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The association between depressive symptoms and social support in Taiwanese women during the month
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International Journal of Nursing Studies 41 (2004) 573–579
The association between depressive symptoms and social support in Taiwanese women during the month Shu-Shya Heha,*, Lindsey Coombesb, Helen Bartlettc a
Department of Nursing, Fu-Jen Catholic University, 510 Chung-Cheng Road, Taipei County, Taiwan b School of Health Care, Oxford Brookes University, Oxford, UK c Centre for Human Ageing, Faculty of Health Sciences, University of Queensland, Australia Received 30 September 2003; accepted 15 January 2004
Abstract The purpose of the study was to explore the association between depressive symptoms and social support in Taiwanese women doing the month. A correlational survey design using the Postpartum Social Support Questionnaire (PSSQ) and the Edinburgh Postnatal Depression Scale (EPDS) to measure social support and postnatal depressive symptomatology was employed. Two hundred and forty postpartum women receiving care in two teaching hospitals in Taipei, Taiwan, aged between 20 and 35, with no peri-natal complications or previous psychiatric history, experiencing a normal spontaneous delivery of one full term healthy baby, were selected. Each was mailed the PSSQ and the EPDS as well as a short, semi-structured self-report questionnaire requesting demographic details and subjective data relating to the experience of doing the month and depressive symptoms during the fourth week following birth. One hundred and eighty six women (78%) returned questionnaires. Taiwanese postpartum women were less depressed when they stayed in their parents’ home and had their own mothers take care of them. It was found that the greater the level of postpartum social support received by the women doing the month, the lower the risk of postnatal depressive symptoms experienced. Almost a quarter (24%) of the variance of the symptoms was attributed to dissatisfaction with parents’ instrumental support and unwanted emotional support from parents-in-law. It is concluded that the ritual of doing the month provides valuable social support and may help to prevent postnatal depression in Taiwanese women. r 2004 Elsevier Ltd. All rights reserved. Keywords: Social support; Doing the month; Postnatal depression; Nursing
1. Introduction The traditional Chinese rite of ‘‘Tso-Yueh-Tzu’’, translated as ‘doing the month’, is concerned with beliefs and practices associated with the postpartum period where, Chinese women are relieved of most work duties for a month so they can recuperate (Wong, 1993). It can be traced back to the Song dynasty (AD 960– 1279) and its conceptual origins may extend as far back as 2000 years (Pillsbury, 1978). According to traditional Chinese medicine, Chinese women become very ‘cold’ *Corresponding author. Fax: +886-2-29043500. E-mail address: [email protected] (S.-S. Heh).
(meaning vulnerable) following childbirth. Through doing the month the inner heat of a woman’s body can be augmented so that they may recover more quickly. When doing the month women are required to stay indoors and to follow certain restrictive prescriptions and proscriptions. Whilst the process of doing the month may vary, these include avoiding washing or contact with cold water and wind, and eating tonic food. Additionally, someone (usually female family members) assumes most of the responsibilities for baby care and housework. When the month is completed, a celebration is held and the mother can leave the house. The changes in the Taiwanese family from an extended to a nuclear structure, which have occurred since the 1960s, have
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meant that women have often found it difficult to identify a family member to assist them with doing the month. As a consequence, there has been a development of Doing the Month Centres. These centres provide services to new mothers which enable them to follow the traditional custom of doing the month on a commercial basis (Lu, 1985). The majority of the Taiwanese women choose western trained professionals for peri-natal care, however, they still follow the traditional Chinese postpartum custom of doing the month (Harn, 1992). Wong (1994) undertook surveys in both urban and rural settings and found that 95% of their samples had experienced doing the month. The Chinese postpartum custom of doing the month has been investigated in a number of studies in Taiwan (Chu, 1993; Harn, 1992; Lu, 1985; Pillsbury, 1978; Wong, 1993). In addition, studies of the phenomenon have been conducted in Hong Kong (Holroyd et al., 1997) and Scotland (Cheung, 1997). These studies demonstrate that most Chinese postpartum women still follow the practice and believe that it can improve their health, not only immediately following birth, but also in later life. However, with the exception of Harn (1992) and Chu (1993), the majority of the studies do not seek to measure the variables thought to be important, or to examine the relationship between them. Whilst there are many variables involved in the practice of doing the month that might contribute to the health of postpartum women, one important aspect that has been identified concerns social support. Pillsbury (1978), Chu (1993) and Wong (1994) suggest that because so much attention and help is given to the new mother while she is doing the month, postnatal depression may be prevented. But can doing the month prevent postnatal depression? Several recent studies have produced findings that would suggest it does not. It has been found that there is a high incidence of between 37% and 40% of postnatal depression in Taiwanese women postpartum (Chen et al., 1994; Harn, 1992; Ko et al., 1996). Furthermore, Tseng et al. (1994) concluded that women attending a Doing the Month Centre suffer even higher scores of postnatal depression. Postnatal depression is a mental and behavioural disorder associated with the puerperium, typically commencing within 6 weeks of delivery given by the International Classification of Diseases—ICD-10 (World Health Organization, 1992). It is characterized by episodes of irritability, guilt, exhaustion, anxiety, sleep disorders and somatic symptoms which have a disabling effect on mothers, children and families of sufferers, following childbirth (Green et al., 1990). Estimates of the incidence of postnatal depression vary widely, depending on the measuring instruments used, the criteria for diagnosis employed, the time that it is assessed and the characteristics of the women studied. It appears that the more stringent the diagnostic criteria
