ConQual Summary of Findings
Childbirth is a life transition for new mothers and fathers. The birth of a child constitutes a major developmental event for both women and men. It has profound effects on the parents’ identities and couples’ relationships; therefore, it has an impact on family life.2 It has been estimated that 50% to 80% of women suffer from baby blues after childbirth.3
Postpartum depression (PPD), also called postnatal depression (PND), is a leading complication after childbirth. Although depression is thought to be most commonly experienced by new mothers and fathers soon after the birth, some women and men experience depression during pregnancy. The estimated prevalence of antenatal depression is 10% to 20% in high-income countries.4,5
Postpartum depression is a form of clinical depression that affects women and, less frequently, men, typically during the first months after childbirth. As many as 10% to 20% of women experience a depressive episode following childbirth.3,6
According to the results of various studies,7-9 PPD was evident in about 10% to 13% of men and was relatively high in the three to six months following childbirth. The correlation between paternal and maternal PPD is likely positive.7 It is estimated that rates of PPD range from 24% to 50% for fathers whose spouses have maternal PPD.10
Postpartum depression is a mood disorder with several symptoms that can be mild (baby blues), moderate and severe (psychosis). The symptoms of baby blues are tearfulness, fatigue and melancholy. In moderate PPD, symptoms are melancholy, anxiety, irritability, tearfulness, changes in eating and sleeping patterns, a feeling of inadequacy and suicidal thoughts. Those symptoms are more intense in severe PPD.3,6 Furthermore, the meaning of the symptoms and how they are expressed may vary depending on the cultural context.11,12
Although several risk factors have been identified, the causes of PPD are not well understood. Extensive research suggests a multifactorial etiology. The strongest predictors of PPD for women are antenatal depression and anxiety,13 fear of childbirth14 and a personal and family history of depression. In addition, socioeconomic (e.g. low-income status, financial pressures, social isolation),15 physical (e.g. hormonal changes)6 and psychosocial (e.g. difficulties in partner relationship, isolation)3 factors are well-known elements in the incidence of postnatal mood disorders.
Postpartum depression can have serious consequences for mothers, fathers and their children.16 It affects breastfeeding and infant nutritional status and health.17 When mothers experience PPD, the mother-infant relationship is more likely to have difficulties, and infants are more likely to develop an insecure attachment and psychopathology.18-21 Mothers and fathers with depression are more likely to exhibit behaviors that have negative impacts on their children. As a result, PPD can lead to poor emotional and behavioral outcomes for children.22 In addition, the relationships between maternal depression and child hyperactivity or inattention, physical aggression and separation anxiety symptoms have been recognized.23 Therefore, it is important to identify the symptoms of PPD as soon as possible and to provide support and help to those who need it.
According to a Cochrane review,24 morbidity associated with PPD can be decreased with psychosocial and psychological interventions, such as home visits by healthcare staff and peer support. We must understand how PPD influences new mothers’ and fathers’ beliefs, attitudes and willingness to seek help. At the same time, we must also recognize specific cultural needs and explore their influence on parents’ emotions during the postnatal period.25
Prior to conducting this systematic review, a preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, MEDLINE, PROSPERO and DARE databases revealed no similar systematic review or protocol on this topic. Three reviews were published after the process for this review began: Mollard,26 Schmied et al.27 and Tobin et al.28. This review differs from Mollard's26 in methodology, from Schmied et al.'s27 in methodology and breadth, and from Tobin et al.'s28 in breadth. Mollard's26 systematic review was about the experiences of women with PPD; however, Mollard's meta-synthesis utilized meta-ethnography and is therefore not comparable with the meta-aggregation methodology utilized in this review. Schmied and colleagues,27 as well as Tobin and colleagues,28 targeted migrant women for analysis, a substantially narrower group, whereas this review not only covered the experiences of a normal sampling of mothers but also included fathers.
The number of qualitative studies on lived experiences of PPD is increasing. Still, this review seems to be only the third to systematically review the findings of those studies. Our knowledge of PPD will continue to be limited until more such reviews are conducted.
The objective of this systematic review was to synthesize the existing evidence on new mothers’ and fathers’ experiences of PPD after childbirth. This review was conducted according to an a priori published protocol (PRO678).29
- i) What are the experiences of new mothers with PPD?
- ii) What are the experiences of new fathers with PPD?
This qualitative review considered studies that included new mothers and fathers with PPD symptoms (evaluated with the Edinburgh Postnatal Depression Scale) or who received a medical diagnosis of PPD. Study participants were mothers and fathers within a one-year postpartum period with any number of children. There were no restrictions regarding age, marital status, employment status, number of children or the newborn's characteristics.
Phenomena of interest
This review considered studies that explored the lived experience of new mothers and fathers with PPD.
The review considered studies of new mothers and fathers who lived at home. Because of their PPD symptoms, some mothers and fathers were clients of outpatient clinics, and some attended support groups.
Types of studies
This review considered studies that focused on qualitative data, including designs such as phenomenology, grounded theory, ethnography, action research and feminist research that explored new mothers’ and fathers’ experiences of PPD. The quantitative perspective of mixed-methods studies, review articles, meta-synthesis, studies with no available full text in the database, editorials, commentaries, letters, conference abstracts, and non-English, non-Finnish or non-Swedish studies were excluded.
This review follows the JBI approach and guidelines for qualitative synthesis with regard to search strategy, assessment of methodological quality, data extraction and data synthesis.30
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was used. An initial limited search of the databases PubMed (MEDLINE) and CINAHL was conducted, followed by an analysis of the text words contained in the title and abstract. A second search using all identified keywords and index terms was then undertaken across all included databases (MEDLINE, CINAHL, PsycINFO, Scopus and the Finnish database MEDIC). In addition, the search for unpublished articles included ProQuest Dissertations and Theses. Third, the reference lists of the included papers were then searched for any other relevant studies. Each database was searched from inception, and searches were conducted on June 24, 2014; February 7–14, 2017; and May 18, 2018. Studies published from 1946 to May 18, 2018, in English, Finnish or Swedish were considered for inclusion in this review.
Systematic searches were developed for each database and conducted by the health sciences librarian for this review in consultation with both reviewers. The search strategy is presented in Appendix I.
After searching the selected databases, all retrieved articles were exported into the RefWorks version 2.0 (ProQuest LLC, Ann Arbor, USA). Two reviewers performed the initial database search, reference list search and citation tracking. After removal of duplicates, the titles and abstracts (if available) were read by both reviewers independently to remove irrelevant articles and select those of relevance to the topic of the systematic review. The final list of potential papers was created by compiling the lists of the two reviewers, and the full text of potentially relevant papers was retrieved. The same process was repeated during the full-text screening. Disagreements between the reviewers were resolved through comprehensive discussions to reach agreement.
Assessment of methodological quality
Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the critical appraisal checklist for qualitative research from the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia).30 Any disagreement that arose between the reviewers was resolved through discussion, so a third reviewer was not needed. Before the assessment, the reviewers determined that questions 2, 3, 4, 5 and 10 on the critical appraisal checklist were essential to methodological quality. Papers were included if they received a “yes” to these questions.
Qualitative data were extracted from the papers by two independent reviewers and included in the review using the standardized data extraction tool from JBI SUMARI.30 After screening the included papers, it was evident that mothers’ and fathers’ experiences differ to some extent. Moreover, mothers described their experiences in more detail than fathers. Therefore, it was justifiable to present the data separately and give a more detailed description of the experiences of mothers and fathers. Because of this, the data were extracted into two data sets: mothers and fathers. By dividing the data sets, it was possible to obtain a fairer picture of fathers’ experiences. Each set of data included specific details about the populations, study methods and findings significant to the review question and the phenomena of interest. The findings were extracted verbatim at a sub-theme or sub-category level (seven papers), a theme or category level (five papers) and a key area or constituent level (two papers). The included studies used different analysis methods; therefore, the results are also described at different levels.
The qualitative research findings were pooled using JBI SUMARI, and the findings were synthesized by consensus from both authors. This involved assembling and rating the findings according to their quality: once for mothers and once for fathers. Findings were considered to be “unequivocal”, “credible” or “not supported”. Unequivocal findings were accompanied by an illustration (a direct quotation from a participant) that was beyond reasonable doubt and therefore not open to challenge. Credible findings were accompanied by an illustration lacking a clear association with the finding and therefore open to challenge. Not supported findings were not supported by an illustration.30 If the findings were not supported by an illustration, they were not included in the meta-aggregation.
