Postpartum depression in puerperal women: knowing the interactions among mother, son and family

Abstracts

OBJETIVO: Conhecer a interação de puérperas, que apresentam depressão pós-parto, com seus filhos e compreender a percepção de familiares sobre a doença e cuidados maternos prestados por essas puérperas. MÉTODOS: Estudo qualitativo de caráter exploratório que teve como sujeitos do estudo quatro puérperas com depressão pós-parto, acompanhadas em um Centro de Atenção Psicossocial do município de Quixadá - CE e quatro familiares. Foram realizadas visitas domiciliárias para a execução de entrevistas em profundidade. Os dados foram analisados conforme a técnica de análise de conteúdo proposta por Morse e Field. RESULTADOS: As principais alterações emocionais relatadas foram o choro fácil e nervosismo. As puérperas sentiam-se frustradas e/ou inseguras quanto ao exercício da maternidade. Como agravante foi observado que familiares desconheciam o problema da depressão pós-parto. CONCLUSÃO: O cuidado de enfermagem nessa situação deve começar no pré-natal com avaliação da auto-estima, da rede de suporte social e da satisfação das futuras mães.

Depressão pós-parto; Relações familiares; Enfermagem

ORIGINAL ARTICLE

Postpartum depression in puerperal women: knowing the interactions among mother, son and family^*

Depresión posparto en puérperas: conociendo interacciones entre madre, hijo y familia

Francisca Cláudia Sousa da Silva^I; Thiago Moura de Araújo^II; Márcio Flávio Moura de Araújo^III; Carolina Maria de Lima Carvalho^IV; Joselany Áfio Caetano^V

^INurse. Neonatal Nursing specialist. Center of Psychosocial Care of Quixadá. Quixadá (CE), Brazil

^IIPost Graduate (MSc) of the Post Graduation Program in Nursing of the Federal University of Ceará. Fortaleza (CE), Brazil

^IIIPost Graduate (MSc) of the Post Graduation Program in Nursing of the Federal University of Ceará - UFC - Fortaleza (CE), Brazil. CAPES Scholarship

^IVPost Graduate (PhD) of the Post Graduation Program in Nursing of the Federal University of Ceará - UFC - Fortaleza (CE), Brazil

^VPhD Nursing. Professor of the Post Graduation Program in Nursing of the Federal University of Ceará - UFC - Fortaleza (CE), Brazil

Corresponding Author

ABSTRACT

OBJECTIVES: To study the interaction of puerperal women who have postpartum depression and to understand the perception of family about the disease and maternal care provided by these mothers.

METHODS: This is an exploratory and qualitative study which had as a subject of study four puerperal women (with postpartum depression, being followed at the Psychosocial Care Center in the municipality of Quixada, state of Ceara) and four relatives. Home visits were made to carry out the interviews. The data were analyzed according to the content analysis technique proposed by Morse and Field.

RESULTS: The main changes reported were emotional easy-tears and nervousness. The puerperal women were frustrated and/or lacking confidence in the exercise of motherhood. To make matters worse it was observed that the families were unaware of the postpartum depression problem.

CONCLUSION: Nursing care in this situation should begin assessing the prenatal self-esteem, the received social support from the network and the mother satisfaction.

Keywords: Depression, postpartum; Family relations; Nursing.

RESUMEN

Objetivo: Conocer la interacción de puérperas, que presentan depresión posparto, con sus hijos y, comprender la percepción de familiares

sobre la enfermedad y cuidados maternos prestados por esas puérperas. Métodos: Estudio cualitativo de carácter exploratorio que tuvo

como sujetos de estudio cuatro puérperas con depresión posparto, acompañadas en un Centro de Atención Psicosocial del municipio de

Quixadá (estado de Ceará), y cuatro familiares. Fueron realizadas visitas domiciliarias para la ejecución de entrevistas en profundidad. Los

datos fueron analizados conforme la técnica de análisis de contenido propuesta por Morse e Field. Resultados: Las principales alteraciones

emocionales relatadas fueron el llanto fácil y el nervosismo. Las puérperas se sentían frustradas y/o inseguras en lo referente al ejercicio de la

maternidad. Como agravante fue observado que los familiares desconocían el problema de la depresión posparto. Conclusión: El cuidado

de enfermería en esa situación debe comenzar en el prenatal con evaluación de la autoestima, de la red de suporte social y de la satisfacción

de las futuras madres.

