Postpartum Depression among Chinese American Women
Postpartum depression (PPD), which is defined as the onset of an affective mood disorder within the first 12 months after childbirth, continues to be among the top morbidities affecting childbearing women. Postpartum depression affects one in seven women in the United States (American College of Obstetricians & Gynecologists, 2015; Association of Women's Health, Obstetric and Neonatal Nurses, 2015; Wisner et al., 2013) with increased rates noted in diverse racial/ethnic groups, including Asian American women (Cheng & Pickler, 2009; Goyal, Park, & McNiesh, 2015; Goyal, Wang, Shen, Wong, & Palaniappan, 2012; Ta Park, Goyal, Nguyen, Lien, & Rosidi, 2017). When left untreated, PPD can disrupt the maternal–infant bond that can lead to poor infant cognitive and language development (Kingston, McDonald, Austin, & Tough, 2015), behavioral difficulties in elementary school, and poor high school performance (Netsi et al., 2018). Maternal consequences of unidentified PPD include suicidal ideation, infanticide, and poor maternal adjustment (Kendig et al., 2017; Sit et al., 2015).
Compared with other racial/ethnic groups, Asian Americans are less likely to report PPD symptoms, be clinically diagnosed with PPD, and use mental health services (Goyal et al., 2012). Hallmarks of the Asian American culture include a strong sense of familial hierarchy and honoring the family name, which may contribute to lower use of mental health services. Negative public perception and stigma that may accompany psychiatric treatment further contribute to the nondisclosure of depressive symptoms and lower rates of mental health help-seeking behavior (Fancher, Ton, Le Meyer, Ho, & Paterniti, 2010). The deep-rooted cultural values also present barriers for women seeking help for postpartum depressive symptoms. Asian Americans prefer to use social support networks, familial ties, indigenous healers, religious and spiritual outlets to ward against any psychological or somatic symptoms (Inman & Yeh, 2007), rather than seek professional treatment.
Chinese Americans represent the largest Asian American group (United States Census Bureau, 2017a). Chinese cultural traditions during the postpartum period include “Doing the Month” or “Sitting-the-Month,” a period of confining mothers to stay home for postpartum recovery and restoring balance and harmony between the “yin” and “yang” (Liu, Petrini, & Maloni, 2015). The month of maternal confinement consists of dietary and behavioral changes aimed at restoring the body's equilibrium after giving birth. For example, during the postpartum period, the body is thought to be in a cold state; therefore, the new mother is encouraged to consume “hot” foods and beverages. Although postpartum traditions are thought to prevent illnesses from occurring later in life and promote physical and mental health well-being, findings from Liu, Maloni, and Petrini (2014) challenge these assumptions suggesting doing the month can decrease general health and increase in depressive symptoms.
Although research findings suggest that there are adverse effects of untreated PPD, Asian Americans are less likely to report PPD symptoms (compared with other racial/ethnic populations). Given the growing Asian American population (United States Census Bureau, 2017a, 2017b), healthcare providers need to have an in-depth understanding of PPD perception and mental health help-seeking behaviors in culturally diverse populations. The objective of this study was to explore the perspectives and experiences of PPD and help-seeking among Chinese American women.
This qualitative study includes descriptive survey data, which were used to provide additional context about the mental health help-seeking behaviors of the participants. Chinese American women living in Northern California who were ≥18 years old, were able to read, write, and speak English or Mandarin Chinese, and had given birth to a live infant within the past year were eligible to participate. Convenience and snowball sampling were used to recruit participants via flyers, referrals from community partners, and word of mouth. Women meeting the inclusion criteria were interviewed in-person.
Demographic survey. Participants were asked to provide their age, number of years lived in the United States, nativity, marital status, employment status, and highest level of education. Women gave information about any other children at home, age and gender of the most recent infant, type of birth (vaginal or cesarean), and history of lifetime depression.
