Psychiatr Q DOI 10.1007/s11126-015-9367-1 ORIGINAL PAPER

Cross-Cultural Approach of Postpartum Depression: Manifestation, Practices Applied, Risk Factors and Therapeutic Interventions Olympia Evagorou1

•

Aikaterini Arvaniti1 • Maria Samakouri1

Ó Springer Science+Business Media New York 2015

Abstract It is a well known fact that postpartum depression (PPD) is a global phenomenon that women may experience, regardless of cultural identity and beliefs. This literature review presents the cultural beliefs and postnatal practices around the world, in each continent and people’s origins, looking through the extent to which they contribute positively or negatively to the onset of the disease. 106 articles were used in this research, through a systematic electronic search of Pubmed (Medline) and Scopus. Comparison is also made between the prevalence, the risk factors and the different ways of appearance of the disease around the world and among immigrants. Finally, the initiatives and interventions made so far by the governments and institutions with a view to prevent and address this global problem are presented. The results showed (a) that different cultures share the same risk factors towards the disease (b) significant differences in the prevalence of the disease among both Western and non Western cultures and between the cultures themselves (c) more tendencies for somatization of depressive symptoms in non—Western cultures, (d) different postnatal practices between cultures, which are not always effective (e) the more non-West a culture is, the less interventions concern on mental health; the same phenomenon is observed on populations burdened by immigration. The beliefs held by culture should be taken seriously in detecting of PPD, as well as the assessment of the needs of women who have recently given birth. Keywords

Postpartum depression
Transcultural
Cross-cultural
Interventions

Abbreviations PPD Postpartum depression nW non-Western UAE United Arab Emirates

& Olympia Evagorou [email protected] 1

Department of Psychiatry, Medicine School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis-Dragana, Greece

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PRIME MBU PNDSA PMHP MHA PMDs FHS

Program for improving mental health care Mother–baby unit Postnatal depression support association of South Africa Perinatal mental health project Mental health america Perinatal mood disorders Family health strategy

Introduction Giving birth to a child is one of the most important events in a woman’s life and affects every aspect of it; from the perception of herself and her social role until interpersonal relationships [1–4]. According to the literature, during the postpartum period a figure which rises up to 85 % of women will experience some type of emotional disturbance [5], with about 10–20 % of them developing postpartum depression (PPD) [6]. PPD includes the typical symptoms of a depressive episode, plus irrational fears for the child and his health, suicidal and sometimes infanticide ideation [7, 8]. Depressive symptoms can appear any time between the 1st and the 12th month of postpartum period [9], usually beginning between the 2nd and 6th week after birth and the duration and the outcome of which is directly dependent on early diagnosis and treatment [10–12]. It is striking that despite the high prevalence worldwide and the severity of the disease, about 80 % of the cases are not diagnosed and remain untreated [13], resulting in long-term and devastating consequences for both the mother and the child, as well as the family harmony [14, 15, 16, 17]. Notable are the increased danger for severe and chronic maternal depression, the difficulties in performing the duties of parenthood and the risk of suicide [14, 16, 18]. Although the causes of the disorder have not been clarified [19], it is clear that the presence of certain predisposing factors greatly increase the risk of disease onset [20]. The most common of these factors include a family or personal history of depression before pregnancy, low income, poor social support, poor intrafamilial relationships, low selfesteem, stress to care for the child, unwanted or unplanned pregnancy and recent stressful life events in a woman’s life [5, 7, 21–26]. Beliefs and social specificities of each nation directly affect the emotional experiences of an individual and the expression of emotions. Depression is an emotional disorder in which the way of expression differs between Western and non-Western (nW) world [27]. Surveys about the study of PPD in different cultures have come to the result that the occurrence of the disease is directly related to the way the woman receives care, after the birth, of her social surrounding [28]. The majority of research is conducted according to Western standards and diagnostic systems methodology, resulting some of the signs and symptoms, that are not ordinary in Western cultures, and many times the disease itself in nW-cultures, to be omitted [2]. This current literature review aims to explore: (a) the influence of culture in the manifestation of PPD and the differences in symptoms and expression of the disease in different cultures (b) the factors associated with an increased risk of occurrence of PPD in different cultures (c) the initiatives and programs running from governmental and non-

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governmental organizations for the awareness, the prevention, the on time diagnosis and treatment of the disease in each case.

Materials and Methods A systematic electronic search of Pubmed (Medline) and Scopus was conducted in order to identify (a) all relevant articles that dealt with the interculturalism of PPD (b) articles that dealt with the PPD in specific countries and cities of the five continents. Key words used for this search were: ‘‘postpartum depression’’, ‘‘transcultural’’, ‘‘cross-cultural’’, ‘‘interventions’’. Also, studies that were cited in the aforementioned articles were included when necessary. Only studies reported on PPD were selected. Studies that had as topic the prenatal depression, baby blues and psychotic disorders were excluded, even when exploring the influence of culture in these disorders.

Results 106 papers met the criteria. From the selected papers 10 refer to the PPD interculturally and how culture affects the development of it, 18 refer specifically to cultural practices after birth, cultural beliefs and how these influence the appearance and symptoms of PPD, 21 refer to interventions associated with mental health and PPD and 57 refer to symptoms, risk factors and prevalence of PPD in each culture. From these 57: 7 reports come from Asia, 4 from Africa, 14 from Europe, 5 from Australia, 21 from America and 6 from immigrants. Furthermore, 56 articles that were cited in the aforementioned articles were included.

Postpartum Depression Across Cultures The incidence of PPD in Western cultures ranges between 10 and 15 % [29, 30], while in nW-countries between 0 and 40 % [16]. From studies conducted at the international level, the incidence of the disease varies from 0.5 % in Singapore up to 73.7 % in Taiwan [31, 32]. A survey classifies civilizations based on the approach and care the woman receives after she gives birth, in Technocentric and Ethnokinship cultures [16].

Ethnokinship Cultures The main postpartum concern is the immediate social support of the mother from family networks and the care of the newborn [16, 33]. The care provided lasts from 30 to 40 days and involves a period of social isolation, mandatory rest, emotional and physical support for the new mother [2, 16]. The traditional practices of this period aim to succeed a smoother transition of women in the maternal role and reduce psychological tension [2, 16, 34]. Eastern Asia, South Asia, Africa, Eastern Europe and the Middle East are among these cultures [16].

