Midwifery 31 (2015) 728–734
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Causes of women's postpartum depression symptoms: Men's and women's perceptions Catherine Habel, CPNP, MSc, MSc(A) (Candidate to the profession of nursing practice)a,n, Nancy Feeley, RN, PhD (Registered nurse, associate professor, senior investigator)a,b, Barbara Hayton, MD (Director of the Perinatal Mental Health Service)c, Linda Bell, RN, PhD (Registered nurse)d, Phyllis Zelkowitz, EdD (Senior investigator, director of research)e,f a
Ingram School of Nursing, McGill University, Montreal, QC, Canada Center for Nursing Research & Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada Perinatal Mental Health Service, Jewish General Hospital, Montreal, QC, Canada d Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada e Lady Davis Institute & Department of Psychiatry, Jewish General Hospital, Montreal, QC, Canada f Department of Psychiatry, McGill University, Montreal, QC, Canada b c
art ic l e i nf o
a b s t r a c t
Article history: Received 13 November 2014 Received in revised form 27 February 2015 Accepted 20 March 2015
Objectives: To describe men’s and women’s perceptions of the causes of women’s PPD symptoms and to explore similarities and differences between men’s and women’s perceptions. Design: Qualitative-descriptive study involving in-depth semi-structured individual interviews and content analysis. Setting: In-home interviews of participants recruited in two tertiary care hospitals, both in urban centres of the province of Quebec, Canada. Participants: Both members of 30 heterosexual couples from which women scored at least 12 on the Edinburgh Postnatal Depression Scale. Findings: Participants described nine causes underlying women’s depressive symptoms: societal expectations and pressure on women, physical health problems, transition to parenthood, social connectedness, personality and past psychological history, child health and temperament challenges, unmet care needs, unmet expectations for childbirth, and other life stressors. With one exception, all causes were endorsed by both men and women. Only men mentioned societal pressure on women. Key conclusions and implications for practice: Men and women mainly perceived similar causes, which could be explained by socio-cultural factors and extended paternal leaves. Understanding men’s and women’s perceptions could help tailoring health- care professionals’ interventions to couples’ needs. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Postpartum depression Perceptions Causes Men Women Gender
Introduction Postpartum depression Although the transition to motherhood is usually seen as a positive experience in women's lives, it is also a time of physical, psychological and social adaptation that may leave women in a state of increased vulnerability (Miller, 2002; Wisner, 2006). Postpartum depression (PPD) is a relatively common mental disorder that is estimated to affect 13–19% of women in the first n
Corresponding author. E-mail addresses: [email protected] (C. Habel), [email protected] (N. Feeley), [email protected] (B. Hayton), [email protected] (L. Bell), [email protected] (P. Zelkowitz). http://dx.doi.org/10.1016/j.midw.2015.03.007 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
year following childbirth (O'Hara and McCabe, 2013). As per the current versions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorder (DSM-V) and the International Classification of Mental and Behavioral Disorders (ICD-10), PPD has symptoms, developments and outcomes that are similar to those encountered in non-postpartum-related depressive disorders (World Health Organization, 1992; American Psychiatric Association, 2013). Some of the most commonly reported symptoms include recurrent and impairing feelings of dysphoria, tearfulness, hopelessness, anxiety, guilt and fatigue (Robertson et al., 2004). While limited to the first year following childbirth, PPD can have long-term implications for women and their family members. Women suffering from PPD are known to be at higher risk for subsequent depressive episodes (Robertson et al., 2004). PPD can
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negatively affect the mother–child relationship (Poobalan et al., 2007; Darcy et al., 2011) and is associated with an increased frequency of cognitive development delays and attachment insecurity (Hipwell et al., 2000), as well as poorer social engagement, in children of women who have suffered from PPD (Feldman et al., 2009). PPD also affects women's partners. Partners experience a range of negative emotions such as self-doubt, helplessness, anger and fear due to concern and to a perceived inability to help their partner as well as relationship uncertainty (Meighan et al., 1999; Letourneau et al., 2011). Partners of women suffering of PPD have an increased risk of experiencing psychological disturbances (Goodman, 2004, 2008; Roberts et al., 2006). A recent metaanalysis showed that about 10% of fathers experience depressive symptoms and that they are moderately and positively correlated with maternal depressive symptoms (Paulson and Bazemore, 2010). Perceptions of the causes of PPD symptoms Despite the efficacy of treatments available for PPD, numerous studies find that women with depressive symptoms are reluctant to seek help and decline a referral for mental healthcare (Callister et al., 2011). A major reason for the poor uptake of healthcare is a lack of fit between the women's perceptions of their needs and the care offered (McIntosh, 1993; O'Mahen et al., 2009). How women and their partners understand women's symptoms may shape their help-seeking behaviour and preferences for care. This knowledge might be an important step in the development of services and intervention programs for PPD that would be more acceptable to women and their partners (Dennis and Chung-Lee, 2006). There has however been little systematic study of women's understanding of what caused their symptoms. Although many of the causes perceived by women seem to be endorsed worldwide, some are only mentioned in some settings, indicating that women's perceptions are to some extent shaped by cultural influences (Oates et al., 2004). Caribbean women believed that a pile-up of multiple psychosocial stressors or hormonal problems lead to the development of their symptoms (Edge et al., 2004; Edge and Rogers, 2005). Indian women attributed their symptoms to social adversity, poor marital relationships and gender preferences (Rodrigues et al., 2003). Patel and colleagues (Patel et al., 2013) found that British women held a number of different beliefs about their symptoms. Some women attributed symptoms to incongruence between their actual postpartum experience and their idealised expectations. Others considered that a current or previous psychosocial stressor such as a difficult pregnancy or childbirth, relationship problems, financial worries, lack of support, or a change in lifestyle lead to their symptoms. Yet other women considered their symptoms to be due to their personality and blamed themselves for their depressive state. Biomedical factors, such as genetics or hormones, were another category of possible causes for symptoms. To our knowledge, a single previous study has investigated what women's partners perceive as having caused women's symptoms, and compared men's and women's perceptions. Everingham and colleagues (Everingham et al., 2006) found that the perceptions of men and women differed. Women were anxious about being a “good mother” and preoccupied with how others viewed their mothering abilities. They believed their symptoms were the result of their feelings of inadequacy as a mother. In contrast, their partners attributed symptoms to women's previous history of mental health problems, personality characteristics, or postpartum physical health problems. This study included a small homogenous group of older, well-educated, first-time Australian parents. It is unknown if it achieved saturation. The particular
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characteristics of this group of older first-time mothers may have shaped their perceptions of the cause of their symptoms. Further exploration of women's and their partners' perceptions is clearly warranted. Thus, the current study examined two questions: ‘What are men's and women's perceptions of the causes of women's PPD symptoms?’ and ‘What are the similarities and the differences between men's and women's perceptions?’
