Postnatal Depression, Changing Childbirth and Faltering Families
Professor John Cox on behalf of the Marce` Society
The title of the 1996 Marcé Lecture was chosen because of my greater awareness that Perinatal Mental Disorders have adverse consequences for Children, and because Parenting in a "post-modern" society is difficult and, at times, very stressful. I also wished to describe the implications of these changes in family life during the last forty years for our work, and their impact on the prevention of Postnatal Mental Disorder. Children born in the Sixties (whose parents may have been included in Brice Pitt's 1968 seminal study of PND in London) were brought up in a different family environment from their parents, and may have experienced less family support.
The nuclear family (see Neuberger 1994) has been reshaped by changing attitudes to sexual intimacy and contraception, as well as by greater uncertainty about the durability of relationships including that of marriage. This massive cultural shift is reflected by the media (Storkey 1996); the family has indeed been changed by sharp increases in the divorce rate (1 in 4), postponed marriage, delayed childbearing, as well as by cohabitation and step families. These trends are similar to those occurring in the US, where Acock and Demo (1994) have reported that in 1992 71% of children lived with two parents, compared with 88% in 1960; and 27% of children lived with a single parent in 1992 compared with only 9% in 1960.
The family is however still described as the "pivotal institution" (United Nations 1994) from which societies derive strength and forge the future. Yet across the world many families are also faced with problems of famine, poverty, unemployment, drugs and AIDS, as well as the impact of new wage earning life-styles. Desjarlais et al (1995) have discussed evidence for an adverse effect especially on economically marginalised children. Consequent role overload and low power for women has been suggested (Rosenfield 1989) as an explanation for the increased frequency of anxiety and depression in women when compared with men.
In Britain these changes have occurred alongside another Social revolution, also with implications for the family: Mental Health Services are provided "in the community", Mental Hospitals are being closed and there is an expectation that those with mental illness will be cared for by their family. The family, already under siege, is to assume more, not less, responsibility for the health of its members, including those with Mental Disorder.
Yet mental disorder in parents may increase the risk to the life and well being of their children. In a survey of 100 Child Death Reviews by Falkov (1996), psychiatric morbidity occurred in 32 families, and in 25 the perpetrators were suffering from a mental disorder. The greatest risk to the life of the infant is in the first year (Marks and Kumar 1993), when an infant is four times more at risk than in later years. In the Confidential Inquiry into Homicides and Suicides by Mentally Ill People (1994), of the 7 women within the remit of the Inquiry all but one of their victims were young children of the perpetrators, and most of the women had an affective disorder.
These findings underline the need for a Perinatal Mental Health service, including Mother and Baby Units as well as closer links with Social Services. Prettyman and Friedman (1991) found that only 20% of Health Districts in the UK had a designated Mother and Baby Unit, and it is unlikely that this proportion has increased since then.. A specialist Perinatal Day Hospital, such as Charles Street Parent and Baby Day Unit, may reduce the need for admission to a Mother and Baby Unit, but does not prevent admission when there is a serious risk to the mother and her baby, and no 24 hour domiciliary service is available (Boath et al 1995; Cox 1993).
There is at the present time a greater awareness that both clinicians and researchers need to consider the Policy implications of their studies and in particular the adverse effect of Postnatal Depression on children. Greater awareness of the adverse effect of Separation and Divorce on mental health and safety of children (Ayalon and Flasher 1993) is also relevant in this context; Murray and Stein (1991) have drawn attention to the Public Policy implications of such knowledge and to the need to be firm advocates for improved resources.
The perspective of Social Anthropology for understanding the causes and consequences of childbearing mental disorders is particularly apposite when considering a Needs-led service. Childbirth is a "Rite of Passage" which is not restricted to a discrete localised 'life event' similar to a burglary or the death of a pet - or even to an unwanted house-move. It is a staged social transition, which includes Separation, Liminal and Reincorporation phases, and establishes a different valency of relationship between parents, and a secure environment for infant learning and development. Price (1995) has speculated that such parenting behaviour is facilitated in evolutionary terms by neuro-hormonal mechanisms including the effect of Oxytocin and Prolactin which maintains mothering behaviour such as Maternal/Infant proximity. Is it possible that the new parenting behaviours, now selected by an evolutionary process, will modify further these neuro-hormonal mechanisms?
Fitzgerald (1993) has cogently argued that the transmission of parenting skills is impeded by "breaks" in Women's knowledge transfer between generations. Such breaks in knowledge transfer are caused by, inter alia, the migration of the mother from her own mother (e.g. Cambodian refugees), delayed childbearing, smaller families. Lack of knowledge transfer can lead to lowered self-esteem and to clinical depression.
Thus cultural competence is especially necessary for Health Professionals in the Perinatal field, and facilitates greater sensitivity to the way that cultural values and attitudes are transferred between mother and infant.