for depression, the lower the prevalence rate. O’Hara and Swain (1996) conducted a meta-analysis of fifty-nine studies, self-report methods (14%) significantly yielded higher estimates of postnatal depression than interviewbased methods (12%). Whilst the cause of postnatal depression is multi-factored it has been shown that psychosocial elements play an important role. A metaanalysis of 84 studies was conducted to determine the predictors of postnatal depression. Thirteen significant predictors were revealed: prenatal depression, selfesteem, childcare stress, prenatal anxiety, life stress, social support, marital relationship, history of previous depression, infant temperament, maternity blues, marital status, socioeconomic status, and unplanned pregnancy (Beck, 2001). There is strong evidence in the literature that lack of social support is an important factor in the development of postnatal depression. Taiwanese women may receive and perceive high levels of social support through the traditional postpartum practice of doing the month and could therefore be hypothesized to be less likely to develop postnatal depression. Specific aspects of social support during doing the month can then be investigated in relation to postnatal depressive symptomatology. Kumar (1994) stated that there is no good evidence for or against the theory that postnatal depression is partly the consequence of the rituals being stripped away. However, the lack of relevant research and limitations of method severely restrict any conclusions that can be drawn. The purpose of the study was to explore the association between social support received and perceived by Taiwanese women during doing the month and postnatal depressive symptomatology. 2. Methodology The study employed a survey design and aimed to collect detailed descriptions of social support and postnatal depressive symptoms in a sample of Taiwanese women doing the month. 2.1. Participants Participants attending two teaching hospitals in Taipei, were recruited into the study. Inclusion criteria were: married, first time mothers; age 20–35, and normal spontaneous delivery with full term healthy baby (gestation age 38–42 weeks, body weight over 2.5 kg and APGAR score >8). Exclusion criteria were: women suffering peri-natal complications, with a previous psychiatric history and not following doing the month. 2.2. Instruments The Postpartum Social Support Questionnaire (PSSQ) is an 81 item self-report scale specially designed
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to assess the degree of social support in the postpartum period (Hopkins et al., 1987). The scale measures both emotional and instrumental support received from spouse, and others (parents, parents-in-law, relatives and friends). It comprises four subscales: Spouse’s Emotional Support, Spouse’s Instrumental Support, Others’ Emotional Support and Others’ Instrumental Support. Each item of the PSSQ is rated on a 7-point scale in two ways: (a) frequency of occurrence and (b) desired frequency of occurrence. The scale of scores goes from 1 to 7 with 7 being the most and 1 the least. The PSSQ has adequate internal consistency and test-retest reliability (Heh et al., 2001). Dissatisfaction with social support is calculated by using a difference score between the support desired and support received in this study. The Edinburgh Postnatal Depression Scale (EPDS) was developed by Cox et al. (1987). The EPDS is a simple screening questionnaire consisting of ten short statements, taking less than five minutes to complete. Both the EPDS and PSSQ were translated into Chinese and the validity and reliability of each ascertained (Heh, 2001; Lee et al., 1998). 2.3. Data collection Access to undertake the study was gained from the directors and ethical approval was obtained from the Research Committee of the hospitals. A letter was sent to 300 postpartum women who met the criteria for selection. The information about the purpose and the procedure of the study and an invitation to take part in this study were included. Assurances were provided that involvement in the study would not make any difference to their medical care and that all information from the questionnaire would be treated confidentially and used for the purposes of the research only. The address and telephone number of subjects were confirmed when 240 subjects signed the consent form personally while they were staying in hospital. A short, semi-structured selfreport questionnaire was also constructed to obtain demographic data and data relating to the experience of doing the month (places and key helper) and postnatal depression (reasons, onset, duration and its influence). This was sent to participants with the PSSQ and EPDS during the fourth week postpartum. 2.4. Data analysis Data was analyzed using the statistical package SPSS for Windows. Descriptive statistics for each measure were calculated. T-tests, ANOVA and Pearson correlation coefficients were calculated for EPDS scores and the demographic variables of place, key helper during ‘‘doing the month’’. Pearson correlation coefficients between PSSQ and EPDS scores were calculated. Stepwise multiple regression was used to examine the
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contribution of the independent variables social support received and dissatisfaction with social support to EPDS scores.