Descriptores: Depresión posparto; Relaciones familiares; Enfermería

INTRODUCTION

Postpartum depression (PPD) occurs worldwide, depending on region and measuring instrument, its incidence varies from 10% to 20% in the proportion of one case in 1000 mothers^(1-2). In Brazil, the latest published population-based survey on the subject held in Pelotas RS, with 410 women, published in 2006, highlighted a prevalence of 19.1%⁽³⁾. Another previous publication, developed in São Paulo-SP, in 2005, identified a prevalence of 37.1% in a sample of 70 puerperae⁽⁴⁾.

This type of depression seems to be the result of inadequate psychological, social and cultural adaptation of the woman faced with maternity. According to some studies, women with more stressful life events during pregnancy and early puerperium have higher levels of depressive symptoms^(1-5). Furthermore, cultural differences related to the customs, rituals and the roles of family members are also credited for playing key roles in the reduction or intensification of PPD^(1,5-6). Finally, psychiatrists report that the etiology of postpartum psychiatric syndromes involves the interaction of organic/hormonal, psychosocial factors and the female predisposition^(5-7).

Family history of depression, personal history or even an episode of puerperal depression are factors of analysis for the risk of postpartum depression, other aspects are as follows: premorbid personality, quality of maternal health, complications of pregnancy, risk or complication in the birth and the puerperium with some clinical impairment⁽⁸⁾. An article was identified that evaluated a series of studies on aspects of the puerpera with this clinical condition, besides the factors already cited: marital status has been associated, mainly in the cases of single mothers without social support; also the meeting between mother and child after birth can induce a specific disease, i.e. the risks of illness, as she experiences a series of mixed emotions in real time⁽⁹⁾. So, how can it be confirmed that postpartum depressive disorders are determined by the interaction more than they are by the woman's pre-existing disease.

In general, postpartum depressive disorder has the same clinical condition characteristics of depression at other times of women's life, with the addition of particularities related to maternity itself and the performance of the role of mother. Negative feelings, disinterest in the baby and culpability for failing to take care of it are frequent and can result in the unsatisfactory development of mother-infant interaction. Moreover, the removal or separation of the child due to the necessity for it to be cared for by someone else, can make it more difficult to establish emotional bonds and can strengthen the feeling of maternal inadequacy^(7,10).

Different life conditions exercise a crucial role in the development of depressive disorder, especially the undesirable factors, along with social factors. Finally, one might say, the etiology of puerperal depression is not determined by isolated factors, but rather by a combination of psychological, social, obstetric and organic factors.

Today, with the legacy of the Psychiatric Reform and the proposal of intersectoriality of the Unified National Health System, the Centers for Psychosocial Care (CAPS) have been absorbing and following the great demand of women, victims of maternal psychiatric disorders. The Family Health Strategy, based on the principle of integrality, as an example of other initiatives, offers physical and human resources to the prenatal in order to tackle the issue of PPD. In this sense, it is for health professionals, in particular the nurse, not just to provide a clinical performance in the identification and treatment of cases, but also care, such as psychological comfort, affection and health education in the experience of PPD.

In the postpartum phase, the type and nature of support received are possible factors contributing to better adaptation and launch of the maternal role. In this phase, the nurse can provide decisive collaboration, because to know the situation experienced, this professional helps the puerperae to overcome it and better adapt to their difficulties, contributing to the healthy exercise of maternity with impacts, both the binomial mother-child as well as in the family⁽¹¹⁾.

As observed, up to the present, most studies on PPD have adopted quantitative approaches, especially with the list of risk factors and/or stressful events^(1,3).

Although the literature shows qualitative studies that examine the experience of puerperae with PPD, a detailed description of this problem among mothers of Ceará was not identified, according to a consultation of the Bireme Electronic Library carried out by the authors. Thus, this article aims to understand the interaction of new mothers, with a diagnosis of PPD, with their children, and to understand the families' perception with respect to the disease and the maternal care of the women in the presence of postpartum depression.

METHODS

Type of study

This is an exploratory, qualitative study, derived from a survey from the research "The therapeutic relationship in the new mental health services".