Mental health help-seeking behaviors. Participants completed the mental health services questionnaire, which was developed and used for other studies with Vietnamese Americans and Native Hawaiians (Ta Park et al., 2017; Ta Park, Kaholokula, Chao, & Antonio, 2018). The questionnaire assesses past year and lifetime use and satisfaction of mental health services. Participants were asked about the type of mental health service received and indicated their satisfaction with services on a 5-point scale (dissatisfied = 0 to very satisfied = 4).
Depressive symptoms. The well-validated 10-item Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden, & Sagovsky, 1987) was used to assess frequency of depressive symptoms over the past week. Rated on a 4-point scale (0-3), scores range from 0 to 30. An EPDS score of ≥10 indicates a risk of PPD (Wisner et al., 2001); however, this study used the suggested score of ≥9 for Chinese women (Lau, Wang, Yin, Chan, & Guo, 2010). Satisfactory reliability and validity among mainland Chinese, Hong Kong (Lau et al.; Lee et al., 1998), and Taiwanese women (Heh, 2001) have been established.
Interview guide. Interview questions (see Table 1 Supplemental Digital Content, http://links.lww.com/MCN/A49) were developed using the Behavioral Model and Access to Medical Care (Aday & Andersen, 1974) that explores factors that influence a person's decision to seek mental health services treatment. Aday and Andersen's model has been used to examine use of mental health services in Asian Americans (Jang, Chiriboga, & Okazaki, 2009; Ta, Juon, Gielen, Steinwachs, & Duggan, 2008) and depression as a predictor of healthcare use (Hamilton et al., 2016). Participants were asked to describe how PPD is viewed in the Chinese culture, postpartum traditions, mental health help-seeking attitudes and behaviors. Examples: “What would you do if you felt sad/depressed? Would you seek help?”
The research team included three trained female interviewers, the primary investigator, and two nursing students, including a Chinese bilingual/bicultural person. Participants completed demographic information, the health services questionnaire, and the EPDS. Audio-recorded interviews were conducted in participants' homes (73%) or in quiet areas of coffee shops based on the participant's place of choosing. One interview was conducted in Mandarin and the remaining in English. All participants received a $25 gift card for their time and a list of local mental health resources.
Participant characteristics and questionnaire data were analyzed using descriptive statistics including frequencies, means, and other measures of central tendency. Interview data were transcribed verbatim and analyzed using content analysis. The principal investigator created a coding dictionary based on the questions a priori. Then two raters independently used the coding dictionary as a guide to analyze the qualitative data. Discrepancies in coding were reviewed and resolved by group consensus and the research team discussed and derived emergent themes and subthemes from coded data. During data analysis, checks for trustworthiness included transferability and dependability. Transferability demonstrates the research findings are applicable to other contexts including similar populations (Shenton, 2004). The researchers used similar methods in other studies with Asian Indian and Vietnamese women (Goyal et al., 2015; Ta Park et al., 2017).
Participant characteristics. Fifteen married Chinese women aged 33.2 (SD = 3.1) years participated (Table 2). All had lived in the United States for 2 to 35 years (mean = 15.1, SD = 12.2), with most being foreign-born. Seven were stay-at-home mothers and eight educated at the graduate level. Twelve had a vaginal birth, nine gave birth to female infants, and nine were exclusively breastfeeding. The mean number of months postpartum at the time of their participation was 8.5 (SD = 4.5).
Lifetime mental health use. Eight reported ever receiving any mental health help, and among these, three used an in-person self-help group, and two received at least one psychological counseling session that lasted ≥30 minutes. Two women had been prescribed antidepressants. Most were “satisfied” with their experience across various types of professionals.
Depressive symptoms. Total EPDS scores ranged from 0 to 11 with two women reporting a previous history of depression. Three of the participants scored ≥9 on the EPDS, indicating risk for developing PPD.
Qualitative findings. There were two main themes: 1) Culture-specific postpartum traditions; and 2) Help-seeking for mental health issues.
Cultural specific postpartum traditions. Subthemes included: 1) Chinese cultural identity; 2) practice of postpartum traditions; 3) significance of infant gender; and 4) perceptions of sadness or depression after giving birth.