Technocentric Cultures Primary concern is postpartum care of the baby while the woman’s care comes second. Postnatal care practices usually last 24–48 h [16]. These cultures monitor the welfare of the

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mother through technological mechanisms [16, 28]. When woman leaves the hospital she re-circulates in society, without any specific provision for institutionalized care. The only social facilitation provided is the professional maternity leave, which usually lasts up to 16 weeks without adequate social, family and emotional support. Often, the woman is forced to take full responsibility of herself and her child [16, 28, 33]. USA, Canada, Western Europe, Great Britain, New Zealand and Australia are among these cultures [16].

PPD in Asia Most of the researches for PPD in Asia were carried out in East and South Asia, and in the Middle East mainly in the states of the Arab world. Most Asian countries are part of the ethnokinship culture [28]. The emotional disturbances are mainly manifested through physical symptoms [2, 21, 35]. In Asian cultures it is considered that pregnancy and childbirth affect the balance between ‘‘hot and cold’’ in the woman’s body and therefore postnatal practices focus on the restoration of this ‘‘abnormal’’ situation [36]. Indicatively, cultural beliefs and postnatal practices of Asian countries are listed in Table 1.

PPD in East and South Asia Higher levels of symptomatology in Asian women than in women in N. Europe and Australia have been revealed [49]. This fact probably reflects the reduced awareness of society towards the seriousness of the disease. The prevalence of the disease in South and East Asia, ranges between 12.7 and 17.3 % in China [2], 22.35 % in Indonesia [50], between 13.5 and 73.7 % in Taiwan [32, 51], 0.5–6.8 % in Singapore [31, 52], 16.8 % in Thailand [53], 33 % in Vietnam [2], 4.9 % in Nepal [54], 3.9–9.8 % in Malaysia [55, 56], 22 % in Jordan [4] and between 11 and 32.4 % in India [2, 57]. Typical syndrome of PPD in women in China is the ‘‘wind illness’’, caused by ‘‘doing something wrong in the postpartum month’’. It is believed to affect the ‘’yang’’ area of the body and is manifested through fever, muscle pain, chills and low energy [2, 45]. There are also symptoms such as ‘‘numbness’’ of the head, feeling of pressure in the heart and exhaustion [2, 27]. In Hong Kong, the disease is usually manifested with symptoms of fatigue, confusion, loss of control, frustration, sadness, stress, panic and an intense fear of being helpless. Women may also experience the ‘‘phantom crying’’, during which they can hear their babies crying while the babies are actually asleep [58, 59]. Women in Taiwan describing their experiences during PPD period, highlighted feelings of stress, social isolation and entrapment in a situation in which they felt that they had to give a constant struggle to maintain their physical integrity [28]. In Korea, the disease is mainly manifested with headaches, dizziness, numbness, sleep disturbances and polyarthralgia. In Indonesia women describe symptoms of self-pity, anxiety, sadness and intense feelings of being in trouble [21]. Japan is a mixture of ethnokinship and technocentric culture. The prevalence of PPD varies from 5 to 27 % [21]. Japanese women express the negative aspects of their mood mainly through intense concern for the infant’s care. They also tend to conceal their depressive mood, which is expressed through physical symptoms and as a result, the depression of these women is not diagnosed with additional negative effects on their mental health [2].

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Psychiatr Q Table 1 Cultural beliefs and postpartum practises of Asia Country

Cultural beliefs and postpartum practises (Asia)

China, Tawian, Vietnam, Singapore

‘‘Doing the month’’/‘‘Zuo Yue’’/‘‘Tso-yueh-tzu’’: This is used to restore the balance of yin and yang of the body. The women of the family take over the care of the new mother, infant and household. The mother rests and avoids activities (sexual intercourse, bathing, washing of hair, reading, and sun exposure). Avoid crying. A special diet is followed (raw, cold food and chicken are banned) [1, 28, 37–39].

China

‘‘Peiyue’’:‘‘Mothering the mother’’. The new mother rests while her mother or mother-in-law takes care of both the baby and the household [14, 39].

Vietnam

The birth of a male child raises the social status of the family. The expression of negative emotions is prohibited. The mother is not allowed to be present at weddings and funerals [21, 36].

Japan

‘‘Satogaeri Bunben’’ The pregnant woman returns to her parents home during her 32–33rd week of pregnancy. Her family (mother and grandmother) offers her physical care and psychological support.Tips and techniques for infant’s care are given by the grandmother to the new mother. Usually women stop working after marriage or pregnancy [16, 40–42].

Korea

‘‘Sam Chil Ill’’: A period of 21 days—5 weeks. A special traditional diet (seaweed soup ‘‘mi-yukgook’’) for at least 2 months is followed. Hot foods and liquids are included. The woman has to wear warm clothes and avoid the exposure to cold water or air.Women are encouraged to ‘‘form’’ the shape of the infant’s head with their hands so that it becomes rounded [28, 43, 44].

Thailand

‘‘Yu Duan’’: A period of 27–29 days in male births and 31–32 days in female births. Dieting with foods without strong odor. Warm outfits and avoidance of cold water. Sprawled over fire source to obliterate the blood left by the placenta, the uterus involution and the prevention and rehabilitation of physical problems. Help from the family, especially her mother and sisters. Avoiding that traditional period will have negative effects on their lives [21, 38, 45].

Malaysia

‘‘Pantang Period’’: A candle is lit for 40 days and 40 nights. The woman stays in a warm room, dressed in warm clothes and fed with hot food. The aim is to restore the body’s balance and protect it from evil spirits [21].

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Psychiatr Q Table 1 continued Country

Cultural beliefs and postpartum practises (Asia)

India

40 days of home care from family and friends. Women should look cheerful and happy for the child’s good luck. There is an intense criticism, resentment and hostility from society when a baby girl is born [21, 36, 46].

Tibet

Traditional birth at home. There is the fear of attack by spirits and demons during transportation to the hospital. Fear for the health care services [47].

Arab countries

A quarantine period of 40 days. The mother gets great help from her family. Islam gives great emphasis on the role of the family [18].

UAE

Support of the woman from the husband’s family. The greater the number of children in the family the woman enjoys greater respect from society [21].

Jordan

Ultimate responsibility of the woman is the formation of the family. The woman’s social reputation is raised after giving birth to a male child [16, 18].

