POSTPARTUM ILLNESS:

A SOCIOLOGICAL EXPLANATION
Project Report Submitted to University of Kerala in Partial Fulfilment of the Requirement
for the Award of B A (CBCSS) Degree Examination in Sociology

MARCH 2023

Submitted by

Name Candidate Code

Aleena Dixon 15620127004

Ardra R Shiji 15620127007

Anaswara Prasad L 15620127006

Sajana Binoy 15620127045

Sivan S 15620127008

Exam code: 15614608 Subject code: SG 1645

DEPARTMENT OF SOCIOLOGY

SREENARAYANA COLLEGE, CHEMPAZHANTHY

MARCH 2023
 DECLARATION

We Aleena Dixon, Ardra R Shiji, Anaswara Prasad L, Sajana Binoy, Sivan S, hereby declare
that the project work titled “Postpartum Illness: A Sociological Explanation” submitted to
University of Kerala in fulfillment of the Degree of Bachelor of Arts in Sociology, is a bonafide
work carried out under the guidance of Dr Lekha N. B., Assistant Professor of Sociology, Sree
Narayana College, Chempazhanthy and that it has not found the basis for award of any Degree or
Diploma Course.

Chempazhanthy

March,2023

Aleena Dixon

Ardra R Shiji

Anaswara Prasad L

Sajana Binoy

Sivan S
 CERTIFICATE

Certified that the project work entitled “Postpartum Illness: A Sociological Explanation” is an
original investigation carried out by (Aleena Dixon, Ardra R Shiji, Anaswara Prasad L, Sajana
Binoy, Sivan S) under the guidance of Dr. Lekha N.B., Assistant Professor of Sociology,
submitted to the University of Kerala in lieu of a core paper for BA (CBCSS) Degree
Examination in Sociology, is a bonafide work and that it had not found the basis for award of
any Degree or Diploma Course.

Supervising teacher Head of the Department

Principal
 ACKNOWLEDGEMENT

We express our sincere gratitude and profound obligation to our supervisor Dr Lekha N.B.,
Assistant Professor of Sociology Sree Narayana College Chempazhanthy, for her valuable
guidance, advice and constructive criticism of every stage of the study have taken in the present
shape.

We heartly express our gratitude to Smt. Aiswarya A.S Head of Department of Sociology, Sree
Narayana College Chempazhanthy, for her encouragement, love and timely advice.

We indebted to Dr Kavitha V, Guest faculty Department of Sociology, Sree Narayana College

Chempazhanthy, for her encouragement, love and timely advice.

We cannot approve to ignore our respondents who co-operate willingly and provided us the
requirement for this studies our sincere thanks to all of them.

Our special thanks to all of our classmates for their valuable support and assistance.

Researchers had to spend a lot of time and effort to resolve the technical hurdles in collecting
data from primary health centre. Heartfelt thanks for all who has helped us in our way.

We express our deepest gratitude to our parents for their moral support in every twist in our
journey.

Last but least we forever remains indebted to God’s blessing and we continue pray for it.
 CONTENTS

1) Introduction 1 - 30

2) Literature Review 31 - 39

3) Methodology 40 – 43

4) Data Analysis 44 - 60

5) Conclusion 61 - 65

APPENDIX
Bibliography
 CHAPTER 1

INTRODUCTION

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest.
Also called major depressive disorder or clinical depression, it affects how you feel, think and
behave and can lead to a variety of emotional and physical problems. You may have trouble
doing normal day to day activities and sometimes you may feel as if life isn’t worth living.

The birth of a baby can trigger a jumble of powerful emotions, from excitement and joy to fear
and anxiety. But it can also result in something you might not expect Postpartum depression.
(https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007)

POSTPARTUM DEPRESSION

Postpartum depression (PPD) is a complex mix of physical, emotional, and behavioral changes
that happen in some women after giving birth. According to the DSM-5, a manual used to
diagnose mental disorders, PPD is a form of major depression that begins within 4 weeks after
delivery. The diagnosis of postpartum depression is based not only on the length of time between
delivery and onset but on the severity of the depression.

Postpartum depression is linked to chemical, social, and psychological changes that happen when
having a baby. The term describes a range of physical and emotional changes that many new
mothers experience. PPD can be treated with medication and counseling.

The chemical changes involve a rapid drop in hormones after delivery. The actual link between
this drop and depression is still not clear. But what is known is that the levels of estrogen and
progesterone, the female reproductive hormones, increase tenfold during pregnancy. Then, they
drop sharply after delivery. By 3 days after a woman gives birth, the levels of these hormones

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drop back to what they were before pregnancy. In addition to these chemical changes, the social
and psychological changes of having a baby create an increased risk of depression.

While the exact cause of PPD is unclear, the cause is believed to be a combination of physical,
emotional, genetic, and social factors. These may include factors such as hormonal changes and
sleep deprivation. Risk factors include prior episodes of postpartum depression, bipolar disorder,
a family history of depression, psychological stress, complications of childbirth, lack of support,
or a drug use disorder. Diagnosis is based on a person’s symptoms. While most women
experience a brief period of worry or unhappiness after delivery, postpartum depression should
be suspected when symptoms are severe and last over two weeks.

Among those at risk, providing psychosocial support may be protective in preventing PPD. This
may include community support such as food, household chores, mother care, and
companionship. Treatment for PPD may include counseling or medications. Types of counseling
that have been found to be effective include interpersonal psychotherapy (IPT), cognitive
behavioral therapy (CBT), and psychodynamic therapy. Tentative evidence supports the use of
selective serotonin reuptake inhibitors.

Postpartum depression is not only associated with women but also with men. Research shows
that about 1 in 10 new fathers get depression during the year their child is born. Abortions, ill-
birth, and birth of disabled children can also cause postpartum depression.

(https://www.webmd.com/depression/guide/postpartum-depression )

CAUSES

The cause of PPD is unknown. Hormonal and physical changes, personal and family history of
depression, and the stress of caring for a new baby all may contribute to the development of
postpartum depression.

Evidence suggests that hormonal changes may play a role. Understanding the
neuroendocrinology characteristic of PPD has proven to be particularly challenging given the
erratic changes to the brain and biological systems during pregnancy and postpartum. A review

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of exploratory studies in PPD have observed that women with PPD have more dramatic changes
in HPA axis activity, however directionality of specific hormone increases or decreases remain
mixed. Hormones which have been studied include estrogen, progesterone, thyroid hormone,
testosterone, corticotrophin releasing hormone, endorphins, and cortisol. estrogen and
progesterone levels drop back to pre-pregnancy levels within 24 hours of giving birth, and that
sudden change may cause it. Aberrant steroid hormone–dependent regulation of neuronal
calcium influx via extracellular matrix proteins and membrane receptors involved in responding
to the cell’s microenvironment might be important in conferring biological risk. The use of
synthetic oxytocin, a birth-inducing drug, has been linked to increased rates of postpartum
depression and anxiety.

Fathers, who are not undergoing profound hormonal changes, can also have postpartum
depression. The cause may be distinct in males.

Profound lifestyle changes that are brought about by caring for the infant are also frequently
hypothesized to cause PPD. However, little evidence supports this hypothesis. Mothers who have
had several previous children without experiencing PPD can nonetheless experience it with their
latest child. Despite the biological and psychosocial changes that may accompany pregnancy and
the postpartum period, most women are not diagnosed with PPD. Many mothers are unable to
get the rest they need to fully recover from giving birth. Sleep deprivation can lead to physical
discomfort and exhaustion, which can contribute to the symptoms of postpartum depression.

(https://www.healthline.com/health/depression/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:

1. Biological

• Administration of labor-inducing medication synthetic oxytocin.

• Chronic illnesses caused by neuroendocrine irregularities.

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 • Genetic history of PPD.
• Hormone irregularities.
• Inflammatory illnesses (irritable bowel syndrome, fibromyalgia).
• 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 bowel 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.

2.Psychosocial

• 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

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 • 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
• Maternal age, family food insecurity and violence against women

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.
These women already have fewer spending options, and having a child may spread those options
even further. Low-income women are frequently trapped in a cycle of poverty, unable to
advance, affecting their ability to access and receive quality healthcare to diagnose and treat
postpartum depression.

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,

5
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. Postpartum depression is more common among lesbian women than
heterosexual women, which can be attributed to lesbian women’s higher depression prevalence.
Lesbian women have a higher risk of depression because they are more likely to have been
treated for depression and to have attempted or contemplated suicide than heterosexual women.
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.

VIOLENCE

A meta-analysis reviewing research on the association of violence and postpartum depression

showed that violence against women increases the incidence of postpartum depression. About
one-third of women throughout the world will experience physical or sexual violence at some
point in their lives. Violence against women occurs in conflict, post-conflict, and non-conflict
areas. The research reviewed only looked at violence experienced by women from male
perpetrators. Further, violence against women was defined as “any act of gender-based violence

6
that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to
women”. Psychological and cultural factors associated with increased incidence of postpartum
depression include family history of depression, stressful life events during early puberty or
pregnancy, anxiety or depression during pregnancy, and low social support. Violence against
women is a chronic stressor, so depression may occur when someone is no longer able to
respond to the violence.

SIGNS AND SYMPTOMS

Symptoms of PPD can occur any time in the first year postpartum. Typically, a diagnosis of
postpartum depression is considered after signs and symptoms persist for at least two weeks.

1.Emotional
• Persistent sadness, anxiousness or “empty” mood
• Severe mood swings
• Frustration, irritability, restlessness, anger
• Feelings of hopelessness or helplessness
• Guilt, shame, worthlessness
• Low self-esteem
• Numbness, emptiness
• Exhaustion
• Inability to be comforted
• Trouble bonding with the baby
• Feeling inadequate in taking care of the baby
• Thoughts of self-harm or suicide

2.Behavioral

• Lack of interest or pleasure in usual activities

• Low libido
• Changes in appetite
• Fatigue, decreased energy and motivation

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 • Poor self-care
• Social withdrawal
• Insomnia or excessive sleep
• Worry about harming self, baby, or partner

NEUROBIOLOGY

FMRI studies indicate differences in brain activity between mothers with postpartum depression
and those without. Mothers diagnosed with PPD tend to have less activity in the left frontal lobe
and increased activity in the right frontal lobe when compared with healthy controls. They also
exhibit decreased connectivity between vital brain structures, including the anterior cingulate
cortex, dorsal lateral prefrontal cortex, amygdala, and hippocampus. Brain activation differences
between depressed and non-depressed mothers is more pronounced when stimulated by non-
infant emotional cues. Depressed mothers show greater neural activity in the right amygdala
toward non-infant emotional cues as well as reduced connectivity between the amygdala and
right insular cortex. Recent findings have also identified blunted activity in anterior cingulate
cortex, striatum, orbitofrontal cortex, and insula in mothers with PPD when viewing images of
their own infants.

More robust studies on neural activation regarding PPD have been conducted with rodents than
humans. These studies have allowed for greater isolation of specific brain regions,
neurotransmitters, hormones, and steroids.