Chinese cultural identity. The majority of women reported a strong Chinese identity and/or they practice Chinese customs. Three reported that Chinese traditions and way of thinking have been instilled in them from their parents, and a third said they practice Chinese customs. Nine said they cooked and ate Chinese foods and eight taught their children to speak Chinese. Two said they read Chinese books and kept up with Chinese current events. Six reported that they identified as both Chinese and American. One participant said, “I still have - keep my old traditional things, Chinese culture, but I'm more open to American culture, too.”
Significance of infant gender. Six women reported that the Chinese culture places a higher value in having a son versus a daughter, and two acknowledged that sons were treated differently and received preferential treatment than the daughters. Conversely, three women stated the preference for boys was an old time versus modern time way of thinking. One participant said, Modern society's really not that much anymore, like people — “I have to have a boy to carry my family name,” stuff like that. Not really. It's kind of like more — the thoughts more open and more — I think there's — in like undeveloped area in China, people all like poor area or rural area. So, they have more land and they want a boy to help manpower in the family, most time, too.
Practice of postpartum traditions. Ten women stated they practiced the 30-day period, Doing the month, and not bathing or washing their hair. New mothers are encouraged to stay indoors, rest, and not do any household chores and the maternal grandmother moves into the home and assists with household chores and caring for the infant so the new mother can rest and recuperate. New mothers are encouraged to eat food and drink fluids (e.g., chicken, pig's feet, soups, dates, ginseng, and herbal tea) that aid in healing and restoring the body's balance. Pig's feet are thought to stimulate breast milk production and red blood cell production (Lynch, 2017). Herbal tea helps to cleanse the body after the birth (Lynch). One participant said, You have to stay at home for a month... she (mom) didn't want me open the window because the wind would blow in. Going to have a headache and trouble with the abdominal area exposed. You can't expose yourself to any open area — to anything. You can't have anything cold... need something to help your body to restore the energy and to recover. A lot of traditional food or like herbs stuff that you use.
Although some stated a strong personal belief in the practice of Chinese postpartum traditions, they found it difficult for example, to not bathe for a month after the birth. Some women who were not fully wedded to the traditions, still practiced traditions out of respect for their elders because there was no perceived harm in doing so. Some women felt that complying with the traditions helped them recover and heal, where others stated it was no longer necessary to practice Chinese postpartum traditions in these modern times. One participant said, I think that's 30 or 40 years ago in China and people are very poor and do not have the air condition, do not have the heater. So they say it is very easy to get sick or get a cold if you go to take shower or cause the one thing is true is that after you give birth to baby, you feel very weak.
Perceptions of sadness/depression after giving birth. Women stated several reasons that related to the development of depression. Half thought depression was caused by having your life change when you become a new parent, lack of social support, and hormonal changes. One thought depression was due to the inability to breastfeed. Some said that depression is a sign of weakness, caused by another illness, and is all in the head or self-inflicted.
A few women believed depression did not exist in the Chinese culture, as another participant stated, No, I don't think there's such thing as postpartum depression in Chinese culture, as far as I know. People definitely don't talk about it because I don't hear about it. So, if Chinese women do get postpartum depression, I don't feel like there's a lot of resources for them, or a lot of help.
Although mental illness, including depression, is stigmatized in Asian cultures such as the Chinese culture (Augsberger, Yeung, Dougher, & Hahm, 2015; Chen et al., 2016; Wang & Liu, 2016), some women thought their mothers would listen to them if they expressed sadness/depression and be supportive if they wanted to seek mental health treatment.
Help-seeking for mental health issues. This theme included two subthemes: 1) Help-seeking behaviors; and 2) Barriers to mental health help-seeking.
Help-seeking behaviors. Twelve women said they would first disclose any depressive symptoms to their spouses and could rely on them for support. Nine women were willing to seek professional help or help from other family and friends, if needed. If they were feeling sad or depressed, one said they would sit and cry and two others said they would preoccupy themselves with activities such as going to the library to read or exercising. One participant said, “I try and go out on walks once a day. I do try and talk with friends. I try and keep connections with friends, because being with friends helps me get to hear about them and helps me not feel so alone in my depression.”