Turkey

The woman and the child are not left alone for 40 days after childbirth. Woman’s mother or mother-in-law or some female relatives stay with her throughout the day for protection from the evil spirit ‘‘Jinni’’ [21].

Pakistan

‘‘Chila’’: 40 days of seclusion and relaxation. The new mother is considered dirty and she is not allowed any activity. Decisions about the care of the child are taken by the whole family (parents, mother-in-law, other family members). A positive fact is the birth of a male child [14].

Special Populations Hmong (ethnic group from mountain regions of China, Laos, Vietnam, Thailand, Southeast Asia)

The family focuses on the mother and child. Eating chicken soup containing the plant ‘‘ntiv’’ (absolves from bad blood after birth). Ceremony at home with a therapist, the ‘‘Shaman’’, for the return of the soul to the body of the woman and prevention of depression [48].

PPD in Middle East and the Arab world Studies show rates of appearance of 21 % in Lebanon, 5–22.6 % in Israel [2], 28.8–63.3 % in Pakistan [60, 61], 18 % in United Arab Emirates (UAE) [2], 25.3 % in Iran [62] and 14–42.7 % in Turkey [2]. In Israel, women tend to express their depression through hypochondriac behaviors. They are dominated by anxious thoughts for normal physical symptoms that occur after childbirth [21]. In Iran, the disease manifests itself mainly with somatization of depressive symptoms and feelings of guilt [63].

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Programs and Therapeutic Interventions Recently, significant progress has been made on the awareness of PPD and strategies for the diagnosis and treatment have been developed [64]. We specially mention: (A) The 6-year duration Program for Improving Mental Health Care (PRIME) in low-income countries in Africa and Asia, which started in 2011. PRIME’s main aim is to reduce the treatment gap and to improve the mental health services provided to psychiatric disorders, including those of the maternal period [65]. (B) Since 1982, several programs have been focused on providing mental health services in India, coming from Governmental and nonGovernmental Organizations (National Mental Health Programme, District Mental Health Programme) [66, 67]. In 2009, the first mother–baby unit (MBU) of the country was created, in Bangalore [68]. (C) Since 1995, the government of Israel has mandated universal health insurance including perinatal follow-up. In 1999, a screening program for mental disorders was joined to the primary health system of Israel, including perinatal screening for PPD and PPD-risk in the national network of Mother–Child Health [64, 69].

PPD in Africa Africa constitutes another ethnokinship culture [16]. In these cultures, as well as in Asia, PPD is characterized primarily by physical symptoms, because of the fear of social stigmatization of women [27, 70]. A lot of attention is given to postnatal care, during which great importance is given on supporting the new mother. This support comes mainly from the family and her social environment, which focus on both the mother and the infant [16, 27]. The midwives have full responsibility for prenatal, postnatal care and childbirth [71]. Postnatal care includes a period of 4–8 weeks of rest. The body is painted with henna, which ‘‘elevates’’ the spirit, protects from depression and marks her new position in society as a mother. The new mother should be kept warm, to maintain the balance of ‘‘hot and cold’’ on her body [37]. The placenta is thought to bear evil spirits and should be buried in a place where it could not be disturbed and harm the baby. It is considered that children come from the spirit world. They are not given names until they are sure they will survive and so the evil spirits cannot see and harm them [71, 72]. Indicatively cultural beliefs and postnatal practices of specific African countries are presented in Table 2. Life in Africa is under extreme poverty conditions. During pregnancy increased incidents of morbidity appear, as well as increased risk of deaths and incidents of AIDS [24, 73, 77]. PPD is the most common postnatal psychological disorder in Africa, with prevalence rate 18.3 % [24]. A systematic review in six African countries [24] showed incidence rates of the disease from 3.7 to 20.9 % in Nigeria, 5.6 to 20.1 % in Morocco, 3.2 to 6.9 % to The Gambia, 34.7 to 48 % in South Africa, 12 % in Ethiopia and 10 to 43 % in Uganda [24, 70]. In Egypt, the disease showed a prevalence of 17.9 % [22]. Main symptoms are: frequent headaches, general body pain, muscle aches, frequent crying, and feeling of internal failure and increased irritability [78]. Notable is the outbreak of the disease in Nigeria, which is manifested mainly by nausea, vomiting and a burning sensation in the head [79], while women often complain of feeling ants walking into their head [80]. In Uganda, the disease may manifest itself in suicidal ideation [81], in Morocco with multiple aches or sensation of ball in the throat and in Tunisia very common are the

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Psychiatr Q Table 2 Cultural beliefs and postpartum practises of Africa Country

Cultural beliefs and postpartum practises (Africa)

Egypt

40 days of isolation and relaxation follow the birth of a child. Help with child care and housework is provided by relative women. The woman gets hot meals and avoids cold foods and beverages. The woman gets strong criticism by her husband and his family after the birth of a female child which may even lead to a divorce [18, 22].

Ghana

Childbirth at home. The women of the family take the decision about the place of the labor. The pregnant woman has no right to express an opinion [73].

Mozambique

For protection from evil spirits the woman’s pregnancy should stay within the family. Women are not subjected to any prenatal and postnatal care and have little contact with medical services [73].

Nigeria

Pregnancy is guided by the mother and the mother-in-law. A boy’s birth is celebrated as a victory. The woman and child are isolated in a room for 2–3 months. The woman’s obligation is the good nutrition and gaining of weight, resting and taking care of the child. She is provided the best food for a month. In rural areas people reject the existing health systems [16, 28, 73–75].

Somalia

After birth the mother wears earrings made of garlic for protection against the ‘‘evil eye’’. A great feast in honor of the new mother and baby is organized 40 days after the child’s birth [38].

Uganda

The husband and relatives select the place of the labor. The birth is considered a normal event that doesn’t require medical intervention. Few women prefer medical facilities and the majority chooses the traditional home birth.Postnatal home isolation for 3 months. Great physical care and neglect of mental health [38, 70, 76].

Special populations San Bushmen (native group of South Africa)

The woman’s thoughts during pregnancy affect both the childbirth and the child. During pregnancy, the woman is obliged to continue her routine and obligations without any resentment. Most of them have to give birth alone, in areas just outside their neighborhoods. Assistance at delivery is provided only for primiparous women. The little girls are encouraged to attend the labor of other women, so they are able to control their fears when they are in the same position [71].

generalized pains, heaviness, dyspnea, malaise and vertigo. Women may also report a feeling of ‘‘broken neck’’ due to the burden of depression carried by them [78].