Methods Design A primary qualitative descriptive study was undertaken to examine women's and men's preferences for care to manage the women's symptoms (Feeley et al., 2015). The need for the current study emerged as the first interviews from the primary study were analysed. When describing their experience and preferences for care during semi-structured interviews, all participants spontaneously described what they thought caused the women' symptoms. Thus for remaining subsequent interviews, the guide for the primary study was modified to include specific questions to elicit participants' perceptions of the causes of the woman's symptoms. For example, “What does your partner think about your symptoms? ‘What does he think would help?’ or ‘What do you think is the cause of your [or your partner's] symptoms?’ were some of the questions asked. The same team of researchers conducted this secondary analysis to describe men's and women's perceptions of what causes the women's symptoms. The purposive sample consisted of 30 heterosexual couples and included two groups: women with symptoms of depression who accepted a referral for a mental health assessment and their partners, and those who chose not to accept a referral. Couples were included if: (1) both partners agreed to participate and to be audio-taped during the interviews; (2) the women had given birth in the 12 months that preceded the interview; (3) they were able to communicate in English or French; and (4) the women had a score of 12 or more on the Edinburgh Postnatal Depression Scale (EPDS) at the time of enrolment. The EPDS is a validated measure of depressive symptoms in the perinatal period (Cox et al., 1987; Hewitt et al., 2009). In this 10-item self-report questionnaire, respondents report their feelings over the past seven days on 4-point scales. A cut-off point of 12 is used to indicate depression. Enrolment, setting and data collection Participants were recruited at two tertiary care hospitals, both in urban centres of the same Canadian province during a routine visit to the obstetrics clinic. Others were recruited at the same study sites from among the participants of a longitudinal study of women's mental health in the postpartum period. The study received approval from the institutional research ethics boards at both centres before initiation. In this province, mothers are entitled to a maximum of 18 weeks of paid maternal leave whereas fathers are entitled to a maximum of five weeks. In addition, both parents can share a maximum of 25 supplemental weeks of paid leave (Gouvernement du Québec, 2015). In these centres, women who obtained a score of 12 or above on the EPDS were offered a mental health referral and asked if they would be interested in learning about the study. If they agreed, research staff explained that the study's purpose was to understand men's and women's PPD experience and preference for care to manage symptoms. If the woman provided verbal consent, they were asked to provide contact information for their partner, and staff contacted the partners directly to explain the study and to obtain verbal consent. Of those approached, 62%
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agreed to participate and be interviewed. Written informed consent was obtained at the time of the interviews. Interviews were conducted between March 2012 and May 2013. Face-to face in-depth semi-structured interviews of 45 to 90 minutes were conducted in participants' homes at a time set by participants. The interviews were conducted by the first author or by master's-prepared professional research assistants trained in interviewing. Women and their partners were interviewed separately but simultaneously in a private setting. This approach allowed each to freely express their views. Interviews were conducted by a person of the same gender as the participant. Interviews were transcribed verbatim from the audiotapes. Participants were given a 20$ gift certificate as compensation for their time. Analysis Content analysis was used to analyze the data (Berg and Lune, 2004; Elo and Kyngas, 2008). In short, interviews were transcribed and read to achieve a better understanding of the content. The transcripts were perused for quotes relevant to the study questions. This open-coding step was followed by axial-coding. Codes were condensed into categories of perceived causes. Peer debriefing was used to discuss the coding, and discussions amongst team members continued until consensus was reached. Data saturation was reached in that no new categories of causes emerged after 24 couples had been interviewed. The categories endorsed by each participant were entered into data matrices and these matrices were used to compare women's and men's perceptions. Representative quotes are included in this report to allow readers to assess the transferability of findings. Transferability was also addressed by collecting data about and reporting the sociodemographic characteristics of the participants (Chiovitti and Piran, 2003). An audit trail was kept to make all decision-making processes amenable to external evaluation and to increase the confirmability and dependability of the findings (Carnevale, 2002).
Table 1 Participants' characteristics. Women Age EPDS score at recruitment EPDS score at interview Average number of children First child† Canadian-born Language at home† English French Other Education University degree or certificate College (general or technical) Secondary (general or technical) Accepted mental health referral History of mental illness
%
Men
%
32.5 (5.6) 14.8 (2.7) 9.6 (4.9) 1.6 (0.9) 19 20
63.3 66.7
35.0 (7.4) n.a.n 6.8 (4.5) 1.7 (1.0) 19 15
63.3 50.0
7 15 8
23.3 50.0 26.7
7 15 8
23.3 50.0 26.7
18 2 10 19 6
60.0 6.7 33.3 63.3 20.0
13# 5# 11# – 2
44.8# 17.2# 37.9# – 6.7
Note: Numbers in the Women and Men columns are given as means (standard deviations) or as absolute numbers of participants. n
Only women completed the EPDS at recruitment. Although proportions were the same across genders, they were not necessarily the same between members of a couple. # n¼29. †
Findings Participant characteristics More than half of the participants were first-time parents experiencing the birth of their first child, had at least a college or a university degree and were Canadian born. Only seven of the 30 women were taking antidepressants at the time of the interview, six had a personal history of mental health problems and seven a family history of mental illness. Almost two-thirds (63%) of the women had accepted a mental health referral. Women were on average 32.5 years old, whereas men were 35.0 years old (Table 1).
Fig. 1. Causes of women's PPD symptoms. Pink represents causes that were identified by women and blue represents causes that were identified by men. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Causes of symptoms Nine different causes were believed to have contributed to the development of women's symptoms: (a) societal pressure, (b) physical health problems, (c) transition to parenthood, (d) social connectedness and support, (e) personality and past psychological history, (f) child health and temperament, (g) unmet care needs, (h) unmet birth expectations, and (i) other life stressors (Fig. 1). All these causes except one were mentioned by both men and women. Only men thought that societal expectations contributed to the development of symptoms. There was no difference between care acceptors' and decliners' perceptions. When describing what they thought was the cause of the women's symptoms, participants often described one primary cause.