ONSET AND DURATION

Postpartum depression onset usually begins between two weeks to a month after delivery. A
study done at an inner-city mental health clinic has shown that 50% of postpartum depressive
episodes there began prior to delivery. Therefore, in the DSM-5 postpartum depression is
diagnosed under “depressive disorder with peripartum onset”, in which “peripartum onset” is
defined as anytime either during pregnancy or within the four weeks following delivery. PPD
may last several months or even a year. Postpartum depression can also occur in women who

8
have suffered a miscarriage. For fathers, several studies show that men experience the highest
levels of postpartum depression between 3–6 months postpartum.

PARENT-INFANT RELATIONSHIP

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect
acute and long-term child development. Postpartum depression may lead mothers to be
inconsistent with childcare. These childcare inconsistencies may include feeding routines, sleep
routines, and health maintenance.

In rare cases, or about 1 to 2 per 1,000, the postpartum depression appears as postpartum
psychosis. In these, or among women with a history of previous psychiatric hospital admissions,
infanticide may occur. In the United States, postpartum depression is one of the leading causes of
annual reported infanticide incidence rate of about 8 per 100,000 births.

According to research published in the American Journal of Obstetrics and Gynecology, children
can experience the effects of postpartum depression. If a mother experiences postpartum
depression that goes untreated, it can have adverse effects on her children. When a child is in
infancy, these problems can include unusual amounts of crying (colic) and not having normal
sleeping patterns. These problems can have a cyclical effect, meaning that they can further
agitate the mother’s postpartum depression and can even lead to the mother further developing
postpartum depression. These cyclical effects can affect the way the mother maintains her
relationship with her child. These can include the stopping of breastfeeding, as well as negative
emotions such as withdrawal, disengagement, and even hostility. If a mother develops a hostile
relationship, it can lead to extreme outcomes such as infanticide.

As the child grows older, postpartum depression can lead to the child experiencing irregularities
in cognitive processes, behaviors, and emotions. In addition to these abnormalities, children who
grew up around postpartum depression also are susceptible to developing violent tendencies.

(https://my.clevelandclinic.org/health/diseases/9312-postpartum-depression)

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POSTPARTUM DEPRESSION IN FATHERS

Paternal postpartum depression has not been studied as intently as its maternal counterpart.
However, postpartum depression affects 8 to 10% of fathers. In men, postpartum depression is
typically defined as “an episode of major depressive disorder (MDD) occurring soon after the
birth of a child”. There are no set criteria for men to have postpartum depression. The cause may
be distinct in males. Causes of paternal postpartum depression include hormonal changes during
pregnancy, which can be indicative of father-child relationships. For instance, male depressive
symptoms have been associated with low testosterone levels in men. Low prolactin, estrogen,
and vasopressin levels have been associated with struggles with father-infant attachment, which
can lead to depression in first-time fathers. Symptoms of postpartum depression in men are
extreme sadness, fatigue, anxiety, irritability, and suicidal thoughts. Postpartum depression in
men is most likely to occur 3–6 months after delivery, and is correlated with maternal
depression, meaning that if the mother is experiencing postpartum depression, then the father is
at a higher risk of developing the illness as well. Postpartum depression in men leads to an
increase risk of suicide, while also limiting healthy infant-father attachment. Men who
experience PPD can exhibit poor parenting behaviors’, distress, and reduce infant interaction.
Reduced paternal interaction can later lead to cognitive and behavioral problems in children.
Children as young as 3.5 years old experience problems with internalizing and externalizing
behaviors’, indicating that paternal postpartum depression can have long-term consequences.
Furthermore, if children as young as two are not frequently read to, this negative parent-child
interaction can have a harmful impact on their expressive vocabulary.

(https://www.parents.com/parenting/dads/sad-dads/)

DIAGNOSIS

Postpartum depression in the DSM-5 is known as “depressive disorder with Peripartum onset”.
Peripartum onset is defined as starting anytime during pregnancy or within the four weeks
following delivery. There is no longer a distinction made between depressive episodes that occur

10
during pregnancy or those that occur after delivery. Nevertheless, the majority of experts
continue to diagnose postpartum depression as depression with onset anytime within the first
year after delivery.

The criteria required for the diagnosis of postpartum depression are the same as those required to
make a diagnosis of non-childbirth related major depression or minor depression. The criteria
include at least five of the following nine symptoms, within a two-week period:

• Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day or
the observation of a depressed mood made by others
• Loss of interest or pleasure in activities
• Weight loss or decreased appetite
• Changes in sleep patterns
• Feelings of restlessness
• Loss of energy
• Feelings of worthlessness or guilt
• Loss of concentration or increased indecisiveness
• Recurrent thoughts of death, with or without plans of suicide

DIFERENTIAL DIAGNOSIS

1.Postpartum blues

Postpartum blues, commonly known as “baby blues,” is a transient postpartum mood disorder
characterized by milder depressive symptoms than postpartum depression. This type of
depression can occur in up to 80% of all mothers following delivery. Symptoms typically resolve
within two weeks. Symptoms lasting longer than two weeks are a sign of a more serious type of
depression. Women who experience “baby blues” may have a higher risk of experiencing a more
serious episode of depression later on.

2. Psychosis

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Postpartum psychosis is not a formal diagnosis, but is widely used to describe a psychiatric
emergency that appears to occur in about 1 in a 1000 pregnancies, in which symptoms of high
mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia,
hallucinations and delusions begin suddenly in the first two weeks after delivery; the symptoms
vary and can change quickly. It is different from postpartum depression and from maternity
blues. It may be a form of bipolar disorder. It is important not to confuse psychosis with other
symptoms that may occur after delivery, such as delirium. Delirium typically includes a loss of
awareness or inability to pay attention.

About half of women who experience postpartum psychosis have no risk factors; but a prior
history of mental illness, especially bipolar disorder, a history of prior episodes of postpartum
psychosis, or a family history put some at a higher risk.

Postpartum psychosis often requires hospitalization, where treatment is antipsychotic

medications, mood stabilizers, and in cases of strong risk for suicide, electroconvulsive therapy.

The most severe symptoms last from 2 to 12 weeks, and recovery takes 6 months to a year.
Women who have been hospitalized for a psychiatric condition immediately after delivery are at
a much higher risk of suicide during the first year after delivery.

3. Birth-Related/Postpartum Posttraumatic Stress Disorder

Although birth-related posttraumatic stress disorder is not recognized in the DSM-5, there is
extensive research being conducted to bring awareness to the posttraumatic stress disorder
symptoms one could experience following childbirth. Some research examines the differences
and comorbidity when looking into birth-related posttraumatic stress disorder, or postpartum
posttraumatic stress disorder, and postpartum depression. In the recent research, similarities and
differences in symptoms have been identified when it comes to postpartum posttraumatic stress
disorder and postpartum depression. Although both diagnoses have overlap in their diagnostic
criteria, some of the criteria specific to postpartum depression include intense hopelessness and
sadness, excessive worry or anxiety, intrusive thoughts of harm to oneself or harm to the baby,
feelings of guilt or thoughts of worthlessness, and a change in appetite which could result in

12
under-eating or overeating. On the other hand, diagnostic criteria specific to postpartum
posttraumatic stress disorder includes being easily startled, recurring nightmares and flashbacks,
avoiding the baby or anything that reminds one of birth, aggression, irritability, and panic
attacks. Although these are the symptoms that often help differentiate between postpartum
posttraumatic stress disorder and postpartum depression, it is important to note that some of
these symptoms can cross over to the other diagnosis (e.g., someone meeting the diagnostic
criteria of postpartum depression may also present with panic attacks, or someone meeting the
diagnostic criteria for postpartum posttraumatic stress disorder may experience depressive
episodes, etc.). Another crucial element in diagnosing postpartum posttraumatic stress disorder
following childbirth is when there is a real or perceived trauma before, during, or following
childbirth, which is not always required when it comes to diagnosing someone with postpartum
depression.[80] This real or perceived traumatic event that could happen before, during, or
following labor and delivery could be toward the baby, mother, or both. These traumatic events
could include, but are not limited to unplanned C-section, death, the baby going into the NICU,
the use of the vacuum extractor, or forceps during delivery, lack of support and/or reassurance
during the delivery (from friends, family, and/or the medical staff), or any other severe physical
complication or injury related to childbirth such as preeclampsia, or an unexpected hysterectomy.

Conclusions have been made related to the idea of childbirth stressors and the contribution those
can play in an increased risk of developing comorbid birth-related posttraumatic stress disorder
and Postpartum depression rather than only a postpartum depression diagnosis. Findings like the
one mentioned above are crucial in accurate diagnosis to provide the mothers with the most
appropriate and effective treatment options, and to advance the validity and reliability of
preventative assessments and strategies. Other studies have been able to identify obstetric and
perinatal risk factors associated specifically with birth-related posttraumatic stress disorder
including educational level, gestational age at delivery, number of prenatal care visits, pregnancy
intervals, mode of delivery, any complications with pregnancy, and labor duration. Based on
current meta-analytic research, it has been concluded that the prevalence of postpartum
posttraumatic stress disorder was 3.1% in community settings and 15.7% in at-risk populations;
however, those findings do state various limitations, including underreporting biases, across the
examined studies which lead many researchers to believe the prevalence may be higher.

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As of right now, there are no widely recognized assessments that measure for postpartum
posttraumatic stress disorder in clinical and medical settings. However, researchers and
physicians will often use more reliable posttraumatic stress disorder questionnaires and
assessments, which are unfortunately not always specific enough to the posttraumatic symptoms
and experiences that are felt before, during, or after childbirth. One assessment for postpartum
posttraumatic stress disorder, the City Birth Trauma Scale (CBTS), has been used in some
research settings; however, it is not widely used in clinical and medical settings. The CBTS is a
29-item self-report questionnaire developed to measure birth-related posttraumatic stress
disorder, according to the DSM-5 criteria of: symptoms of re-experiencing the event, avoidance,
negative cognitions and mood, and hyperarousal, as well as the duration of one’s symptoms and
the amount of distress and impairment the symptoms have caused in the individual’s life. The
creators of the CTSB also added in two items from the DSM-IV that they felt were relevant to
the population being assessed with this measure – that the mothers responded to the traumatic
events during childbirth with intense fear, helplessness, or horror and that there were symptoms
of emotional numbing. Although the emotional numbing component was excluded in the DSM-5
criteria for posttraumatic stress disorder, research has shown that when studying mothers who
have been exposed to trauma, emotional numbing is more predictive of parenting stress than
other posttraumatic stress disorder symptoms. Although this assessment shows strong reliability
(Cronbach’s alpha = 0.92), and participants from the pilot study found the measure to be easy to
understand, this assessment is still not used in clinical or medical settings as often as it is used in
research settings. The researchers that have utilized the CTSB have been able to identify various
limitations with the pilot study, including the lack of diversity in the sample demographic
characteristics (93% White postpartum women) as well as the self-report nature of the
assessment which could lead to underreporting of symptoms. Another assessment that has also
been used in research more often than in clinical or medical settings is the Perinatal
Posttraumatic Stress Disorder Questionnaire (PPQ), which has since been modified into the
Perinatal Posttraumatic Stress Disorder Questionnaire-II (PPQ-II), with the modified version
being a 14-item scale which does not address all the necessary diagnostic criteria. Further
research and development are needed to create a more accurate assessments and screening tools
that can differentiate among posttraumatic stress disorders, postpartum/childbirth-related

14
posttraumatic stress disorder, and postpartum depression so that the most adequate treatment
interventions and options can be implemented as quickly as possible.