3. Results One hundred and eighty six women (78%) responsed. The mean age of mothers was 2873.47 years (ranged from 20 to 35 years). The majority of the primiparas (80.6%) in the sample were pregnant for the first time. One hundred and thirty eight women (74%) were employed. Two-thirds (67.2%) of the sample reported that their pregnancy had been planned. Thirty-nine women (21%) had EPDS scores of 10 or above. Seventy-eight women (42%) indicated that they experienced depressive symptoms following giving birth. The majority of these symptoms commenced during the first week after discharge from hospital. The postpartum symptoms experienced were: anxiety, sleep disturbance, depression, crying, anger, shouting, nervousness, feeling of weakness, stress, inability to cope with life. The main reasons given for experiencing the symptoms were: the stress of baby care, insufficient sleep and lack of family support. In most cases these symptoms persisted for up to 2 weeks. Twenty women (10.8%) said that that the severity of these symptoms was sufficient to affect their daily life. The demographic variables, maternal age, education, working status, and family income, were found not to be related to postnatal depressive symptoms. However, unplanned pregnancy (t ¼ 2:15; d.f. =184, 95% CI: 0.34/2.69, po0:05), the place of doing the month (F ¼ 4:63; d.f. =4,181, po0:01) and key helper (F ¼ 4:24; d.f. =4,181, po0:01) were related to postnatal depressive symptoms. Postpartum women who stayed at their parents-in-law’s home and had their mothers-in-law as their key helpers demonstrated higher EPDS scores. Women who stayed in their parents’ home and had their own mothers take care of them during doing the month recorded lower EPDS scores. Parents’ support is strongly negatively correlated with EPDS score especially parents’ instrumental support. Whilst supports from other components of the social network are also negatively correlated with EPDS, none are statistically significant (p > 0:05). Total emotional support from the social network is very strongly negatively correlated with EPDS score. Total social support is very strongly negatively correlated to EPDS score (Table 1). The greater the level of postpartum social support received by the women during doing the month, the lower the risk of postnatal depressive symptoms experienced. Dissatisfaction with parents’ support (especially parents’ instrumental support) is strongly positively correlated with EPDS score. Dissatisfaction with
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Table 1 The relationship between social support received and postnatal depression (n ¼ 186) The characteristics of social support
Pearson r value
(1) Husband’s emotional support (2) Husband’s instrumental support Husband’s support (1) and (2) (3) Parents’ emotional support (4) Parents’ instrumental support Parent’s support (3) and (4) (5) Parents-in-law’s emotional support (6) Parents-in-law’s instrumental support Parents-in-law’s support (5) and (6) (7) Relative’s emotional support (8) Relative’s instrumental support Relative’s support (7) and (8) (9) Friend’s emotional support (10) Friend’s instrumental support Friend’s support (9) and (10) (A) Total emotional support (1)+(3)+(5)+(7)+(9) (B) Total instrumental support (2)+(4)+(6)+(8)+(10) Total social support (A)+(B)
0.18 0.11 0.18 0.21 0.35 0.33 0.00 0.02 0.04 0.21 0.08 0.18 0.09 0.01 0.08 r ¼ 0:38 r ¼ 0:16 r ¼ 0:51
po0.01, po0.001.
parent-in-law’s emotional support was strongly negatively correlated with EPDS score. Total dissatisfaction with instrumental support is very strongly positively correlated with EPDS score as is total dissatisfaction with social support (Table 2). These results suggest that the higher the dissatisfaction with social support received by Taiwanese women during doing the month the higher the EPDS score. Stepwise multiple regression analyses of EPDS scores with social support received, dissatisfaction with social support as predictor are shown in Table 3. Dissatisfaction with parents’ instrumental support and dissatisfaction with parents-in-law’s emotional support also accounted for 24% of the variability in EPDS score.
4. Discussion Previous research has shown that social support is related to postnatal depression. However, which specific social support is received and perceived as supportive to Taiwanese postpartum women and its relation to postnatal depression is not clearly defined. This study used the PSSQ to measure the characteristics and the
Table 2 The relationship between dissatisfaction of social support and postnatal depression (n ¼ 186) The dissatisfaction of social support
Pearson r value
(1) Dissatisfaction of husbands emotional support (2) Dissatisfaction of husband’s instrumental support Dissatisfaction of husband’s support (1)+(2) (3) Dissatisfaction of parent’s emotional support (4) Dissatisfaction of parent’s instrumental support Dissatisfaction of parent’s support (3)+(4) (5) Dissatisfaction of parents-in-law’s emotional support (6) Dissatisfaction of parents-in-law’s instrumental support Dissatisfaction of parents-in-law’s support (5)+(6) (7) Dissatisfaction of relative’s emotional support (8) Dissatisfaction of relative’s instrumental support Dissatisfaction of relative’s support (7)+(8) (9) Dissatisfaction of friend’s emotional support (10) Dissatisfaction of friend’s instrumental support Dissatisfaction of friend’s support (9)+(10) (A) Total dissatisfaction of emotional support (1)+(3)+(5)+(7)+(9) (B) Total dissatisfaction of instrumental support (2)+(4)+(6)+(8)+(10) Total dissatisfaction of social support (A)+(B)
0.12 0.09
0.18 0.18 0.47 0.41 0.36 0.01
0.19 0.12 0.18
0.22 0.12 0.07
0.09
0.20 0.39 0.58
po0.001.