The next phase involved categorizing the findings separately for mothers and fathers based on their similarity in meaning. These categories were then subjected to meta-aggregation to produce a comprehensive set of synthesized findings that could be used for evidence-based practice.
The ConQual approach for qualitative systematic reviews allows synthesized findings to be downgraded based on their dependability and credibility.1 Qualitative studies are ranked as high, and from this starting point, each study is then graded for dependability and credibility. Finally, the Summary of Findings compiles the ConQual score for each synthesized finding, and from this, a rating of confidence in the synthesized findings can be considered. Therefore, it serves as a practical tool to assist in decision making.1,30
A search of the literature yielded 1202 potentially relevant studies. Five potential studies were found from the reference lists of relevant studies. After 272 duplicates were removed, 935 studies were screened by title and abstracts. After screening, 903 studies were excluded, leaving 32 studies for full-text review. From these, 17 were excluded because they did not meet the inclusion criteria (Appendix II). Fifteen studies were assessed for methodological quality. Figure 1 presents a PRISMA flow diagram of the search results and study selection process.31
Table 1 summarizes the methodological quality of the 15 studies.32-46 Most of the criteria were met in the included studies. Six studies met all the criteria,32,40,42,44-46 and the nine other studies met at least seven criteria.33-39,41,43 Two studies included findings without any illustrations,34,38 and therefore, the participants’ voices were not adequately represented (Q8). These findings were excluded from the meta-aggregation (Appendix III). Two studies had unclear congruity between the stated philosophical perspective and the research methodology (Q1).39,41 One study did not mention ethical issues as Q9 criterion requires.36 The two criteria that were least addressed were Q6 (a statement locating the researcher culturally or theoretically) and Q7 (influence of the researcher on the research, and vice-versa, is addressed). For Q6 and Q7, only nine32,34,39,40,42-46 and 1032-34,36,37,40,42,44-46 of the 15 studies, respectively, met these criteria. Overall, the methodological quality of studies was considered good, and there were no studies that were excluded following critical appraisal.
Characteristics of included studies
The qualitative studies included within the review were published between 2002 and 2016. Thirteen studies32-35,37,38,40-46 concerned new mothers’ experiences of PPD, and two studies36,39 concerned new fathers’ experiences. Different qualitative methodologies were represented: phenomenology,34-36,40,42-45 grounded theory,32,37,46 and one study33 used a hermeneutic approach. Three included studies did not mention the specific qualitative methodology used.38,39,41 The data were collected by in-depth, semi-structured, unstructured, open narrative and focus group interviews, and the analysis methods consisted of different kinds of qualitative analysis, such as inductive content analysis, Colaizzi's method, and the constant comparative method (Appendix IV). The studies were conducted in the United States,32,35,45 the United Kingdom,36,41,46 Sweden,37-39 Hong Kong,34,42 Norway,43,44 Australia33 and China.40 Overall, the findings consisted of 199 mothers’ voices and 20 fathers’ voices. All participants were either diagnosed with PPD or reported symptoms of PPD. The age range of the mothers was 16 to 45 years, and fathers’ ages ranged from 25 to 52 years. The age of the infants was one year or younger during the data collection in the included studies. Appendix IV provides details of the included studies.
Mothers’ and fathers’ synthesized findings of PPD experiences are presented separately because they differed (see the “Data extraction” section). Tables 2 through 5 (results of meta-aggregation, mothers’ experiences) and Tables 6 and 7 (results of meta-aggregation, fathers’ experiences) describe the relationship between the findings, categories and synthesized findings.
Synthesized findings of mothers
Key findings were extracted from the 13 included studies that considered the mothers’ experiences of PPD. A total of 98 findings were extracted (Tables 2 through 5) and aggregated into 14 categories. From the 14 categories, four synthesized findings were developed. The synthesized findings were i) Depressed mothers feel unable to control their own lives due to low resilience; ii) The ambivalent feelings depressed mothers experience towards their babies, partners and in-laws cause distress and suffering; iii) Depressed mothers experience anger and despair if they perceive imbalances between their support needs and the support they get from healthcare providers and significant others; and iv) Depressed mothers experience hopelessness and helplessness resulting from their new-found motherhood and financial worries.
Synthesized finding 1: Depressed mothers feel unable to control their own lives due to low resilience
After childbearing, depressed mothers became more aggravated, leading some to experience feelings of a loss of control, an inability to attend to their baby, unhappiness, anxiety, fatigue and being horrified with changes in their body image.
This synthesized finding was generated from the aggregation of five categories underpinned by 47 extracted findings (Table 2). Forty-three findings were rated as unequivocal and four as credible. Four findings were excluded from the meta-aggregation because there were no illustrations available (Appendix III). These findings were not counted in the extracted findings.
Category 1.1: Depressed mothers felt they had lost control over their own life and emotions
Depressed mothers were surprised at how everything changed after childbirth. They were surprised that they could not control their own life's issues, their feelings and private time after childbirth. It was surprising how everything changed, and they could not live the life they were used to living. In addition, depressed mothers felt they were stuck, and they missed their professional and social life. Before childbirth, they assumed that the baby would not interfere with their social life because the baby could be with them. This category was supported by seven findings.
- 1. Loss of control over their emotion and behavior (U)
- 1. “I suffered greatly. I could not control my emotion and behavior. I have no idea of how to solve the problem. In the past, I was so full of confidence, but at that time I lost all my abilities to cope.”34(p.574)
- 2. Loss of old life (U)
- 2. “Everything needs to change; my former life needs to change to a ‘mother life’ now so... It's not what I used to be... it is not an easy something...”41(p.760)
- 3. Unreal self (U)
- 3. “Trapped, I can’t get out, I can’t start doing anything. I can’t start to live the life I want to live and the way I was… There are lots of things I plan on doing and want to get done, but I can’t do them because I’m kind of not really [me].”43(p.186)
- 4. Loss of emotional control (U)
- 4. “Just that little episode, I was talking on the phone and suddenly I upset my coffee cup, and there was coffee all over the table, and I just could not cope, no, no! I just sat down, and started to cry, and it was like, um, why did I do that? Why did I despair so much just because I upset the coffee cup?”44(p.814)
- 5. Too little time on her own (U)
- 5. “There is one thing that depresses me, that is, um, that is that I cannot get out. I feel locked up. As soon as there is a chance for me to dress and get out for some fresh air, then I have to feed him again, and then I have to feed myself, because that I had forgotten to do. And when I have eaten then it's his turn again, and… I feel trapped.”44(p.814)
- 6. Stuck here (U)
- 6. “Stuck in a big bubble, and all the air was being slowly sucked out of it.”45(p.109)
- 7. Missing professional and social life (U)
- 7. “I had hoped it wouldn’t be like this. During pregnancy, me and my husband talked a lot about these matters, for instance, how to organize our lives so that we could bring the baby with us and go on like before. And maybe we have been taking him out too much; he is still just a few weeks, but nevertheless we prioritize social life. And I really should wish that my whole life wasn’t totally changed, but it is; to a certain degree, it really is.”44(p.813)
Category 1.2: Depressed mothers were suffering because they did not feel able to attend to all the needs of their baby
Depressed mothers’ self-perceived feelings of inadequacy and frustration in handling mothering tasks caused them distress and suffering. Mothers felt that there was an expectation-experience gap because childcare demands were bigger than they expected, and mothers had no time to breathe. Mothers thought themselves to be incompetent and imperfect. This category was supported by 23 findings.