Nonetheless, they recognised that other factors also contributed. Representative quotes are included in the description of the findings along with the participant's identification code. Care acceptors' code numbers begin with ‘A’ and decliners' code numbers begin with ‘D’. Quotes from women end in an ‘W’, whereas statements ending with ‘M’ were made by men. Societal expectations and pressure Only men thought that society's expectations of women was a key cause of their partner's symptoms. They believed that their spouses were trying to achieve multiple, unrealistic goals and that
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when their sense of themselves and of their abilities as women and as mothers fell short of societal expectations, this had a negative effect on their psychological well-being. Some men mentioned general societal expectations of women whereas others referred to specific pressures such as the pressure to breast feed. One participant explained: ‘Let's say that I think that modern society asks too much. […] Before, a woman was staying home and taking care of the kids. Now, a woman is a professional, a mother, a lover. […] So it is heavy in terms of demands’ (A05M). Physical health problems Physical health problems, such as childbirth complications (e.g., slow-healing or painful incisions) and hormonal fluctuations were often perceived as causes of the PPD symptoms. These physical health challenges were seen as having a negative effect on women's ability to cope with caring for newborns and on their psychological well-being. Lack of sleep, due to infant care demands and/or physical health problems, and the ensuing fatigue were other types of health challenges perceived as contributing to the symptoms. One woman explained: ‘I wasn't sleeping at all and really, I was to the point where my exhaustion was tremendous. Night after night (…). I wasn't sleeping at all. After a few nights, it was too much…’ (A07W). Transition to parenthood Some participants attributed women's PPD symptoms to difficulty coping with the transition to parenthood, the demands of parenting, or the desire to be a ‘good mother’. In some cases, a loss of their previous identity as a person was experienced, and the women had difficulty adjusting to this change. For example, one woman stated: ‘Because of that [having a baby] I was feeling bad about myself because I had made a lot of effort to go to university, to have a career, to try to work, to do a lot of things. And because of that, everything has stopped…’ (D11W). Others felt that their current experience of motherhood did not coincide with their expectations and that this led to unhappiness. One woman elaborated on how lack of time for herself contributed to symptom development: ‘[You have] less time for yourself, less time for spontaneity. Obviously less freedom and a really full schedule of days that go by and you don't see the time going. You just… you're running and you're running’ (A05W). Women's striving to meet their self-expectations as mothers was seen by participants as a fairly prevalent cause of symptoms. Some women had expectations for themselves as mothers and felt they were failing to meet these expectations. They wanted to provide the best possible care to their infant and to establish a positive mother–child relationship. One partner explained it in this way: ‘At first, my wife was […] worried about being able to do things, to do them well so the baby will have everything he needs. It was about her role as a mother, and about doing it well’ (D06M). Social connectedness and support At least one member of most couples perceived that symptoms were related to a lack of support and/or of social interaction with others. In some cases, help from the partner, family and or friends did not coincide with or meet women's needs. For example, one participant who would have liked to receive more help from her partner stated: ‘[My partner] was awake, but he never offered to help me out. He was telling me ‘I'm too tired, I can't even offer it [help with the baby] to you because I'm too tired’. But he was awake. That was frustrating’ (A07W). Remaining at home for extended periods to take care of the infant or the household resulted in a lack of social contact with
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others, and this isolation was perceived as contributing to the symptoms. One participant who attributed his partner's symptoms to isolation noted: ‘Maybe [she was depressed] just because she wasn't going out enough. She was just home with the baby. She just needed to get a breath’(D03M). Personality traits and past psychological history Both women and their partners considered personality characteristics, temperament, and a history of mental health problems as possible causes of symptoms. One woman explained that being a perfectionist played a role in the onset of her symptoms: ‘I am demanding on myself and I want everything to be perfect. It [the depression] was because I couldn't do it’ (A13W). All the women who had a history of mental health problems, with the exception of one, thought that their previous history contributed to the development of their symptoms. For example, one woman explained how her ongoing mental health problems began: ‘When I was young, I was very shy. I had a lot of problems in school. Other students were hurting me all the time. I think it all began at this time’ (A08W). Child health or temperament Some participants considered that the health or temperament of their newborn or of their other children played a role in the onset of their PPD symptoms. The additional challenges of dealing with a child who was unwell or perceived as being difficult to care for, in conjunction with the normal challenges of the postpartum period, caused great stress and resulted in PPD symptoms. In this regard, one participant mentioned: ‘[The child] also has a terrible temper. That's also hard on the couple. We try to work it out but it's hard. You have your Friday nights of one […] temper tantrum after the other […] It's just ‘Ahhh!’ all the time’ (A05W). Unmet healthcare needs Participants also attributed women's PPD symptoms to the quality of the healthcare they received during pregnancy and/or after childbirth. The medical or nursing care received was perceived as inappropriate, or inadequate in meeting their needs. Pressure to breast feed from the healthcare providers was a very common example of care that caused distress. One woman stated: ‘At the hospital, they were brainwashing me with ‘You have to breastfeed, you have to breastfeed’ and nothing was coming out, so all I was doing was crying. It was really that. That really got to me’ (A19W). Inadequate or insufficient communication from the healthcare team and difficulty navigating the healthcare system were also amongst the events that participants identified as contributing to the development of symptoms. For example, one participant who would have liked more information regarding the medical condition of her hospitalised infant mentioned: ‘Some nurses, probably involuntarily, because they are busy, were forgetting to tell us things, and then after we did not understand, we asked questions’ (D04W). Unmet birth expectations Some participants had preferences regarding how their childbirth experience would transpire. They felt that as their actual experience did not match their expectations of what they had hoped for, the women developed PPD symptoms. One man explained the development of his partner's symptoms: ‘In both cases [births], it ended-up being a C-section. Obviously, it wasn't what we wanted. But it was necessary, emergency C-sections. […] that was
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one thing, according to what I could observe, that really had a negative impact on her, on her conscious state, everything’ (D11M). Other life stressors Events unrelated to the pregnancy or to parenting were also perceived as having contributed to the aetiology of women's PPD symptoms. Both discrete events, such as immigration difficulties, financial uncertainty or changes related to return to work, and the accumulation of multiple stressors were seen as causes. One participant explained the cause of her symptoms saying: ‘It was a sum of events, all the time, that were piling up… financial, conflicts with [my partner's] family…’ (A21W).
