by Arwa Iqbal
Background
Seeking treatment for mental health is often stigmatized in many South Asian cultures, especially for women experiencing pregnancy. Depression that occurs during pregnancy or after giving birth is known as maternal depression. Maternal depression manifests in two ways (Mayo Clinic Staff, 2022). Peripartum depression starts during pregnancy while postpartum depression begins after childbirth. Mothers with untreated maternal depression can have severe mood
swings, isolate themselves from friends and family, lose their appetite, insomnia, panic attacks, and thoughts about suicide that can last indefinitely (Mayo Clinic Staff, 2022). In addition to drastically affecting the mother, her child is more likely to develop anxiety, poor social skills, sleep troubles later in their life, and negative behavior at 2 years old (Slomian et al., 2019).
Pakistan has among the highest rates of untreated maternal depression in Asia (Gulamani et al., 2013). Many cases in this country are untreated because women are ashamed to seek help (Khan, 2017). In Pakistani culture especially, childbirth is associated with being the happiest time for a woman. This time is seen to be one faced with gratitude and positivity. As a result, new mothers feel shame in bringing up their “negative” internal thoughts. Paired with lack of awareness, little money, and societal expectations, some women chose to ignore their depressive thoughts, causing their illness to go undiagnosed (Khan, 2017). Failure to diagnose ends up endangering the mother and her child’s future health.
Causes/Prevalence of Maternal Depression in Pakistan
The average prevalence of postpartum depression in Pakistan is 45.5% (Gulamani et al., 2013). Globally, postpartum depression occurs in about 6.5% to 20% of women (Mughal et al., 2022). The greater prevalence of postpartum depression in Pakistan specifically emphasizes how widespread it is there. Multiple biological and environmental factors are known to cause maternal depression.
At a biological level, maternal depression is caused by cells called autophagy that fail to clean up old protein and genetic material. The result is a toxicity, which can change the brain, and cause maternal depression (Barney, 2022). This finding has opened up an avenue for discovering new treatment for maternal depression (Barney, 2022). Genetics also influence postpartum and perinatal depression. Family history can increase the risk of the child developing maternal depression in the future (Mayo, 2022).
In addition to biological, many environmental causes are also known to explain the large prevalence of postpartum depression in Pakistan. Mainly because surroundings greatly impact an individual’s internal state. Lower socioeconomic status tied with little social support from family is seen to largely lead to maternal depression, due to fear surrounding the future child’s quality of life (Jawed et al., 2021). While mothers in upper classes develop depression, those in lower classes are at a far greater risk. People in these households often encounter situations where mothers develop depression out of fear for not living up to societal expectations. A doctor described several examples of these mothers. One mother developed depression after having pressure from her in-laws about giving birth to a male instead of a female while another because they had an abusive partner. Some scenarios involved patients having unwanted pregnancies or because they were anxious in disappointing their future child due to poor living conditions. Further, for others, health dangers like sudden nutritional changes (hypertension, anemia), can lead to frustrations and loneliness, causing depression (Jawed et al., 2021).
Health Disparities
People in Pakistan who have little education, live in rural cities, or are in poverty, are most impacted by maternal depression (Aliani & Khuwaja, 2016). Women are affected because they experience this mental illness, but their children are at greatest risk when the mother is unable to get treated.
Lack of education surrounding women health causes many women to believe that their symptoms are a normal consequence of becoming a mother. Many less educated patients do not speak English, making them unaware or unable to understand postpartum depression. Other times, people incorrectly interpret information about postpartum depression because the writing is too advanced, creating a barrier for them in seeking proper treatment (Aliani & Khuwaja, 2016).
Mothers living in rural areas especially have reduced access to medical providers. Responsibilities for family or children tied with doubt and large travel time make mothers much less likely to go out of their way to pursue care. Some worry that being gone for so long will result in people finding out they are not “mentally sane” because of the cultural taboos surrounding mental health in Pakistan. Thus, mothers are unwilling to put in work to improve their health because of the logistical challenges (Aliani & Khuwaja, 2016).
Pakistani women in poverty are unable to afford care for maternal depression. Sometimes people experiencing postpartum depression can afford the doctors, but they are unable to pay for day care for their children. Other times health insurance fails to cover expenses for mental health, causing treatment to be a financial burden. There are instances where women aspire to seek treatment but the large wait time in the hospital due to underfunding in poorer regions makes it difficult because of work schedules (Aliani & Khuwaja, 2016).
The health disparities in Pakistan arising due to education, geography, and status often pose significant challenges to mothers in seeking care. On top of the systematic barriers, the shame in treatment for postpartum depression makes mothers even less likely to get help, damaging themselves and their future kids (Aliani & Khuwaja, 2016).
Interventions
There have been several cultural and social interventions to address maternal depression in Pakistan.