Research scenario

The research was conducted in the period from January to July 2008, in the city of Quixadá, located in the Central Sertão of the State of Ceará in northeastern Brazil, one of the regions with the lowest human development indices of the state, with a territorial area of 2020 km. The city has a population of 76,105 inhabitants, with the rates of urban population and female of 67.3% and 50.3% respectively⁽¹²⁾.

The study was carried out in the CAPS of Quixadá, the only one in the city and the second created in the State. Since 1993, the quality of service of this institution has been a reference for the adjacent municipalities as, since its introduction, there has been a reduction from 105 to five psychiatric hospitals. It currently has 18 professionals, eight of the top level and attends 5672 clients. Among these, 80% presented a diagnosis of depressive conditions.

Study participants

Initially, an active search for records of mothers diagnosed with PND and with prevailing treatment in CAPS was conducted. After the survey, several meetings between these women and the first author occurred for the treatment of PPD, which established a mutual trust. Based on this assumption, we selected four women and their families through the following inclusion criteria: being a mother living in an urban zone of Quixadá-CE, having a proven medical diagnosis of PPD; being accompanied in this CAPS. Among the exclusion criteria were: being younger than 18 years, presenting irregular frequency of medical consultations; puerperae whose newborns had congenital malformations or died. Besides the women four subjects also joined the research, represented by their respective partners and family members present at the data collection.

Methods and procedures for data collection

The first author conducted the interviews in depth at the residences of the mothers, through the use of open questions supported by instructions. On average, interviews lasted between 45 minutes and one hour. In total, there were four interviews with each participant and their family. The scheduling of domicile visits was at the criteria of the mother. However, the importance of the presence of their partner and other family members at that time was stressed, which, fortunately, was considered in choosing the date for all genitors.

During the first visit, there was an explanation of the objectives and methodology of the study, followed by reading and signing of the Free Prior Informed Consent form (FPIC) for the development of the study. Also during the first visit, the sociodemographic, obstetric, maternal emotional changes in PPD and knowledge of research on the disease data was collected. It is worth noting that the data collection instrument was previously tested, and the necessary adjustments made, with other mothers with PPD accompanied in the CAPS cited. However, these were not included in the group of women presented here.

In the other three visits, the interview questions and interviewer/interviewee interaction converged in order to understand the interference of behavioral and emotional changes of PPD in relation to the mother-child-family and the perceptions and attitudes of the family about the problem of PPD.

Data analysis

For data analysis, we considered the reference of Morse and Field that advocates, in qualitative analysis, the following steps: identification, coding and categorization of data. This implies that the researcher must seek the meaning of specific passages and allocate them into appropriate categories⁽¹³⁾.

First, there was the description of the mothers, followed by transcription of collected data, for a critical reading and the organization of the statements. In this final step, we observed the conformity and similarity of the statements, which were finally divided into three thematic categories, namely: emotional and behavioral postpartum changes in the perceptions of the puerperae; insecurity of the puerperae regarding maternity and perceptions of the family members about the disease and maternal care in the PPD.

Ethical aspects

As recommended by Resolution no. 196/96 of the National Health Council - Ministry of Health, which regulates research involving human beings, the ethical-legal aspects of the research were respected⁽¹⁴⁾. Aiming to preserve anonymity, the puerperae were identified with fictitious names. The research project was approved by the Ethics Committee on Human Research of the Federal University of Ceará. As mentioned, all mothers and their family members signed the FPIC.

RESULTS

The four mothers surveyed were between 19 and 35 years of age, all residents of Quixadá-CE. With regard to education, only one had not attended high school, and one had attended a further education course. Regarding obstetric history, they were, mostly, first time mothers and had normal delivery, however, two had clinical complications during childbirth. Regarding marital status, two were married, one had an informal relationship and the other was single. Two had professional lives, one as a salesperson and the other as an administrative agent. The others carried out activities working in the home, and of these, one was a student. They had monthly family incomes which ranged from just over R$ 400.00 to R$ 1,000.00.

The risk factors related to PPD most cited by interviewees were: depressive symptoms during pregnancy, history of depression prior to pregnancy, limited selfesteem, marital problems, lack of partner and financial instability.