- 1. Please stop crying (U)
- 1. “While I’m trying to be quiet for the other two, somehow the 4-year-old will wake up the other ones. Like, he’ll start crying, like, “Camry, Camry, Camry!” I’m like, “Please stop calling your brother.” Then he’ll start crying, like, “Mom, cup, cup, cup.” Like that means he wants juice. I’m like, “Okay, hold on a sec. I’m gonna get you a cup. One sec.” And then when I turn around, bam, the refrigerator's already open, and the 1-year-old is already pouring out juice, and he’ll throw it all on the floor… It's just me. It's like, oh, my God. Okay, hold on. So I’ll just like a minute to myself, and I’m like, “Please stop crying!”32(p.356)
- 2. I need a break (U)
- 2. “So, it be like, sometimes it affects me like—like I need a break or something.”32(p.356)
- 3. I can’t do it anymore (U)
- 3. “…you have to wake up, do the feedings, change the diapers, wash the clothes. You know, cook, and it becomes a lot. I think sometimes I’m actually doing so much, and sometimes I couldn’t explain how I manage to get through it all... But I do have moments where after everything is done, I just go and I sit, and I think about it. “Why? Why is it so hard? Can I really still do this?” ’Cause it's four of them now, “can you really still do this?” I think on the hardest day, sometimes I almost say, “just give em up, it's the right thing, somebody needs to take them from me.” ’Cause I can’t do it anymore...”32(p.356)
- 4. No time to breathe (U)
- 4. “I only work [at a chain restaurant] on the weekends, but I have like school Monday through Thursday or Monday through Friday. So, I’ll get done with my homework maybe 2 o’clock in the morning, and then take my shower, and then go to bed like maybe 3:30–4:00—you know, just actually going to sleep, getting to sleep and then wake up with my kids up in the morning.”32(p.357)
- 5. Suddenly realizing motherhood (U)
- 5. “Well, when it actually bit me I was in the Moms Program and I was just sitting there, and all of a sudden I just felt like, damn, I have a kid. Oh my God! And I just sat there real depressed. I didn’t know why. I just felt depressed. Like I was ready to just like sit there and cry and scream and kick like a little kid and have a tantrum. They were like: “What's the matter? What's the matter?” I was like: “I don’t know. I just feel sad and I don’t like the way I’m feeling.” I’m a Mom. Oh! And I started crying, and then I was real depressed.”35(p.557)
- 6. Being pulled and torn between two realities (U)
- 6. “I’m still in school right now. Right now during Black history month I am doing so many things. And like the prom is getting closer. And all the classes right now, so I mean I was like -- Oh my God! … The baby is sick; I don’t want to go to school because of her. But then I have to because I have to do this, and I got to do that. And I was just like, boom, it just fell on me. I started crying. Everything hit me all at once.”35(p.557-8)
- 7. Living up to the image of the “good mother” (U)
- 7. “… you get fed with this—that you should be breastfeeding, you should be breastfeeding at every price, it is like harassment…”37(p.264)
- 8. Practical care (U)
- 8. “… I was scared to death on the maternity ward that they would send me home, because I felt that I couldn’t do this, I don’t know what to do with him...”37(p.264)
- 9. Not enough food (C)
- 9. “I have a big sorrow in my heart… I cannot look after my baby the way I would like to. I can’t feed him properly. I have such pain in my heart for this.”38(p.5)
- 10. Infant health (C)
- 10. “I just look how thin my baby is. I don’t know what I am supposed to give her.” 38(p.5)
- 11. Incompetent mother (U)
- 11. “I have read a lot of books on how to take care of babies. However, it makes me even more anxious. When my baby cries more at night, I worry whether she is sick because the books say that babies cry because they might be sick. I am not a doctor. I know very little about the illness of babies, and feel anxious and useless.”40(p.307)
- 12. Imperfect mother (U)
- 12. “When I was pregnant, I learned from the antenatal education class that breastfeeding is the best way to feed a baby. The nurse encouraged us to breastfeed. When I could not breastfeed the baby because of a mammary gland infection, I was so disappointed and thought that I was such a failure. I was not a good mother.”40(p.307)
- 13. Fear of stigma (U)
- 13. “I didn’t just … open up totally… to them. I wouldn’t want to… You know, it's like an African community, and I felt, you know… If one person knows about it, 2 people know about… 3 people know about it… so I just cut off, um... I know it's just the stigma... It's just, you know, oh… look at the girl… I think it's just, it's just that I don’t want the stigma to just keep following me around.”41(p.760)
- 14. Parenting competence (U)
- 14. “I didn’t know what to do about it, I let him take breast milk and always let him suck for the whole day, I didn’t know whether he got milk or not… he just cried, always cried.”42(p.356)
- 15. The expectation-experience gap (U)
- 15. “Actually, both my husband and I didn’t expect so many problems in having a baby… but there is so much responsibility, we’d never thought about… actually they couldn’t manage, they even made us worry more… my husband and I always had to call home to see if they were okay.”42(p.356)
- 16. Baby-minder arrangements (U)
- 16. “…I worry a lot, after all, your baby is in others’ hands, and you often hear the news [of child abuse], very scary… one whole day is a long time, you don’t know what might happen.”42(p.356)
- 17. Childcare demands (U)
- 17. “She didn’t sleep, cried at night… I comforted her, changed her diaper, but none of these worked… she cried even when I carried her… I cried too.”42(p.357)
- 18. The vulnerable baby and threatening world (U)
- 18. “I don’t know really, it was frightening to take her out then, out of the house, right outside. Because we’d been indoors for a month then, we… I was completely, I was all shaken up, really nervous and afraid. I was so scared I didn’t look at the speedometer all the way down there, my only thoughts were for the little baby in the back seat.”43(p.181)
- 19. Perforated, anxious self and motherhood (U)
- 19. “I often wondered when she cried if there was something wrong, and why I couldn’t comfort her. I’m worried about her, and I’m worried that I’m not coping very well.”43(p.181)
- 20. The lived body as a heavy physical obstacle and a mother's attunement (U)
- 20. “But I always felt like this is in the everyday routines, an ordinary day, getting up and changing her, and feeling it was incredibly tough, a new day ahead.”43(p.181)
- 21. Ambivalence concerning practical support and positive feedback (U)
- 21. “Everyone's just been saying positive things. Everything's just fine with the baby. Some of these aunts, my sisters-in-law, said, “It's ok if she cries a bit.” It's all right for little kids to cry a bit. So they’ve kept impressing on me that it's such a lovely baby, and everything's just fine, but I could still feel things weren’t just fine, I often thought things were absolutely awful. It was… I felt inadequate, and I think that's the feeling I’ve had the most.”43(p.184)
- 22. Not mastering new tasks (U)
- 22. “I think it's really hard; you just get a baby on your lap, and that's it, and the child is supposed to be with you your whole life. A small child, it cannot express what it wants or needs. It was very hard, there was no information.”44(p.813)
- 23. Unable to cope with conflicting demands (U)
- 23. “I feel that it is very hard with the toddler; he is a bit jealous, so I feel a bit torn between them. I cannot concentrate 100% on both of them. I wasn’t prepared for two kids screaming and that I had to choose between them. That feeling, um, I was not prepared for how hard that feeling was, torn apart every day. And I don’t know how to deal with it.”44(p.814)
Category 1.3: Depressed mothers did not like what was happening to them mentally and emotionally
Depressed mothers did not understand what was happening to themselves, because nothing seemed to be like it was before. Being a mother was a totally different world. They didn’t know how they were going to cope with this huge change. This category was supported by six findings.
- 1. “Stuck” in the liminal phase (U)
- 1. “It's a totally different world [being a mother] and it's like going into a new job, you have to learn things that you are not trained for but at the same time I was still struggling with something in here [she points to her chest] that stops me moving on like other people… I just wasn’t like them [other mothers].”33(p.365)
- 2. Constantly questioning and trying to explain the unexplainable (U)
- 2. “Oh my God! What am I going to do for my whole life? I didn’t know what I was going to do or where I was. I felt lost. I felt like I had nothing going for me.”35(p.558)
- 3. You are changing and regrouping, seeing a different future (U)
- 3. “I’m glad that I did have him because now I’m more responsible. Now, I’m more outspoken. Now, I want to teach young girls that are following in the same footsteps that I followed, that I’m trying to stop. So, in a way it's good because I’m more educated, more responsible, more reliable in everything… but then, in a way, it's sadness and darkness.”35(p.560)
- 4. Gap between expectations and reality (U)
- 4. “It is not easy to be a mother. It is such a huge change. It is beyond my imagination. It is so difficult for me to adapt to the change.”40(p.308)
- 5. Unreal world and others (U)
- 5. “I feel I’m getting, oh, everything's, I don’t have any feelings for anyone. And that's the way it is all the time… I’m not here at home, I’m not, the car, the house, they kind of don’t belong to me. Nothing belongs to me in a way.”43(p.186)
- 6. Internalizing misery (U)
- 6. “I really don’t understand what is happening in my head. I have lots of thoughts going through my mind, I am not even sure what they are, just about how my life is crap. My head feels like it is going to explode, so much tension.”46(p.486)
Category 1.4: Depressed mothers felt their unhappiness, anxiety and fatigue were almost unbearable
Depressed mothers suffered from a lack of sleep, anxiety, helplessness, fearfulness and physical symptoms. They felt that nobody could help them because everything was falling. This category was supported by eight findings.