Programs and Therapeutic Interventions Although PPD is a major public health issue, is characterized by incomplete diagnosis and treatment and inadequate intervention by health services as well [24, 70]. In 1997 and 2002, Postnatal Depression Support Association of South Africa (PNDSA) and Perinatal Mental Health Project (PMHP) were respectively created for the awareness of health professionals and of the community about the disease and to provide appropriate support and treatment to women experiencing PPD as a routine part of their health care [82]. PNDSA works with community health services and professionals, researchers interested in mental health of women, practitioners of ‘‘alternative’’ medicine and religious organizations, aiming to break the silence and stigma surrounding perinatal depression [83]. PMHP in

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collaboration with the Ministry of Health addresses pregnant and postnatal women with mental illness [82].

PPD in Europe Western Europe is placed among the technocentric cultures [16]. The disease manifests itself mainly with the typical depressive symptoms that have already been described [2] and the support to depressed mothers is offered by mental health professionals [84]. A lot of technological devices are provided which monitor the welfare of the new mother. In the United Kingdom because of the modern lifestyle, the habit of the new mother to be absent from work, taking care and rest, tends to be abandoned. The woman leaves the hospital 1–2 days after birth and soon returns to daily obligations. On a review carried out, British women report a significant degree and high quality physical and emotional care during the postnatal period by health professionals [85]. The institution of the family and traditions are characteristics of the culture of the Greek society. Postpartum woman confined at home usually for 40 days, on which rests, takes care of the child and receive support and help from her mother and family [86, 87]. In Sweden, during pregnancy, unemployed women receive from the state the lowest parental income [88]. The mother’s postnatal social support has proven a potent protective factor for the disease. The support to women suffering from PPD is mainly provided by psychologists [84]. In Malta there is a great practical and emotional support to the new mother, especially from her mother [89]. Studies in European countries revealed prevalence rates of 2.84–13 % in Italy [5, 8], 11 % in France [23, 90], 11,1 % within the first 2 months postpartum and 13.7 % within a year after delivery in Sweden [88], 12.4 % within the first 2 months after delivery in Greece [87], 3.6 % in Germany [91], 8.7 % in Malta [89], 5–22 % in the UK [92] and 10.9 % in Hungary [93]. A study in France revealed that more than half of women with depressive symptoms in the postpartum period had experienced prenatal depression [90]. In these cases, they faced the situation with a strong sense of guilt and extreme behaviors such as substance abuse. In a study, women with PPD in the U.K reported symptoms of easily fatigued, often crying, feeling guilty about their condition and stress, anxiety, panic and fear, without a clear provoking factor [85]. The majority of depressed mothers in Malta described their child’s upbringing as particularly ‘‘difficult’’ [89]. Unlike Western and Central Europe, Eastern Europe countries implement the traditions of ethnokinship cultures concerning the prenatal and postnatal period. The woman after childbirth is isolated at home for 5 days. Then, the father and relatives visit the mother and see the baby for the first time and a period of social isolation for the mother follows again for a month [28].

Programs and Therapeutic Interventions A study carried out in seven European countries revealed different views about the social services deemed suitable to provide practical and emotional support to mothers during postpartum period [84]. Marce´ Society, with members from all parts of the world, is an international society, open to all professionals, which since 1980 aims at improving the understanding, prevention and treatment of mental disorders associated with childbirth. Today, national bodies of the society have been created, in countries such as France (Society Marce´ Francophone), Germany (Marce´ Gesellschaft) [94], U.K and Ireland and Spain [95]. A lot of MBUs have also been developed in many countries, including Great

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Britain, France, Netherlands, Hungary, Luxembourg, Switzerland and Belgium [96, 97]. In Germany, despite the fact that the creation of MBUs is delayed, admissions of mother– baby in psychiatric hospitals and clinics are done when necessary. MBUs provide full time psychiatric care for women, while allowing the parent–infant bonding and a proper care for the child’s development [97]. The United Kingdom provides significant support from governmental and non-governmental associations for depressed mothers with easy access to treatment programs [98]. The public health system provides for 1 month home monitoring for women with great need of care, in order to estimate the risk of depression [34]. As most suited to provide support to postnatal women appears to be the health visiting midwives and general practitioners [84]. In Sweden prenatal health system comes in contact with almost all women, providing regular physical and psychological checkups during pregnancy and the postpartum period. The Swedish Child Health Services suggest control for PPD in all women, 8–10 weeks after labor [88].

PPD in Australia Australia is another technocentric culture. Until 2011 it was one of the three countries that hadn’t implemented the law to provide financial support during maternity leave [16]. Women suffering from PPD experience the typical symptoms of a depressive episode. In Australia PPD is the most common and treatable mental illness. The reported prevalence rates range between 10 and 20 % [99]. According to the literature review, women with PPD report significant frustration because of the gap between their expectations of motherhood and the reality due to their illness, with problems in adapting to maternal role. They describe loss of joy and interest in their simple and everyday habits before pregnancy, very early after childbirth [100]. They may also experience symptoms such as sadness, guiltiness, fear and panic, suicidal ideation, loss of control and frustration [59]. In another study, women with a history of PPD described the disease as a frightening and isolating experience [101].

Programs and Therapeutic Interventions Even though in the previous years there have been reports of gaps and deficiencies concerning the care of postnatal women [102], today the Australian Government has developed programs and initiatives for the best provision of postpartum care. In 1995 ‘‘The Marce´ Society - Australian Branch’’ was founded, with the same objectives as the international association, but focusing more on the promotion of mental health, the prevention and early intervention [94]. In 2008, at the Australian Health Ministers’ Advisory Council meeting, state and territory governments alongside with the Australian Government agreed to collaborate on the development of a National Perinatal Depression Initiative, aiming to improve the prevention and the on time diagnosis of prenatal and postnatal depression and to provide optimal support and treatment for expectant and new mothers who experience depression [103]. A number of public and private MBUs have also been developed, mainly in Melbourne and the state of Victoria [97].

PPD in North America The countries of North America are included in technocentric cultures [16]. PPD is manifested mainly through psychological symptoms [2].

