Maternal postnatal depression (PND) has far-reaching consequences, with research identifying the potential impact of PND on the woman (Cooper and Murray, 1995), infant (O'Hara and McCabe, 2013), the woman's partner (Meighan et al, 1999; Boath et al, 2007) and the family unit (Boath et al, 2007). As disclosure is a prerequisite to accessing social support (Chaudoir and Fisher, 2010), this highlights the importance for women with PND to be aware that they are able and entitled to disclose their symptoms in a safe and trusting environment. There are three forms of support (Robertson et al, 2003):
Studies have consistently found a negative correlation between PND and a lack of emotional and instrumental support (Menaghann, 1990; Beck, 1996; Seguin et al, 1999; Webster et al, 2011). These two forms of support may require greater safety and trust to establish.
When women disclose PND symptoms to front-line health professionals, including midwives and health visitors, these professionals have the opportunity to provide immediate support, particularly informational and emotional support, through creating safe contexts where they listen and help women with PND to understand their experiences, including their emotional ones. Considering this further, several studies across cultures have found that talking about emotive experiences can improve emotional, cognitive and physiological adjustment, as well as the ability to cope with these experiences (Lepore et al, 2004; Jonzon and Lindblad, 2005).
In addition to listening, midwives and health visitors are able to refer women to other sources of support, including medical and psychological interventions. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines for PND recommend facilitated self-help for persistent sub-threshold symptoms, and high-intensity psychological interventions (e.g. cognitive behavioural therapy) and/or medication as first-line treatments for mild to moderate symptoms (Tait and Heron, 2010; NICE, 2014). Signposting women to support networks is an important role that many health professionals undertake diligently.
The literature indicates that women with PND prefer to speak to other women who have disclosed similar problems (Brugha et al, 1998; Caramlau et al, 2011). Researchers have suggested that peer support groups may provide a simple intervention with the potential to reduce depressive symptoms in women with PND, and prevent PND in women at high risk (Dennis, 2003; Dennis et al, 2009). Clearly, there is benefit in facilitating instrumental and emotional support for women with PND.
However, women must feel safe enough to disclose PND symptoms and access professional and peer support, which not all women are willing or feel able to do. Indeed, while a meta-analysis of 59 studies highlights that PND is prevalent in about 13% of women in the first few months following childbirth (O'Hara and Swain, 1996), prevalence rates may be significantly higher due to under-reporting (Hendrick, 2003). Thus, PND is branded the ‘hidden depression’ (Nicolson, 1998), with more than half of cases of PND going undetected and undiagnosed because women are often unwilling to reveal these experiences to health professionals, family or friends (Kennedy et al, 2002; Beck, 2006).
PND exists in relational and social contexts, and the interaction between and within these contexts may make the decision to disclose symptoms particularly complex. Indeed, while there may be benefits for individuals with concealable stigmatised identities, such as PND, there may be a fear of negative consequences surrounding the decision to disclose (Pachankis, 2007; Quinn and Chaudoir, 2009). In turn, this may mean that women do not receive treatment in a timely manner (Edwards and Timmons, 2005).
Women report a number of relational and social factors that can inhibit or facilitate disclosure of PND, including characteristics of the professional to whom they are disclosing (Heneghan et al, 2004) and fears of rejection, criticism and stigma from people in personal and professional contexts (Lauer-Williams, 2001; Kennedy et al, 2002; Edwards and Timmons, 2005). In addition, research suggests that women who conceive through assisted conception, for example, in vitro fertilisation (IVF), have a lowered sense of perceived entitlement to complain or seek help owing to their sense that their babies were highly desired (Fisher et al, 2005). This sense of perceived entitlement to disclose is again influenced by safety and trust in relational and social contexts, and has received minimal attention in the literature. It may be useful to consider this to further facilitate the important role front-line professionals undertake.