level of social support during doing the month. It provides an objective way to assess the degree of the postpartum social support among Taiwanese women and provides knowledge regarding its relationship with postnatal depressive symptoms. 4.1. Social support as a mediator of depression during doing the month The findings sustain the conjecture that social support can protect against the development of postnatal depression and lessen the stress or the impact of stress
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Table 3 Stepwise multiple regression analysis of EPDS scores with dissatisfaction with social support as predictor (n ¼ 186) Predictors
Variables
Dissatisfaction with social support
Dissatisfaction with parents’ instrumental support Dissatisfaction with parentsin-law’s emotional support
R
R2
F
p
0.52
0.40
0.16
9.60
0.002
0.37
0.49
0.24
6.98
0.001
b
(Beck, 2001; Spangenberg and Pieters, 1991). Not only the characteristics of social support Taiwanese postpartum women received, but also how their perception of social support during the period of doing the month are related to their postpartum depressive symptoms, especially the parents’ instrumental support are demonstrated. Taking social support actually received and dissatisfaction with social support together when predicting postnatal depressive symptoms, the most influential factor is postpartum women’s perception of their dissatisfaction with parents’ instrumental support. This is consistent with the findings of O’Hara (1986) that depressed women express dissatisfaction with the frequency of their parents’ support. 4.2. Depressive symptoms during doing the month The study used the EPDS as a measure of postnatal depressive symptomatology. Twenty-one percent of the women had EPDS scores of 10 and above. Whilst there are some cultural difficulties in interpreting conditions like postnatal depression in non-Western cultures, the study results contradict the thesis that postnatal depression is a culture-bound phenomenon as proposed by Stern and Kruckman (1983) and there is no depression in Chinese postpartum women as proposed by Pillsbury (1978) and Chu (1993). Studies such as those of Pillsbury and Chu cited above, lacked formal diagnostic testing or observation in depression in the postpartum period. On the contrary, the finding supports the idea that postnatal depression, which has a predominantly psychosocial aetiology, surprisingly does not appear to vary in incidence across different cultures (Kumar, 1994). The results suggest that postnatal depression of Taiwanese women is not uncommon. The prevalence of postnatal depression was closer to 19% in Taiwanese by using the EPDS with a cut-off score of 12/13 within 3 months of delivery (Huang and Mathers, 2001). Demographic characteristics were not found to be related to the risk of postnatal depression. Unplanned pregnancy was found to be related to postnatal depression in this study. This result supports the earlier findings of Chen et al. (1994) and Ko et al. (1995). Chen et al. (1994) suggested that an unplanned pregnancy increases the feeling of loss of control of one’s life and is linked to lower self-esteem. Low self-esteem was found
to be related to postnatal depression (Affonso and Arizmendi, 1986). 4.3. The importance of parents’ instrumental support while doing the month The multidimensional nature of social support is clearer after analysing the correlation between social support actually received, dissatisfaction with social support and postpartum depressive symptomatology. The results suggest that Taiwanese postpartum women receiving instrumental support from their own parents can be protected from the risk of postnatal depression. However, the source and type of postnatal support could have an important influence on the level of postpartum women’s satisfaction. Too much emotional support from parents-in-law and too little instrumental support from parents appeared to explain postpartum women’s dissatisfaction. This is demonstrated by the significant correlation between the place, the key helper during doing the month and postnatal depressive symptoms. Taiwanese women prefer to stay at their parents’ home and be looked after by their own mothers during doing the month. It suggests that the Taiwanese ritual of doing the month protects postpartum women from the risk of postnatal depression, if social support during the period of doing the month satisfies them and meets their true needs. Logsdon et al. (2000) suggested that the importance of support is a better predictor of postpartum depression than the quantity of support a woman receives. It seems quite obvious that the event of childbirth brings postpartum women back to their original family for help, especially from their own mother. A person who experiences stress or anxiety at a certain stage of development may seek a resource, which gives unconditional love and support. Parents are the first choice for providing a refuge for those who experience stressful events in the Chinese culture (Cheng et al., 1994). 4.4. The impact of social change on social support and postnatal depression The mean EPDS score of twelve women who stayed at a Doing the Month Centre was over 10. This supports the finding of Tseng et al. (1994) that Taiwanese
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postpartum women who stayed in Doing the Month Centres felt more depressed. This study found that although women can rest and have traditional care from the staff of the centre, they felt that their association with the centre was a business relationship. They felt that there was a lack of support from their family during the period of doing the month, therefore they had to go to a Doing the Month Centre for their own good. LiuChiang (1995) used the focus group to explore the worries of 21 Taiwanese primiparas and found that all the worries focused on the need for the integration of self while they went through doing the month in a Doing the Month Centre. Those women expressed potential loss of self through their worries that the nurses in the centre concentrated on the ritual of doing the month and excluded them as the core component in it. A Chinese postpartum woman must have someone to accompany her during doing the month in following the rules. Traditionally, this person is the woman’s motherin-law. However, as the nuclear family increases and bilateral kin relations become more common, some mothers-in-law are relinquishing their influence to the natural mother. On the other hand, others still believe that it is their responsibility to ‘‘do the month’’ for the son’s wife. The strain between the mother-in-law and daughter-in-law is a sensitive problem and might be a cause of postnatal depression in Chinese society (Chen et al., 1999). Steinberg (1996) suggested that the strain between the mother-in-law and daughter-in-law often offsets the potential benefits of assistance and may even contribute to develop a mood disorder during the postpartum period.
5. Conclusion The ritual of childbirth may provide valuable social support for women after giving birth. This support may help to alleviate postnatal distress and depression. However, the support during the transition to motherhood needs to be considered from the perspective of the recipients, and the appropriate support during doing the month need to be evaluated by Taiwanese postpartum women nowadays. The imposition of a ritual or only one right way to approach postpartum women is inappropriate in a complex and secular society (Littlewood and McHugh, 1997). It seems that an alternative concept of rite offering greater flexibility in terms of considering the individual expectation of postpartum women is needed. 5.1. Limitations The correlational design of the study enabled the collection of a large amount of data regarding the practice of doing the month and postnatal depression
within the limitations of time and resources available to undertake the study. However, there are two main drawbacks with the chosen research design: firstly, it assumes that the data collected at one point will give us information about what happened over a period of time. Secondly, the sample was selected using a non-probability method and is therefore unlikely to be representative. 5.2. Implication for healthcare practice Health policy makers should take into consideration that the need for postnatal care to be provided in the community after discharge from the maternity unit in Taiwan. The EPDS is an effective tool to identify high risk case of postnatal depression. The relationship between daughter-in-law and mother-in-law may influence the quality of care received by daughters-in-law during doing the month. This observation could be explored in further research.