SCREENING

Screening for postpartum depression is critical as up to 50% of cases go undiagnosed in the US,
emphasizing the significance of comprehensive screening measures. In the US, the American
College of Obstetricians and Gynecologists suggests healthcare providers consider depression
screening for perinatal women.[92] Additionally, the American Academy of Pediatrics
recommends pediatricians screen mothers for PPD at 1-month, 2-month and 4-month visits.
However, many providers do not consistently provide screening and appropriate follow-up. For
example, in Canada, Alberta is the only province with universal PPD screening. This screening is
carried out by Public Health nurses with the baby’s immunization schedule. In Sweden, Child
Health Services offer a free program for new parents that includes screening mothers for PPD at
2 months postpartum. However, there are concerns about adherence to screening guidelines
regarding maternal mental health.

The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be

used to identify women who have postpartum depression. If the new mother scores 13 or more,
she likely has PPD and further assessment should follow.

Healthcare providers may take a blood sample to test if another disorder is contributing to
depression during the screening.

The Edinburgh Postnatal Depression Scale, is used within the first week of their new born being
admitted. If mothers receive a score less than 12 they are told to be reassessed because of the
depression testing protocol. It is also advised that mother’s in the NICU to get screened every
four to six weeks as their infant remains in the neonatal intensive care unit. Mothers who score
between twelve and nineteen on the EPDS are offered two types of support. The mothers are
offered LV treatment provided by a nurse in the NICU and they can be referred to the mental
health professional services. If a mother receives a three on item number ten of the EPDS they
are immediately referred to the social work team as they may be suicidal.

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It is critical to acknowledge the diversity of patient populations diagnosed with postpartum
depression and how this may impact the reliability of the screening tools used. There are cultural
differences in how patients express symptoms of postpartum depression; those in non-western
countries exhibit more physical symptoms, whereas those in western countries have more
feelings of sadness. Depending on one’s cultural background, symptoms of postpartum
depression may manifest differently, and non-Westerners being screened in Western countries
may be misdiagnosed because their screening tools do not account for cultural diversity. Aside
from culture, it is also important to consider one’s social context, as women with low
socioeconomic status may have additional stressors that affect their postpartum depression
screening scores.

PREVENTION

A 2013 Cochrane review found evidence that psychosocial or psychological intervention after
childbirth helped reduce the risk of postnatal depression. These interventions included home
visits, telephone-based peer support, and interpersonal psychotherapy. Support is an important
aspect of prevention, as depressed mothers commonly state that their feelings of depression were
brought on by “lack of support” and “feeling isolated.”

Across different cultures, traditional rituals for postpartum care may be preventative for PPD, but
are more effective when the support is welcomed by the mother.

In couples, emotional closeness and global support by the partner protect against both perinatal
depression and anxiety. In 2014, Alasoom and Koura found that compared to 42.9 percent of
women who did not get spousal support, only 14.7 percent of women who got spousal assistance
had PPD. Further factors such as communication between the couple and relationship
satisfaction have a protective effect against anxiety alone.

In those who are at risk counseling is recommended. In 2018, 24% of areas in the UK have no
access to perinatal mental health specialist services.

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Preventative treatment with antidepressants may be considered for those who have had PPD
previously. However, as of 2017, the evidence supporting such use is weak.

TREATMENTS

Treatment for mild to moderate PPD includes psychological interventions or antidepressants.

Women with moderate to severe PPD would likely experience a greater benefit with a
combination of psychological and medical interventions. Light aerobic exercise has been found
to be useful for mild and moderate cases.

• Therapy

Both individual social and psychological interventions appear equally effective in the treatment
of PPD. Social interventions include individual counseling and peer support, while psychological
interventions include cognitive behavioral therapy (CBT) and interpersonal therapy (IPT).
Interpersonal therapy (IPT) has shown to be effective in focusing specifically on the mother and
infant bond. Support groups and group therapy options focused on psycho education around
postpartum depression have been shown to enhance the understanding of postpartum symptoms
and often assist in finding further treatment options. Other forms of therapy, such as group
therapy, home visits, counseling, and ensuring greater sleep for the mother may also have a
benefit. While specialists trained in providing counseling interventions often serve this
population in need, results from a recent systematic review and meta-analysis found that
nonspecialist providers, including lay counselors, nurses, midwives, and teachers without formal
training in counseling interventions, often provide effective services related to perinatal
depression and anxiety.

Internet-based cognitive behavioral therapy (ICBT) has shown promising results with lower
negative parenting behavior scores and lower rates of anxiety, stress, and depression. ICBT may
be beneficial for mothers who have limitations in accessing in person CBT. However, the long
term benefits have not been determined.

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 • Medication

A 2010 review found few studies of medications for treating PPD noting small sample sizes and
generally weak evidence. Some evidence suggests that mothers with PPD will respond similarly
to people with major depressive disorder. There is low-certainty evidence which suggests that
selective serotonin reuptake inhibitors (SSRIs) are effective treatment for PPD. The first-line
anti-depressant medication of choice is sertraline, an SSRI, as very little of it passes into the
breast milk and, as a result, to the child. However, a recent study has found that adding sertraline
to psychotherapy does not appear to confer any additional benefit. Therefore, it is not completely
clear which antidepressants, if any, are most effective for treatment of PPD, and for whom
antidepressants would be a better option than non-pharmacotherapy.

Some studies show that hormone therapy may be effective in women with PPD, supported by the
idea that the drop in estrogen and progesterone levels post-delivery contribute to depressive
symptoms. However, there is some controversy with this form of treatment because estrogen
should not be given to people who are at higher risk of blood clots, which include women up to
12 weeks after delivery. Additionally, none of the existing studies included women who were
breastfeeding. However, there is some evidence that the use of estradiol patches might help with
PPD symptoms.

Oxytocin Has been shown to be an effective anxiolytic and in some cases antidepressant
treatment in men and women. Exogenous oxytocin has only been explored as a PPD treatment
with rodents, but results are encouraging for potential application in humans.

In 2019, the FDA approved brexanolone, a synthetic analog of the neurosteroid

allopregnanolone, for use intravenously in postpartum depression. Allopregnanolone levels drop
after giving birth, which may lead to women becoming depressed and anxious. Some trials have
demonstrated an effect on PPD within 48 hours from the start of infusion. Other new
allopregnanolone analogs under evaluation for use in the treatment of PPD include zuranolone
and ganaxolone.

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Brexanolone has risks that can occur during administration, including excessive sedation and
sudden loss of consciousness, and therefore has been approved under the Risk Evaluation and
Mitigation Strategy (REMS) program. The mother is to enrolled prior to receiving the
medication. It is only available to those at certified health care facilities with a health care
provider who can continually monitor the patient. The infusion itself is a 60-hour, or 2.5 day,
process. People’s oxygen levels are to be monitored with a pulse oximeter. Side effects of the
medication include dry mouth, sleepiness, somnolence, flushing and loss of consciousness. It is
also important to monitor for early signs of suicidal thoughts or behaviors’.

BREASTFEEDING

Caution should be exercised when administering antidepressant medications during

breastfeeding. Most antidepressants are excreted in breast milk in low quantities which can have
adverse effect on babies.Regarding allopregnanolone, very limited data did not indicate a risk for
the infant.

OTHER

Electroconvulsive therapy (ECT) has shown efficacy in women with severe PPD that have either
failed multiple trials of medication-based treatment or cannot tolerate the available
antidepressants. Tentative evidence supports the use of repetitive transcranial magnetic
stimulation (RTMS).

As of 2013 it is unclear if acupuncture, massage, bright lights, or taking omega-3 fatty acids are
useful.

INTERNATIONAL

Postpartum Support International is the most recognized international resource for those with
PPD as well as healthcare providers. It brings together those experiencing PPD, volunteers, and

19
professionals to share information, referrals, and support networks. Services offered by PSI
include the website (with support, education, and local resource info), coordinators for support
and local resources, online weekly video support groups in English and Spanish, free weekly
phone conference with chats with experts, educational videos, closed Facebook groups for
support, and professional training of healthcare workers.

United States

Educational interventions

Educational interventions can help women struggling with postpartum depression (PPD) to
cultivate coping strategies and develop resiliency. The phenomenon of “scientific motherhood”
represents the origin of women’s education on perinatal care with publications like Ms.
Circulating some of the first press articles on PPD that helped to normalize the symptoms that
women experienced. Feminist writings on PPD from the early seventies shed light on the darker
realities of motherhood and amplified the lived experiences of mothers with PPD.

Instructional videos have been popular among women who turn to the internet for PPD
treatment, especially when the videos are interactive and get patients involved in their treatment
plan. Since the early 2000s, video tutorials on PPD have been integrated into many web-based
training programs for individuals with PPD and are often considered a type of evidence-based
management strategy for individuals. This can take the form of objective-based learning, detailed
exploration of case studies, resource guides for additional support and information, etc.

National Government-funded programs

National Child and Maternal Health Education Program functions as a larger education and
outreach program supported by the National Institute of Child Health and Human Development
(NICHD) and the National Institute of Health. The NICHD has worked alongside organizations
like the World Health Organization to conduct research on the psychosocial development of
children with part of their efforts going towards the support of mothers’ health and safety.

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Training and education services are offered through the NICHD to equip women and their health
care providers with evidence-based knowledge on PPD.

Other initiatives include the Substance Abuse and Mental Health Services Administration
(SAMHSA) whose disaster relief program provides medical assistance at both the national and
local level.The disaster relief fund not only helps to raise awareness of the benefits of having
healthcare professionals screen for PPD, but also helps childhood professionals (home visitors
and early care providers) develop the skills to diagnose and prevent PPD. The Infant and Early
Childhood Mental Health Consultation (IECMH) center is a related technical assistance program
that utilizes evidence-based treatments services in order to address issues of PPD. The IECMH
facilitates parenting and home visit programs, early care site interventions with parents and
children and a variety of other consultation-based services. The IECMH’s initiatives seek to
educate home visitors on screening protocols for PPD as well as ways to refer depressed mothers
to professional help.

RATE OF PPD IN COUNTRIES

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-birth weight
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-birth weight 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.

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Canada

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

22
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

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.

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

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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 US, 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 US 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.

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ISSUES IN REPORTING PREVALENCE

Most studies regarding PPD are done using self-report screenings which are less reliable than
clinical interviews. This use of self-report may have results that underreport symptoms and thus
postpartum depression rates.

HISTORY

Prior to the 19th century

Western medical science’s understanding and construction of postpartum depression has evolved
over the centuries. Ideas surrounding women’s moods and states have been around for a long
time, typically recorded by men. In 460 B.C., Hippocrates wrote about puerperal fever, agitation,
delirium, and mania experienced by women after child birth. Hippocrates’ ideas still linger in
how postpartum depression is seen today.