This paper reports a subset of data from a wider research study, conducted as part of a clinical psychology doctorate (Abraham-Smith, 2015). The qualitative study explores the experiences of women who disclose postnatal depression. Unlike the majority of existing literature, this study includes wider relational and social contexts relating to experiences of disclosing to individuals in personal support networks (i.e. family members and friends) and professionals. This current paper focuses on a major theme in the findings, which describes a ‘weighing up’ process preceding disclosure. Here, participants consider a range of factors that either facilitate or inhibit disclosure. Participants also question whether they are entitled to experience PND or receive support, based on their preconceptions of women with PND.
Methods
Design
This study adopted an interpretative phenomenological analysis (IPA) methodology. IPA is a qualitative methodology concerned with exploring and understanding the lived experience of a specified phenomenon (Smith, 2004). It involves detailed examination of participants' lifeworlds—their experiences of a particular phenomenon, their sense-making of these experiences and meanings attached to them (Smith, 2004).
Ethics
Ethical approval for this study was granted by the University of Hertfordshire Psychology Ethics Committee. The study was conducted in compliance with the University of Hertfordshire's (2004)Guide to Good Practice in Research and the British Psychological Society's (2010)Code of Human Research Ethics.
Recruiting participants
Purposive criterion sampling (Patton, 1990) was carried out to identify and select information-rich cases related to the phenomenon of interest (Palinkas et al, 2013). Inclusion and exclusion criteria were applied to establish a homogenous sample and increase analytic sensitivity (Smith et al, 2009). The inclusion criteria were:
Women were excluded if they:
Participants were recruited via advertisements in quarterly publications of three different National Childbirth Trust branches in a county in England, and an email detailing the research forwarded by a manager of a local nursery to all parents. Of the 25 respondents, seven met the above criteria. However, two decided not to participate after initial telephone contact. Participants were aged between 29 and 40 years, and were either married or cohabiting.
Data collection and analysis
Informed consent was gained from each participant and the right to withdraw was reiterated prior to interview. All participants chose to be interviewed in their own homes. Interviews were audio recorded and lasted between 59 and 151 minutes. Questions were open and expansive to encourage participants' exploration of their lived experiences (Smith et al, 2009). The schedule was divided into four topics:
Participants' names were replaced with aliases in the interview transcripts. In-depth analyses for two transcripts (Anne and Louise) were conducted, and the themes emerging from these were used to orient the analyses for the other three transcripts, while remaining open to new and additional themes—known as the ‘idiographic approach’ (Smith and Osborn, 2003; 2008). All the themes were reconsidered and refined, leading to a master list of superordinate themes, with corresponding subordinate themes for the whole sample.
Common to IPA studies, a process of triangulation was conducted to establish the credibility and transferability of the findings (Smith and Osborn, 2003). Triangulation occurred via convergence of themes across the sample and by reviewing the coherence and comprehensibility of analyses and emerging themes through supervision.
Findings
While analysis of the five interview transcripts resulted in the emergence of four superordinate themes related to disclosure of PND, this paper focuses on one theme centred on the period prior to disclosure entitled ‘Deciding whether to disclose: Facilitative and inhibiting factors’. In support of previous research, its subthemes centre on the influence of stigma and judgement (Lauer-Williams, 2001; Kennedy et al, 2002; Edwards and Timmons, 2005) and the characteristics of the confidant on disclosure (Heneghan et al, 2004). However, the subtheme ‘Factors that influence perceived entitlement to have postnatal depression and receive support’ is a novel finding, extending this beyond research that has focused on IVF and PND (Fisher et al, 2005).