Discussion In this study, we found that men and women had many different explanations for the development of women's PPD symptoms. Societal expectations of women, physical health problems, the transition to parenthood, lack of support, personality characteristics and history of mental health problems, childrelated challenges, unmet healthcare needs, unmet childbirth expectations and other stressing events were thought to be the causes underlying these symptoms. Although some participants attributed women's symptoms to one main cause, all considered that several factors were involved. This finding is in concordance with other studies that find that persons living with depression perceive the aetiology of their depression as multicausal (Budd et al., 2008; Hansson et al., 2010; Foulkes, 2011). We also found that, except for societal expectations of women, all the causes were endorsed by both men and women. This pattern of findings is in contrast to the only previous study comparing men and women. Everingham and colleagues (Everingham et al., 2006) reported striking differences between men and women. Australian men attributed symptoms to physical hardships during childbirth or postpartum, personality or a previous history of mental health problems. In contrast, women attributed symptoms to their experience of becoming mothers and to their failure at being ‘good mothers’. In our study, transition to motherhood was only one of the many causes identified by both men and women. In both studies, both partners needed to agree to participate and were interviewed separately. However, the Australian study had a small, homogenous group of participants who were well educated, older, first-time parents. Our sample was larger and more heterogeneous with respect to socio-demographic characteristics. Aside from participant characteristics, cultural differences between the two countries may be a possible explanation. In addition, men in the current study might have been more familiar with the daily experience of their partners. In the Canadian province where the study took place, partners are entitled to a paid leave from their employment. Men who avail themselves of such a leave may have different social values, a different understanding of their partners' experience or may be more likely to arrive at a shared meaning with their partners. Interestingly, only one of the six men in the Australian study had taken paternity leave and he was the only man whose perceptions coincided with his partner (Everingham et al., 2006). In the present study, men thought societal expectations of women played a role in symptom development. The men believed that expectations for women were different than for men, that women were expected to fulfil multiple roles simultaneously and that this expectation placed great pressure on their partners. It is interesting that mothers who identified their PPD as being caused by their desire to be ‘good mothers’ only referred to their own personal expectations of themselves and not to societal
expectations. It is plausible that women do not see societal expectations as giving rise to symptoms because they consider their symptoms through an individual lens rather than a gender lens. According to the literature, gender stigma may be a strategy to protect one's self-esteem (Major and O’Brien, 2005). For example, one can attribute negative feedback to sexism instead of attributing it to personal failure. Men who mentioned undue societal pressure may thus be attempting to normalise their partners' symptoms by doing so. Of the nine causes described by our participants, only one was related to physical health problems. Some participants attributed women's symptoms to hormonal changes, complications following childbirth, or lack of sleep. In this way, our findings concur with the conclusion that women tend to attribute symptoms to psychosocial rather than to strictly biological causes (Edge et al., 2004; Patel et al., 2013), and extend this finding to their partners. This conclusion is also in line with studies of depressed patients that show that only a minority of these individuals identify physical health issues as the main cause of their depression (Henningsen et al., 2005; Hansson et al., 2010). Other causes identified by participants of the current study included the transition to parenthood, social isolation and lack of support, and stressful life events. These findings echo those of previous studies (Ahmed et al., 2008; O’Mahen et al., 2009; Henshaw et al., 2013; Patel et al., 2013), and also support the conclusion that overall, women tend to externalise their symptoms (Patel et al., 2013). Our study suggests that the pattern is similar for their partners. Another example of externalising is attributing symptoms to child-related factors such as children's health problems or difficult temperaments. To our knowledge, the present study is the first to find that child-related factors are considered to play a role in PPD symptom development. Perceiving the infant as having a difficult temperament may also be a consequence of having depressive symptoms though. It is of interest that all but one of the women in the current study with a history of mental health problems identified their personality or personal history as a cause of their PPD symptoms. This finding is congruent with depressive patients' beliefs that their personality contributes to their depressive symptoms (Hansson et al., 2010). Women who have suffered from depression in the past, or men who have witnessed their partners' previous depressive episodes, viewed women's symptoms in the postpartum period as the resurgence of their previous mental health problem. Furthermore, they were aware that having a history of depression leads to increased risk of subsequent depressive episodes, which might explain why this group was inclined to cite it as a cause. Participants who attributed women's symptoms to unmet healthcare needs often mentioned the pressure exerted by healthcare providers with respect to breast feeding, an issue reported in previous studies on PPD (Ugarriza, 2002; Everingham et al., 2006; Foulkes, 2011). Although they understood the reasons underlying this advocacy, they also believed that healthcare providers failed to balance the importance of breast feeding for infants with its effects on women. Implications for practice Participants identified numerous causes as having contributed to women's depressive symptoms. In clinical settings, an assessment of women's and of their partners' perceptions is essential and can provide healthcare professionals with a better understanding of their experience, as well as their preferences as to how to manage symptoms. This assessment will allow for care to be tailored to their beliefs about the symptom causes and to their preferences for care. As a result, care options are more likely to be
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acceptable to women and their partners. It would also be important to assess whether women and their partners have similar or dissimilar views on this matter, and what impact this might have on women's symptoms. Healthcare professionals also need to nuance their discourse about breast feeding so that women who are struggling with symptoms do not feel undue pressure to breast feed. Limitations and future directions A number of limitations warrant consideration. Although participants were relatively heterogeneous with respect to their sociodemographic characteristics, they were all recruited through urban institutions and lived in urban settings. This could have influenced perceptions as depression studies have found significant perceptual differences between rural and urban populations (Rost et al., 1993; Jones et al., 2011). Both partners needed to agree to participate in the study to be eligible, so it is possible that this led to the recruitment of partners who communicate effectively or who share similar views or who are supportive, and thus to the overall pattern of similarities in men's and women's perceptions found in this study. Moreover, the first interviews conducted did not include explicit questions about the cause of the women's symptoms. It is possible that additional causes may have been described. However, no new categories of causes emerged after 24 of the 30 participating couples were interviewed. Finally, our research team was composed of nurses and mental health professionals and our health professional status may have shaped the analysis of the data. Future studies are needed that explore how the level of agreement or disagreement within couples on the causes of symptoms influences women's symptom level and course, as well as their help-seeking behaviour. Moreover, it would be interesting to investigate further whether the similarity observed across men and women could be attributed to socio-cultural factors or to shared meaning that might arise when men are at home on parental leave with their partner after childbirth. The partners' ability to provide support may be linked to their perception of the causes of the symptoms and this also warrants investigation. Likewise, longitudinal studies are needed to explore how perceptions might change over time.
Conclusion The findings of this study provide a beginning understanding of how women with PPD symptoms and their partners perceive the women's symptoms. This line of enquiry is important to pursue in order to enhance the uptake of care. Understanding perceptions of causation can foster the provision of care that is tailored to couples' views and thus more acceptable.
Conflict of interest The authors declare no conflict of interest.
Acknowledgements We wish to acknowledge the assistance of Madeleine Tait, Philippe Blouin, Marie-Eve Carrier, Roxanne Harel-Courtemanche, and Didier Maillot-Bisson with the interviews and Stephanie Robins with recruitment. This study was funded in part by the Fonds de recherche du Québec – Santé, the Réseau de recherche en interventions en sciences infirmières du Québec, and the Lady Davis Institute.
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Catherine Habel is supported by a Research Scholar Award from the Ingram School of Nursing, McGill University, Quebec, Canada.