A woman who lived in the 14th century, Margery Kempe, was a Christian mystic. She was a
pilgrim known as “Madwoman” after having a tough labor and delivery. There was a long
physical recovery period during which she started descending into “madness” and became
suicidal. Based on her descriptions of visions of demons and conversations she wrote about that
she had with religious figures like God and the Virgin Mary, historians have identified what
Margery Kempe was experiencing as “postnatal psychosis” and not postpartum depression. This
distinction became important to emphasize the difference between postpartum depression and
postpartum psychosis. A 16th century physician, Castello Branco, documented a case of
postpartum depression without the formal title as a relatively healthy woman with melancholy
after childbirth, remained insane for a month, and recovered with treatment. Although this
treatment was not described, experimental treatments began to be implemented for postpartum
depression for the centuries that followed. Connections between female reproductive function
and mental illness would continue to center around reproductive organs from this time all the
way through to modern age, with a slowly evolving discussion around “female madness”.

25
19th century and after

With the 19th century came a new attitude about the relationship between female mental illness
and pregnancy, childbirth, or menstruation. The famous short story, “The Yellow Wallpaper”,
was published by Charlotte Perkins Gilman in this period. In the story, an unnamed woman
journals her life when she is treated by her physician husband, John, for hysterical and
depressive tendencies after the birth of their baby. Gilman wrote the story to protest societal
oppression of women as the result of her own experience as a patient.

Also during the 19th century, gynecologists embraced the idea that female reproductive organs,
and the natural processes they were involved in, were at fault for “female
insanity.”Approximately 10% of asylum admissions during this time period are connected to
“puerperal insanity,” the named intersection between pregnancy or childbirth and female mental
illness.It wasn’t until the onset of the twentieth century that the attitude of the scientific
community shifted once again: the consensus amongst gynecologists and other medical experts
was to turn away from the idea of diseased reproductive organs and instead towards more
“scientific theories” that encompassed a broadening medical perspective on mental illness.

SOCIETY AND CULTURE

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

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When stigma occurs, a person is labeled by their illness and viewed as part of a stereotyped
group. There are three main elements of stigmas,

• problems of knowledge
• Ignorance or misinformation
• problems of attitudes
• problems of behavior
• discrimination and prejudice

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

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Postpartum depression can be influenced by socio-cultural 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
bath 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. After giving birth to five children in
the coming years, she had 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

28
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.

(https://www.webmd.com/depression/guide/postpartum-depression )

NEED AND SIGNIFICANCE OF THE STUDY

Pregnancy and postpartum are the periods which are being glorified. Motherhood is considered
as a period of happiness. But it is just a lie. It can trigger many emotional traumas and even
depression.

Postpartum depression should be cured or solved as soon as possible. Because it can create many
problems to the mother and the baby. Suicidal tendency and the tendency to harm or kill the
child are seen among mothers who are affected by PPD.

So the necessity to understand the postpartum depression is significant. It is a need as we can’t

solve or reduce a problem that is unaware to us. This awareness should be created not only in
women but also in their husbands, parents, society etc. For the same the studies and researches
on this topic is a need of contemporary society.

STATEMENT OF THE PROBLEM

The pregnancy, delivery, and postpartum are the periods full of changes. The birth of a baby can
create many emotions from happiness to fear. It may also result anxiety, tension, emotional

29
imbalance etc. Postpartum is a period full of worries. Motherhood is always considered as a
blessed period. But in real it is a period of hormonal, physical, mental, behavioral changes. These
quick changes may cause Postpartum depression. It may seriously affect the health condition of
mother and baby. The researcher attempts to study the psychosocial issues faced by women
during Postpartum period, tries to find out how far they get family and social support during this
period and analyses the postpartum depression and it’s causes in detail.

30
 CHAPTER 2

LITERATURE REVIEW

1.Postpartum Depression: Review

Teri Pearlstein MD, Margaret Howard PhD, Amy Salisbury PhD, Caron Zlotnick PhD. American
Journal of Obstetrics and Gynecology, Volume200,Issue 4,April 2009, Pg 357-364

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified
several psychosocial and biologic risk factors for PPD. The negative short-term and long-term
effects on child development are well-established. PPD is under recognized and under treated.
The obstetrician and pediatrician can serve important roles in screening for and treating PPD.
Treatment options include psychotherapy and antidepressant medication. Obstacles to
compliance with treatment recommendations include access to psychotherapists and concerns of
breastfeeding mothers about exposure of the infant to antidepressant medication. Further
research is needed to examine systematically the short-term and long-term effect of medication
exposure through breast milk on infant and child development.

2. Rates and risk of Postpartum depression: a meta –analysis

Michael W.O’ Hara and Annette M. Swain

The average prevalence rate of non-psychotic postpartum depression based on the results of a
large number of studies is 13%. Prevalence estimates are affected by the nature of the assessment
method (larger estimates in studies using self-report measures) and by the length of the
postpartum period under evaluation (longer periods predict high prevalences). A meta-analysis
was undertaken to determine the sizes of the effects of a number of putative risk factors,
measured during pregnancy, for postpartum depression. The strongest predictors of postpartum
depression were past history of psychopathology and psychological disturbance during
pregnancy, poor marital relationship and low social support, and stressful life events. Finally,
indicators of low social status showed a small but significant predictive relation to postpartum

31
depression. In sum, these findings generally mirror the conclusions from earlier qualitative
reviews of postpartum depression risk factors.

3. Postpartum Depression: Current Status and Future Directions

Michael W. O’Hara and Jennifer E. McCabe. Annual Review of Clinical Psychology,Vol 9:374-
407

Postpartum depression (PPD) is a common and serious mental health problem that is associated
with maternal suffering and numerous negative consequences for offspring. The first six months
after delivery may represent a high-risk time for depression. Estimates of prevalence range from
13% to 19%. Risk factors mirror those typically found with major depression, with the exception
of postpartum-specific factors such as sensitivity to hormone changes. Controlled trials of
psychological interventions have validated a variety of individual and group interventions.
Medication often leads to depression improvement, but in controlled trials there are often no
significant differences in outcomes between patients in the medication condition and those in
placebo or active control conditions. Reviews converge on recommendations for particular
antidepressant medications for use while breastfeeding. Prevention of PPD appears to be feasible
and effective. Finally, there is a growing movement to integrate mental health screening into
routine primary care for pregnant and postpartum women and to follow up this screening with
treatment or referral and with follow-up care. Research and clinical recommendations are made
throughout this review.

4. Postpartum Depression: What we know.

Michael W. O’Hara. Journal of Clinical Psychology, Vol 65,Issue 2,p.1258-1269

Postpartum depression (PPD) is a serious mental health problem. It is prevalent, and offspring
are at risk for disturbances in development. Major risk factors include past depression, stressful
life events, poor marital relationship, and social support. Public health efforts to detect PPD have
been increasing. Standard treatments (e.g., Interpersonal Psychotherapy) and more tailored
treatments have been found effective for PPD. Prevention efforts have been less consistently

32
successful. Future research should include studies of epidemiological risk factors and prevalence,
interventions aimed at the parenting of PPD mothers, specific diathesis for a subset of PPD,
effectiveness trials of psychological interventions, and prevention interventions aimed at
addressing mental health issues in pregnant women.

5. Postpartum Depression: A Review

Milapkumar Patel, Rahn K. Bailey, Shagufta Jabeen, Shahid Ali, Narviar C. Barker, Kenneth
Osiezagha. Journal of Health Care for the Poor and Underserved

Postpartum depression is a disorder that is often unrecognized and undertreated. Many

psychosocial stressors may have an impact on the development of postpartum depression. The
greater risk of postpartum depression is a history of major depression and those who have
experienced depression during past pregnancies. Untreated maternal depression can have a
negative effect on child development, mother-infant bonding, and risk of anxiety or depressive
symptoms in infants later in life. Management of postpartum depression is a vital part of
adequate medical care. The obstetrician and pediatrician can serve important roles in screening
for and treating postpartum depression. To prevent adverse outcomes associated with depression
and its impact on the child, it is important that all health care professionals and nurse
practitioners are aware of specific signs and symptoms, appropriate screening methods, and
proper treatment. This review article covers major traits of postpartum depression.

6. Postpartum depression: A critical review.

Hopkins, J., Marcus, M., & Campbell, S. B.

A review of the literature suggests that there are 3 types of postpartum dysphoric mood states:
the maternity blues (a fairly common, transient disorder), postpartum affective psychosis
(relatively rare), and postpartum depression (as many as 20% of postpartum women may develop
mild to moderate depression). The etiology of postpartum depression remains unclear, although
numerous biological, psychological, and sociopsychological factors have been proposed as
etiologically relevant. There is some empirical support for these notions, but methodological and

33
conceptual problems hinder the development of a coherent theoretical framework for
understanding the etiology, course, and treatment of the disorder. Recent data indicate a relation
between stress and depression; future research into postpartum depression is needed to determine
the contribution of psychosocial factors (e.g., life events and social support). Medical
complications during pregnancy, infant variables, and the effect on the infant–mother
relationship also need to be studied.

7. The Functions of Postpartum Depression

Edward H Hagena
Evolutionary approaches to parental care suggest that parents will not automatically invest in all
offspring, and they should reduce or eliminate investment in their children if the costs outweigh
the benefits. Lack of paternal or social support will increase the costs born by mothers, whereas
infant health problems will reduce the evolutionary benefits to be gained. Numerous studies
support the correlation between postpartum depression (PPD) and lack of social support or
indicators of possible infant health and development problems. PPD may be an adaptation that
informs mothers that they are suffering or have suffered a fitness cost, which motivates them to
reduce or eliminate investment in offspring under certain circumstances, and that may help them
negotiate greater levels of investment from others. PPD also appears to be a good model for
depression in general.

8. Postpartum Depression Isn’t just Blues

Beck, Cheryl Tatano DNSc, CNM, FAAN.
American Journal of Nursing: May 2006 - Volume 106 - Issue 5 - p 40-50

Postpartum depression is a crippling mood disorder, historically neglected in health care, leaving
mothers to suffer in fear, confusion, and silence. Undiagnosed it can adversely affect the mother–
infant relationship and lead to long-term emotional problems for the child. This article
differentiates postpartum depression from other postpartum mood and anxiety disorders and
addresses these aspects of postpartum depression: symptoms, prevalence, risk factors,

34
interventions, and the effects on relationships and child development. Instruments available to
screen for postpartum depression are also reviewed.

The author has described it as “a thief that steals motherhood”: postpartum depression can have
long-ranging implications for mother and child. Distinguishing its symptoms from those of other
disorders is the first step in treatment.

9. Postpartum Depression : A Major Public Health Problem

Katherine L. Wisner, MD, MS; Christina Chambers, Dorothy K. Y. Sit

Postpartum psychiatric disorders, particularly depression, have received increasing attention in

the United States for several reasons. Postpartum depression is very common. One of 7 new
mothers (14.5%) experience depressive episodes that impair maternal role function.1 The
neurobiology of women with postpartum mood instability appears differentially sensitive to the
destabilizing effects of hormonal withdrawal at birth.2 Coupled with entry of the newborn into
the family, postpartum depression affects crucial infant and adult developmental processes. The
disruption to the early mother-infant relationship contributes to short- and long-term adverse
child outcomes.3 The negative effects of maternal depression on children include an increased
risk of impaired mental and motor development, difficult temperament, poor self-regulation, low
self-esteem, and behavior problems.