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PPD in USA 1–2 days after delivery the woman is provided with the necessary advice of how to take care of herself and of the newborn and then leaves the hospital. The state gives to the new mothers 12 weeks of unpaid maternity leave; however few of them and under very strict criteria can take the benefit of it. The only states which provide paid maternity leave are Hawaii, New York, New Jersey, California and Rhode Island [16]. The medical care of women after childbirth has a low interest and is not assessed to the extent it should [102, 104]. Women who are covered by medical insurance receive home visits from a nurse 3–4 days after leaving the hospital. However, the time available to them is short and insufficient, so the probability of proper risk assessment for PPD is limited [16]. A systematic review of the literature on the prevalence of the disease in the U.S. from 1982 to 2011, shows rates of 3.7 % up to 36 % [2, 105]. In the specific cultural groups of the U.S, the reported prevalence vary within 4.6–10.7 % in Asian-American [106, 107], 6.4–16.7 % in Hispanic [107, 108], 3.7–20.7 % in African-American and 2.6–14.8 % in Caucasian [107–109]. Even though a study reports greater prevalence of the disease among Asian–American women compared with women from other ethnic groups [107], an other study revealed very low prevalence among them (about 4.6 %) [106]. This rate of prevalence is considerably lower compared with the relevant one in the native countries of these women and it has been attributed to the specific negative beliefs of these cultures concerning mental illness. Trying to avoid the stigma brought about by the diagnosis of a mental disorder, they tend to minimize the psychological discomfort and express mainly physical symptoms of the disease. It has been found that these women, unlike other ethnic groups of the USA, are more likely to be diagnosed for the disease, after contact with mental health providers and be informed about the changes in mood during the postpartum period. However, the probability of information in this population is very small [107]. Hispanic women are the second in frequency cultural group who appears with the disease [107, 108]. However, the probability of being diagnosed compared with the Caucasians is comparatively very low [107]. Women who experienced PPD referred as the most frequent symptom: anxiousness without the presence of specific reasons [108]. In African–American cultures depression is considered a sign of weakness and believed to derive from the seizure of the body by demons as a form of punishment for sins. Women with PPD think that they don’t meet with the image of the ‘‘strong black woman’’ and feel guilty about their condition. Shey turn to family, friends and religion to face their problem and often believe that ‘‘conversation’’ with themselves will help them heal. Usually they hide their negative mood symptoms and the disease manifests itself mainly through physical symptoms such as fatigue, back pain and headaches [110]. They may also experience intense anxiety for the child’s care, frequent and uncontrollable crying and inability to control their emotions and thoughts [14, 110]. Despite the fact that these women are more likely than all other cultural groups in the U.S. to be aware from health professionals for PPD, most are not willing to reveal their symptoms [107].

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Caucasian women, compared with other cultural groups, have the lowest risk for PPD [107–109] and a greater chance for their disease to be diagnosed by professionals of mental health [107].

Programs and Therapeutic Interventions U.S provide several home visitation programs to control women at increased perinatal risk for depression, such as the ‘‘Healthy Families America’’, ‘‘Healthy Start’’ and ‘‘NurseFamily Parentship’’ [111]. In 2008 the ‘‘Mental Health America’’ (MHA) recognizing the need to develop an integrated system of prevention, awareness and treatment of perinatal mood disorders (PMDs), proposed the Position Statement 38 Perinatal Mental Health, which was approved from the MHA Board of Directors for 5 years effect. This policy proposed education about PPD, screening for PMDs and follow up care in all health plans in all business health areas, health programs and information on PMDs (in the workplace, during the perinatal care, in pediatric visits and during the hospital discharge). It also proposed the increased research for the causes and the prevalence of the disease, the differences between racial groups and the improvement of the detection, diagnosis and management of it [112]. In 2011 the University of North Carolina—Department of Psychiatry, created the Center for Women’s Mood Disorders, for treating women with PMDs. This unit is the first of its kind in the U.S, providing inpatient services through nursing units for specialized care for women in need and outpatient services with clinical and research programs [113]. In some cities, like Providence of Rhodes Island, inpatient day units with benefits similar to those of MBUs have also been developed [114].

PPD in Canada According to the literature, PPD displays low prevalence, with reported rates from 4.5 to 8.69 % [115–117]. Canadian women with PPD history describe that period as isolated and moody, during which they felt worthless, guilty and very emotional. They experienced symptoms such as fatigue, lack of energy and sleep, anhedonia, irritability, anxiety and forgetfulness. They cried a lot and without a reason and didn’t feel like their selves anymore. A lot of those women tended to normalize their symptoms in order not to be labeled as ‘‘crazy’’ or ‘‘bad mothers’’ and they didn’t seek for help, as they felt ashamed and embarrassed about their condition [118, 119]. There are also some reports of suicidal tendency and somatization of depressive symptoms [63].

Programs and Therapeutic Interventions The system provides home health monitoring of new mothers a few days after their exit from the hospital [102]. Many nonprofit charitable organizations have also been developed, aiming at the public and professional awareness of perinatal depression, the care of women experiencing PMDs as well as their families, and to improve access to health services. Some of these organizations are the ‘‘Mother Reach’’, ‘‘Postpartum Disorder Project Ontario’’, ‘‘Moms Supporting Moms’’, ‘‘Pacific Postpartum Support Society’’, and ‘‘Postpartum Depression Awareness’’ [120].

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PPD in South America In South America PPD occurs in alarmingly increasing frequency. The literature mentions high prevalence rates of about 42.8 % in Brazil [2], 4.6–48 % in Chile [2, 121], 57 % in Guyana [49], 57 % in Colombia [122] and 22 % in Venezuela [123]. In Chile the disease manifests itself mainly with suicidal ideation, disturbance of appetite and sleep, emotional instability, insecurity and anxiety. Women may also feel shame and guilt about their condition and often have a feeling of ‘‘losing’’ themselves [78, 121]. The majority of women who experience depressive symptoms in Brazil are identified by their family environment, which observes extraordinary changes in their behavior. Most women feel regret without specific reason and refuse to take care of the baby [124].