Behavioral and emotional changes postpartum perceptions of the puerperae

During the interviews, the emotional changes most mentioned by the mothers were the increase in nervousness, sadness and tearfulness; these changes, were a reflection of the pressure they put themselves under, in order to achieve an attitude of calm and patience, as outlined below:

"I was mostly nervous. Ah! I was too nervous. I had no patience. I had patience for her, but for others, I didn't have. I had no patience with people who I liked most, I had no patience ..." (Margarida)

"I was too nervous, I fought a lot with everyone, I was unable to care for my son..." (Angélica)

"I was nervous. She cried a lot and wanted to suckle all the time. I did not know how to put her on the breast to suckle. So, I was more nervous". (Gardênia)

Despite the prominence of nervousness during this period experienced by the puerperae, without doubt, from their statements, crying was the most marked emotional changes of the puerperium, as exemplified with the statements below:

"I ate and cried, I drank coffee and cried, I looked at my daughter suckling and cried". (Gardênia)

"I realized that I was very sensitive. I cried for nothing, cried for nothing". (Angélica)

"I felt strange at the first feeding and cried to have someone touching my body, indeed, I cried for anything". (Margarida)

"The first time at home, I looked at her and started crying nonstop because I saw all my dreams walking away". (Íris)

In general, crying may appear as a lament for the various losses that maternity apparently brings. Loss of space for their dreams, as related by Iris; loss of freedom to come and go as before; loss of time for herself and for her partner and friends; loss of control over her life. This calls into question the sense of fulfillment and gain experienced during pregnancy.

Insecurity of the puerperae concerning maternity

The interviewees felt frustrated and suffered from a strong sense of failure because they considered themselves incompetent to exercise maternity. Although the birth of a child is a unique moment of fulfillment and happiness for mothers, especially for the primiparae, there was a feeling of insecurity about the care for the newborn, as shown by these statements:

"I cried a lot. I looked at my daughter and cried, I was afraid of not knowing how to take care of her, will I know how to care for her when she has an earache, or if she is crying from colic or hunger?" (Margarida)

"I was not sure if I would be a good mother, whether it would be good for me, if I would be able to give my all to take care of that child." (Íris)

"The worst moment was when I had to put my daughter on my lap because I was afraid of hurting her, I did not know how to bathe her." (Angélica)

To them being a mother is anchored in the necessity of presenting an attitude of knowing how to care for the baby, which causes them concern. This new status acquired by women through maternity and being a mother, requires a redefinition of roles and the necessity for personal adjustments and change. Consequently, there may be a major impact on their lives, especially in the primiparae. Their statements also reinforce the urgency of understanding the exercise of maternity as a long process, socially and culturally constructed in quotidian life, through teaching, experiences and help.

Families' perception about the disease and maternal care in PPD

It was noticed that many of the family members interviewed reported knowing the sensitivity of the mental health of the respective mothers with PPD, some accompanied them to CAPS. Even so, ignorance of family members about the problem of PPD, unfortunately, predominated, as seen in the discourse of some family members studied.

"I think it is a disease where the woman is very fragile, cries and gets very sad". (Gardênia's husband)

"I do not know much, but I think it is the sadness, the desire to cry... after delivery the woman is very depressed". (Íris' aunt)

"I think it's a depression after the birth". (Angélica's mother)

"Nothing. I now know with your explanation". (Margarida's husband)

According to the apprehended, the family perceptions about maternal care offered to children by the puerperae, in the presence of PPD, varied. Some, in the statements shown below, offered favorable support, others only highlighted the limitations of these women with an adverse psychological condition.

"Despite her problem she cares very well. She never did anything against him. I think the baby is giving her reason to live". (Gardênia's husband)

"She is not caring. Sometimes, she rejects him, and, sometimes, she cares a little bit. But I think she is still very immature to be a mother". (Íris' aunt)

"I think the baby made her recover faster, her problem is with me". (Margarida's husband)

"She is still not well, the baby is with an uncle because, she's sick, I am unable to care for it. But once in a while she sees the baby and plays with him". (Angélica's mother)

As mentioned, the symptomology of postpartum depression of the puerperae in this study are mainly summarized by the manifestation of crying, nervousness and sadness. These conditions may incapacitate their maternal activities. During this, in some cases, other family members have assumed this responsibility. When analyzing the presence of depression in the family there is a need to understand that depression affects all family members, even indirectly, in varying degrees. Consequently, behavioral and functional organization is modified. Thus, the maintenance of equilibrium based on mutual assistance between puerpera and family is relevant to the treatment, in addition to promoting the psychosocial development of the child.