Acknowledgements The authors would like to thank Professor Mavis Kirkham and Jane Ribbens for their recommendation.
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The association between depressive symptoms and social support in Taiwanese women during the month Shu-Shya Heha,*, Lindsey Coombesb, Helen Bartlettc a
Department of Nursing, Fu-Jen Catholic University, 510 Chung-Cheng Road, Taipei County, Taiwan b School of Health Care, Oxford Brookes University, Oxford, UK c Centre for Human Ageing, Faculty of Health Sciences, University of Queensland, Australia Received 30 September 2003; accepted 15 January 2004
Abstract The purpose of the study was to explore the association between depressive symptoms and social support in Taiwanese women doing the month. A correlational survey design using the Postpartum Social Support Questionnaire (PSSQ) and the Edinburgh Postnatal Depression Scale (EPDS) to measure social support and postnatal depressive symptomatology was employed. Two hundred and forty postpartum women receiving care in two teaching hospitals in Taipei, Taiwan, aged between 20 and 35, with no peri-natal complications or previous psychiatric history, experiencing a normal spontaneous delivery of one full term healthy baby, were selected. Each was mailed the PSSQ and the EPDS as well as a short, semi-structured self-report questionnaire requesting demographic details and subjective data relating to the experience of doing the month and depressive symptoms during the fourth week following birth. One hundred and eighty six women (78%) returned questionnaires. Taiwanese postpartum women were less depressed when they stayed in their parents’ home and had their own mothers take care of them. It was found that the greater the level of postpartum social support received by the women doing the month, the lower the risk of postnatal depressive symptoms experienced. Almost a quarter (24%) of the variance of the symptoms was attributed to dissatisfaction with parents’ instrumental support and unwanted emotional support from parents-in-law. It is concluded that the ritual of doing the month provides valuable social support and may help to prevent postnatal depression in Taiwanese women. r 2004 Elsevier Ltd. All rights reserved. Keywords: Social support; Doing the month; Postnatal depression; Nursing
1. Introduction The traditional Chinese rite of ‘‘Tso-Yueh-Tzu’’, translated as ‘doing the month’, is concerned with beliefs and practices associated with the postpartum period where, Chinese women are relieved of most work duties for a month so they can recuperate (Wong, 1993). It can be traced back to the Song dynasty (AD 960– 1279) and its conceptual origins may extend as far back as 2000 years (Pillsbury, 1978). According to traditional Chinese medicine, Chinese women become very ‘cold’ *Corresponding author. Fax: +886-2-29043500. E-mail address: [email protected] (S.-S. Heh).
(meaning vulnerable) following childbirth. Through doing the month the inner heat of a woman’s body can be augmented so that they may recover more quickly. When doing the month women are required to stay indoors and to follow certain restrictive prescriptions and proscriptions. Whilst the process of doing the month may vary, these include avoiding washing or contact with cold water and wind, and eating tonic food. Additionally, someone (usually female family members) assumes most of the responsibilities for baby care and housework. When the month is completed, a celebration is held and the mother can leave the house. The changes in the Taiwanese family from an extended to a nuclear structure, which have occurred since the 1960s, have
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meant that women have often found it difficult to identify a family member to assist them with doing the month. As a consequence, there has been a development of Doing the Month Centres. These centres provide services to new mothers which enable them to follow the traditional custom of doing the month on a commercial basis (Lu, 1985). The majority of the Taiwanese women choose western trained professionals for peri-natal care, however, they still follow the traditional Chinese postpartum custom of doing the month (Harn, 1992). Wong (1994) undertook surveys in both urban and rural settings and found that 95% of their samples had experienced doing the month. The Chinese postpartum custom of doing the month has been investigated in a number of studies in Taiwan (Chu, 1993; Harn, 1992; Lu, 1985; Pillsbury, 1978; Wong, 1993). In addition, studies of the phenomenon have been conducted in Hong Kong (Holroyd et al., 1997) and Scotland (Cheung, 1997). These studies demonstrate that most Chinese postpartum women still follow the practice and believe that it can improve their health, not only immediately following birth, but also in later life. However, with the exception of Harn (1992) and Chu (1993), the majority of the studies do not seek to measure the variables thought to be important, or to examine the relationship between them. Whilst there are many variables involved in the practice of doing the month that might contribute to the health of postpartum women, one important aspect that has been identified concerns social support. Pillsbury (1978), Chu (1993) and Wong (1994) suggest that because so much attention and help is given to the new mother while she is doing the month, postnatal depression may be prevented. But can doing the month prevent postnatal depression? Several recent studies have produced findings that would suggest it does not. It has been found that there is a high incidence of between 37% and 40% of postnatal depression in Taiwanese women postpartum (Chen et al., 1994; Harn, 1992; Ko et al., 1996). Furthermore, Tseng et al. (1994) concluded that women attending a Doing the Month Centre suffer even higher scores of postnatal depression. Postnatal depression is a mental and behavioural disorder associated with the puerperium, typically commencing within 6 weeks of delivery given by the International Classification of Diseases—ICD-10 (World Health Organization, 1992). It is characterized by episodes of irritability, guilt, exhaustion, anxiety, sleep disorders and somatic symptoms which have a disabling effect on mothers, children and families of sufferers, following childbirth (Green et al., 1990). Estimates of the incidence of postnatal depression vary widely, depending on the measuring instruments used, the criteria for diagnosis employed, the time that it is assessed and the characteristics of the women studied. It appears that the more stringent the diagnostic criteria