Programs and Therapeutic Interventions In these cultures, the disease is not recognized as a serious condition for women’s health, and as a result, programs for the prevention and treatment are absent from their health system [34]. In Colombia PPD is characterized by poor understanding and diagnosis by health professionals [125]. In Chile the reduced funding and inadequate staffing of primary health services delay the access of depressed mothers of low social classes to the public mental health services. This, results in a limited treatment of these women, increasing the duration of their depressive symptoms and the prevalence of the disease among them [126]. Even though the Chilean Health Service has been providing free screening in women who have depressive postpartum symptoms since 2008, preventing screening for PPD is not part of its priorities [121]. Despite the high prevalence of the disease in Brazil, the Brazilian Ministry of Health has not adopted specific protocols and guidelines for diagnosis and treatment of the disease [127]. Postnatal medical care has as focus the physical health of women and so the disease is a neglected topic in primary healthcare [124]. Postnatal checkups on women are carried out in their homes 1 week and 40 days after labor, from the Family Health Strategy (FHS). FHS is a group of health professionals, but with inadequate education and limited clinical knowledge about the recognition, diagnosis and treatment of PPD, and as a result the only help they can provide to women with depressive symptomatology is recommending them to a psychiatrist, risking the status of women to be deteriorated in case of delay referral [124].

Migration and PPD Several studies have revealed a very strong correlation between migration and PPD [18, 128–133]. A study concluded that the extent to which migration affects the occurrence of postpartum depressive symptoms, depends on the time of migration and the degree of acculturation of immigrants in the new cultural environment [116]. Unlike, a study didn’t find a consistent relationship between acculturation and PPD [134]. The difficult conditions under which people are led to migration and the stress, which is associated with living in a new and unfamiliar cultural environment, can often negatively affect the psychology of the new mother [116]. The negative experiences of women before migration, the difficulties in language and communication, the low socio-economic status, the difficulty in adjusting to the new culture, the isolation of immigrants from society and the lack of postnatal social support, are some of the difficulties which women faced in their new environment and can adversely affect their mental health [18, 131]. In other cases, illegal migration and fear of

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deportation are extra stressful stimuli with a negative impact on the psychology of the new mother [135]. Studies reveal particular vulnerability to the disease in immigrants living in Canada. This phenomenon is attributed mainly to the difficulty in communication due to language barriers, cultural and socio-economic factors [131]; while another study suggests an increased risk of the disease in women born outside Canada, even after adjusting to the socio—economic status of the country [115]. A study [130], found that of women with PPD from the Caribbean living in the UK, most of them felt socially isolated and had little postnatal support from the state. In Sweden the reduced support of immigrants from the family and society causes intense anxiety during the prenatal and postpartum period. The risk of hospitalization due to psychiatric cause is particularly high among them [128]. There is a report of increased stressors associated with migration which affect negatively pregnancy and postpartum period in Spanish female immigrants in the U.S. Many were those who felt sadness with the birth of their child, after being reminded of their other children left behind in order to be able to emigrate [133]. Equally increased risk appears in Puerto Ricans and Mexican immigrants in the U.S. [134], while another study reported lower incidence of the disease in Mexican immigrants in the U.S. who have followed the postnatal practices of their tradition [136]. A study revealed a significantly increased risk in Jordan women who migrated to Australia. The lack of family support and the inability to perform traditional practices cause feelings of loneliness and despair for these women, contributing to the appearance of their depressive symptoms [18]. Equally increased incidences of the disease are reported among immigrants from India, Bangladesh and Portugal living in the U.K. The factors associated with immigration and favored towards the development of the disease in these women represented the feeling of isolation in the new country, the difficulty of separation from their family, negative feelings about the place they were staying and the absence of their husbands from the country in which they emigrated [129]. The absence of postnatal social support has proven to be a strong predisposing factor for the disease, for immigrant women as well. A survey highlights the increased risk in women who come from countries where special emphasis is given to the perinatal period, where the new mother is greatly appreciated and receives increased physical and emotional support from family and society [137]. Immigrant women with PPD in a study [129], felt that the conditions would be different if they had the ability to give birth at home near their families. The financial difficulties, the unequal treatment in the workplace and the dependence on their employers, created to these women the feeling that they don’t have the control of their lives and the care of their family. These considerations reduce their selfesteem and as a result they are more vulnerable towards the disease [132].

The Gaps of Therapeutic Interventions Most immigrant women with PPD remain untreated with serious consequences for themselves and their child. Fear for notification of the disease, the social stigmatization, the isolation from the family and society, and for the chance to be considered unfit mothers with the risk of losing custody of the child, prevent these women to reveal their negative feelings and seek assistance [129, 131, 133]. On the other hand, those who want to seek help often find many obstacles. Most have little knowledge about available health services and do not know to whom and where they must apply; while others consider that health services in a foreign country are not affordable [129, 131]. Some women are pressured by their families not to reveal any symptoms they have, which they interpret as ‘‘natural consequences’’ following childbirth. They believe that the contact of women with a

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psychiatrist will have further negative and long-term consequences for their health. Other factors preventing the search for help are the limited financial resources, difficulty in communication and lack of relevant persons to care for the child during the woman’s therapy sessions [132]. Nevertheless, many women who eventually sought help, reported negative experiences after their contact with medical services. There are reports of racist attitudes and unequal treatment of entities experienced by immigrants with PPD in Canada. The researches also found that the therapeutic support groups, in which the women participated, were not always helpful and responsive to their individual needs [131]. Jordanians in Australia who came into contact with health professionals indicated conflicting views about their care. While the women wanted to follow the traditional practices of their homeland, health care professionals were trying to change their behaviour and to integrate them into their own therapeutic treatments [18]. Muslim immigrants who addressed in postnatal care programs, experienced discrimination and lack of awareness and knowledge for their religious and cultural practices [138]. A survey also highlights the unequal treatment of immigrants who sought help from health services, such as unavailable translation services, discrimination and prejudice. The poor economic status of these women grew the possibility of unequal responses [132]. The women from the Caribbean living in the UK reported the need for more practical help from health services rather than dealing through simple discussion, since many times the disease may result from the presence of other problems [129].