- 1. Symptomatology (C)
- 1. “I felt tired all the time, I still do. Exhausted actually. I can’t pull myself out of it. I am so tired most of the time and have great difficulty staying awake... I even bought a book, what's it called, on babies, but I don’t seem to be able to read even a paragraph on some days.”33(p.365)
- 2. Feelings of hopelessness and helplessness (U)
- 2. “I could not see any light in the future. There is no one helping me. I lost hope at that time.”34(p.574)
- 3. Everything is falling down on you and around you (U)
- 3. “And sometimes, I would just break out and cry like I am right now because like every day I am depressed. I mean every day I’m happy but every day I am down and out like nobody could help me. I just wanted to isolate myself from everyone… there's not a day that goes by that I am not feeling depressed. Not a day. Every day is something.”35(p.560)
- 4. Maternal mental health (U)
- 4. “I have mental anxiety and depression. My husband has another wife, they show love for each other, which makes me unhappy.”38(p.5)
- 5. Physical exhaustion (U)
- 5. “You cannot sleep at all at night. Every two or three hours you have to get up to feed the baby. I am exhausted and easily lose my temper because of sleep deficiency.”40(p.307)
- 6. Emotional exhaustion (C)
- 6. “When you have a baby, you have to save a lot of money. But for us, it is such a great burden. When I think about it, I am so worried that I cannot sleep.”40(p.307)
- 7. Unbearable anxiety (U)
- 7. “Insane anxiety, I didn’t sleep a wink that night. It's been like that, in fact, for so many nights. Real anxiety, tossing and turning, I don’t know what to do with myself. And then nightmares the few times I sleep a bit.”43(p.187)
- 8. Overwhelmed and stressed (U)
- 8. “It's like I just can’t get nothing done, and everything just piles up on you. The faster you get something done, the faster something else piles back up on you, you know. Like, God, you know? I probably get way overwhelmed with all this work and pressure… Your work needs your full attention, and your kids need your full attention. You know, you’re just like pulling. It's like one's going one way pulling the other, you know… nerves, aggravation, it all just combines at one time and you just want to go POW. Just explode everywhere.”45(p.82)
Category 1.5: Depressed mothers were horrified with the changes in their body image
Depressed mothers disliked their body after childbirth. They even felt a loss of their former self, and this caused self-disgust. This category was supported by three findings.
- 1. Negative body image (U)
- 1. “I am so worried that I look old and fat. I am concerned about beauty. I also worry about sexual intercourse after the episiotomy, because it may have changed the shape of my vagina. Up to now, I have refused to have sexual intercourse with my husband because I am so worried.”40(p.307)
- 2. Loss of self (U)
- 2. “Oh God... I hate myself. I really, really hate myself. I put on weight, because… and I am always very, very conscious of my body. Always, you looking at yourself in the mirror, and you just don’t like what you see.”41(p.759)
- 3. Loss of former body (U)
- 3. “I discovered myself after birth, um, being there with the child, and I looked awful. I wasn’t prepared at all, think of it, a woman that is slim and fit and working all the time, doing exercise and workouts, and suddenly she is supposed to sit at home with the baby, um… then you rapidly gain weight.”44(p.813)
Synthesized finding 2: The ambivalent feelings depressed mothers experience towards their babies, partners and in-laws cause distress and suffering
Control and pressures from grandparents, a lack of support from their own partner, and the mother-baby relationship cause ambivalent feelings in mothers after childbirth.
This synthesized finding was generated from the aggregation of three categories underpinned by 25 extracted findings (Table 3). Twenty-one findings were rated as unequivocal, and four were rated as credible. One finding was excluded from the meta-aggregation because there was no illustration available (Appendix III). This finding was not counted in the extracted findings.
Category 2.1: Ambivalent feelings towards the baby confused depressed mothers
Depressed mothers felt that the baby was not their own and they were even jealous of their baby, because other people paid too much attention to the baby. Due to their ambivalent feelings, the mothers cared for their baby mechanically. If the pregnancy was unwanted, the mothers were not prepared for the baby, and therefore, even little things bothered them. This category was supported by eight findings.
- 1. I didn’t want any more children (U)
- 1. “I think one of my things is a pregnancy is always good when you want to have it. When it's what you want, and you’ll do anything and everything that's possible to make it work. But if you’re not deep down wanting it, you know, then it's like then every little thing bothers you. It's just me. Everything little thing just bothers me...”32(p.356)
- 2. I wasn’t prepared for this baby (U)
- 2. “[Pregnancy was] kinda heart breaking and how hard it would be and for [her] to actually have to go through the whole process.”32(p.355)
- 3. Mechanical infant caring (U)
- 3. “I remember thinking that's not my baby, actually, I actually said that! … Even after I nursed him, he didn’t feel like mine… I really felt that it wasn’t my child. I didn’t want to be near him.”33(p.366)
- 4. Emotional feelings (U)
- 4. “When he is in bad mood, you can get the idea that he doesn’t like me, that he doesn’t care about me… that I am merely a milk-cow...”37(p.264)
- 5. Father-child relationship (U)
- 5. “… since he is away all day, he takes him in the afternoon, and then I try to stay away and let the two be alone together.”37(p.265)
- 6. Preference for boys (U)
- 6. “Not disappointed. But I feel a little bad. Everybody wants a boy.”38(p.4)
- 7. The baby as a catalyst for guilt, shame and remorse (U)
- 7. “But then it started even more, my guilty conscience about him and her. I felt I couldn’t give enough to both of them.”43(p.183)
- 8. Loss (C)
- 8. “I’m glad that everyone loves him, and it's kind of odd to sit there and just be jealous of your own kid when you now sit in the background, and people forget to say bye to you, but they’ll say bye to the baby and [said with a slight laugh]. I’ve gotten pretty much used to it now, and it really doesn’t faze me when people will do it, but at the beginning, it really rattled my nerves because I’m sitting there thinking, OK you just talk to me every day and come see me to see what I’m doing and now that, you know, the baby's here, then I’m completely different, I don’t exist. Basically, I’m just his mom.”45(p.91)
Category 2.2: Depressed mothers felt disappointed with their partner's support and behavior
Depressed mothers felt isolated due to a lack of partner support and participation in child care and home responsibilities. Unclear interactions with spouses as well as domestic violence burdened mothers. This category was supported by 11 findings.