for depression, the lower the prevalence rate. O’Hara and Swain (1996) conducted a meta-analysis of fifty-nine studies, self-report methods (14%) significantly yielded higher estimates of postnatal depression than interviewbased methods (12%). Whilst the cause of postnatal depression is multi-factored it has been shown that psychosocial elements play an important role. A metaanalysis of 84 studies was conducted to determine the predictors of postnatal depression. Thirteen significant predictors were revealed: prenatal depression, selfesteem, childcare stress, prenatal anxiety, life stress, social support, marital relationship, history of previous depression, infant temperament, maternity blues, marital status, socioeconomic status, and unplanned pregnancy (Beck, 2001). There is strong evidence in the literature that lack of social support is an important factor in the development of postnatal depression. Taiwanese women may receive and perceive high levels of social support through the traditional postpartum practice of doing the month and could therefore be hypothesized to be less likely to develop postnatal depression. Specific aspects of social support during doing the month can then be investigated in relation to postnatal depressive symptomatology. Kumar (1994) stated that there is no good evidence for or against the theory that postnatal depression is partly the consequence of the rituals being stripped away. However, the lack of relevant research and limitations of method severely restrict any conclusions that can be drawn. The purpose of the study was to explore the association between social support received and perceived by Taiwanese women during doing the month and postnatal depressive symptomatology. 2. Methodology The study employed a survey design and aimed to collect detailed descriptions of social support and postnatal depressive symptoms in a sample of Taiwanese women doing the month. 2.1. Participants Participants attending two teaching hospitals in Taipei, were recruited into the study. Inclusion criteria were: married, first time mothers; age 20–35, and normal spontaneous delivery with full term healthy baby (gestation age 38–42 weeks, body weight over 2.5 kg and APGAR score >8). Exclusion criteria were: women suffering peri-natal complications, with a previous psychiatric history and not following doing the month. 2.2. Instruments The Postpartum Social Support Questionnaire (PSSQ) is an 81 item self-report scale specially designed
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to assess the degree of social support in the postpartum period (Hopkins et al., 1987). The scale measures both emotional and instrumental support received from spouse, and others (parents, parents-in-law, relatives and friends). It comprises four subscales: Spouse’s Emotional Support, Spouse’s Instrumental Support, Others’ Emotional Support and Others’ Instrumental Support. Each item of the PSSQ is rated on a 7-point scale in two ways: (a) frequency of occurrence and (b) desired frequency of occurrence. The scale of scores goes from 1 to 7 with 7 being the most and 1 the least. The PSSQ has adequate internal consistency and test-retest reliability (Heh et al., 2001). Dissatisfaction with social support is calculated by using a difference score between the support desired and support received in this study. The Edinburgh Postnatal Depression Scale (EPDS) was developed by Cox et al. (1987). The EPDS is a simple screening questionnaire consisting of ten short statements, taking less than five minutes to complete. Both the EPDS and PSSQ were translated into Chinese and the validity and reliability of each ascertained (Heh, 2001; Lee et al., 1998). 2.3. Data collection Access to undertake the study was gained from the directors and ethical approval was obtained from the Research Committee of the hospitals. A letter was sent to 300 postpartum women who met the criteria for selection. The information about the purpose and the procedure of the study and an invitation to take part in this study were included. Assurances were provided that involvement in the study would not make any difference to their medical care and that all information from the questionnaire would be treated confidentially and used for the purposes of the research only. The address and telephone number of subjects were confirmed when 240 subjects signed the consent form personally while they were staying in hospital. A short, semi-structured selfreport questionnaire was also constructed to obtain demographic data and data relating to the experience of doing the month (places and key helper) and postnatal depression (reasons, onset, duration and its influence). This was sent to participants with the PSSQ and EPDS during the fourth week postpartum. 2.4. Data analysis Data was analyzed using the statistical package SPSS for Windows. Descriptive statistics for each measure were calculated. T-tests, ANOVA and Pearson correlation coefficients were calculated for EPDS scores and the demographic variables of place, key helper during ‘‘doing the month’’. Pearson correlation coefficients between PSSQ and EPDS scores were calculated. Stepwise multiple regression was used to examine the
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contribution of the independent variables social support received and dissatisfaction with social support to EPDS scores.