DISCUSSION

In agreement with the literature, the results of this study showed that the principle emotional and behavioral changes of the interviewees were nervousness, sadness and tearfulness. In southern Brazil, a study found, among puerperae from a public service, being a mother as a moment of antagonistic feelings, varying simultaneously from happiness/pleasure to psychological distress⁽¹⁵⁾.

The experience of pregnancy, giving birth and caring for a child can give the woman a new dimension of life and contribute to their emotional and personal growth. At the same time, it can cause internal disorganization, disruption of bonds and roles and even result in postpartum depression conditions⁽¹⁶⁾. This is perhaps justified by the fact that the dynamics of being a mother, wife, household manager and woman, are almost always in default of the hormonal, biochemical and psychological female status at this time⁽⁵⁾.

It is therefore essential that nurses understand the modalities of stress and cultural factors that influence the emotional well-being of mothers after the birth. This knowledge not only qualifies the nursing care offered, but it can also assist in the mediation of cultural aspects inherent to the postpartum experiences of the primiparous and multiparous⁽¹⁾.

This study found the puerperae aged between 19 and 35 years, with less than eight years of schooling, classified in social classes C and D, primiparous and with stable relationships, including informal marital union. Indeed, it is in agreement with the largest Brazilian research published on the theme, which reveals that women, affected by PPD are married, aged between 20 and 29, with less than eight years of schooling and inserted in the social classes C and D⁽³⁾.

Social factors such as lack of conjugal and family support strongly influence the etiology and management of PPD⁽⁹⁾. Another important aspect is the lack of knowledge of family members on the issue of PPD. Often family members associated signs and symptoms of PPD to physiological stress and the difficulty of adaption inherent to the puerperium⁽¹⁷⁾. However, there are other authors that reflect specifically on the quality of the conjugal relationship of the new mother. As shown, this relationship has a significant role in the intergenerational transmission of depression in these families⁽¹⁸⁾.

Meta-analysis, published recently, composed of 141 studies, conducted by nurse researchers from nine countries (USA, Australia, Canada, China, Finland, Iceland, Sweden, Turkey and Malaysia), found that the main contributions of nursing for coping with PPD are: detection of new cases; care of the binomal mother-child and in the family dynamics, the strengthening of breastfeeding, transcultural care, encouraging the use of health services and health education on maternal health regarding PPD⁽⁹⁾.

In this vital phase of the woman, the occurrence of depression draws attention, also to the significance of the intervention of health professionals, not only in the area of the health of the pregnant woman, but, in women's health in general, particularly in programs designed towards reproductive function allied to the mental health services.

Thus, nurses must provide themselves with knowledge of PPD, in particular, to establish the health service where they are inserted as an entrance for adequate reception and guidance of the puerpera related to treatment and prevention of this mental disorder. Although nurses recognize their importance and function in caring for these clients in primary care, they reaffirm that they have little knowledge or experience with the problem. Given these limitations, they delegate, to other professionals, all therapeutic actions in the rehabilitation of these women⁽¹¹⁾.

In this situation, integral nursing care should begin in the prenatal period with the assessment of self-esteem, the social support network and the satisfaction of mothers. In addition, nurses must possess skills such as insight, observation and empathy to direct their care to overcome the difficulties inherent in PPD.

CONCLUSION

In this study, we observed that the most salient emotional changes of the puerperium were crying, nervousness and sadness. The interviewees felt frustrated and suffered from a strong sense of failure because they considered themselves incompetent to pursue maternity.

Yet, as noted, although the family does not possess knowledge about the problem of PPD, it represents a bulwark for the puerperae with this symptom.

Given the perceived, for nurses in this municipality, the focus of this study, and other locations around the country, the development of better delimited qualitative research is believed to be a priority. This would be carried out with larger groups in order to achieve a greater understanding of the problem of postpartum depression and would include maternal depression screening with individual and group psychotherapeutic care, as well as lectures and educational orientation on the issues of concern to mothers who experience the postpartum period. Based on appropriate information, it would be possible to establish interventive measures of impact in the promotion of the health of puerpera patients or those with risk factors for postpartum depression.

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*

Trabalho realizado no município de Quixadá, localizado no Sertão Central do Estado do Ceará, Brasil.

Publication Dates

• Publication in this collection
  05 Aug 2010
• Date of issue
  June 2010

History

• Received
  01 June 2009
• Accepted
  23 Feb 2010