CLINICAL AND RESEARCH PRIORITIES
What is the relevance of these changes in family structure for the recognition and management of postnatal depression? It is well established that these women with young children are more likely to become depressed if there is no confidante, intimate partner or husband. The findings of Brown and Harris (1978) have since been replicated in the USA (1988), and more recently in the UK (OPCS 1995); lone parents, and those living alone or without close relatives, were more likely to have neurotic symptoms than other women; people living in couples with no children were the least likely to have Mental Health problems. Having children increased the prevalence of psychiatric symptoms and especially of irritability. Living in a one-person family was associated also with increased of alcohol and drug dependence. Single first-time mothers have a greater risk of being admitted with a Puerperal Mental Illness within 30 days of delivery (Kendell 1987).
In comprehensive reviews by O'Hara and Zekoski (1996) and Boyce (1994), dysfunctional marriages (marital problems, partner hassles) were found to be causes of PND as well as a secondary consequences. In only one study reviewed by O'Hara and Zekoski was no such association found; but in no study was the frequency of Separation or Divorce investigated. RELATE counsellors nevertheless report that these events do occur in the postpartum period. Interestingly, Dominian (1968; 1980) has specifically referred to this possibility. It is likely that research in this field would be particularly important; the hypothesis of increased likelihood of separation and divorce in the peripartum period could readily be tested. In most studies marital difficulties occur in the setting of untreated Postnatal Depression. It is not known the extent to which such problems would have been ameliorated, or not occurred at all, if depression had been identified and fully treated. Clinical experience would suggest that if this occurred, family breakup would be more unlikely.
What are the implications of these observations for the prevention (Primary, Secondary and Tertiary) of Perinatal Mental Disorder - and Postnatal Depression in particular? Although there is evidence for increased depression in Sweden (Hagnell et al 1982) and in Cross National Comparisons (1992), no studies have established whether the rates of Postnatal Depression have increased. A replication of Brice Pitt's study of Postnatal Depression would therefore be particularly pertinent. It is a most plausible hypothesis that the frequency of PND - Incidence and Prevalence - is increased by diminished social support, and in particular lack of continued family relationships. It is possible, also, that changes in the nature and duration of the marital relationship would explain the greater interest in postnatal depression compared to thirty years ago.
Useful generalisations about the Prevention of Perinatal Mental Disorder include Education about Parenting and Child Development being more widely available, and revision of the curricula of Parentcraft classes to emphasise the impact of reduced Family support and the increased vulnerability to Depression and Anxiety in women who are single because of separation or divorce.
There is a need for Pre-marital counselling and Health Education in schools with an emphasis on culturally appropriate family values relevant for a multi-faith society. The benefits of encouraging greater expectation of a more enduring marital relationship and of ongoing responsibility for the care of children could be emphasised in Primary Prevention Programmes. Greater provision of nursery facilities at the workplace, and adequate Welfare supports will help reduce the prevalence and personal impact of Postnatal Depression.
Secondary prevention of PND by early screening (Cox and Holden 1987)and advice to parents who experience "Relationship-Strain" secondary to depression will assist to break the "vicious circles" which may maintain depression.
Early intervention using treatments of PND known to be effective (e.g. Counselling and Anti-depressants) is more likely to occur if Education packages developed by General Practitioners for General Practitioners are available, and if specific training for Primary Care based Community Mental Health Nurses and Health Visitors is undertaken.
Attempts to restructure Postnatal "routines " to be more culturally appropriate and to enhance parental self-esteem and affirm core tasks of parenthood could be considered. For example a review of the purpose of the postnatal "visit" is worthwhile, and incorporating more professional and lay support will enhance the value of such routines, and help to provide "structure" to the postpartum period which in Western society has so largely been lost. Churches, temples and mosques might consider holding a more popular, yet secular, Naming ceremony to emphasise the importance of the infant and family responsibilities. Such rituals might facilitate the provision of more informal social support from neighbours and friends at that time. In this way the advantage of new family structures, and of more diverse parental responsibilities would become apparent and the disadvantage of post-modern families diminished.
In conclusion, a response to the early challenge of Aubrey Lewis (1956) quoted by Rutter (1996) to determine more precisely the effect of parental mental disorder on family structure, and to understand more fully how adverse effects are ameliorated, is necessary.
"For the Sociologist the family is a nuclear unit; for the anthropologist, bonds of kinship are of the first importance; and for the psychiatrist the family is the matrix within which the individual is moulded and developed, the area where his strongest emotional ties are formed, the background against which much of his most intense personal life is enacted. There is, therefore, need to study the family, not only from the psychoanalytical and psychological standpoint, but also to discover how mental illness impinges upon it, and what effects this sort of incapacity has on the family structure".
Postnatal depression can adversely affect family structure and function and lead to an 'unwanted' divorce or separation. One of our tasks is therefore to understand the nature of this process and, when appropriate, establish and evaluate prevention strategies.
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