Study identifies risk factors for postpartum depressive symptoms

Many Norwegian women postpone pregnancy until they have completed their education and are well established on their career path. This may make them more vulnerable to postpartum depression.

"There are some indications that older, first-time mothers are vulnerable to postpartum depression (PPD), perhaps because they are used to being in control of their own lives: they have completed a long education and established a career before they have children. But you can't control a baby; on the contrary, you have to be extremely flexible. Several of the women I interviewed said themselves that this contributed to the huge feeling of letdown when things did not turn out as they had planned," says Silje Marie Haga, who recently defended her doctoral thesis Identifying risk factors for postpartum depressive symptoms: the importance of social support, self-efficacy, and emotion regulation.

International studies have found that teenage mothers are at increased risk of postpartum depression, and previously this group has received extra attention. But in Norway this is a small group. Haga therefore believes that initiatives should now be targeted towards the much larger group of older mothers.

"Having very clear expectations and a great need for control is a risk factor. Those who prepare themselves to a very high degree for how life with the child will be have a hard time when things do not go as planned. So it's not the need for control in itself, but rather the failure to achieve specific expectations that can trigger a depression. In contrast, women who take a more relaxed approach to motherhood with more undefined expectations cope better with unexpected challenges," Haga observes.

She stresses that she is not warning women against postponing pregnancy, but that she believes it is vital to be aware of this correlation. This gives an opportunity to launch initiatives targeted towards this group of women so that they acquire more realistic expectations of what lies ahead.

"Feeling like a failure after delivery"

One of the informants in Haga's interview study relates:

"I looked forward to having the baby throughout the whole pregnancy. There was nothing I didn't look forward to. I even looked forward to the birth itself. […] At 04:15 a.m. our little princess came into this world with a c-section. That wasn't how I was supposed to have a baby. I was so tired and so disappointed, I was so sad. My biggest nightmare had happened; I had to do a c-section. I hadn't been able to give birth to my baby; someone had to do it for me. I had carried her for 9 months, but I wasn't able to bring her into this world."

"In my study the women who had the greatest need for control often had the strongest wish to have a natural birth. If they had to have an epidural or a c-section, they could feel that they had not mastered the birth. They assume an extra burden with this idea of how the birth should be, and they feel that it says something about themselves as a woman and mother," adds Haga.

Haga's findings indicate that difficulty with breastfeeding is also an important factor in the development of postpartum depression in new mothers. Previously there has been a common belief that women with postpartum depression often stop breastfeeding because they are depressed. In Haga's opinion it is important to recognize that the opposite may be the case.

"Everyone wants the best for their child, and of course breastfeeding is important. But in Norway breastfeeding is associated with being a good mother. This exerts a lot of pressure on first-time mothers, not least because many of them have difficulty breastfeeding."

Support from others

It is crucial that new mothers receive practical and emotional support from their surroundings, as well as an understanding that life can be exhausting for them.

"Social support is not only about receiving support but also about experiencing that support is available if you should need it. It has been demonstrated that the most important factor is a feeling that support is available - particularly from the partner," the researcher explains. It is vital that the woman receives emotional support from her partner, and that he acknowledges and validates how she feels.

"I was surprised at how little help women felt they got at the well baby clinic. They reported that the healthcare staff were mainly focused on normalizing the situation. They tell the mothers that it's common to feel that life is tough as a new mother, and that this will pass."

"This is useful information, but insufficient as the women experience that their feelings are not acknowledged. By normalizing negative feelings the well baby clinic also misses out on the opportunity to identify those who are actually depressed," Haga points out.

Moreover, postpartum depression does not necessarily lift as quickly as what has usually been believed. The women in Haga's survey-questionnaire answered the questions six weeks after the birth, and again three and six months after the birth. Depressive symptoms proved to remain relatively stable throughout this period.

Self-belief

The researcher also found a range of other factors that contribute to or protect against depression, in both the mother's personality and in her surrounding environment.

"Self-efficacy is vital: How do I face these challenges? When things are difficult, do I believe that I will succeed in the end? General self-efficacy and not least the feeling that one will master breastfeeding can have a preventive effect on developing PPD," Haga relates.

Another important variable is regulating feelings centred on negative experiences. Women who tend to catastrophize, to ruminate, or to blame themselves are at increased risk. Protective strategies include focusing on planning and positive re-focusing, i.e. finding something positive even in negative experiences.

A complex problem

Haga stresses that PPD, like other types of depression, can have many interlinked causes. A number of those affected have experienced depression earlier in their lives or during pregnancy. Mental disorders within the family may also pose a risk factor.

"Biology must be taken into consideration, and it is difficult to do anything about this. What I examine are the psychological factors that play a role in order to acquire greater knowledge of what can prevent and improve the situation of those affected or at risk," explains the researcher.

The study includes a survey-questionnaire with approximately 350 respondents as well as in-depth interviews with 12 first-time mothers.

Large number of undetected cases

International figures show that between 10 and 15 per cent of mothers suffer from PPD. Most studies are from Western countries but the problem is regarded as universal. Haga's study found that 16.5 per cent of mothers experience PPD. Her survey-questionnaire does not incorporate sufficient participants to be representative, but several Norwegian studies find similar prevalence rates, indicating that the number is a reasonable estimate.

"An increasing number of cases are being identified because we have more screening than before. Nevertheless, I believe that there is a large number of undetected cases because PPD is still stigmatized. Moreover, a number of new mothers don't understand that they are actually suffering from depression, because they expect the postpartum period to be difficult," continues Haga.

It is common that three-four days after the birth women experience what can be referred to as postpartum blues, i.e. they cry very easily without quite knowing the reason. This can last up to a week, but in some cases it continues. If this is so, there may be talk of postpartum depression, which resembles other kinds of depression with feelings of hopelessness, sadness, exhaustion and sleep problems also when the child is asleep.

"These women are unable to enjoy having a baby. Being depressed at precisely this period is an extra emotional burden to bear because of expectations that you should be happy."

The entire family is affected

Postpartum depression can have consequences for the entire family, the researcher stresses.

The mother must live with the stigma attached to depression. Often she is not aware that she can get help and it may be difficult for others to detect that she is suffering. A woman who has suffered from PPD is also at increased risk of being depressed later in life. In addition, her partner is also at risk of depression.

"For the baby, this is a period when it is often the mother who is the primary caregiver, and if she is depressed this can affect the interaction between her and her baby. For example, if a child is uncertain about what something in its surroundings means, he/she looks at the mother to see if she is smiling and communicating that it's safe, or if she looks frightened, thus communicating that it's dangerous. In contrast, a mother who is depressed has a more neutral facial expression that gives the child little information. The worst-case scenario is that the child experiences a greater degree of unrest and anxiety in situations that are not necessarily dangerous," adds the researcher.

Haga emphasizes that for this to have a long-term effect, the mother must be seriously depressed for a considerable period of time.

"Depressed mothers are aware that there is a risk that the child may be affected and they do everything they can to ensure that this doesn't happen. Moreover, for most children there is also a father in the picture who can give the child what the mother may not be able to supply," remarks Haga.

Develops programs for prevention

Together with the Regional Centre for Child and Adolescent Mental Health and the web-based company Changetech, Silje Marie Haga has developed a web-based program that will monitor pregnant and new mothers from the 22nd week of pregnancy and up to six months after the birth. They hope that the program will support women during this very sensitive phase and potentially prevent postpartum depression. Haga and her colleagues have received funding from the Research Council of Norway to evaluate the effects of the program.