- 1. I really don’t have any help (U)
- 1. “A down day for me, probably, probably like in these last few days. It's been harder because umm, his dad has been working a lot, a lot of overtime, so I don’t even get his help or when I need him get the baby, or his bottle, or all that.”32(p.358)
- 2. My baby has no father (U)
- 2. “The sadness came around, knowing that the father can just come in and out when he wants to… it wasn’t nothing about being in a relationship ‘cause he has his significant other, I got mines, you know… it's sad ‘cause everyone wants a father like in their life, you know, and he's a boy so he should have a father.”32(p.358)
- 3. Uncaring husband (U)
- 3. “He did not understand the hurt, hard feelings that I was experiencing. He only responded that it was not worth mentioning.”34(p.575)
- 4. Redefine identity (U)
- 4. “… I sometimes miss my work, because you get confirmation there… because you are an independent individual. At home, you are taken for granted.”37(p.263)
- 5. Partner relationship (U)
- 5. “… when I have had difficult times here, I have been sitting thinking that my husband lives a luxurious life, getting to his office, while he, of course, is under enormous pressure at work, as he arrives late at his job and leaves early and has to be able to get the work done and to show up… it is very easy for me to sit here and be bitter… but it is dangerous too.”37(p.265)
- 6. Intimate partner violence (U)
- 6. “He just beats me… ever since this woman [the first wife returned after husband's second marriage] came, he can’t stand the sight of me.”38(p.4)
- 7. Fear for dying during the delivery (C)
- 7. “Who will look after them [children], love them, if my husband marries again?”38(p.5)
- 8. Conflicting feelings regarding the roles of the mother and partner (U)
- 8. “Like when we went to bed at night, on the one hand, I wanted to lie close to my husband because I figured it would be so good to be myself again, without that big belly. And he was so safe and protective, so I wanted him. And on the other hand, I just wanted to have the baby with me in bed. So, this was a huge conflict for me. It was hard to choose between the two.”44(p.813)
- 9. Lack of support from partner (U)
- 9. “I really want him to stay at home, but it is really difficult to ask. I don’t want our friends, or him, to think that I am prudish; rather I want them to think that I give him the freedom he needs.”44(p.814)
- 10. Restrictions (C)
- 10. “I had to be with him. I can’t say no to my husband, it is a sin to deny him.”38(p.6)
- 11. Abandoned and alone (U)
- 11. “Well, he’ll tell me all the time, you know, well, you give ’em a bath, and I’ll stay up with him, so I’ll do everything: get ’em to bed, give him his bath, get him to bed, you know, all that, get ’em to sleep. He [fiancé] goes to sleep, baby wakes up, he doesn’t move, you know, nothing, and so again I’m up with the baby. Oh, I do that, and he just like totally, like I’m not doing it. I kick him, yell in his ear, he’ll look up at me and just roll back over. And me and him talked about it. You know, we had a fight. You know, there was one morning he wanted to go hunting, I don’t know what day it was, and I told him to get out. Because, it was like I was up, I’d had like an hour of sleep, and I was exhausted. I was physically exhausted and mentally exhausted. The baby was up a lot. He had a real bad stuffy nose where he’d lay down, and it was hard for him to breathe, and he’d cry and...”45(p.102)
Category 2.3: Depressed mothers felt that their in-laws and own parents were controlling and causing pressure
Depressed mothers felt that in-laws had too much power over them. Their resistance to that power led to conflicts and even violence between generations. This category was supported by six findings.
- 1. Controlling and powerful in-laws (U)
- 1. “My father-in-law chose a name for the baby, which we [participant and her husband] considered as an awful name. Neither of us liked the name, and we asked if there was a second choice. He said “No, this was the best name and we had to use it”. My mother-in-law and sister-in-law gave us pressure, asked us to follow my father-in-law's wishes. I was very unhappy about it.”34(p.576)
- 2. Living together with in-laws (C)
- 2. “There is always a quarrel in a family when money is needed.”38(p.4)
- 3. Violence in the family (U)
- 3. “I am scared of them [the parents-in-law], they look at me threateningly, and they want to pick issues. When they come home, I stay in my room and don’t go out.”38(p.4)
- 4. Dilemma between traditional and modern practices (U)
- 4. “The ‘doing the month’ practice [a Chinese tradition after childbirth] is not suitable for modern women in China. It is like being in prison for me to be confined at home. I was not allowed to do anything but lie in bed. It was so boring. You know, I was a career woman before the baby was born, but I could not work during that month. I wanted to go back to work as soon as possible.”40(p.307)
- 5. Conflicts with mother-in-law (U)
- 5. “[My mother-in-law] always criticizes me. Nothing that I do is right at all. She hurts me and makes me lose confidence. Before the baby was born, I was a confident career woman, but now I have lost my confidence and feel depressed.”40(p.308)
- 6. Gender preference (U)
- 6. “When I was in the hospital bed after delivery, the woman who was in the bed next to me commented, “It seems that your mother-in-law does not like your daughter”… I knew that she didn’t like that I’d had a baby girl, as she asked me to have another baby. You know, in China, we cannot have a second baby. She is putting a lot of pressure on me. I don’t know what to do; I wish I were dead.”40(p.308)
Synthesized finding 3: Depressed mothers experience anger and despair if they perceive imbalances between their support needs and the support they get from healthcare providers and significant others
An imbalance between support needs and received support caused disappointment towards healthcare professionals, significant others, and the mothers themselves.
This synthesized finding was generated from an aggregation of three categories underpinned by 12 extracted findings (Table 4). Eleven findings were rated as unequivocal and one as credible.
Category 3.1: Depressed mothers felt that health professionals did not understand what they were going through
Depressed mothers felt isolated when they were discharged. They did not receive the support they needed from health professionals. This category was supported by two findings.
- 1. Lack of professional support (U)
- 1. “After you came back from the hospital, you have visitors… you have midwife coming... Oh, that is good! That is a good period, but when everybody stops coming you are on your own… then the door closes, and nobody comes again… Oh God… it feels very bad… So, it's not nice… we need more support. We need more support... Even if it is just once a week people come to your house to see you.”41(p.759)
- 2. I go and talk to my health professionals, and they do not understand (U)
- 2. “I got answers from professionals like, there is nothing wrong with you, go back home stop disturbing us, basically you are wasting our time, and they were horrible. It was a doctor that said that to me, my husband sat with me that day as well. I don’t know if they would have said that if I was white.”46(p.487)
Category 3.2: Depressed mothers felt disappointed with the support they received from significant others
Depressed mothers felt they did not get enough practical or emotional support from their friends or their own family because they were absent when the mothers needed their support. This category was supported by seven findings.
- 1. Feeling alone, betrayed, and abandoned by those that you need to love you (U)
- 1. “The friends that I used to have, I don’t have. So, that is another reason why I am depressed because they say, “Oh! I can’t go out with them or hang out with them no more”, so they are not going to hang with me or call me anymore. I honestly have no friends. And you know, it's a lot of things because people look at me now differently because they see me carrying a baby. And that hurts too because I feel that you shouldn’t look at anybody because you know they have a child. So unfair, you know, and then people always have a thing that, “Oh! She dropped out of school”, and all sorts of stuff. I made high honours… and I’m graduating in June. It's like I tell people that and they don’t even believe me.”35(p.559)
- 2. Support from own family (C)
- 2. “My husband does not do women's work.”38(p.6)
- 3. Lack of practical support (U)
- 3. “Well I have nobody, it's just like you are an island on your own. I have got nobody to help me.”41(p.759)
- 4. Lack of emotional support (U)
- 4. “Even when you are living with somebody, that person doesn’t know you are even going through it. Oh… buying a can of beer or something and give me it… and [saying] “let's drink together”. That's not keeping me company! Or him sitting on his laptop while I am here with the baby, he's not keeping me company ‘cause he is not talking to me...”41(p.759)
- 5. Causes of isolation (U)
- 5. “I don’t talk, if I am hurt, I won’t say it. I haven’t got any friends... So, I keep myself to myself, and then that's it.”41(p.759)
- 6. Conflict with culture and tradition (U)
- 6. “Right after I gave birth… four days later, I went home… when I was home, nobody took care of me, my husband didn’t know how to take care of me. Originally, I wanted myself… to have the Chinese practice… like ginger pork… so I did it myself. I took care of myself… I took care of myself, it's really tough, very hard, so hard that I don’t know how to express.”42(p.357)
- 7. Others will judge me, and I feel like I am on my own (U)
- 7. “The thing is, I have nobody, I feel totally alone, I have no support, and this makes me feel worse.”46(p.487)
Category 3.3: Depressed mothers’ attitudes about good mothering hindered them from receiving support
Depressed mothers’ own inability to request help when they needed it caused despair and disappointment in themselves. This category was supported by three findings.
- 1. A mother's withdrawal from others and loneliness (U)
- 1. “I don’t think any of the other people around me, except for my husband of course, could see how awful I felt. But I gave the impression that things were really great, and I was so happy, and everything was going fine. And that's what they saw when they came to see us, a lovely baby and a nice home.”43(p.184)
- 2. Keeping up the facade (U)
- 2. “Well, I should have calmed down, taken things more easily and then just said that “no, we won’t deal with visitors right now”. But I was also proud and happy and everything, so it wasn’t easy to know what was the right thing to do. But we should have just relaxed and enjoyed ourselves and the new baby, our own little family.”44(p.814)
- 3. Fiercely responsible (U)
- 3. “Whenever you’re off work you know and sometimes I just feel like going into a room and locking myself in there and never coming out, but I don’t because if I give up on my kids, there wouldn’t be anybody to take care of them, you know? I mean, I know my mom would take care of them, but it's not my mom's responsibility to take care of my kids and… I’m not going to leave my kids with my mom cuz I’ve thought plenty of times, you know, my kids would be better off without me, but I wouldn’t want to grow up without a mom.”45(p.118)
Synthesized finding 4: Depressed mothers experience hopelessness and helplessness resulting from new-found motherhood and financial worries
Challenging life situations and financial worries led to hopelessness and helplessness. In these situations, hope was received from the mothers’ close relationships and their own dreams.