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Midwifery journal homepage: www.elsevier.com/midw
Causes of women's postpartum depression symptoms: Men's and women's perceptions Catherine Habel, CPNP, MSc, MSc(A) (Candidate to the profession of nursing practice)a,n, Nancy Feeley, RN, PhD (Registered nurse, associate professor, senior investigator)a,b, Barbara Hayton, MD (Director of the Perinatal Mental Health Service)c, Linda Bell, RN, PhD (Registered nurse)d, Phyllis Zelkowitz, EdD (Senior investigator, director of research)e,f a
Ingram School of Nursing, McGill University, Montreal, QC, Canada Center for Nursing Research & Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada Perinatal Mental Health Service, Jewish General Hospital, Montreal, QC, Canada d Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada e Lady Davis Institute & Department of Psychiatry, Jewish General Hospital, Montreal, QC, Canada f Department of Psychiatry, McGill University, Montreal, QC, Canada b c
art ic l e i nf o
a b s t r a c t
Article history: Received 13 November 2014 Received in revised form 27 February 2015 Accepted 20 March 2015
Objectives: To describe men’s and women’s perceptions of the causes of women’s PPD symptoms and to explore similarities and differences between men’s and women’s perceptions. Design: Qualitative-descriptive study involving in-depth semi-structured individual interviews and content analysis. Setting: In-home interviews of participants recruited in two tertiary care hospitals, both in urban centres of the province of Quebec, Canada. Participants: Both members of 30 heterosexual couples from which women scored at least 12 on the Edinburgh Postnatal Depression Scale. Findings: Participants described nine causes underlying women’s depressive symptoms: societal expectations and pressure on women, physical health problems, transition to parenthood, social connectedness, personality and past psychological history, child health and temperament challenges, unmet care needs, unmet expectations for childbirth, and other life stressors. With one exception, all causes were endorsed by both men and women. Only men mentioned societal pressure on women. Key conclusions and implications for practice: Men and women mainly perceived similar causes, which could be explained by socio-cultural factors and extended paternal leaves. Understanding men’s and women’s perceptions could help tailoring health- care professionals’ interventions to couples’ needs. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Postpartum depression Perceptions Causes Men Women Gender
Introduction Postpartum depression Although the transition to motherhood is usually seen as a positive experience in women's lives, it is also a time of physical, psychological and social adaptation that may leave women in a state of increased vulnerability (Miller, 2002; Wisner, 2006). Postpartum depression (PPD) is a relatively common mental disorder that is estimated to affect 13–19% of women in the first n
Corresponding author. E-mail addresses: [email protected] (C. Habel), [email protected] (N. Feeley), [email protected] (B. Hayton), [email protected] (L. Bell), [email protected] (P. Zelkowitz). http://dx.doi.org/10.1016/j.midw.2015.03.007 0266-6138/& 2015 Elsevier Ltd. All rights reserved.
year following childbirth (O'Hara and McCabe, 2013). As per the current versions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorder (DSM-V) and the International Classification of Mental and Behavioral Disorders (ICD-10), PPD has symptoms, developments and outcomes that are similar to those encountered in non-postpartum-related depressive disorders (World Health Organization, 1992; American Psychiatric Association, 2013). Some of the most commonly reported symptoms include recurrent and impairing feelings of dysphoria, tearfulness, hopelessness, anxiety, guilt and fatigue (Robertson et al., 2004). While limited to the first year following childbirth, PPD can have long-term implications for women and their family members. Women suffering from PPD are known to be at higher risk for subsequent depressive episodes (Robertson et al., 2004). PPD can
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negatively affect the mother–child relationship (Poobalan et al., 2007; Darcy et al., 2011) and is associated with an increased frequency of cognitive development delays and attachment insecurity (Hipwell et al., 2000), as well as poorer social engagement, in children of women who have suffered from PPD (Feldman et al., 2009). PPD also affects women's partners. Partners experience a range of negative emotions such as self-doubt, helplessness, anger and fear due to concern and to a perceived inability to help their partner as well as relationship uncertainty (Meighan et al., 1999; Letourneau et al., 2011). Partners of women suffering of PPD have an increased risk of experiencing psychological disturbances (Goodman, 2004, 2008; Roberts et al., 2006). A recent metaanalysis showed that about 10% of fathers experience depressive symptoms and that they are moderately and positively correlated with maternal depressive symptoms (Paulson and Bazemore, 2010). Perceptions of the causes of PPD symptoms Despite the efficacy of treatments available for PPD, numerous studies find that women with depressive symptoms are reluctant to seek help and decline a referral for mental healthcare (Callister et al., 2011). A major reason for the poor uptake of healthcare is a lack of fit between the women's perceptions of their needs and the care offered (McIntosh, 1993; O'Mahen et al., 2009). How women and their partners understand women's symptoms may shape their help-seeking behaviour and preferences for care. This knowledge might be an important step in the development of services and intervention programs for PPD that would be more acceptable to women and their partners (Dennis and Chung-Lee, 2006). There has however been little systematic study of women's understanding of what caused their symptoms. Although many of the causes perceived by women seem to be endorsed worldwide, some are only mentioned in some settings, indicating that women's perceptions are to some extent shaped by cultural influences (Oates et al., 2004). Caribbean women believed that a pile-up of multiple psychosocial stressors or hormonal problems lead to the development of their symptoms (Edge et al., 2004; Edge and Rogers, 2005). Indian women attributed their symptoms to social adversity, poor marital relationships and gender preferences (Rodrigues et al., 2003). Patel and colleagues (Patel et al., 2013) found that British women held a number of different beliefs about their symptoms. Some women attributed symptoms to incongruence between their actual postpartum experience and their idealised expectations. Others considered that a current or previous psychosocial stressor such as a difficult pregnancy or childbirth, relationship problems, financial worries, lack of support, or a change in lifestyle lead to their symptoms. Yet other women considered their symptoms to be due to their personality and blamed themselves for their depressive state. Biomedical factors, such as genetics or hormones, were another category of possible causes for symptoms. To our knowledge, a single previous study has investigated what women's partners perceive as having caused women's symptoms, and compared men's and women's perceptions. Everingham and colleagues (Everingham et al., 2006) found that the perceptions of men and women differed. Women were anxious about being a “good mother” and preoccupied with how others viewed their mothering abilities. They believed their symptoms were the result of their feelings of inadequacy as a mother. In contrast, their partners attributed symptoms to women's previous history of mental health problems, personality characteristics, or postpartum physical health problems. This study included a small homogenous group of older, well-educated, first-time Australian parents. It is unknown if it achieved saturation. The particular
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characteristics of this group of older first-time mothers may have shaped their perceptions of the cause of their symptoms. Further exploration of women's and their partners' perceptions is clearly warranted. Thus, the current study examined two questions: ‘What are men's and women's perceptions of the causes of women's PPD symptoms?’ and ‘What are the similarities and the differences between men's and women's perceptions?’