Barriers to mental health help-seeking. Half of the women perceived depression as a private matter due to cultural reasons, as one participant stated, They don't really want to tell other people, “I have a mental issue.” This is a culture thing. Other barriers included costs, lack of, or being unaware of services, stigma, and language or culture barriers (i.e., Western doctors do not understand Chinese culture) (20%). Another participant said, They did tell me a little more later (about PPD), but it was like I had to kind of ask and poke around. Some suggested that PPD education be provided early on during prenatal care as many had limited understanding of PPD.
Clinical Nursing Implications
This study describes the perceptions and experiences of PPD and help-seeking of Chinese American women. Based on EPDS scores, three women were experiencing elevated depressive symptoms, which is similar to another study's finding where 37 out of 151 Chinese women in the United States scored in the high depressive symptom range (Cheng, Walker, & Chu, 2013). Almost all were foreign-born, reported having a strong identity to the Chinese culture, and observed Chinese postpartum traditions. Nine women reported sadness or PPD symptoms, either by scoring above the cutoff of the EPDS for risk of PPD or disclosing such information during the interview. Despite PPD being prevalent among women in the general population, three women did not believe depression was applicable to Chinese, and many have not heard about PPD. Importantly, six participants indicated that even if they had experienced depression or its symptoms, they would deny they had depression and view that having depression was a sign of weakness.
Most etiology and triggers for depression symptoms perceived by Chinese American women in the sample were consistent with that shared by women of the general population (e.g., stress related to becoming a new parent, lack of social support, hormonal changes, breastfeeding difficulties, and other life events/illnesses) (Cheng & Pickler, 2009; Ngai & Chan, 2012; Xie et al., 2010). Although there was not a direct association, as perceived by participants, between PPD symptoms experienced and specific Chinese cultural values and specific Chinese postpartum traditions, the findings offer some insights into understanding risk factors that may underlie the high prevalence of PPD observed or increase the vulnerability of postpartum Chinese American women to PPD. All participants were aware of some Chinese postpartum traditions, and though some indicated seeing no harm of observing them, many indicated partaking the practices out of respect of the elder family members. Particularly among women who might not have the sufficient resources and support to partake and fulfill some of those traditions, it is worth exploring whether or not the failure of partaking any of the traditions might have had a negative impact on family harmony or perceived self-worth, and whether or not these might exacerbate some of the reported PPD triggers as lacking social support and self-inflictions. Participants discussed the close involvement of their family who provided practical support of child caring or cooking. It is unclear whether such increased practical support (and change in roles and expectations) from their family during the postpartum period would increase the frequency of family conflicts or disharmony or perceived stress that could trigger PPD symptoms.
Healthcare professionals working with diverse populations must be aware of culture-specific childbearing traditions to provide culturally competent care and promote optimal maternal–infant well-being outcomes. Findings from this study may be used to provide vital information to those working with Chinese American families and develop culturally appropriate outreach programs to increase use of mental health services for Chinese American women, particularly at risk for developing PPD.
The authors would like to thank the Chinese mothers who participated in this study. This research was supported by a Research, Scholarship, and Creative Activities (RSCA) Grant at San José State University.
SUGGESTED CLINICAL NURSING IMPLICATIONS
- Chinese American women may not believe that depression applies to them, may not have heard about PPD or think that it exists, and may view depression as a sign of weakness.
- Chinese American women may prefer to seek help through their families and social networks versus professional help.
- Awareness of Chinese American childbearing traditions may aid in the delivery of culturally competent care and promote optimal maternal–infant well-being outcomes.
- Nurses caring for Chinese American women may identify PPD risk both by asking if they have experiences with sadness or depression as well as through conventional PPD screening methods (e.g., EPDS).
- Culturally appropriate outreach and education programs may be developed to increase the knowledge and understanding about PPD and awareness about available mental health care for Chinese American women particularly at risk for developing PPD.
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