10.The Impact of Cultural Factors Upon Postpartum Depression: A Literature Review

Rena Bina

Postpartum depression is a serious disorder that affects many women globally. Studies have
shown that cultural factors play a significant role in postpartum depression; they may trigger
postpartum depression as well as contribute to the alleviation of its depressive symptomatology.
The cultural aspects of the postpartum period have been described in the literature; however, the
impact of cultural factors upon postpartum depression has been less investigated, and studies that
looked at this association have yielded oppositional conclusions. In addition, the literature is
inconclusive as to whether there are significant differences among various cultures in the

35
prevalence of postpartum depression. The purpose of this literature review is to identify and
critically review published and unpublished studies regarding the effect of cultural factors on the
alleviation or deterioration of postpartum depression. Results show that cultures have different
rituals and beliefs that may affect the severity of postpartum depression.

11. Identifying and Treating Postpartum Depression

June Andrews Horowitz,Janice H. Goodman. Journal of Obstetric, Gynecologic and Neonatal
Nursing 34(2) 264-273.2005
Postpartum depression affects 10% to 20% of women in the United States and negatively
influences maternal, infant, and family health. Assessment of risk factors and depression
symptoms is needed to identify women at risk for postpartum depression for early referral and
treatment. Individual and group psychotherapy have demonstrated efficacy as treatments, and
some complementary/alternative therapies show promise. Treatment considerations include
severity of depression, whether a mother is breastfeeding, and mother’s preference. Nurses who
work with childbearing women can advise depressed mothers regarding treatment options, make
appropriate recommendations, provide timely and accessible referrals, and encourage
engagement in treatment.

12. The impact of postpartum depression on child development

Lynne Murray &Peter J. Cooper

There is evidence for an association between postpartum depression and a number of indices of
adverse child outcome. In infants of mothers with postpartum depression, deficits have been
found in their early interactions and their cognitive functioning. A high rate of insecure
attachment is also apparent. There is also evidence for a longer term association: cognitive
development in the four-year-olds of mothers who have had a postpartum depression appears
compromised (at least in boys from lower socio-economic backgrounds), and there is an
association with behavioural disturbance. Longitudinal analyses reveal that the impaired
patterns of early interaction occurring between mother and infant in the context of the maternal
mood disorder may be an important determinant of some of these adverse child outcomes. With

36
respect to cognitive development, there is evidence of a sensitive developmental period,
although its precise parameters are uncertain. Observational and experimental studies are
needed to elucidate the process by which maternal and infant behaviour becomes disturbed. The
explanatory potential of treatment studies has been little exploited and that of sibling studies not
at all. Such enquiry could contribute much to elucidating the relative contributions of genetic
and environmental factors to the association between postpartum depression and adverse child
outcome.

13. Management of Postpartum Depression

Constance Guille MD, Roger Newman MD, Leah D. Fryml BS, Clay K. Lifton BS,C. Neill
Epperson MD. Journal of Midwifery and Women’s Health.

The mainstays of treatment for peripartum depression are psychotherapy and antidepressant
medications. More research is needed to understand which treatments are safe, preferable, and
effective. Postpartum depression, now termed peripartum depression by the DSM-V, is one of
the most common complications in the postpartum period and has potentially significant negative
consequences for mothers and their families. This article highlights common clinical challenges
in the treatment of peripartum depression and reviews the evidence for currently available
treatment options. Psychotherapy is the first-line treatment option for women with mild to
moderate peripartum depression. Antidepressant medication in combination with therapy is
recommended for women with moderate to severe depression. Although pooled case reports and
small controlled studies have demonstrated undetectable infant serum levels and no short-term
adverse events in infants of mothers breastfeeding while taking sertraline (Zoloft) and paroxetine
(Paxil), further research is needed including larger samples and long-term follow-up of infants
exposed to antidepressants via breastfeeding controlling for maternal depression. Pharmacologic
treatment recommendations for women who are lactating must include discussion with the
patient regarding the benefits of breastfeeding, risks of antidepressant use during lactation, and
risks of untreated illness. There is a growing evidence base for nonpharmacologic interventions
including repetitive transcranial magnetic stimulation, which may offer an attractive option for
women who wish to continue to breastfeed and are concerned about their infants being exposed
to medication. Among severe cases of peripartum depression with psychosis, referral to a

37
psychiatrist or psychiatric advanced practice registered nurse is warranted. Suicidal or homicidal
ideation with a desire, intent, or plan to harm oneself or anyone else, including the infant, is a
psychiatric emergency, and an evaluation by a mental health professional should be conducted
immediately. Peripartum depression treatment research is limited by small sample sizes and few
controlled studies. Much work is still needed to better understand which treatments women
prefer and are the most effective in ameliorating the symptoms and disease burden associated
with peripartum depression.

14. Is postpartum depression a distinct

diagnosis? Valerie E. Whiffen

Controversy exists about the relationship between postpartum and nonpostpartum depression in
both research and practice. While some researchers argue that these diagnoses cannot be
differentiated, others insist that postpartum depression is distinct. The construct validity of the
diagnosis “postpartum depression” is evaluated by critically reviewing the empirical evidence
regarding prevalence, symptomatology, course, duration, relapse, and etiology. The literature
suggests that women are at elevated risk for depression in the postpartum period. However,
postpartum depressive episodes tend to be mild and to resolve quickly, which suggests that
postpartum depression is best conceptualized as an adjustment disorder. Etiologically,
postpartum depression is related to the same variables that predict nonpostpartum depression.
These findings suggest that postpartum depression does not differ qualitatively from
nonpostpartum depression. The implications of this conclusion for research and treatment are
considered.

15. Postpartum depression risk factors: A narrative review

Maryam Ghaedrahmati, Ashraf Kazemi, Gholamreza Kheirabadi, Amrollah Ebrahimi, and

Masood Bahrami.

Postpartum depression is a debilitating mental disorder with a high prevalence. Biological factors
and social factors create intertwined rings that each makes women prone to postpartum
depression by affecting each other. According to the findings of this study, many biological and

38
environmental factors, such as lifestyle-related factors, are involved in the incidence or
prevention of postpartum depression through direct and indirect impact on the level of serotonin
in the brain and its function. Furthermore, many environmental factors such as socioeconomic
factors cause crisis conditions and postpartum depression through influencing the mental health
during pregnancy. Therefore, postpartum depression prevention programs need to focus on
individuals interpersonal relationships to reduce domestic violence and increase social protection
in addition to modify the women's lifestyle and increase their ability to cope with the crisis
conditions. Moreover, based on the results of this research, the postpartum depression predictor
tools should focus on social factors and lifestyle in addition to physical health conditions of
individuals.

16. Postpartum Depression: A comprehensive Approach for Nurses

Kathleen A. Kendall Tackett, Glenda Kaufman Kantor
The birth of a baby can be extremely stressful life event, often accompanied by depression,
anxiety, and dread- sometimes mild with short duration; sometimes profound and long lasting.
Postpartum Depression integrates recent research on postpartum depression (PPD) and organizes
it into a conceptual model to provide practical steps professionals can take to help their clients.
The author proposes a model based on five risk factors that combine biological and psychosocial
views - hormonal factors, other biological factors, traumatic birth experiences, infant factors, and
psychosocial factors. She then shows how this model can be used to develop nursing
interventions for the prevention of PPD and the implementation of specific treatment plans. The
author also demonstrates how the nursing professional can build a resource network, find referral
agencies, and assemble a resource guide for helping the new mother find community-based
resources.

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 CHAPTER 3

METHODOLOGY

AIM

The study is intended to find the prevalence of psychological and physical illness in women after
delivery in Kerala. It also tries to find out thefunctional association of these postpartum illnesses
with selected sociodemographic, gynaecological and other chosen variables and thedeterminants
of these illnesses.

OBJECTIVES

• To understand the Gynaecological and Obstetric factors related to Postpartum illness

• To analyze the psycho-social issues faced by women during postpartum period
• To examine the supporting system for women during the postpartum period.

CONCEPT (OPERATIONAL DEFINITION)

• Postpartum
The time after child birth we selected a time between 2 weeks to 24 weeks

• Depression
A mental condition characterized by feelings of severe despondency and dejection, typically also
with feelings of inadequacy and guilt, often accompanied by lack of energy and disturbance of
appetite and sleep

• Postpartum depression
Depression suffered by a mother following childbirth, typically arising from the combination of
hormonal changes, psychological adjustment to motherhood, fatigue, postnatal depression.

40
 • Postpartum Blues
It is defined as low mood and mild depressive symptoms include sadness, crying, exhaustion,
irritability, anxiety,decreased sleep,decreased concentration and liable mood.

• Postpartum Psychosis
It is the most severe of the postpartum illness. Postpartum psychosis is a serious mental health
illness that can affect someone soon having a baby.It is the mental illness characterised by
extreme difficulty in responding emotionally to a new-born baby.It can even include thoughts of
harming the child.

• Puerperium
The period of about six weeks after childbirth during which the mother's reproductive organs
return to their original non-pregnant condition.

RESEARCH DESIGN

In this study narrative method is used to describe and analyse the socio-psycho issues faced by
women in postpartum period. So this study is descriptive in nature. We have used narrative
paradigm, based on a notion of narrative rationality by the 20thcentury communication theorist
Walter Fisher (1984 , 1985) in contrast to the conventional model of formal rationality where
human communication is expected to follow the rules of formal logic (logico-scientific mode).
Here narrative is regarded as a common mode of communication. The notion of narrative as a
mode of communication stemmed from a conception of the human being as Homo
narrans(Fisher 1984), as enacted narrative as a basic form of social life (MacIntyre
1981/1990:120), which has been elaborated by several Social Anthropologists (Burke 1945,
Geertz 1980). In this sense, narrative is regarded as a fundamental mode of knowing (Bruner
1987) which consists in organizing experience with the help of a scheme assuming the
intentionality of human action.

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SOURCE OF DATA

The researcher collected data from primary and Secondary sources. Primary data was collected
directly from the respondents. The researcher collated data directly from the respondent i.e
postpartum women. These were the primary sources of data. The data from the primary sources
were collected in the months from November 2022 to December 2022. All the respondents
selected for the study responded. Text books, articles were used as a secondary source of data.

PILOT STUDY

Before the actual study the researchers visited two woman and carried out detailed discussion
with the respondents about their postpartum period

POPULATION AND SAMPLING

Women in 2 weeks to24 weeks after delivery are defined as eligible women for interview, who
constitute the population for the study. With the help of ICDS supervisors, Anganwadi workers
and Junior public health nurses working in Pangappara health centre we identified women in
postpartum period. Seven women were selected as a sample by using purposive sampling
method. Husband of these women was also taken as a sample for understanding the supportive
system given to these women. Two psychologist and two psychiatrist from IMB Hospital
Venchavode and Cosmopolitan Hospital pattom was the key informants of the study.