Methods Design A primary qualitative descriptive study was undertaken to examine women's and men's preferences for care to manage the women's symptoms (Feeley et al., 2015). The need for the current study emerged as the first interviews from the primary study were analysed. When describing their experience and preferences for care during semi-structured interviews, all participants spontaneously described what they thought caused the women' symptoms. Thus for remaining subsequent interviews, the guide for the primary study was modified to include specific questions to elicit participants' perceptions of the causes of the woman's symptoms. For example, “What does your partner think about your symptoms? ‘What does he think would help?’ or ‘What do you think is the cause of your [or your partner's] symptoms?’ were some of the questions asked. The same team of researchers conducted this secondary analysis to describe men's and women's perceptions of what causes the women's symptoms. The purposive sample consisted of 30 heterosexual couples and included two groups: women with symptoms of depression who accepted a referral for a mental health assessment and their partners, and those who chose not to accept a referral. Couples were included if: (1) both partners agreed to participate and to be audio-taped during the interviews; (2) the women had given birth in the 12 months that preceded the interview; (3) they were able to communicate in English or French; and (4) the women had a score of 12 or more on the Edinburgh Postnatal Depression Scale (EPDS) at the time of enrolment. The EPDS is a validated measure of depressive symptoms in the perinatal period (Cox et al., 1987; Hewitt et al., 2009). In this 10-item self-report questionnaire, respondents report their feelings over the past seven days on 4-point scales. A cut-off point of 12 is used to indicate depression. Enrolment, setting and data collection Participants were recruited at two tertiary care hospitals, both in urban centres of the same Canadian province during a routine visit to the obstetrics clinic. Others were recruited at the same study sites from among the participants of a longitudinal study of women's mental health in the postpartum period. The study received approval from the institutional research ethics boards at both centres before initiation. In this province, mothers are entitled to a maximum of 18 weeks of paid maternal leave whereas fathers are entitled to a maximum of five weeks. In addition, both parents can share a maximum of 25 supplemental weeks of paid leave (Gouvernement du Québec, 2015). In these centres, women who obtained a score of 12 or above on the EPDS were offered a mental health referral and asked if they would be interested in learning about the study. If they agreed, research staff explained that the study's purpose was to understand men's and women's PPD experience and preference for care to manage symptoms. If the woman provided verbal consent, they were asked to provide contact information for their partner, and staff contacted the partners directly to explain the study and to obtain verbal consent. Of those approached, 62%
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agreed to participate and be interviewed. Written informed consent was obtained at the time of the interviews. Interviews were conducted between March 2012 and May 2013. Face-to face in-depth semi-structured interviews of 45 to 90 minutes were conducted in participants' homes at a time set by participants. The interviews were conducted by the first author or by master's-prepared professional research assistants trained in interviewing. Women and their partners were interviewed separately but simultaneously in a private setting. This approach allowed each to freely express their views. Interviews were conducted by a person of the same gender as the participant. Interviews were transcribed verbatim from the audiotapes. Participants were given a 20$ gift certificate as compensation for their time. Analysis Content analysis was used to analyze the data (Berg and Lune, 2004; Elo and Kyngas, 2008). In short, interviews were transcribed and read to achieve a better understanding of the content. The transcripts were perused for quotes relevant to the study questions. This open-coding step was followed by axial-coding. Codes were condensed into categories of perceived causes. Peer debriefing was used to discuss the coding, and discussions amongst team members continued until consensus was reached. Data saturation was reached in that no new categories of causes emerged after 24 couples had been interviewed. The categories endorsed by each participant were entered into data matrices and these matrices were used to compare women's and men's perceptions. Representative quotes are included in this report to allow readers to assess the transferability of findings. Transferability was also addressed by collecting data about and reporting the sociodemographic characteristics of the participants (Chiovitti and Piran, 2003). An audit trail was kept to make all decision-making processes amenable to external evaluation and to increase the confirmability and dependability of the findings (Carnevale, 2002).
Table 1 Participants' characteristics. Women Age EPDS score at recruitment EPDS score at interview Average number of children First child† Canadian-born Language at home† English French Other Education University degree or certificate College (general or technical) Secondary (general or technical) Accepted mental health referral History of mental illness
%
Men
%
32.5 (5.6) 14.8 (2.7) 9.6 (4.9) 1.6 (0.9) 19 20
63.3 66.7
35.0 (7.4) n.a.n 6.8 (4.5) 1.7 (1.0) 19 15
63.3 50.0
7 15 8
23.3 50.0 26.7
7 15 8
23.3 50.0 26.7
18 2 10 19 6
60.0 6.7 33.3 63.3 20.0
13# 5# 11# – 2
44.8# 17.2# 37.9# – 6.7
Note: Numbers in the Women and Men columns are given as means (standard deviations) or as absolute numbers of participants. n
Only women completed the EPDS at recruitment. Although proportions were the same across genders, they were not necessarily the same between members of a couple. # n¼29. †
Findings Participant characteristics More than half of the participants were first-time parents experiencing the birth of their first child, had at least a college or a university degree and were Canadian born. Only seven of the 30 women were taking antidepressants at the time of the interview, six had a personal history of mental health problems and seven a family history of mental illness. Almost two-thirds (63%) of the women had accepted a mental health referral. Women were on average 32.5 years old, whereas men were 35.0 years old (Table 1).
Fig. 1. Causes of women's PPD symptoms. Pink represents causes that were identified by women and blue represents causes that were identified by men. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
Causes of symptoms Nine different causes were believed to have contributed to the development of women's symptoms: (a) societal pressure, (b) physical health problems, (c) transition to parenthood, (d) social connectedness and support, (e) personality and past psychological history, (f) child health and temperament, (g) unmet care needs, (h) unmet birth expectations, and (i) other life stressors (Fig. 1). All these causes except one were mentioned by both men and women. Only men thought that societal expectations contributed to the development of symptoms. There was no difference between care acceptors' and decliners' perceptions. When describing what they thought was the cause of the women's symptoms, participants often described one primary cause.