This synthesized finding was generated from the aggregation of three categories underpinned by 14 extracted findings (Table 5). Twelve findings were rated as unequivocal, and two as credible. Two findings were excluded from the meta-aggregation because there were no illustrations available, and one finding was excluded because the illustration did not support the finding (Appendix III). These findings were not counted in the extracted findings.
Category 4.1: Financial worries were overwhelming for depressed mothers
Financial worries exacerbated depressed mothers’ burdens. This category was supported by three findings.
- 1. I don’t have money (U)
- 1. “I guess it depends on the level of depression you have cause with me, my depression is, I think, totally different. That's from not working, from not having a car, not having, you know, money just to go out and have a good time, go out to eat, shop... You know, and I’m poor.”32(p.358)
- 2. Economic difficulties (C)
- 2. “Suffer hardships and live hand to mouth.”38(p.4)
- 3. Financial concerns (U)
- 3. “Well, we don’t have much money to spare, and I’d like to have more and give him more than what he has, and I see all these people, all these kids out here with nice clothes and everything. I don’t have the money for all that. And they think they’re high and mighty and everything. It makes me sit down in a corner and just want to cry because they treat me dirty. I’m proud of what I do got for him, and the only thing that really counts is that he's got a roof over his head, and he's got a vehicle to be transferred to the doctor and back, and he's got clothes to put on his back. It doesn’t matter if they’re perfect or anything, it's just that he's got it.”45(p.94)
Category 4.2: Depressed mothers felt they were unable to cope in the face of challenging life situations
Stressful life situations were too much for depressed mothers. The mothers felt that everything and everybody depended on them. In addition, they believed that some friends were jealous of them because they had a husband and a baby. This category was supported by five findings.
- 1. Everybody depends on me (U)
- 1. “I was feeling depressed because I didn’t have nothing else to do but sit around and think about everything that was going on. And plus, everybody depended on me... Everybody was bringing their issues to me - my brother, sisters, and my dad... And I was responsible for my son, my little brother, and sister, who's five - I made sure she had to get to school every day. And then my sister, who is 18, she's not responsible - I had to make sure she got up to go to school... You know, It's like too many responsibilities for me.”32(p.357)
- 2. Navigating the maze (U)
- 2. “Well, just recently my apartment was broken into, and the fact that his Medicaid, for some reason, was cancelled, so a lot of things were happening within the last 2 weeks all at one time. So, that in itself, I don’t want to say almost drove me mad, but it put me in a funk... Like I really was depressed.”32(p.357)
- 3. Is my baby OK? (U)
- 3. “It was hard going every day and having to leave her, it was the anxiousness and the anxiety, when can I take her home, when can I take her home?”32(p.358)
- 4. It is not safe here (U)
- 4. “So, it's like when you live in these types of areas you have to worry about a lot of stuff cause it's got gangs and all types of stuff… A boy wear the wrong colors, he could get shot walking down the street so, it's like you don’t really want to grow your kids around here, but if you have no choice, you know being a low-income family, it's not like a lot of choices where to move.”32(p.358-9)
- 5. Distrust in others (U)
- 5. “Sometimes when you are married, it's not good for you to have single people as a friend ‘cause some of your friends are bad, they can just snatch your husband away… you know out of hatred… they just hate you just like that because you are married.”41(p.760)
Category 4.3: Depressed mothers found hope and support through various personal and social mechanisms
Depressed mothers felt that their own dreams and good relationships with other people could give them hope. This category was supported by six findings.
- 1. Relationship with self (U)
- 1. “For me, when I am down, I just want to do something, go out window shopping or sometimes tidy the house. But the best thing for me is to go out… What I did, I went out, and I got a salary… a shop. I started working, and all of a sudden, it took my mind off it.”41(p.760)
- 2. Relationship with baby (U)
- 2. “There are so many things that she does that just make me you know, forget my sorrows, forget the pains I am going through.”41(p.760)
- 3. Relationship with others (U)
- 3. “Any little problem I had I used to call my friends… [I would] say this is what has happened… then they say ‘ok, it's a normal thing’, it happens to [them], just advice from other parents.”41(p.761)
- 4. Relationship with faith (U)
- 4. “… it was my belief and faith in God cause I kept praying, my church prayed for me at all times and all that… and I believed that I would be well again, it was in my head… so it was… my faith in God.”41(p.761)
- 5. Services as African maternal figure, African community (U)
- 5. “[… when you start going to the group] you know that you are not alone. So many mothers are going through what you are going through. And some are even MORE than yourself… [I think] there should be a gathering for mothers… so you can chat with another mother… it does help.”41(p.761)
- 6. Hopes and dreams (C)
- 6. “That independence, you know, I don’t have that yet. I don’t have my own, you know, independence, where I can say, “OK, kids lets go somewhere. I’m tired of here and let's go.” I can’t deal with it. And I know after I’m able to do that, I think it's going to help a lot.”45(p.120)
Synthesized findings of fathers
Key findings were extracted from the two included studies that considered fathers’ experiences of PPD. A total of 19 findings were extracted and aggregated into six categories. From the six categories, two synthesized findings were developed. The synthesized findings were i) Depressed fathers experience disappointment arising from perceived imbalances between their support needs and the support they get from their partner and significant others, and ii) Depressed fathers are more imbalanced after childbirth than fathers who are not suffering from PPD, so they feel unable to control their own lives due to low resilience.
Synthesized finding 1: Depressed fathers experience disappointment arising from perceived imbalances between their support needs and the support they get from their partner and significant others
An imbalance between support needs and received support caused the fathers to feel disappointed with their partners and significant others.
This synthesized finding was generated from the aggregation of three categories underpinned by eight extracted findings (Table 6). All of them were rated as unequivocal.
Category 1.1: Depressed fathers felt disappointed in how their partner relationship changed after childbirth
Depressed fathers felt their partner did not pay any attention to them. They felt that their partner was not interested in them at all, and their relationship had worsened radically. This category was supported by three findings.
- 1. Excitement thwarted by partner's reticence (U)
- 1. “Our relationship between the two of us has deteriorated quite drastically now. We are actually going to see Relate [the parenting group]… We go to Relate, we’ve been to Relate twice because Esme [the wife] suggested we’d better go to Relate because we were, really we were, our relationship is not touching, not talking, nothing, nothing.”36(p.153-4)
- 2. Relationship deterioration (U)
- 2. “Er, loss of, cos we were very interested, sexually active, before he was born, and now everything has stopped for weeks. I started to get a bit hacked off in a way because she did sort of say right, ok, we could start - we could start loving again [but] she didn’t sort of pick it back up again. Um, it got to the stage where I thought, mmm, even if you asked me, I wouldn’t say yes, I would turn you down, you know, cos I was… you’re not interested in me, so why should I be interested in you, in a way.”36(p.154)
- 3. Changes in the partner relationship (U)
- 3. “The relationship is the hardest… when the relationship becomes difficult and strenuous; you have nothing to fall back on.”39(p.433)
Category 1.2: Depressed fathers were disappointed with the support they received from significant others
Depressed fathers felt they did not get enough support from other people because they did not understand what fathers go through. This category was supported by two findings.
- 1. Where do dads go for help (U)
- 1. “I mentioned [at work] we were going to Relate, and … uh… there tends to be “oh”, and that's it really. You don’t have much of a heart to heart with blokes. Um… but it's been nice in a way just to say something.”36(p.158)
- 2. Turbulent everyday life with parental stress and lack of social support (U)
- 2. “There is no time for anything else than work and taking care of the infant, I feel like a robot with no choices or happiness in life.”39(p.432)
Category 1.3: Depressed fathers felt that their partner was dominating and underestimated their fatherhood
Depressed fathers felt their partner did not trust and value their way of taking care of their baby. This category was supported by three findings.