3. Results One hundred and eighty six women (78%) responsed. The mean age of mothers was 2873.47 years (ranged from 20 to 35 years). The majority of the primiparas (80.6%) in the sample were pregnant for the first time. One hundred and thirty eight women (74%) were employed. Two-thirds (67.2%) of the sample reported that their pregnancy had been planned. Thirty-nine women (21%) had EPDS scores of 10 or above. Seventy-eight women (42%) indicated that they experienced depressive symptoms following giving birth. The majority of these symptoms commenced during the first week after discharge from hospital. The postpartum symptoms experienced were: anxiety, sleep disturbance, depression, crying, anger, shouting, nervousness, feeling of weakness, stress, inability to cope with life. The main reasons given for experiencing the symptoms were: the stress of baby care, insufficient sleep and lack of family support. In most cases these symptoms persisted for up to 2 weeks. Twenty women (10.8%) said that that the severity of these symptoms was sufficient to affect their daily life. The demographic variables, maternal age, education, working status, and family income, were found not to be related to postnatal depressive symptoms. However, unplanned pregnancy (t ¼ 2:15; d.f. =184, 95% CI: 0.34/2.69, po0:05), the place of doing the month (F ¼ 4:63; d.f. =4,181, po0:01) and key helper (F ¼ 4:24; d.f. =4,181, po0:01) were related to postnatal depressive symptoms. Postpartum women who stayed at their parents-in-law’s home and had their mothers-in-law as their key helpers demonstrated higher EPDS scores. Women who stayed in their parents’ home and had their own mothers take care of them during doing the month recorded lower EPDS scores. Parents’ support is strongly negatively correlated with EPDS score especially parents’ instrumental support. Whilst supports from other components of the social network are also negatively correlated with EPDS, none are statistically significant (p > 0:05). Total emotional support from the social network is very strongly negatively correlated with EPDS score. Total social support is very strongly negatively correlated to EPDS score (Table 1). The greater the level of postpartum social support received by the women during doing the month, the lower the risk of postnatal depressive symptoms experienced. Dissatisfaction with parents’ support (especially parents’ instrumental support) is strongly positively correlated with EPDS score. Dissatisfaction with
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Table 1 The relationship between social support received and postnatal depression (n ¼ 186) The characteristics of social support
Pearson r value
(1) Husband’s emotional support (2) Husband’s instrumental support Husband’s support (1) and (2) (3) Parents’ emotional support (4) Parents’ instrumental support Parent’s support (3) and (4) (5) Parents-in-law’s emotional support (6) Parents-in-law’s instrumental support Parents-in-law’s support (5) and (6) (7) Relative’s emotional support (8) Relative’s instrumental support Relative’s support (7) and (8) (9) Friend’s emotional support (10) Friend’s instrumental support Friend’s support (9) and (10) (A) Total emotional support (1)+(3)+(5)+(7)+(9) (B) Total instrumental support (2)+(4)+(6)+(8)+(10) Total social support (A)+(B)
0.18 0.11 0.18 0.21 0.35 0.33 0.00 0.02 0.04 0.21 0.08 0.18 0.09 0.01 0.08 r ¼ 0:38 r ¼ 0:16 r ¼ 0:51
po0.01, po0.001.
parent-in-law’s emotional support was strongly negatively correlated with EPDS score. Total dissatisfaction with instrumental support is very strongly positively correlated with EPDS score as is total dissatisfaction with social support (Table 2). These results suggest that the higher the dissatisfaction with social support received by Taiwanese women during doing the month the higher the EPDS score. Stepwise multiple regression analyses of EPDS scores with social support received, dissatisfaction with social support as predictor are shown in Table 3. Dissatisfaction with parents’ instrumental support and dissatisfaction with parents-in-law’s emotional support also accounted for 24% of the variability in EPDS score.
4. Discussion Previous research has shown that social support is related to postnatal depression. However, which specific social support is received and perceived as supportive to Taiwanese postpartum women and its relation to postnatal depression is not clearly defined. This study used the PSSQ to measure the characteristics and the
Table 2 The relationship between dissatisfaction of social support and postnatal depression (n ¼ 186) The dissatisfaction of social support
Pearson r value
(1) Dissatisfaction of husbands emotional support (2) Dissatisfaction of husband’s instrumental support Dissatisfaction of husband’s support (1)+(2) (3) Dissatisfaction of parent’s emotional support (4) Dissatisfaction of parent’s instrumental support Dissatisfaction of parent’s support (3)+(4) (5) Dissatisfaction of parents-in-law’s emotional support (6) Dissatisfaction of parents-in-law’s instrumental support Dissatisfaction of parents-in-law’s support (5)+(6) (7) Dissatisfaction of relative’s emotional support (8) Dissatisfaction of relative’s instrumental support Dissatisfaction of relative’s support (7)+(8) (9) Dissatisfaction of friend’s emotional support (10) Dissatisfaction of friend’s instrumental support Dissatisfaction of friend’s support (9)+(10) (A) Total dissatisfaction of emotional support (1)+(3)+(5)+(7)+(9) (B) Total dissatisfaction of instrumental support (2)+(4)+(6)+(8)+(10) Total dissatisfaction of social support (A)+(B)
0.12 0.09
0.18 0.18 0.47 0.41 0.36 0.01
0.19 0.12 0.18
0.22 0.12 0.07
0.09
0.20 0.39 0.58
po0.001.