TOOLS OF DATA COLLECTION

The postpartum unstructured interview schedule which was administered in postpartum period
included questions regarding the delivery details. The details included the data regarding, mode
of delivery, gender of the newly born baby, and satisfaction regarding the gender of the baby
born. For better understanding of postpartum the following questions were also asked. Family
Support during Pregnancy and Postpartum Period Inadequacy to Meet the Job Demands during
Pregnancy and Postpartum Period Frequency of the Women Going to Office during pregnancy

42
and postpartum period changes during pregnancy and postpartum period. A broad interview
guideline was maintained to ensure that all broad areas were covered. Thus gathering qualitative
perceptions was done by means of a non-participant observation and a detailed conversation with
the participants with the aid of a interview guide.

VARIABLES

Pregnancy and Post-partum period are considered as independent variables. General health,
psychological wellbeing, depression, supporting system are considered as dependent variable of
this study.

ANALYSIS OF DATA

The audio records of the qualitative interviews were subjected to preparation of the case
narratives through a verbatim transcription. Qualitative narratives were subjected to systematic
content analysis, based on the themes developed on the basis of the research questions.

LIMITATIONS OF THE STUDY

As we are carrying out this project within six month of study, time constrain was one of the
major limitation of our study. The diagnosis of postpartum depression was established with a
self-reportrating scale rather than a clinician-administered structured diagnostic interview.So we
should be more careful about that. As we are studying postpartum illness, being a mother had
change women’s lifestyle specially to engage in leisure-time especially physical activity. Women
seem to be a lack of doing any physical activity because of time constraints and managing their
kids. We have to approach most of the women atleast two times as in the one stretch we cannot
complete our interview as the kid were interfered the interview.

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 CHAPTER 4
DATA ANALYSIS

The postpartum period is well established as an increased time of risk for the development of
serious mood disorders. There are three common forms of postpartum affective illness: the blues
(baby blues, maternity blues), postpartum depression and postpartum psychosis each of which
differs in its prevalence, clinical presentation and management. Postpartum depression is the
most common affective illness found after delivery. Untreated postpartum depression can have
adverse long-term effects; it affects physical health of women, family relationship, quality of life
and intellectual and motor development of children. Thorough knowledge of postpartum
depression, its prevalence and risk factors is necessary to prevent this morbidity to a certain
extent by clinical or public health intervention.

3.1 PROFILE OF THE RESPONDENTS

We collected data from 7 respondents . They are Nikhitha , Athira , Akhila , Anupama, Pavithra
, Veena and Divya.

Nikhitha is a 30 year old women . She completed her MBA and working at techno park. Her
native place is Hyderabad. Now she is staying at Pangapara with her husband. They are upper
class.It is their first child. The pregnancy was planned . She didn’t had any miscarriages. She had
cesarean. The child is 6 month old now.

Athira is 24 year old women . She is unemployed. Her husband is an auto driver. They are
lower middle class. Her native place is Ulloor. She didn’thad any miscarriages. The pregnancy
was planned. It was cesarean. It is their first child. The child is 5 months old now.

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Akhila is a 28 year old women. She had completed Btech .Now she is working at KTU – IT
section. They are middle class. Her place is Sreekaryam. She had 2 miscarriages. The
pregnancy was planned. It was vacuum delivery . It is their first child. The child is 3 month old.

Anupama MS is a 31 year old women. She had completed degree. And now working as
receptionist. They are middle class. Her place is chavadimukk . She had no miscarriages. The
pregnancy was planned. It was cesarean. It is her second child. The child is 3 and half months
old.

Pavithra is a 30 year old women. She had completed her Btech and now working at techno park.
They are middle class. She is living in Karyavattom. She had no miscarriages. The pregnancy was
unplanned. It was normal delivery. It is their first child. The child is 2 and half months old.

Veena is 28 years old. She had completed degree. She is unemployed. They are middle class. She
is living in n Gandhipuram. She had difficulty in conceiving. The pregnancy was planned.It was
normal delivery. It is their first child. The child is 3 months now.

Divya is 27 years old women. She had completed Btech and now working in techno park. They
are middle class She is living in Sreekaryam. She had an abortion. The pregnancy was planned.
It was cesarean. It is their first child. The child is 4 months now.

3.2 GYNAECOLOGICAL AND OBSTETRIC FACTORS

Many women experience joy, relief, and elation upon the birth of their child, some women report
symptoms compatible with stress disorder after birth. Several studies (Beck, 1996, O'Hara and
Swain, 1996) suggest that gynaecological and obstetric factors make a significant contribution to
the development of postpartum depression.

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3.2.1 Delivery process

Pregnancy and delivery-related (obstetric) complications also cause physical and mental troubles
for the mother and comprise a single predictor variable for PPD. Obstetric factors, including
pregnancy-related complications such as hyperemesis, preeclampsia, premature contractions and
labor, hypertension, headache, pain, anemia, gestational diabetes, diabetes mellitus, and
amniocentesis as well as delivery-related complications, such as difficult and painful labor,
caesarean section, instrumental delivery, premature delivery, and complicated puerperium-like
excessive bleeding, have been examined as potential risk factors for PPD.

Delivery process and related issues are different for each mother. Most of them was tensed and
anxious of their delivery. And there are chances for complications in delivery. It can affect a
mother’s mental and emotional health. Each of our respondents have a different story.

Divya , 27yrs,workingattechno park, middleclass

“ I was a bit tensed as I had an abortion once but everything went

normal . I had caesarean and there was no issues before and after
delivery.”

Pavithra, 30 yrs working at techno park, middle class

“My pregnancy was planned. I didn’t have any kind of worries and
tensions I was expecting a normal delivery. I took tablet for
inducing pain but it was unsuccessful and had caesarean so I went
through both the pain. And it was hard for me.”

Most of the respondents agreed that cesarean is more complicated and difficult than normal
delivery. The mothers who had cesarean experienced more physical discomfort than others.

3.2.2. Breastfeeding

46
Initially the relationship between breastfeeding and postpartum depression was conceptualized to
be unidirectional, with postpartum depression resulting in lower rates of breastfeeding initiation
and early cessation. More recently however, reports indicate that the relationship may be
bidirectional in nature, suggesting that while postpartum depression may reduce rates of
breastfeeding, not engaging in breastfeeding may increase the risk of postpartum depression.
Additionally, there is some evidence that breastfeeding may protect against postpartum
depression or assist in a fast recovery from symptoms.

Breastfeeding is a key factor in parent infant bonding. And it also important for the health of the
baby. The women we studied give a lot of care in breastfeeding the baby. They make sure that
they feed in every two three hours. Some of them had issues like low breast milk supply.

Aathira, 24 yrs , unemployed , lower middle class

“ usually feeds the baby in every two three hours . AS I don’t have
much milk formula is used. Now both breast milk and formula is used
to feed the baby.

Akhila , 28 yrs, Working at KTU IT section, middle class

“ Breast feeds in every two three hours .I don’t have any issues
relating breastfeeding.”

Some of the women we studied had issues with breastfeeding even though they
make sure that the feed their baby in every two three hours. Many of them uses
formula.

3.2.3 Health Issues

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Health issues can foster postpartum depression. Women experience a lot of health issues during
postpartum period. It includes uterine shrinkage, perineum pain , blood glucose swing, urinary
incontinence, postpartum thyroiditis, bleeding, hypertension, back pain , infections, trouble
breathing, intense headaches etc

Veena, 28 yrs, unemployed, middle class

“ I had PCOD a d thyroid since the age of 13 yrs as my menstruation

was not regular I had difficulty in conceiving so I consulted a
gynecologist it was found out that I had blockages in both of my
fallopian tubes . So I underwent chemo surgery to clear it. And I took
medications for 6 months . And I was finally able to conceive.
Everything went normal till the due date . I thought it would be a
normal delivery but the baby was in transverse position so the
delivery was cesarean . I also had issues after pregnancy. My stitches
bled for a long time . I still have pain from the stitches especially
when I lift heavy objects.”

Like Veena many women experiences health issues and complications during pregnancy,
delivery, and postpartum period.Health issues can also be a reason for the depression they are
facing.

3.3 SOCIAL FACTORS AFFECTING POSTPARTUM ILLNESS

The position of being a mother imposes a number of stresses for all women, irrespective of the
order of delivery. The mother usually tends to do a greater share of parenting tasks. With the
added burden of childcare, there is less time for socializing.

Postpartum period may isolate a mother from her surroundings. It can reduce her social
interaction and thereby reducing the chance of an open conversation of their problems. It may
slow the cure. Social support is an important element to prevent postpartum depression.

Divya, 27 yrs, working at techno park, middle class

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 “ I was a person who like to go for outing regularly but it is not
possible.”

Pavithra , 30 yrs , working at techno park, middle class

“ I used to do whatever I wanted.But now it is not possible. Now I have a baby , I

need to care of her . I am not able to attend any functions or family gatherings.”

Nikhitha , 30 yrs , working at techno park, upper class

“ I loved to watch movies during the weekends. I was a critique of movies. But
now I don’t have time to watch movies. I need to feed my baby in every two three
hours and look after her. So I don’t get the leisure time for pursuing my hobbies
and interests.”

Like Divya many of them lacks their opportunity for social interaction. They are being isolated
from their surroundings. They don’t receive enough space and time for pursue their interests and
to interact with their surroundings.

3.4 PSYCHOLOGICAL FACTOR

Mental difficulties are common in the postpartum period. They can manifest in a mild form, but
also as serious disorders which need to be treated in a timely manner. The most common
psychological problem is “Baby blues” characterized by relatively short duration without
consequences and treatment is largely unnecessary. Postpartum depression is characterized by a
sense of sadness, loss of interest, insomnia, discomfort, loss of energy, reduced concentration.
Postpartum psychosis is the most serious disorder but is also rare and may have serious
consequences for the mother and child.

Postpartum period is mentally exhausting for all the mothers. In our study our respondents
shared many common psychological issues like insomnia, tensions, worries, anxiety, discomfort,
loss of interest, stress, panic, over thinking, anger, emotional imbalance , mood swings etc. Some

49
of them even doubted that if it is really their child. The anecdotes from Pavithra, 30yrs, working
at techno park, middle class testifies this.
“ Being a mother I couldn’t adjust at the beginning. I was not in track.
Initially I even doubted that is it really my child ? I couldn’t accept the
quick change and the reality of being a mother. I was a person who
everything free and independently but no more.”

Anupama , 31 yrs working as receptionist

“ This is my second child.My first one was comparatively easy for me. But now I feel mentally
exhausted. I become more anxious and tensed. I lost my mother . If she is there for me I would be
more comfortable. Because I couldn’t deal all of these alone. “

3.4.1 Childhood

Women with childhood trauma experienced greater depressive symptoms through six months
postpartum. The history of depression in their life or in their family members can trigger their
postpartum depression.

Nikhitha is a woman we studied and she shared that her childhood was traumatic. And she also
had postpartum depression.

“ My childhood was not much ok . I don’t want to think about it . It

was bit of poverty and lot of discrimination so I am not happy about
it.”

Divya ,28 yrs , unemployed, middle class

“ I had a good childhood filled with colorfulmemories. I was the favorite of everyone. I
considered myself as a child even after marriage. It was only after the baby I feel like an adult .
Now I miss my childhood.”