- 1. Wanting to bring baby up in best way (U)
- 1. “One thing I kept saying to Esme is, “I am an engineer, I can do things precisely. I could build this, this table precisely. I could screw it, but the screw has to go in a particular place, and the top goes on the top, and the legs go in the right directions, so they are a precise science.” So, I wanted to get this… the baby, I tried to organize this baby in precise ways. Getting a baby monitor, the cot goes there, nappies can go there, that, that, that's how I… treated the whole childhood thing, the baby, um, yeh.”36(p.157)
- 2. Apprehension about criticism (U)
- 2. “I enjoy that [taking Alfie to the health visitor]. I enjoy getting involved with it, but… Esme… tends to take over… she seems to feel that she's the mother… that I can’t do it properly.”36(p.157)
- 3. Contradictory messages about equality in parenthood from the society and the partner (U)
- 3. “We have shared [household tasks] even if I have done most of them… then I think… that I also feel that it is still the woman who is the head parent somehow… Fathers should not whine, nor be in the center… they should be happy because they had become fathers and can take parental leave.”39(p.434)
Synthesized finding 2: Depressed fathers are more imbalanced after childbirth than fathers who are not suffering from PPD, so they feel unable to control their own lives due to low resilience
The imbalance fathers feel after childbirth became more aggravated in some leading to feelings of a loss of control and unmet expectations.
This synthesized finding was generated from the aggregation of three categories underpinned by 11 extracted findings (Table 7). All of them were rated as unequivocal.
Category 2.1: Depressed fathers felt they have lost control over their own life
Depressed fathers were disappointed at how everything changed after childbirth, and they could not live the life they were used or expected to. This category was supported by three findings.
- 1. Going to work, wanting to parent (U)
- 1. “Yesterday, I didn’t see him very much because there was… when I went to work, he was in bed, and when I came back he was in bed, and I didn’t see him at all… probably it was an hour yesterday, which I felt wasn’t sufficient connection. So, when I saw him today, I felt “Look, it's Dad! Please, I’m Dad!” You know, “Please recognize me! And don’t forget me!”36(p.158)
- 2. Discrepancy with expectations and reality (U)
- 2. “I had expected a normal delivery and a healthy infant after we had twins in week 23 the last time and just recovered from that experience.”39(p.432)
- 3. Negative life events and sense of loss (U)
- 3. “The main adjustment for us was to suddenly have very little own time, and if you take time, it required something of the other… it intrudes on everything, social life, exercise… suddenly there was no time left.”39(p.433)
Category 2.2: Depressed fathers’ expectations of their role after childbirth differed dramatically from the reality they experienced
Depressed fathers did not identify themselves with their new role. Everything seemed to center around the baby, and the fathers felt they were not involved. This category was supported by five findings.
- 1. The focus shifting from us to him (U)
- 1. “You run around after [the baby], whereas I felt that I… I felt that he could… he would join in with my life or our life. He would be… I always felt that I was in this relationship with the two of us, and he would be an addition to it. Whereas now, I feel that he is, he is the life, and we are running around after him.”36(p.154)
- 2. Feeling left, pushed out (U)
- 2. “And I felt really out of the whole thing... I wasn’t involved in that [the pregnancy]… I couldn’t be because it wasn’t in me… and all I could do was be there for her.”36(p.155)
- 3. Wanting to cherry pick the best bits from own childhood (U)
- 3. “Um, my mother seems to have given me the impression that my job will be later on, when he's older, playing with him, entertaining him, teaching him things, um, but that this stage now, the maternity, the maternal bit is maternal, you know, it's her, and she's… the baby… feeding and all that sort of thing is hers.”36(p.157)
- 4. Life's restrictions on becoming a parent (U)
- 4. “One of the feelings I have been getting is of… I can’t do all the things I want to do. I found it very frustrating... I’ve been on leave for quite a lot recently… I find it very frustrating when I can’t, I can’t get to go and do something I want to do like… like the washing… something simple like that.”36(p.158,159)
- 5. What is expected of men is different to how I feel! (U)
- 5. “But I suppose as a man I think… it's always been a perception that we’re supposed to able to handle it… we’re supposed to be able to get on with it. We’re not supposed to get upset about things. Esme only ever asks me what I am thinking… “Is everything alright?”… If I’m upset and she can see that I am physically upset… I’m… I’m crying. If I’m not crying, she won’t ask. I don’t think she expects me to be upset or possibly even be… want to talk about something.”36(p.158)
Category 2.3: Depressed fathers were insecure about their ability to be a good father
Depressed fathers felt lost in their new role when performing their fatherly duties, which led to self-doubt and uneasiness. This category was supported by three findings.
- 1. Wanting to get things right (U)
- 1. “I am also worried of not getting it right. Uh… do I let him play on the floor with a baby gym with all the things hanging all over the top; he's interested in that. But do I, do I leave him or not? Do… er… is that not interacting with him enough? But then, if I put him in the cot in his springy seat thing, but what am I supposed to say to him? Am I supposed just to play with him? Cuddle him? Am I supposed to? And… and I don’t naturally sort of feel, I don’t know what to do.”36(p.156)
- 2. Worries about being a good enough dad (U)
- 2. “One minute he's over there being fed, then he's being winded, then he's on the floor in the baby gym, then he's up on his spring seat over there, and then he's upstairs in his cot, then he's back… I don’t know, and he doesn’t know, you know, bouncing in the doorway, he doesn’t quite know, I don’t think he quite knows what he's up to, up to, because I’m worried that I’m not going to be good enough, I’m not being good enough.”36(p.156)
- 3. Struggling to find a role (U)
- 3. “Ah, and I’ve being struggling in a way to try and find what… what is my role with this child. Um, is it to do as [Esme] does, feed him, wind him, change his nappies, bathe him, clothe him? Do all those things. Everything.”36(p.157)
The aim of this review was to bring to light the experiences that both mothers and fathers have with PPD within a one-year postpartum period. To ensure the child's well-being, focusing on the parents’ wellbeing is imperative. If a mother or father or both have emotional problems such as PPD, it has consequences for the child's development.47-50 In addition, there are consequences for the couple's relationship and social life.51,52
The majority of included studies focused on mothers’ experiences of PPD. Furthermore, the studies on fathers focused mostly on the father's experiences of the mother's PPD.53-55 There were few studies about depressed fathers’ experiences of their own PPD. Therefore, the data in this review did not describe fathers’ experiences as broadly as mothers’. However, fathers can also suffer from PPD,49 and their experiences are as important as mothers’. Furthermore, it is important to realize that, in some cases, both parents experience PPD at the same time.48,56
The synthesized findings of mothers’ and fathers’ experiences of PPD were presented separately. By dividing the data sets, it was possible to obtain a fairer picture of the fathers’ experiences. Although the data synthesis and results for mothers and fathers were divided, it was justifiable to describe these experiences in the same review. This gave a more comprehensive picture of the topic, particularly because studies indicated that there was a positive correlation between maternal and paternal PPD.48,52 This means that in the same family, both the mother and father can suffer from PPD.
There were some similarities in depressed mothers’ and fathers’ experiences, but how they described these experiences differed. For example, both mothers and fathers felt that they had lost control over their own life, and they did not receive enough support from their significant others. Mothers tended to describe their emotions in more detail than fathers. One reason for this could be that depressed fathers do not admit that they have these kinds of problems after childbirth. In most cultures, fathers are expected to be strong, and their duty is to take care of their families.57 This is probably changing, and today it is more acceptable than before for fathers to experience emotional difficulties and even depression after childbirth.
Depressed mothers’ experiences
“Depressed mothers feel unable to control their own lives due to low resilience” was the first of four synthesized findings. These kinds of feelings can harm the mother, the father and the child or other children of the family. It seemed that with the symptoms of PPD, new mothers felt that they were not able to handle the new situation, and they also felt a loss of their sense of self.26 Childbirth is a time of transition; therefore, it demands the ability to cope with new situations.48 Depressed mothers especially needed support and guidance in this process.58
The second synthesized finding was “the ambivalent feelings depressed mothers experience towards their babies, partners and in-laws cause distress and suffering”. Previous studies have confirmed severe consequences in the mother-child relationship when mothers feel ambivalently about their baby (e.g. bonding to the baby negatively, the mother's wish to be rid of her child).18,21 In this review, these feelings caused distress and suffering to the mothers. Depression, with its core symptoms of a loss of interest and low mood, was likely to disturb the ability of mothers to undertake the tasks of parenting, affecting the day-to-day interactions between the parent and child as well the partner relationship.52
In addition, even a small baby can feel their mother's as well as father's emotions59; therefore, it is crucial to create the conditions for secure attachment between the parents and the child and to strengthen the parents’ resilience when attachment fails.58 According to Enns et al.,60 by supporting parenting resilience, parental wellbeing and the quality of the parent-child relationship, it is possible to improve child developmental outcomes, such as communication skills.