This theme highlights how relational and social contextual factors informed participants' judgements about whether they should or should not have PND. It captures a social comparison process in which participants questioned their entitlement to have PND in comparison to other women. For example, Louise states:
‘If you suffer from postnatal depression you really should be quite on the edge, as in [like being a] single parent, having to work, and life should be really, really hard for you to then suffer from postnatal depression ‘cause you've got a reason not to cope, instead of having a husband who helps, having a child who sleeps through the night.’ (Louise)
Considering the relational and social context, prior to disclosure Louise appeared to hold initial assumptions about women's entitlement to have PND. Furthermore, these assumptions and conditions appeared to hinder her own acknowledgement of her difficulties. Below, she describes feeling ‘luckier’ because she was not suffering from sleep deprivation compared with other women. She chose to avoid disclosure to protect herself from perceived criticisms from others that might make her feel worse:
‘I don't want to talk about it a huge amount because I'm far luckier than a lot of people. So then there's this added thing like the “Well your child's sleeping [but] you're still not coping. What's wrong with you?” Plus my husband helps an awful lot, so again it's, you know, (laughs) it, it says you can't cope at all… so you'd feel even worse.’ (Louise)
Similarly, sleep deprivation also seemed an important contextual PND criterion for Victoria, making her question the reasons for her distress at that time:
‘I went crying to my mum one time, really sobbing, questioning it, ’cause on the other hand [my daughter] was a very good sleeper, things like that, so I got a lot of rest.’ (Victoria)
Financial status and lifestyle were also identified by participants as ‘criteria’ for developing PND. Even in the context of her own family, Louise predicted that she would receive comments about her ‘gilded life’, thus disqualifying her from receiving understanding and support. The following extract captures Louise's prediction that others made comparisons between her and her sister's lifestyles in determining who has the right to experience PND. The comment ‘oh pull yourself together’ suggests she predicted being construed as self-absorbed:
‘We're down here, we're southern, you know. We've got loads of money and everything else and I've got “loads of help”, whereas my poor sister's up there and her husband won't even let her have a cleaner. She's got a boy in hospital… he's young, so… we seem to live a gilded life and if I said, “Oh god I [am] suffering from postnatal depression” or anything, it would just sort of be, “Oh pull yourself together,” you know. It's, “[Your sister's] got it hard, you haven't. Stop worrying.” So I haven't even bothered talking to them about it.’ (Louise)
Similarly, when Marie began to disclose her PND to colleagues, comments she received about her lifestyle made her question her right to experience PND, infringing on building trust and thus hindering further disclosure:
‘Someone coming back with the comments of, “You've got the house, you've got a lovely baby, what are you upset about? What's the real problem?” Almost [like] you've got no right to feel that way, or then snap out of it.’ (Marie)
One can sense the minimisation Marie (above) and Anne (below) may have experienced from other people's responses—a minimisation inconsistent with the strength of their internal distress. Anne reports feeling a pressure to be happy due to the expectations people had of parents who successfully conceived a child via IVF:
‘I think particularly with postnatal depression, it's that thing that, you know, there's obviously something quite odd, that you don't feel this massive euphoria. And, you know, particularly for us having waited a long time to have children… I think they'd think “Well, why would you feel awful once they did come? You should be jumping with joy.”’
‘So you feel that there is an added pressure to be happy and joyful because you went through IVF?’
‘Yeah.’
‘Someone coming back with the comments of, “You've got the house, you've got a lovely baby, what are you upset about? What's the real problem?” Almost [like] you've got no right to feel that way…’
After reading an advertisement about types of people that a local charity supported, Joanne reports feeling as if she did not fit the threshold for support. It seems the phrasing in the advertisement reduced her sense of entitlement for support:
‘It's a local charity that has a wonderful front page where it says: “Single parents, parents of disabled children, if you've lost somebody, if somebody's died in your family or you're bereaved, having problems or you're just finding everything a bit difficult…” (laughs) Well, I have none of those things but I'm still a bit shit.’ (Joanne)
The above extracts illustrate the role that perceived or actual assumptions that other people or organisations have on the context or criteria for needing support, which may hinder disclosure and support-seeking behaviours for these women.
Discussion
For participants in this study, the process of disclosing PND was initially inhibited by a sense of perceived entitlement to have the condition or reach out for support. This had an impact on them feeling safe enough to initially disclose their experiences and was based on their own and others' perceived beliefs about the criteria, contexts or thresholds for PND. Louise felt that ‘life should be really, really hard’ for a woman with PND and listed certain contextual factors (e.g. being a single mother) that provided a reason for it. Joanne spoke about her perception of not fitting a local charity's criteria for support. Other contextual factors were financial status and lifestyles (Louise and Marie), having children who slept well (Louise and Victoria) and, similarly to the findings of Fisher et al (2005), having successful IVF treatment (Anne).