Nonetheless, they recognised that other factors also contributed. Representative quotes are included in the description of the findings along with the participant's identification code. Care acceptors' code numbers begin with ‘A’ and decliners' code numbers begin with ‘D’. Quotes from women end in an ‘W’, whereas statements ending with ‘M’ were made by men. Societal expectations and pressure Only men thought that society's expectations of women was a key cause of their partner's symptoms. They believed that their spouses were trying to achieve multiple, unrealistic goals and that
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when their sense of themselves and of their abilities as women and as mothers fell short of societal expectations, this had a negative effect on their psychological well-being. Some men mentioned general societal expectations of women whereas others referred to specific pressures such as the pressure to breast feed. One participant explained: ‘Let's say that I think that modern society asks too much. […] Before, a woman was staying home and taking care of the kids. Now, a woman is a professional, a mother, a lover. […] So it is heavy in terms of demands’ (A05M). Physical health problems Physical health problems, such as childbirth complications (e.g., slow-healing or painful incisions) and hormonal fluctuations were often perceived as causes of the PPD symptoms. These physical health challenges were seen as having a negative effect on women's ability to cope with caring for newborns and on their psychological well-being. Lack of sleep, due to infant care demands and/or physical health problems, and the ensuing fatigue were other types of health challenges perceived as contributing to the symptoms. One woman explained: ‘I wasn't sleeping at all and really, I was to the point where my exhaustion was tremendous. Night after night (…). I wasn't sleeping at all. After a few nights, it was too much…’ (A07W). Transition to parenthood Some participants attributed women's PPD symptoms to difficulty coping with the transition to parenthood, the demands of parenting, or the desire to be a ‘good mother’. In some cases, a loss of their previous identity as a person was experienced, and the women had difficulty adjusting to this change. For example, one woman stated: ‘Because of that [having a baby] I was feeling bad about myself because I had made a lot of effort to go to university, to have a career, to try to work, to do a lot of things. And because of that, everything has stopped…’ (D11W). Others felt that their current experience of motherhood did not coincide with their expectations and that this led to unhappiness. One woman elaborated on how lack of time for herself contributed to symptom development: ‘[You have] less time for yourself, less time for spontaneity. Obviously less freedom and a really full schedule of days that go by and you don't see the time going. You just… you're running and you're running’ (A05W). Women's striving to meet their self-expectations as mothers was seen by participants as a fairly prevalent cause of symptoms. Some women had expectations for themselves as mothers and felt they were failing to meet these expectations. They wanted to provide the best possible care to their infant and to establish a positive mother–child relationship. One partner explained it in this way: ‘At first, my wife was […] worried about being able to do things, to do them well so the baby will have everything he needs. It was about her role as a mother, and about doing it well’ (D06M). Social connectedness and support At least one member of most couples perceived that symptoms were related to a lack of support and/or of social interaction with others. In some cases, help from the partner, family and or friends did not coincide with or meet women's needs. For example, one participant who would have liked to receive more help from her partner stated: ‘[My partner] was awake, but he never offered to help me out. He was telling me ‘I'm too tired, I can't even offer it [help with the baby] to you because I'm too tired’. But he was awake. That was frustrating’ (A07W). Remaining at home for extended periods to take care of the infant or the household resulted in a lack of social contact with
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others, and this isolation was perceived as contributing to the symptoms. One participant who attributed his partner's symptoms to isolation noted: ‘Maybe [she was depressed] just because she wasn't going out enough. She was just home with the baby. She just needed to get a breath’(D03M). Personality traits and past psychological history Both women and their partners considered personality characteristics, temperament, and a history of mental health problems as possible causes of symptoms. One woman explained that being a perfectionist played a role in the onset of her symptoms: ‘I am demanding on myself and I want everything to be perfect. It [the depression] was because I couldn't do it’ (A13W). All the women who had a history of mental health problems, with the exception of one, thought that their previous history contributed to the development of their symptoms. For example, one woman explained how her ongoing mental health problems began: ‘When I was young, I was very shy. I had a lot of problems in school. Other students were hurting me all the time. I think it all began at this time’ (A08W). Child health or temperament Some participants considered that the health or temperament of their newborn or of their other children played a role in the onset of their PPD symptoms. The additional challenges of dealing with a child who was unwell or perceived as being difficult to care for, in conjunction with the normal challenges of the postpartum period, caused great stress and resulted in PPD symptoms. In this regard, one participant mentioned: ‘[The child] also has a terrible temper. That's also hard on the couple. We try to work it out but it's hard. You have your Friday nights of one […] temper tantrum after the other […] It's just ‘Ahhh!’ all the time’ (A05W). Unmet healthcare needs Participants also attributed women's PPD symptoms to the quality of the healthcare they received during pregnancy and/or after childbirth. The medical or nursing care received was perceived as inappropriate, or inadequate in meeting their needs. Pressure to breast feed from the healthcare providers was a very common example of care that caused distress. One woman stated: ‘At the hospital, they were brainwashing me with ‘You have to breastfeed, you have to breastfeed’ and nothing was coming out, so all I was doing was crying. It was really that. That really got to me’ (A19W). Inadequate or insufficient communication from the healthcare team and difficulty navigating the healthcare system were also amongst the events that participants identified as contributing to the development of symptoms. For example, one participant who would have liked more information regarding the medical condition of her hospitalised infant mentioned: ‘Some nurses, probably involuntarily, because they are busy, were forgetting to tell us things, and then after we did not understand, we asked questions’ (D04W). Unmet birth expectations Some participants had preferences regarding how their childbirth experience would transpire. They felt that as their actual experience did not match their expectations of what they had hoped for, the women developed PPD symptoms. One man explained the development of his partner's symptoms: ‘In both cases [births], it ended-up being a C-section. Obviously, it wasn't what we wanted. But it was necessary, emergency C-sections. […] that was
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one thing, according to what I could observe, that really had a negative impact on her, on her conscious state, everything’ (D11M). Other life stressors Events unrelated to the pregnancy or to parenting were also perceived as having contributed to the aetiology of women's PPD symptoms. Both discrete events, such as immigration difficulties, financial uncertainty or changes related to return to work, and the accumulation of multiple stressors were seen as causes. One participant explained the cause of her symptoms saying: ‘It was a sum of events, all the time, that were piling up… financial, conflicts with [my partner's] family…’ (A21W).