Cultural Diversity of Risk Factors According to the literature review, the absence of postnatal social support and the personal history of psychiatric disorders, particularly of depression, seem to be the main predisposing factors, significantly contributing to the occurrence of the disease in many Western and nW-countries [7, 8, 21, 22, 25, 26, 86, 91, 93, 100, 105, 108, 116, 117, 123, 125, 139– 143]. Additional common predisposing factors according to bibliography are low income and financial difficulties [21, 23, 98, 116, 144], free marital status [24, 70, 93, 109, 134, 140, 144, 145], prenatal mood disorders [21, 90, 93, 105, 108], unwanted or unplanned pregnancy [21–24, 89], poor marital and intrafamilial relationships [21, 23, 26, 56, 84, 86, 89, 146, 147], premature birth and infant’s health problems [21–23, 84, 141, 147], low self-esteem [21, 26, 108, 148], poor conditions of living [21, 93, 149], unemployment [8,21,23,26,8688], stressful life events [8, 21, 25, 26, 86, 88, 116, 145, 150], low education [8, 21, 57, 77, 88, 93, 109, 141, 151], low socio-economic status [21, 109, 142, 144, 145], history of alcoholism within the family [21, 93, 108, 140]. Even though most of the risk factors are the same between different civilizations, some cultural factors play a decisive role in the appearance of the disease and occur almost exclusively in nW-countries. Main factor is the birth of a female child in cultures with overt social preference to a male. In these cultures, where the woman is a victim of genderbased discrimination and which has been found to contribute to the appearance of PPD, many Asian countries are included, such as Japan, China, India, Turkey [21], Jordan [4] and African countries [24] such as Egypt [22]. An additional factor is the postnatal traditional practices. Although the main aim is to relief the postpartum woman, it has been found that many times, the same practices, can adversely affect her psychology, in countries such as Japan [41], Hong Kong, Taiwan [21], Nigeria [24] and Uganda [84]. Moreover, a predisposing factor is the hostility and violence within the family. The frequent occurrence of aggressive behaviors in these cultures could be attributed to the resentment of the husband and his family for the child’s gender. These factors showed an

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association with PPD in countries such as Hong Kong, Turkey [21], India [21, 57] and Egypt [22].

Discussion As with other studies [152], we found that different cultures share the same risk factors towards the disease. Nonetheless, our research revealed significant differences in the prevalence of the disease among both Western and nW-cultures and between the cultures themselves. The disease in Western cultures seems to have a mean prevalence compared with those in nW-cultures and less variations between countries themselves. In most cases, the prevalence ranges between 12 and 20 %, which concurs with the results of other studies [29, 30]. Instead, in nW-cultures, this review revealed (1) significantly higher prevalence, such as 73.7 % (Taiwan), 63 % (Pakistan), 48 % (South Africa, Chile), 43 % (Brazil) and 57 % (Colombia), (2) greater variation of the disease in surveys conducted within the same countries, (3) very small prevalence rates in certain cultures. However, as [2] also concluded, we cannot say for sure if this is really small prevalence or under diagnosis of the disease. The low prevalence in certain countries such as Singapore, Malaysia and Japan probably can be attributed to the adoption of more ‘‘Western’’ lifestyle of these civilizations. Unlike, the low prevalence in certain countries, like Nepal, and the large variation within the same countries, can be attributed, as also demonstrated by previous studies, on (1) cultural aspects, related to the specific perception of these civilizations, for mental health as well as the social exclusion of those who are diagnosed as mentally ill [2, 131], (2) differences in estimation methodology, the time of the evaluation and the specific characteristics of the culture under study in each case [2, 21, 34, 116, 153], (3) the lack of medical information and medical intervention in some cultural groups under study [107, 124], (4) the way in which women in nW-cultures express their symptoms, mainly through physical reactions, in contrast to women from Western cultures [2, 21, 28, 34, 35, 154]. A significant fact, which could also affect the recognition of the disease, could be the absence of reference to the disease in some cultures. Indicatively we mention that in India and Philippines PPD is something people don’t talk about [131], the term ‘‘postpartum depression’’ it was unknown among Jordanian population until recently [18], while in Tunisia and Morocco, the term depression is replaced by expressions such as ‘‘feeling engulfment by black chicken’’ and ‘‘black days’’ respectively [78]. In the topic of PPD symptoms, we found that the more non-West is a culture, the more tendencies there are for somatization of depressive symptoms. This could explain the low prevalence of the disease in some of these civilizations. The emotional disturbances are mainly manifested through physical symptoms, because of the different perceptions of mental health, the negative attitude towards its disorders [2, 21, 35] and the high expectations of some cultures for motherhood [3, 18, 155]. For example, in India women tend to interpret the physical symptoms of PPD as normal symptoms following childbirth [156]. Jordan society has high expectations of the woman in the role of motherhood, and because of this she must cope with the difficulties presented without complaint and regret, otherwise she is considered inadequate for maternal role [18]. Japanese women are willing to endure the physical and psychological discomfort for the sake of the infant [155] and women in Hong Kong hide their depressive mood in order not to be considered inadequate for motherhood [59]. In some cases the disease can manifest itself through strange illusionistic experiences (ants in the head, ball in the throat, ‘‘phantom crying’’) or as a cognitive disorder, because of confusion, forgetfulness and the loss of control [58, 59, 78].