level of social support during doing the month. It provides an objective way to assess the degree of the postpartum social support among Taiwanese women and provides knowledge regarding its relationship with postnatal depressive symptoms. 4.1. Social support as a mediator of depression during doing the month The findings sustain the conjecture that social support can protect against the development of postnatal depression and lessen the stress or the impact of stress
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Table 3 Stepwise multiple regression analysis of EPDS scores with dissatisfaction with social support as predictor (n ¼ 186) Predictors
Variables
Dissatisfaction with social support
Dissatisfaction with parents’ instrumental support Dissatisfaction with parentsin-law’s emotional support
R
R2
F
p
0.52
0.40
0.16
9.60
0.002
0.37
0.49
0.24
6.98
0.001
b
(Beck, 2001; Spangenberg and Pieters, 1991). Not only the characteristics of social support Taiwanese postpartum women received, but also how their perception of social support during the period of doing the month are related to their postpartum depressive symptoms, especially the parents’ instrumental support are demonstrated. Taking social support actually received and dissatisfaction with social support together when predicting postnatal depressive symptoms, the most influential factor is postpartum women’s perception of their dissatisfaction with parents’ instrumental support. This is consistent with the findings of O’Hara (1986) that depressed women express dissatisfaction with the frequency of their parents’ support. 4.2. Depressive symptoms during doing the month The study used the EPDS as a measure of postnatal depressive symptomatology. Twenty-one percent of the women had EPDS scores of 10 and above. Whilst there are some cultural difficulties in interpreting conditions like postnatal depression in non-Western cultures, the study results contradict the thesis that postnatal depression is a culture-bound phenomenon as proposed by Stern and Kruckman (1983) and there is no depression in Chinese postpartum women as proposed by Pillsbury (1978) and Chu (1993). Studies such as those of Pillsbury and Chu cited above, lacked formal diagnostic testing or observation in depression in the postpartum period. On the contrary, the finding supports the idea that postnatal depression, which has a predominantly psychosocial aetiology, surprisingly does not appear to vary in incidence across different cultures (Kumar, 1994). The results suggest that postnatal depression of Taiwanese women is not uncommon. The prevalence of postnatal depression was closer to 19% in Taiwanese by using the EPDS with a cut-off score of 12/13 within 3 months of delivery (Huang and Mathers, 2001). Demographic characteristics were not found to be related to the risk of postnatal depression. Unplanned pregnancy was found to be related to postnatal depression in this study. This result supports the earlier findings of Chen et al. (1994) and Ko et al. (1995). Chen et al. (1994) suggested that an unplanned pregnancy increases the feeling of loss of control of one’s life and is linked to lower self-esteem. Low self-esteem was found
to be related to postnatal depression (Affonso and Arizmendi, 1986). 4.3. The importance of parents’ instrumental support while doing the month The multidimensional nature of social support is clearer after analysing the correlation between social support actually received, dissatisfaction with social support and postpartum depressive symptomatology. The results suggest that Taiwanese postpartum women receiving instrumental support from their own parents can be protected from the risk of postnatal depression. However, the source and type of postnatal support could have an important influence on the level of postpartum women’s satisfaction. Too much emotional support from parents-in-law and too little instrumental support from parents appeared to explain postpartum women’s dissatisfaction. This is demonstrated by the significant correlation between the place, the key helper during doing the month and postnatal depressive symptoms. Taiwanese women prefer to stay at their parents’ home and be looked after by their own mothers during doing the month. It suggests that the Taiwanese ritual of doing the month protects postpartum women from the risk of postnatal depression, if social support during the period of doing the month satisfies them and meets their true needs. Logsdon et al. (2000) suggested that the importance of support is a better predictor of postpartum depression than the quantity of support a woman receives. It seems quite obvious that the event of childbirth brings postpartum women back to their original family for help, especially from their own mother. A person who experiences stress or anxiety at a certain stage of development may seek a resource, which gives unconditional love and support. Parents are the first choice for providing a refuge for those who experience stressful events in the Chinese culture (Cheng et al., 1994). 4.4. The impact of social change on social support and postnatal depression The mean EPDS score of twelve women who stayed at a Doing the Month Centre was over 10. This supports the finding of Tseng et al. (1994) that Taiwanese
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postpartum women who stayed in Doing the Month Centres felt more depressed. This study found that although women can rest and have traditional care from the staff of the centre, they felt that their association with the centre was a business relationship. They felt that there was a lack of support from their family during the period of doing the month, therefore they had to go to a Doing the Month Centre for their own good. LiuChiang (1995) used the focus group to explore the worries of 21 Taiwanese primiparas and found that all the worries focused on the need for the integration of self while they went through doing the month in a Doing the Month Centre. Those women expressed potential loss of self through their worries that the nurses in the centre concentrated on the ritual of doing the month and excluded them as the core component in it. A Chinese postpartum woman must have someone to accompany her during doing the month in following the rules. Traditionally, this person is the woman’s motherin-law. However, as the nuclear family increases and bilateral kin relations become more common, some mothers-in-law are relinquishing their influence to the natural mother. On the other hand, others still believe that it is their responsibility to ‘‘do the month’’ for the son’s wife. The strain between the mother-in-law and daughter-in-law is a sensitive problem and might be a cause of postnatal depression in Chinese society (Chen et al., 1999). Steinberg (1996) suggested that the strain between the mother-in-law and daughter-in-law often offsets the potential benefits of assistance and may even contribute to develop a mood disorder during the postpartum period.
5. Conclusion The ritual of childbirth may provide valuable social support for women after giving birth. This support may help to alleviate postnatal distress and depression. However, the support during the transition to motherhood needs to be considered from the perspective of the recipients, and the appropriate support during doing the month need to be evaluated by Taiwanese postpartum women nowadays. The imposition of a ritual or only one right way to approach postpartum women is inappropriate in a complex and secular society (Littlewood and McHugh, 1997). It seems that an alternative concept of rite offering greater flexibility in terms of considering the individual expectation of postpartum women is needed. 5.1. Limitations The correlational design of the study enabled the collection of a large amount of data regarding the practice of doing the month and postnatal depression
within the limitations of time and resources available to undertake the study. However, there are two main drawbacks with the chosen research design: firstly, it assumes that the data collected at one point will give us information about what happened over a period of time. Secondly, the sample was selected using a non-probability method and is therefore unlikely to be representative. 5.2. Implication for healthcare practice Health policy makers should take into consideration that the need for postnatal care to be provided in the community after discharge from the maternity unit in Taiwan. The EPDS is an effective tool to identify high risk case of postnatal depression. The relationship between daughter-in-law and mother-in-law may influence the quality of care received by daughters-in-law during doing the month. This observation could be explored in further research.
Acknowledgements The authors would like to thank Professor Mavis Kirkham and Jane Ribbens for their recommendation.
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