The assumptions participants made seemed to be established via comparison with others in their social contexts. For example, Louise stated she was ‘luckier’ compared to other women. The literature on social comparison processes highlights the tendency to compare to determine a subjective entitlement function (Kruglanski and Mayseless, 1990). This hindered disclosure as it was deemed inappropriate owing to the type and degree of contextual factors present or absent for participants in this study. The entitlement function influences judgements concerning fairness of outcomes, which can also lead to various reactions in other people (Austin et al, 1980), such as the minimising described by the women in this study.
A number of clinical implications arise from these findings for health professionals who have regular contact with women in the antenatal and postnatal period. Promoting disclosure by creating safe, trusting and open environments, which emphasise the value of instrumental and emotional support, is crucial (Menaghann, 1990; Beck, 1996; Seguin et al, 1999; Webster et al, 2011). Thus, any antenatal or postnatal literature or conversation that provides a woman with information on PND and how to seek support should include a clear message regarding the potential for any woman to experience the condition, regardless of her social context.
Day (2007) claimed that professionals do not adequately attend to depression prior to childbirth. NHS or privately funded antenatal classes could be an ideal time to learn about PND, normalise it and make plans to prevent, identify and manage symptoms (Zauderer, 2009). These classes also provide an opportunity for women to become more aware of, and explore, assumptions regarding the contextual factors associated with PND. Facilitating conversations on the emotional aspects of motherhood between women going through the same (potentially anxiety-provoking) experience of entering motherhood may influence more prompt disclosure and help-seeking.
Further, during postnatal consultations, front-line professionals are perfectly positioned to enquire about the woman's emotional wellbeing. Simply asking about emotional wellbeing and listening to the woman's experience normalises it and sends a message of entitlement to talk about it. In the UK, PND is identified using self-report measures, such as the Edinburgh Postnatal Depression Scale (Cox et al, 1987). However, this is not administered to all new mothers as standard practice, meaning a woman may have to make her own decision to disclose her symptoms before PND is identified (if she is aware of her symptoms).
If women have an additional hindrance of not feeling entitled to have or receive support for PND, their symptoms may remain undisclosed. Even when forms are completed, women may give unreliable responses due to the stigma surrounding PND and their fear of negative consequences (McIntosh, 1993; Shakespeare et al, 2003). As women have expressed a strong preference for talking about feelings, rather than ticking boxes (Shakespeare et al, 2003), in line with other recommendations (Coyle and Adams, 2002), the Edinburgh Postnatal Depression Scale should be used as part of a clinical interview or discussion in which standardised questions are asked and factors commonly found to inhibit disclosure are openly discussed; thus normalising the woman's experience and facilitating more open, validating and compassionate responses to her distress.
While this recommended change in practice may initially be less cost-efficient, requiring some longer consultations, consideration needs to be given to the long-term clinical and economic benefits of enhancing disclosure and early diagnosis of PND for women, their children and their families. Furthermore, as recommended elsewhere (Jardri and Maron, 2006), midwives and health visitors should receive support and supervision from mental health professionals in facilitating and managing distress in others, not only regarding their clinical work with women with PND but also as an opportunity for health professionals to debrief, thus enhancing the entitlement of front-line health professionals to also disclose and seek support.
Limitations
Although all participants discussed the issues pertinent to the perceived entitlement to disclose PND, the causal effects and mechanisms identified cannot be claimed due to the qualitative nature of this study, limiting the generalisability of results. The participants' characteristics also limited the generalisability of findings to other women with PND of different class, culture or age. Furthermore, as the sample was self-selected, it is possible that the current findings were representative of a vocal minority experience.
Conclusions
Participants discussed the times when they were reluctant to disclose PND as they did not feel entitled to have the condition or reach out for support. This was due to their own, and others', perceived assumptions about criteria, contexts or thresholds for PND. These assumptions were derived from comparisons between themselves and other people in their social contexts.
This study has highlighted the importance of raising awareness among health professionals of entitlement as one of many factors that can inhibit disclosure of PND, and then addressing this barrier through written and interpersonal communication, and psychoeducation in antenatal and postnatal programmes in a bid to enhance disclosure and support-seeking.