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3.4.2 Awareness about Postpartum illness

Awareness of postpartum mental health conditions are of utmost important in solving the same.
They need to be aware of their own situations and they need to open up them to the family and
friends.

Akhila , 28 yrs, working KTU IT section, middle class

I was heard and known of postpartum depression. And I am sure that I

had postpartum blues . I recovered myself through family support.

All of the mothers we studied was aware of the postpartum depression. Some of them like Akhila
was sure they had postpartum blues. Postpartum blues , commonly known as “ baby blues” is a
transient postpartum blue disorder characterized by milder depressive symptoms that postpartum
depression. In most of the cases the women can herself deal with it and overcome the situation.
Unlike the past nowadays society and family are much aware of the mental trauma and hardships
that a new mother is going through during the postpartum period. They are ready accept
motherhood as a period of tensions, worries, stress and anxiety other than glorifying it as a
period full of happiness and excitement.

3.4.3 Postpartum Depression

Postpartum depression (PPD) is a type of depression that happens after someone gives birth.
People experience hormonal, physical, emotional, financial and social changes after having a
baby. These changes can cause symptoms of postpartum depression like feeling empty, sad,
emotionless, mood swings,exhaustion,anxiety, helplessness and tensed. They may be ashamed to
admit that life with a new baby is not always bliss. They may assume that everyone else had
made a smoother transition to motherhood than they have. And they may be truly embarrassed
that they are not able to cope better.

Nikhitha,30 yrs, working at techno park, upper class

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 “yes I heard of postpartum depression. I didn’t feel like much
depressed but I was used to get more anger . I don’t know how other
people felt . For me it was a period of lot of tensions and anxiety. I
was more angry anxious and over thinking. I think my negative
emotions were highlighted . I began to panic without reason.”

As per our study most of the women had the similar issues like Nikhitha. Most of them had
postpartum depression. Postpartum blues is the kind of depression commonly seen among them.
Many of them had similar symptoms and issues.

3.4.4 Onset and duration

Postpartum depression usually begins within the first 3 months after giving birth, according to a
2014 review of clinical studies. According to the authors, it can remain a long term problem for
some women, especially if they do not receive treatment.

There are slight variations in the onset and duration of postpartum depression in the women we
studied. But commonly it begins in the initial period of motherhood and decreases gradually. The
same can be understood from the experience of Akhila.

“ Initially I felt like more anxious ,now slowly it is decreasing . I

began to felt it from one two four months . It was not only because of
the baby but also due to the work pressure. But later everything
become fine.

3.4.5 Parent Infant Bonding

Postpartum depression can interfere with normal maternal infant bonding and adversely affect
acute and long-term child development. Postpartum depression may lead mothers to be

52
inconsistent with childcare. These childcare inconsistencies may include feeding routines, sleep
routines and health maintenance.

Veena,28 yrs , unemployed, middle class

“ My first priority has become the child rather than myself. Even I am
hungry I would feed the baby first . I never used to wake up hearing
alarm. But now whenever the baby cries even during the night I wake
up. It just happens and that what motherhood is. I don’t want to feel
cinematic but after pregnancy I felt like now I have a purpose and
meaning to my life .”

From Veena’s story we can understand how she is connected to her child. After pregnancy her
life revolves around her child. Her first priority has become the child rather than herself. It is not
only her story most of the others shared the same.

3.4.6 Mental load of motherhood

The birth of a baby can trigger a jumble of powerful emotions from excitement and joy to fear
and anxiety. But it can also result in something you might not expect , depression. Motherhood is
often glorified but in reality it is a hard period . It includes mood swings , worries, tensions,
anxiety, health issues and stress.

All of the women we studied had gone through the mental load of mother hood. They become
anxious, tensed, worried etc. Pregnancy and postpartum had created a lot mental changes in
them. Let us look into words of Akhila.

“ I had two miscarriages . So right from the pregnancy I was tensed .

Even after delivery , I felt so down and unhappy . I was anxious and
had an increased anger. I went through a lot of mood swings and
tensions of work.

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3.5 SUPPORTING SYSTEM

A supportive relationship with the husband and other elder members of the family can help to
mitigate the stresses of being a new mother. Therefore, the rote of social factors is very crucial
for all mothers. The influence of marital relationship, social support and interpersonal relations
of mothers on the development of depression after delivery is discussed below.

3.5.1 Family Support

The interpersonal relationships with family members play important roles in postpartum
depression. Improving the relationship between new mothers and their husbands or mothers-in-
law and then enhancing social support might reduce postpartum depression and sleep
disturbance.

From our study we understood that unlike the past nowadays family is aware and understanding
the issues faced by women during postpartum period. Especially the mother of a pregnant
woman plays an important role. As they have gone through the same situations it is easy for them
to understand and take care of them. It is difficult to woman who don’t have their parents to take
care of them. This is clearly seen in the case of Anupama MS, 31 yrs.

“ This is my second pregnancy. In the first one my mother was there

for me . So it was easy but now she is not there . My husband tries
hard to make me comfort but still it is not enough.

Nikhitha , 30 yrs , working at techno park

“ ours was love marriage . Since the marriage our families are not at all
cooperative. We didn’t receive any help or support from them during pregnancy.
We managed everything by ourselves.”

Pavithra , 30 yrs , working at techno park

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“ my family was very supportive since the pregnancy. They took much care of me
and baby. They made sure that I am comfortable and healthy. They were there for
me all the time. “

3.5.2 Conjugal family

Support from husband plays an important role in postpartum period. Pregnancy and child birth
can be exhausting both physically and emotionally. The care and support of the spouse can
prevent or reduce the intensity of the postpartum depression.

Even if there is no family support the presence and care of husband can prevent the chance of
postpartum depression to a limit and vice versa. But for a woman who lacks both of them it is too
difficult to recover. Sometimes the lack of open conversation can also increase the chance of
postpartum depression. In a case we studied the husband wasn’t even aware that his wife was
going through such a hard time. At the same time other husbands were much cautious about their
wife and their mental and physical health.

Nikhitha, 30, working at techno park, upper class

“ After years of relationship we finally got married. As from the

beginning he was also supportive. He was there for me always during
the pregnancy, delivery and postpartum period . He cared me a lot.
He was more than what I had expected. I felt so satisfied. Even if there
was no support from our families he made it easy for me .”

Anupama , 31 yrs , working as receptionist

“ It was very hard for me at the beginning. My husband was not able to understand what I was
going through. After a long open conversation things began to change. He gave me more space
and time. As he involved more in looking after the baby , I received more time to sleep and rest.

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3.6 DIAGNOSIS AND TREATMENT

Medical treatments and counseling are available for the treatment of postpartum depression. In
case of postpartum psychosis treatment is necessary. But postpartum blues can self recovered
with the help of self effort, family and social support. It is important to be aware and accept the
problems and changes they are going through. And they need to open up what the feel to their
family or friends.

None of the mothers we studied have taken treatment or medications. They were able to recover
themselves through open conversations. Most of them had postpartum blues so it was easy for
them to recover without medications. One of them received help and suggestions from a
gynecologist who was their family friend. But in other cases the family and husband played the
key role.

Anupama

“ After pregnancy I felt more anxious, anger and tensed . I was aware
that I am going through some kind of depression . So I had an open
conversation with my husband after shifting our first child to his
parents home. I shared all my problems with him . He understood them
and made a lot of changes in our life. He began to involve more in child
caring and he make sure that I am getting more space and sleep. He
comforted me and slowly I started to recover . Now I am fine.”

Pavithra

“ I was sure that I have postpartum depression. As we had a

gynecologist in our family itself it was easy for me . I had a
conversation with her regarding the problems that I was going

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 through . She give me a lot of instructions and suggestions. After
following them gradually I recovered myself “

3.7 WORKING MOTHER AND POSTPARTUM ILLNESS

It is a hard task to handle both the job and pregnancy together. The problem continues from the
pregnancy to the postpartum period. Taking care of a child itself is a big task so doing it along
with work can create stress and tensions .

In our studies we heard the experiences from working and non working women and we
understood that comparatively it is hard for the working women to carry both work and
childcare. The problems begins itself from the pregnancy.

Aathira

“ I am a house wife so it was easy for me to go through pregnancy,

delivery and postpartum period. Because my only responsibility was my
child . I didn’t needed to split my concentration to any other things.

Nikhitha

“ Right now I have work from home option ,so somehow I am

managing . I had a lot pressure but now it’s ok. But I don’t know how
will I manage both after my maternity leave.

3.8 POSTPARTUM CHANGES

The postpartum psychological changes are those expected changes that occur in the woman’s
body after childbirth, in the postpartum period. These changes mark the beginning of the return
of pre-pregnancy physiology and of breastfeeding. It includes physical, behavioural,mental
changes . It can make changes in mother’s life style and her interests.

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3.8.1 Physical change

Body changes a lot after you give birth. Some changes are physical and others are emotional. It
can cause many health issues as well as changes in physical appearance.

All of the women we studied had undergo physical changes after delivery. Many of them gained
weight and stretch marks. Many of them are fine with the changes. But some mothers feel sad.

Aathira

“ I had a lot of physical changes. I have stretch mark in my stomach

and in my back. There was marks in my neck too. The marks were too
dark. I gained a lot of weight and I felt really sad about all these
changes”

3.8.2 Behavioural changes

Most of the new moms experience behavioural changes after child birth which commonly
include mood swings , anger, crying spells , anxiety and difficulty sleeping.

Behavioural changes were there in all the women we studied. Even if the intensity varies they all
have the same problems like anger,mood swings, emotional imbalance, tension, anxiety and
worries.

Akhila 28 yrs , working at KTU IT section , middle class

“ I had two miscarriages . So right from the pregnancy I was tensed.

Even after delivery I felt so down and unhappy. I was anxious and had
an increased anger. I went through lot of mood swings and tensions
on work . But still I am happy about being a mother.”

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3.8.3 Lifestyle

As a new person in introduced in the life many changes took place in it. A new born baby must
be fed in every two three hours so a mother need to adjust her time according to it . It can create
changes in her food habits, sleep,daily routine etc .

The women we studied had many changes in their lives for the sake of child. They began to
adjust their food, sleep, interests, etc. For the health and wellbeing of the baby there are
compromising theirs. It can be understood from Veena's words.

“I have to eat a lot of food since I am breastfeeding so it is not

possible to follow diet and maintain a healthy lifestyle”.

Aathira , 28 yrs , working at KTU

“ My life began to change after the baby. My first priority became the child. My life began to
revolve around her. I have compromise everything else for her. My hobbies and interests was
sidelined.”

3.8.4 Interest

Mothers don’t usually get time to pursue their interests after pregnancy. The life of a mother
revolves around the child. It may the results of hormonal changes or lack of time.

The women we studied had many changes in interests. Many of them doesn’t follows as they
don’t have time. But for some others they are not interested in them anymore. For example.

Divya 27 yrs ,working at techno park, middle class

“I still do some of the things I have interest in . But I can’t follow my

other interests like outing and watching movie. I don’t think that my
interests are changed . They are still the same. But the fact is that I
don’t have enough time to pursue them.”

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3.8.5 Lack of sleep

A new born baby is to be fed in two three hours . So continuous sleep is not possible. Most of the
mothers can’t sleep during time or can’t receive proper rest. It can lead to health issues like
insomnia, head ache, back pain, stress and anxiety.