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In both cultures a postnatal period of rest for the new mother is routinely observed. In most nW-cultures, this period lasts for 40 days [18, 21, 38, 104], including information and practices adjusted to the particular beliefs of each nation. In most cases, the woman is considered to be dirty and therefore should avoid any activity, as well as very vulnerable, so she should be fed well and avoid exposure to cold. In Asia emphasis is given on restoring the balance of ‘‘Yin and Yang’’ in the body of the woman. In both continents, Asia and Africa, gender-based factors affect the image of the new mother and the care she will receive from the family and society. The prestige brought from the birth of a boy and the strong influence of a counter-event to the mental health of women, through the strong criticism she receives, has been studied [21, 22, 107, 152, 157] and is one of the major risk factors for the disease in nW-countries. In Africa it seems that ‘‘the desires and needs’’ of women in relation to pregnancy and maternity are placed on the sidelines, the women themselves do not have the right to express an opinion on these issues and decisions are matters solely concerned their spouses and their family [73]. We have also found that the more isolated are some cultures (Hmong, San Bushmen) the more unusual and extraordinary perinatal practices have. Even though traditional practices are considered being beneficial for the wellbeing and health of women in the postnatal period [45, 158], their effects may not always be a privilege for their emotional stability [16, 21]. It is concluded that despite the great physical relief they provide, many times the same practices are a source of mental conflict and emotional turmoil. The stress on participating, the dissatisfaction with the content of practices and the poor relationships with the people involved in them, has been found that can adversely affect the psychology of the new mother [14, 16, 34]. Many women participate against their will, or under pressure from their immediate family environment in order to avoid conflicts with it [21, 34], while others struggle to adapt to the ‘‘rules’’ of traditional practices because of controversies and bad interpersonal relationships with family members involved [34, 59]. Specifically, in a study [159], Chinese women living in Australia expressed ambivalence about traditional practices, and perceived that they follow them mainly due to pressure from the in-laws. Many are the Japanese women who do not feel they are protected from traditional practices, while studies have shown that participation in ‘‘Satogaeri Bunben’’ does not reduce the risk of PPD [41, 42]. Women from Singapore described their experiences during the traditional practices as ‘‘negative’’, a factor that contributed to the emergence of their depressive symptoms. Many women in Vietnam experienced depressive symptoms despite their participation in the postnatal period of isolation and care. A lot of women argue that the traditional period ‘‘Doing the month’’ is characterized by many environmental restrictions, shows several difficulties during their performance, causes conflicts between the members involved and often restrict the smooth transition of women in their maternal role [21, 59]. Concurring with [21] suggestion, we believe that another reason why the traditional rituals in these cultures often fail, may be their inability to prevent psychological distress against inevitable challenges, such as the child’s sex, physical and mental condition of the woman and the poor economic situation of the family. On the other hand, the postnatal period in the Western world consists of a more technologically tailored care, with short duration. A short period of mother’s hospitalization is provided and soon she returns to her professional obligations. This, leaves little time to train and adapt to her new maternal role [16, 33]. A study argues that the return of woman to work after labour endangers her psychological health since it is difficult for her to manage her time between work and taking care of the infant [160]. Only in France, unlike most technocentric cultures, the return of mother to work, securing a monthly income and time away from the child, is reported as a favourable factor for emotional stability [84].

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Social isolation, financial pressures and lack of postnatal support practices render the mother’s return home from hospital as the most vulnerable time of her period of maternity [27]. Even though the birth and infant’s health problems use of technological devices can successfully protect the woman in the perinatal period, there are no provided procedures to contribute to her psychological adjustment after birth [16, 33]. In the U.S., postpartum care practices are characterized by a lack of individualized care and are considered by the nursing staff difficult to implement [102]. The results from the use of technological devices in Europe and from mother’s frequent contact with maternal health services during the prenatal and postnatal periods may affect either positively or negatively her mental health. Any possible negative treatment by the medical and nursing staff and insufficient time for essential communication with them can be sources for her unhappiness. On the other hand, the potential for medical intervention either on the presence of complications of pregnancy or proactively, provide reassurance with a favourable impact on her fragile emotional state [84]. As far as we know, this review is the first to present a comprehensive picture on the interventions connected to PPD around the world. It is obvious that the more non-West a culture is the less interventions concern on mental health. The same phenomenon is observed on populations burdened by immigration. We believe that the availability of educational and therapeutic programs contribute significantly to reducing the risk of disease appearance and its early treatment. Other studies confirmed these findings [116, 161, 162]. The low prevalence of PPD in Western Europe may be due to educational programs about the disease and the therapeutic intervention that these civilizations provide [49]. There is a suggestion that psychotherapy is the most appropriate mean to improve the ability of the woman to cope with situations that trigger stress in her life. Treatment during pregnancy can significantly reduce the risk of PPD [26]. An other survey proposes interpersonal psychotherapy as the most effective therapeutic approach to the disease [140]. In nW-cultures, although information about the disease is small compared to the prevalence of it [70, 152], significant actions are being implemented against the disease. In Western countries the existing governmental and non-governmental organizations contribute significantly to the prevention and early intervention. However, in countries of southern Europe that have quite a lot of ethnokinship elements seems that the interventions may not always lead to the positive effects. In Greece very few women will seek help from mental health services. There is still a minor update of the Greeks and lack of knowledge and understanding of health professionals about mental disorders during postpartum period [86]; while in Malta most cases of PPD go undiagnosed and untreated, highlighting the need for a more comprehensive and specific approach of the new mother from Mental Health Services [89]. In U.S. despite increased awareness about the disease, Asian American women, even though have access to health systems through work, few of them will seek and receive help for their problem. In this way they utilize inefficiently their ability to use mental health services, thus contributing to underdiagnoses and underreporting of the prevalence of PPD among them [106]. The same elements have been found for African Americans, whose fear of stigma, lack of confidence and the negative attitudes about the psychiatric health services and the interventions which they provide, prevents them from seeking help from specialists [111]. This probably reflects the strong belief that women of both cultures carry, and although they are in a country with easy access to the health system, they refuse to use it. In South America, although the prevalence displays a worrying increase frequency, postpartum interventions do not relate to PPD.

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Conclusions It is clear that cultural beliefs and values of women shape the way in which they approach the health services and affect their expectations for the care and the treatment they will receive. The problem in contact with health professionals is that they consider that the disease is experienced and expressed by all women in the same way. The beliefs held by culture should be taken seriously in detecting of PPD as well as the assessment of the realistic needs of women who have recently given birth. It is vital the development of a trustful relationship and sense of security between the women and their health professionals, especially in those cases where the woman comes from countries with particular perceptions about mental illness. We consider that it would be necessary the integration of a more nation-individually antenatal and postnatal screening for PPD, as well as to be manned with suitable trained personnel on issues of women’s mental health, on every health system where mothers or mothers to be have access.

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Olympia Evagorou MD Resident of Psychiatry at Limassol General Hospital - Cyprus. Member of the clinical team of ‘‘perinatal mental health’’ of the University General Hospital of Alexandroupolis-Greece. Aikaterini Arvaniti MD, PhD Assistant Professor in Psychiatry, Department of Psychiatry, School of Medicine, Democritus University of Thrace, Greece, at the University General Hospital of Alexandroupolis, Greece. She is in charge of the ‘‘perinatal mental health clinic’’ of the University General Hospital of Alexandroupolis. Her main area of clinical and research interest includes the study of stigma in mental illness, social and community psychiatry and perinatal psychiatry. Maria Samakouri MD, PhD Associate Professor in Psychiatry, Head of the Department of Psychiatry, School of Medicine, Democritus University of Thrace, Greece, at the University General Hospital of Alexandroupolis, Greece. She is in charge of the rehabilitation programs in the catchment area of the University General Hospital of Alexandroupolis. Her main area of clinical and research interest is social and community psychiatry.

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