To prevent postnatal depression and treat prenatal depression, the cultural practice of chilla is used as an intervention. Chilla is the 40-day period following childbirth where a woman lives in her mother’s home and is fed healthy foods, has no household duties, and gets help from her family. In a study, out of 823 women, over 80% felt emotionally better after chilla (LeMasters et al., 2020). Those with depression initially had lower depressive symptoms after chilla at 6 months postpartum. Those with no depression at the start of the study remained healthy with chilla. This practice serves as a cure and preventive measure for mothers that is more financially accessible. Because chilla is a traditional practice, women are more likely to partake because it is deemed culturally acceptable (LeMasters et al., 2020).
The Thinking Healthy Programme (THP) is another intervention that uses peer facilitation to treat perinatal depression. THP is performed by local people who employ a simple technique that builds a relationship, based on empathy, the present, and problem solving (Atif et al., 2017). Essentially, local peer volunteers speak with mothers experiencing depression. The goal is to encourage mothers to reflect on their thinking and rely on their families. Because peers deliver the counseling, the therapy technique is relatively simple. This simple technique increases accessibility for patients and allows them to get help in a more private manner in case they fear public shame. Further, the peers are local, making them more relatable to the mother because they know about the respective cultural norms. This intervention was tested in Rawalpindi, Pakistan, and it was found to improve outcomes for mothers with depression and their child’s health outcome. Ultimately, there was a decline in the prevalence for maternal depression with this technique (Atif et al., 2017).
These two interventions have been successful when integrated at a smaller scale. However, these interventions have yet to be applied nationally. These two practices both address shame, the biggest instigator of women not seeking care (Aliani & Khuwaja, 2016). Thus, mothers are more inclined to use them.
Conclusion
Maternal depression is stigmatized in Pakistan, causing women to avoid seeking care. Those with lower socioeconomic status are more likely to develop depression during or after pregnancy. But these women are also even less likely to get help because of the financial and family burdens or little knowledge about the dangers of leaving their condition untreated.
To address the barriers, there must be more research done on understanding the factors explaining why mental health is stigmatized in Pakistani cultures. This research can be done by interviewing mothers and people from various classes, geographic locations, and religions in Pakistan. After, a pattern will likely emerge between these different groups. In the end, by hearing individual perspectives, doctors and nurses will be able to understand the core problems mothers face in acquiring care. They can then better address these concerns when designing treatment plans for patients.
References
Aliani, R., & Khuwaja, B. (2016). Epidemiology of postpartum depression in Pakistan: A review of literature. National Journal of Health Sciences, 2(1), 24–30. https://doi.org/10.21089/njhs.21.0024
Atif, N., Krishna, R. N., Sikander, S., Lazarus, A., Nisar, A., Ahmad, I., Raman, R., Fuhr, D. C., Patel, V., & Rahman, A. (2017). Mother-to-mother therapy in India and Pakistan: Adaptation and feasibility evaluation of the peer-delivered thinking healthy programme. BMC Psychiatry, 17(1). https://doi.org/10.1186/s12888-017-1244-z
Barney, J. (2022, October 4). Potential biological cause for postpartum depression found. UVA Health Newsroom. Retrieved January 16, 2023, from https://newsroom.uvahealth.com/2022/10/04/scientists-discover-potential-biological-causefor-postpartum-depression/
Gulamani, S. S., Shaikh, K., & Chagani, J. (2013). Postpartum depression in Pakistan. Nursing for Women's Health, 17(2), 147–152. https://doi.org/10.1111/1751-486x.12024
Jawed, M., Pradhan, N. A., Mistry, R., Nazir, A., Shekhani, S., & Ali, T. S. (2021). Management of maternal depression: Qualitative exploration of perceptions of healthcare professionals from a public tertiary care hospital, Karachi, Pakistan. PLOS ONE, 16(7). https://doi.org/10.1371/journal.pone.0254212
Khan, Y. S. (2017, August 31). On being South Asian and having postpartum depression | CBC parents. CBC News. Retrieved January 16, 2023, from https://www.cbc.ca/parents/learning/view/on-being-south-asian-and-having-postpartum-depression
LeMasters, K., Andrabi, N., Zalla, L., Hagaman, A., Chung, E. O., Gallis, J. A., Turner, E. L., Bhalotra, S., Sikander, S., & Maselko, J. (2020). Maternal depression in rural Pakistan: The protective associations with cultural postpartum practices. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-8176-0
Mayo Clinic Staff. (2022, November 24). Postpartum depression. Mayo Clinic. Retrieved January 16, 2023, from https://www.mayoclinic.org/diseases-conditions/postpartum-depression/symptoms-causes/syc-20376617
Mughal, S., Azhar, Y., & Siddiqui, W. (2022, October 7). Postpartum depression. National Center for Biotechnology Information. Retrieved January 22, 2023, from https://pubmed.ncbi.nlm.nih.gov/30085612/ /
Slomian, J., Honvo, G., Emonts, P., Reginster, J.-Y., & Bruyère, O. (2019). Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women's Health, 15. https://doi.org/10.1177/1745506519844044
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