue.

of social network in comparison to other girls her age.

themselves. As cited earlier, Tummala-Narra‟s article “Mothering in a Foreign Land” (2004)

at refugees, asylum-seeking non-refugees, and immigrant new mothers with depressive