Discussion In this study, we found that men and women had many different explanations for the development of women's PPD symptoms. Societal expectations of women, physical health problems, the transition to parenthood, lack of support, personality characteristics and history of mental health problems, childrelated challenges, unmet healthcare needs, unmet childbirth expectations and other stressing events were thought to be the causes underlying these symptoms. Although some participants attributed women's symptoms to one main cause, all considered that several factors were involved. This finding is in concordance with other studies that find that persons living with depression perceive the aetiology of their depression as multicausal (Budd et al., 2008; Hansson et al., 2010; Foulkes, 2011). We also found that, except for societal expectations of women, all the causes were endorsed by both men and women. This pattern of findings is in contrast to the only previous study comparing men and women. Everingham and colleagues (Everingham et al., 2006) reported striking differences between men and women. Australian men attributed symptoms to physical hardships during childbirth or postpartum, personality or a previous history of mental health problems. In contrast, women attributed symptoms to their experience of becoming mothers and to their failure at being ‘good mothers’. In our study, transition to motherhood was only one of the many causes identified by both men and women. In both studies, both partners needed to agree to participate and were interviewed separately. However, the Australian study had a small, homogenous group of participants who were well educated, older, first-time parents. Our sample was larger and more heterogeneous with respect to socio-demographic characteristics. Aside from participant characteristics, cultural differences between the two countries may be a possible explanation. In addition, men in the current study might have been more familiar with the daily experience of their partners. In the Canadian province where the study took place, partners are entitled to a paid leave from their employment. Men who avail themselves of such a leave may have different social values, a different understanding of their partners' experience or may be more likely to arrive at a shared meaning with their partners. Interestingly, only one of the six men in the Australian study had taken paternity leave and he was the only man whose perceptions coincided with his partner (Everingham et al., 2006). In the present study, men thought societal expectations of women played a role in symptom development. The men believed that expectations for women were different than for men, that women were expected to fulfil multiple roles simultaneously and that this expectation placed great pressure on their partners. It is interesting that mothers who identified their PPD as being caused by their desire to be ‘good mothers’ only referred to their own personal expectations of themselves and not to societal
expectations. It is plausible that women do not see societal expectations as giving rise to symptoms because they consider their symptoms through an individual lens rather than a gender lens. According to the literature, gender stigma may be a strategy to protect one's self-esteem (Major and O’Brien, 2005). For example, one can attribute negative feedback to sexism instead of attributing it to personal failure. Men who mentioned undue societal pressure may thus be attempting to normalise their partners' symptoms by doing so. Of the nine causes described by our participants, only one was related to physical health problems. Some participants attributed women's symptoms to hormonal changes, complications following childbirth, or lack of sleep. In this way, our findings concur with the conclusion that women tend to attribute symptoms to psychosocial rather than to strictly biological causes (Edge et al., 2004; Patel et al., 2013), and extend this finding to their partners. This conclusion is also in line with studies of depressed patients that show that only a minority of these individuals identify physical health issues as the main cause of their depression (Henningsen et al., 2005; Hansson et al., 2010). Other causes identified by participants of the current study included the transition to parenthood, social isolation and lack of support, and stressful life events. These findings echo those of previous studies (Ahmed et al., 2008; O’Mahen et al., 2009; Henshaw et al., 2013; Patel et al., 2013), and also support the conclusion that overall, women tend to externalise their symptoms (Patel et al., 2013). Our study suggests that the pattern is similar for their partners. Another example of externalising is attributing symptoms to child-related factors such as children's health problems or difficult temperaments. To our knowledge, the present study is the first to find that child-related factors are considered to play a role in PPD symptom development. Perceiving the infant as having a difficult temperament may also be a consequence of having depressive symptoms though. It is of interest that all but one of the women in the current study with a history of mental health problems identified their personality or personal history as a cause of their PPD symptoms. This finding is congruent with depressive patients' beliefs that their personality contributes to their depressive symptoms (Hansson et al., 2010). Women who have suffered from depression in the past, or men who have witnessed their partners' previous depressive episodes, viewed women's symptoms in the postpartum period as the resurgence of their previous mental health problem. Furthermore, they were aware that having a history of depression leads to increased risk of subsequent depressive episodes, which might explain why this group was inclined to cite it as a cause. Participants who attributed women's symptoms to unmet healthcare needs often mentioned the pressure exerted by healthcare providers with respect to breast feeding, an issue reported in previous studies on PPD (Ugarriza, 2002; Everingham et al., 2006; Foulkes, 2011). Although they understood the reasons underlying this advocacy, they also believed that healthcare providers failed to balance the importance of breast feeding for infants with its effects on women. Implications for practice Participants identified numerous causes as having contributed to women's depressive symptoms. In clinical settings, an assessment of women's and of their partners' perceptions is essential and can provide healthcare professionals with a better understanding of their experience, as well as their preferences as to how to manage symptoms. This assessment will allow for care to be tailored to their beliefs about the symptom causes and to their preferences for care. As a result, care options are more likely to be
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acceptable to women and their partners. It would also be important to assess whether women and their partners have similar or dissimilar views on this matter, and what impact this might have on women's symptoms. Healthcare professionals also need to nuance their discourse about breast feeding so that women who are struggling with symptoms do not feel undue pressure to breast feed. Limitations and future directions A number of limitations warrant consideration. Although participants were relatively heterogeneous with respect to their sociodemographic characteristics, they were all recruited through urban institutions and lived in urban settings. This could have influenced perceptions as depression studies have found significant perceptual differences between rural and urban populations (Rost et al., 1993; Jones et al., 2011). Both partners needed to agree to participate in the study to be eligible, so it is possible that this led to the recruitment of partners who communicate effectively or who share similar views or who are supportive, and thus to the overall pattern of similarities in men's and women's perceptions found in this study. Moreover, the first interviews conducted did not include explicit questions about the cause of the women's symptoms. It is possible that additional causes may have been described. However, no new categories of causes emerged after 24 of the 30 participating couples were interviewed. Finally, our research team was composed of nurses and mental health professionals and our health professional status may have shaped the analysis of the data. Future studies are needed that explore how the level of agreement or disagreement within couples on the causes of symptoms influences women's symptom level and course, as well as their help-seeking behaviour. Moreover, it would be interesting to investigate further whether the similarity observed across men and women could be attributed to socio-cultural factors or to shared meaning that might arise when men are at home on parental leave with their partner after childbirth. The partners' ability to provide support may be linked to their perception of the causes of the symptoms and this also warrants investigation. Likewise, longitudinal studies are needed to explore how perceptions might change over time.
Conclusion The findings of this study provide a beginning understanding of how women with PPD symptoms and their partners perceive the women's symptoms. This line of enquiry is important to pursue in order to enhance the uptake of care. Understanding perceptions of causation can foster the provision of care that is tailored to couples' views and thus more acceptable.
Conflict of interest The authors declare no conflict of interest.
Acknowledgements We wish to acknowledge the assistance of Madeleine Tait, Philippe Blouin, Marie-Eve Carrier, Roxanne Harel-Courtemanche, and Didier Maillot-Bisson with the interviews and Stephanie Robins with recruitment. This study was funded in part by the Fonds de recherche du Québec – Santé, the Réseau de recherche en interventions en sciences infirmières du Québec, and the Lady Davis Institute.
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Catherine Habel is supported by a Research Scholar Award from the Ingram School of Nursing, McGill University, Quebec, Canada.
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