The third synthesized finding described how “depressed mothers experience anger and despair if they perceive imbalances between their support needs and the support they get from healthcare providers and significant others”. Depressed mothers benefit from supportive counselling sessions, and they must be referred to further treatment if needed.58,61 However, the mothers’ own attitude about good mothering often prevented them from receiving support. For depressed mothers, seeking help is difficult due to their emotional situation.62-65 Tobin et al.28 and Schmied et al.27 found that mothers did not receive enough help, especially if they did not have family in their new country. In addition, Schmied et al.27 described how, in many cultures, it is not acceptable to seek help for mental health problems.
“Depressed mothers experience hopelessness and helplessness resulting from their new-found motherhood and financial worries” was the fourth synthesized finding. Motherhood was not like they expected; it was more challenging, and mothers felt that they were almost unable to cope with the new life situation. In addition, mothers felt that financial worries were overwhelming. Wszolek et al.15 also found in their study that financial situations had a significant impact on mothers’ emotional states after giving birth.
Depressed fathers’ experiences
“Depressed fathers experience disappointment arising from perceived imbalances between their support needs and the support they get from their partner and significant others” was the first of two synthesized findings of fathers’ experiences. These experiences were quite similar when compared with the mothers’, although it seems that fathers had an even more difficult time asking for help and support than mothers. In their review, Darwin et al.66 found that while fathers experienced perinatal distress, they found it difficult to accept their own experiences as they prioritized their partner's needs. This may be one reason why fathers have difficulties in asking for support from professionals or significant others.
The second synthesized finding was “depressed fathers are more imbalanced after childbirth than fathers who are not suffering from PPD, so they feel unable to control their own lives due to low resilience”. Mothers also had the same experience, but fathers did not describe these feelings in as much detail as mothers.
Strengths and limitations
The strength of this systematic review was that it included 13 studies describing mothers’ experiences. Although there were only two studies that described fathers’ experiences, the data were rich in these studies. A limitation of the review is that while every attempt was made to include all relevant studies, it is possible that some were missed. Further, only English, Swedish and Finnish studies were considered.
Qualitative studies concerning new parents’ experiences of PPD have focused on the mother's perspective, and studies of the father's perspective, especially the father's own experiences of PPD, are scarce. Because PPD has a great influence on the mother's, father's and the child's well-being, it is important to understand what new parents undergo after childbirth. Both mothers and fathers do not receive enough support from their significant others. In addition, mothers want more support from health professionals.
Recommendations for practice
Based on synthesized findings of this review, we have developed the following recommendations for practice. The recommendations have been graded according to the JBI grades of recommendations.67
- i) There is a need to prevent, identify and recognize symptoms of PPD as early as possible among new parents because depressed mothers (Grade B) and fathers (Grade A) feel that they are unable to control their lives.
- ii) Healthcare professionals should evaluate the support needs of depressed mothers (Grade B) and fathers (Grade A) due to an imbalance between the parents’ needed support and received support.
Recommendations for research
Future research should focus on the experiences of both new mothers and fathers. In particular, there is a need for studies from the father's point of view. In addition, more research on the protective and supporting factors of family members’ well-being is needed.
The authors would like to acknowledge Informatic Pia Pörtfors at National Institute for Health and Welfare and Information specialist Katri Larmo at Helsinki University Library, Terkko Health Hub Medical Library. Pia Pörtfors assisted with the initial search stage and Katri Larmo with the final search stage.
Appendix I: Search strategy
MEDLINE, search conducted February 7, 2017 and updated May 18, 2018
CINAHL, search conducted February 7, 2017 and updated May 18, 2018
PsycINFO, search conducted February 7, 2017 and updated May 18, 2018
Scopus, search conducted February 13, 2017 and updated May 18, 2018
MEDIC, search conducted February 14, 2017 and updated May 18, 2018
ProQuest Dissertations and Theses Database
all(mother∗ OR father∗ OR spouse OR parent∗ OR maternal OR paternal)
all(postpart∗ OR postnatal AND depres∗)
Appendix II: Studies ineligible following full text review
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- 1. Reason for exclusion: Time from delivery over two years.
- 2. Beck CT. Teetering on the edge: a substantive theory of postpartum depression. Nursing Research 1993; 42(1):42-48.
- 2. Reason for exclusion: Time from delivery over two years.
- 3. Berggren-Clive K. Out of the darkness and into the light: women's experiences with depression after childbirth. Canadian Journal of Community Mental Health 1998; 17(1):103-120.
- 3. Reason for exclusion: Time from delivery was not mentioned; the study describes experiences of recovery from postpartum depression.
- 4. Bilszta J, Ericksen J, Buist A, Milgrom J. Women's experience of postnatal depression – beliefs and attitudes as barriers to care. Australian Journal of Advanced Nursing 2010; 27(3):44-54.
- 4. Reason for exclusion: Time from delivery was not mentioned.
- 5. Chan SW, Levy V. Postnatal depression: a qualitative study of the experiences of a group of Hong Kong Chinese women. Journal of Clinical Nursing 2004; 13(1):120-123.
- 5. Reason for exclusion: Time from delivery was not mentioned.
- 6. Dennis TR, Moloney MF. Surviving postpartum depression and choosing to be a mother. Southern Online Journal of Nursing Research 2009; 9(4):8p.
- 6. Reason for exclusion: Time from delivery over two years.
- 7. Hall P. Mothers’ experiences of postnatal depression: an interpretative phenomenological analysis. Community Practitioner 2006; 79(8): 256-260.
- 7. Reason for exclusion: Time from delivery was not mentioned.
- 8. Hannan J. Older mothers’ experiences of postnatal depression. British Journal of Midwifery 2016; 24(1): 28-36.
- 8. Reason for exclusion: Time from delivery over two years.
- 9. Lauer-Williams J. Postpartum depression: a phenomenological exploration of the woman's experience. US: ProQuest Information & Learning 2001.
- 9. Reason for exclusion: Time from delivery over two years.
- 10. Lawler D, Sinclair M. Grieving for my former self: a phenomenological hermeneutical study of women's lived experience of postnatal depression. Evidence Based Midwifery 2003; 1(2):36-41.
- 10. Reason for exclusion: Time from delivery was not mentioned.
- 11. McClain S, Torres MIM, Duron J, Davidson M. Latina immigrants’ cultural beliefs about postpartum depression. Journal of Women and Social Work 2018; 33(2): 208-220.
- 11. Reason for exclusion: Time from delivery over one year; included mothers without post-partum depression.
- 12. Morrow M, Smith JE, Lai Y, Jaswal S. Shifting landscapes: immigrant women and postpartum depression. Health Care for Women International 2008; 29(6): 593-617.
- 12. Reason for exclusion: Women's experiences of post-partum depression were not presented independently. Therefore, experiences of post-partum depression were not clear from the findings of this study.
- 13. Nahas V, Hillege S, Amasheh N. Postpartum depression: the lived experiences of middle eastern migrant women in Australia. Journal of Nurse-Midwifery 1999; 44(1): 65-74.
- 13. Reason for exclusion: Time from delivery was not mentioned.
- 14. Regev M. The experience of postpartum depression: a grounded theory study. US: ProQuest Information & Learning;2003.
- 14. Reason for exclusion: Time from delivery over two years.
- 15. Stone M, Kokanovic R. “Halfway towards recovery”: Rehabilitation the relational self in narratives of postnatal depression. Social Science & Medicine 2016; 163: 98-106.
- 15. Reason for exclusion: Time from delivery over one year.
- 16. Templeton L, Velleman R, Persaud A, Milner P. The experiences of postnatal depression in women from black and minority ethnic communities in Wiltshire, UK. Ethnicity & Health 2012; 8(3), 207-221.
- 16. Reason for exclusion: Focus was on the women's and the primary healthcare professional's experiences. Results described issues specific to pregnancy and birth, specific to primary health care, issues relating to culture and other issues.
- 17. Williamson V, McCutcheon H. Postnatal blues. Singapore Nursing Journal 2002; 29(2), 32-36.
- 17. Reason for exclusion: This paper was not available.
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