All the women se studied feeds the baby in every two three hours. So they can’t sleep well. Lack
of sleep can trigger many health issues as well as behavioural and mental issues. And it can also
foster the PPD.

Aathira

“ As my baby doesn’t sleeps in night. I can sleep well. I try to sleep

during day time . But I have to wake up in intervals to feed the baby.

Conclusion
Most of the women we studied had psychosocial issues during postpartum period. Most of them
had postpartum blues. All of them recovered themselves. It was possible because they had family
support. Lack of family support is a risk factor of postpartum depression. Family support plays a
key role in preventing or limiting the issues of postpartum depression. We also identified some
of the common causes of postpartum depression from our respondents. Lack of family support,
work pressure, lack of sleep , health issues , mental load of motherhood and quick changes are
the common causes or risk factors of postpartum depression.

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 CHAPTER 5

CONCLUSION

Postpartum depression (PPD) is a type of depression that happens after someone gives birth.
Postpartum depression doesn’t just affect the birthing person. People experience hormonal,
physical, emotional, financial and social changes after having a baby. These changes can cause
symptoms of postpartum depression.

The Awareness of postpartum depression and the mental, health conditions are utmost important
in solving the same. They need to be aware of their own situations and they need to open up
them to the family and friends.

The study is intended to find the prevalence of psychological and physical illness in women after
delivery in Kerala. It also tries to find out the functional association of these postpartum illnesses
with selected socio demographic, gynecological and other chosen variables and the determinants
of these illnesses.

The study contains Five chapters. First chapter gives an introduction. Second chapter is literature
review about the Postpartum depression and its relevance. Third chapter comprises the
methodology with elaborates aim, objectives, operational definitions, research design, source of
data, pilot study, population sampling, tools of data collection, variables, analysis of data and
limitations of the study. Fourth chapter was the analysis which is done using the narrations of
respondents. The last chapter deals with the conclusion.

61
objectives
• To understand the Gynecological and Obstetric factors related to Postpartum
illness
• To analyze the psycho-social issues faced by women during postpartum
period
• To examine the supporting system for women during the postpartum period.

METHODOLOGY

The researcher follows descriptive research design. The purpose of the study was to find out the
prevalence of psychological and physical illness in women after delivery in Kerala. It also aims to
find out the functional association of the postpartum illness with selected socio demographic
,gynecological and other chosen variables and the determinants of these illnesses. Primary data was
collected directly from the postpartum women using in-depth unstructured interview method. The
secondary data was collected from textbooks, articles etc. Before the actual study the researchers
visited two women and carried out detailed discussion with the respondents about their postpartum
period. Population of the study was women in two to twenty two weeks after delivery. Seven women
were selected using purposive sampling method. Two psychiatrist and two psychologist each from
IMB Hospital, Venchavode and Cosmopolitan Hospital, Pattom were the key informants of the
study. Independent variables used in the study are pregnancy and postpartum period and and the
dependent variables are general health, psychological well-being, depression, and supporting
system. After data collection, the qualitative narratives were subjected to systematic content
analysis, based on themes developed on the basis of the research questions. Time constrain was
the major limitation of the study. The researchers had to approach most of the women at least
two times to complete the interview as the kid interfered the interview.

62
FINDINGS

Most of the women we studied had psychosocial issues during postpartum period. Most of them
had postpartum blues. All of them recovered themselves. It was possible because they had family
support. Lack of family support is a risk factor of postpartum depression. Family support plays a
key role in preventing or limiting the issues of postpartum depression. We also identified some
of the common causes of postpartum depression from our respondents. Lack of family support,
work pressure, lack of sleep , health issues , mental load of motherhood and quick changes are
the common causes or risk factors of postpartum depression.

Gynaecological and Obstetric factors

• Most of them was tensed and anxious of their delivery. Most of the respondents agreed
that cesarean is more complicated and difficult than normal delivery. The mothers who
had cesarean experienced more physical discomfort than others.
• Regarding breast feeding some of the women we studied had issues with breastfeeding
even though they make sure that the feed their baby in every two three hours. Many of
them uses formula.
• Health issues can foster postpartum depression. Women experience a lot of health issues
during postpartum period. It includes uterine shrinkage, perineum pain , blood glucose
swing, urinary incontinence, postpartum thyroiditis, bleeding, hypertension, back pain ,
infections, trouble breathing, intense headaches etc
Psychological factor
• Postpartum period is mentally exhausting for all the mothers. In our study our
respondents shared many common psychological issues like insomnia, tensions, worries,
anxiety, discomfort, loss of interest, stress, panic, over thinking, anger, emotional
imbalance, mood swings etc. Some of them even doubted that if it is really their child.
• Women with childhood trauma experienced greater depressive symptoms through six
months postpartum. The history of depression in their life or in their family members can
trigger their postpartum depression.

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Awareness about Postpartum illness
• All of the mothers we studied was aware of the postpartum depression. Postpartum blues
, commonly known as “ baby blues” is a transient postpartum blue disorder characterized
by milder depressive symptoms that postpartum depression. In most of the cases the
women can herself deal with it and overcome the situation.
Postpartum Depression

Postpartum blues is the kind of depression commonly seen among them. Many of them had
similar symptoms and issues.
Supporting System
Family Support
From our study we understood that unlike the past nowadays family is aware and understanding
the issues faced by women during postpartum period. Especially the mother of a pregnant
woman plays an important role. As they have gone through the same situations it is easy for them
to understand and take care of them. It is difficult to woman who don’t have their parents to take
care of them.
Conjugal family
Even if there is no family support the presence and care of husband can prevent the chance of
postpartum depression to a limit and vice versa. In a case we studied the husband wasn’t even
aware that his wife was going through such a hard time. At the same time other husbands were
much cautious about their wife and their mental and physical health.
Diagnosis and treatment
None of the mothers we studied have taken treatment or medications. They were able to recover
themselves through open conversations. Most of them had postpartum blues so it was easy for
them to recover without medications. One of them received help and suggestions from a
gynecologists who was their family friend. But in other cases, the family and husband played the
key role.

64
Working mother and Postpartum illness

In our studies we heard the experiences from working and non-working women and we
understood that comparatively it is hard for the working women to carry both work and
childcare. The problems begin itself from the pregnancy.

SUGGESTIONS

•Awareness regarding postpartum depression must be given to mothers , their spouse and family.
This will help the mothers and the people surrounding them to know what they are going
through.

• Mothers should feel free to seek medical help or emotional support as soon as possible.

• Medication should be taken if it is necessary.

• Family should provide care and support as it can reduce the risk factors of ppd.

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APPENDICES
 APPENDIX I

BIBILOGRAPHY

Beck Cheryl Tatano. (2006). Postpartum Depression It isn’t just the blues. American Journal of
Nursing. 106(5).40-50

Bina Rena.(2008). The impact of Cultural Factors upon postpartum depression. Health Care for
Women International. 29(6). 568-592

Florio Ariana Di, Samantha Meltzer Brody.(2015). Is Postpartum Depression a distinct Disorder.
Current Psychiatry Reports.17(10).76

Ghaedrahmati Maryam, Ashraf Kazemi.(2017). Postpartum Depression risk factors. Journal of

Education and Health Promotion. 6(60)

Guille Constance, Roger Newman.(2013). Management of postpartum depression. Journal of

Midwifery and Women’s Health.58(6).643-653

Hagena Edward. (1999). the Functions of Postpartum Depression. Evolution of human

behavior.20(50).325-359
Hopkins, Joyce, Marcus.(1984). Postpartum Depression. American Journal of Psychological
Association.95(3).498-515

Horowitz June Andrews, Janice H Goodman.(2005). Identifying and treating postpartum

depression. Journal of Obstetric, Gynecologist, and Neonatal Nursing.8(1).55-63

Murray Lynne, Peter J Cooper.(2009). The Impact of postpartum depression on child

development. International Review of Psychiatry.8(1).55-63

O’Hara Michael W, Annette M. Swain.(1996).Rates and risk of Postpartum Depression a meta

analysis. International Review of Psychiatry .8(1).37-54

O’Hara Michael W, Jennifer E. McCabe.(2013).Postpartum Depression Current Status and future

directions. Annual Review of Clinical Psychology.9.379-407

O’Hara Michael W. Postpartum Depression What we know. Journal of Clinical

Psychology.65(20.1258-1269

Patel Milapkumar,Rahn K Bailey.(2012).Postpartum Depression a review. Journal of Health

Care for the Poor and Undeserved.23(2).534-542

Pearlstein T, Margaret Howard,Amy Salisbury,Caron Zlotnick.(2009).Postpartum Depression.

American Journal of Obstetrics and Gynaecology.200(4).357-364

Wisner Katherine L, Christina Chambers.(2006). Postpartum Depression A Major Public Health

Problem. Jama Network.296(21). 2616-2618
https://my.clevelandclinic.org/health/diseases/9312-postpartum-depression/

https://www.healthline.com/health/depression/postpartum-depression

https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

https://www.parents.com/parenting/dads/sad-dads/

https://www.webmd.com/depression/guide/postpartum-depression
 APPENDIX II
INTERVIEW GUIDE
Profile
1. Profile
2. Age
3. Education
4. Occupation
5. Family status (Income) – Upper / Middle / Lower

Background of pregnancy
1. How long have you been married?
2. Was this pregnancy planned or unplanned?
3. How was your pregnancy Period? (Explain the details)
4. Have you had any issues in pregnancy or during delivery?
Child Caring and Post Delivery issues
1. What kind of delivery you had? Is it normal or caesarean? (Explain the delivery
process)
2. Is this your first or second child?
a. If second, what is the difference you feel between the two deliveries
b. How was the first and how was the second?
3. How often does the baby cry?
4. Do you sleep well?
5. How is often do you feed the baby? (Give the details)
6. Do you have any difficulties in breast feeding?
7. Do you have any health issues after pregnancy (ask about the stiches and infection
they had)
8. Explain the medicine you are taking
Psycho Social Issues
1. What are your thoughts on motherhood as now you've become a mother?
2. Do you still have interest in the things you enjoyed before pregnancy?
3. What are the positive and negative changes coming to your life after delivery?
4. Do you feel sad about the changes happened to your physical appearance?
5. What kind of support you get from your husband? (details needed)
6. Do you get family support though out and after pregnancy? (Explain the family
support system both from their home and inlaws’.
7. Explain your occupation details (How many days you get leave for pregnancy and
child care and how you are going to manage both occupation and the child caring)
Postpartum Depression
1. Do you know anything about postpartum depression?
2. Have you had any miscarriages?
3. Do you feel anxiety problems after delivery?
4. Have you been afraid or panicked for no reason? (Especially about the child and
his/her health)
5. Have you been anxious or worried for no reason?
6. Do you feel down or unhappy?
7. How understanding and supportive was your family in the issues you were going
through?
8. How far you succeeded in understanding yourself and the problems you are going
through and to solve it?

Psychological and Social background

1. Can you tell me about your childhood?
2. Do you or anyone in your family suffered depression?
3. Do you smoke or drink (should ask in an informal manner)