Reported rates of postpartum depression (PPD) bring much-needed attention to social and ethnic disparities in the mental health of women of color. Study findings suggest that women of color are significantly more likely to experience postpartum depressive symptoms compared with White women in the United States (Doe et al., 2017; Howell et al., 2005; Liu & Tronick, 2014; Segre et al., 2006; Wenzel et al., 2021). Patton (1990) explained that "qualitative data can put the flesh on the bones of quantitative results, bringing the results to life through in-depth case elaboration" (p. 132). The purpose of this integrative review of qualitative studies on PPD in U.S.-born women of color was to help increase our understanding of the quantitative prevalence studies that consistently found higher rates of PPD in women of color compared with White women. Using voices of the women themselves from the qualitative studies, this review can help increase our understanding of PPD among women of color representing various ethnic groups. Synthesizing the findings from individual studies together can provide nurses and other clinicians with a higher level of evidence for practice.
Methods
Databases searched were PubMed, CINAHL, Scopus, and PsycInfo using keywords of postpartum depression, perinatal depression, qualitative, Black, African American, Hispanic, Latina, Asian, Korean, Chinese, Vietnamese, Native American, Pacific Islander, Mexican, race, ethnicity, and women of color. Sample inclusion criteria included that the studies were (1) published in English, (2) used a qualitative design, and (3) examined PPD experiences of U.S.-born women of color. There was no limitation on the year the study was published. Qualitative studies were included in this review if a small percentage of immigrant women comprised the sample and that the findings clearly differentiated U.S.-born from foreign-born women (Abrams & Curran, 2009; 2011; Iturralde et al., 2021). In one study (Keefe et al., 2016), both Black and Hispanic women comprised the sample. The authors did not specify whether quotes in their results were from which specific group. When the quotes from this study were included in the findings of this integrative review, they are labeled as Black/Hispanic. A PRISMA diagram (Figure 1) illustrates the search process. Titles, abstracts, and full texts were reviewed. After removing any duplicates, the main reasons for excluding articles were that they were either quantitative, systematic reviews, or included immigrant samples. The researcher critically reviewed the eight qualitative studies using the 10 Critical Appraisal Skills Programme's (CASP, 2018) criteria for qualitative studies. All studies were of acceptable levels and included in this integrative review.
Sample
Eight qualitative studies met the sample criteria and included Black and Hispanic women. Three qualitative studies were found that focused on Asian women, but the samples consisted of foreign-born women and thus did not meet sample inclusion (Goyal et al., 2015; Han et al., 2020; Ta Park et al., 2019). The limited demographic and obstetric characteristics of the samples provided in these eight studies are listed in Table 1. Two studies focused on Black women, two studies on Mexican American adolescents, and four studies included a combination of Black and Hispanic women in the samples. Two studies used focus groups (Iturralde et al., 2021; Sampson et al., 2014), two were grounded theory studies (Abrams & Curran, 2009; 2011), and four used a general qualitative descriptive design (Amankwaa, 2003; Keefe et al., 2016; Recto & Champion 2018a; 2018b).
As only eight studies were located, to supplement this limited qualitative research, blogs were searched to locate any on PPD written by women of color in the United States. A Google search identified Postpartum Progress which is an award-winning blog dedicated to maternal mental illness. The founder of the blog, Katherine Stone, started it after her own postpartum anxiety/obsessive compulsive disorder experiences. In Postpartum Progress is a series called Warrior Moms of Color that focuses on PPD. Six postings by Black women and two by Hispanic women of their PPD experiences were found on this blog and included in this integrative review.
Data Analysis
Krippendorff's (2019) content analysis method was used to analyze the findings from the eight qualitative studies and the blog postings that resulted in five themes. Content analysis is "a research technique for making replicable and valid inferences from texts (or other meaningful matter) to the contexts of their use" (Krippendorff, 2019, p. 24). In his method, qualitative content analysts choose a type of distinction for defining the unit of analysis, that being either preset categories or themes. For this review, thematic distinctions were chosen. The units of analysis were extracted as segments of the experiences of women of color's descriptions of PPD from the published reports. Krippendorff suggests using dendrograms, which are treelike figures, to assist in visualizing the units of analysis as they are collapsed into theme clusters. See Figure 2 for an example of a partial dendrogram for one theme. A graduate assistant in the PhD program in nursing, who completed two courses in qualitative research methods, reviewed the clusters of segments and confirmed their appropriated placement in the themes. Both the researcher and the PhD student who reviewed the themes were White.
Results
Struggling with an Array of Distressing Symptoms
Sadness, crying, anger, overwhelmed, and loneliness were experienced by all women of color in this review. In Sampson et al.'s (2014) study, Black mothers expressed overwhelming sadness and bouts of crying. A Mexican American adolescent recounted It's something you're not used to- crying all the time (Recto & Champion, 2018a, p. 119). Regarding anger, one Hispanic woman shared in her blog, I know my temper was off the charts. Mexican American adolescents explained how they often felt isolated and lonely when they lost friendships as this quote illustrates: Once a young person gets pregnant, all her friends are really not around. They end up leaving and they do judge (Recto & Champion, 2018b, p. 64). In Abrams and Curran's (2009; 2011) studies with low-income Black and Hispanic women, they reported the mothers' PPD was compounded by their economically and socially stressful living conditions as this quote illustrates: They tell me not to stress when I have rent due and electricity and a car note and insurance and a baby behind me and you're telling me not to stress? (Abrams & Curran, 2009, p. 358).
Guilt was another distressing symptom women of color struggled with. One Black woman in her blog wrote, Nothing told me I would spend hours on my bathroom floor, body heaving, tears pouring down my face as my mind and emotions were tossed to and fro in between waves of guilt. Some Mexican adolescent mothers expressed their guilt for feeling depressed when they just gave birth to a beautiful healthy baby (Recto & Champion, 2018a; 2018b).
The most serious symptom women of color experienced was the presence of suicidal thoughts. Some Black mothers in Amankwaa's (2003) study shared their thoughts of suicide and harm to themselves. In her blog posting, one Black mother shared no told me I would want to hurt myself...or my son. A Mexican American adolescent revealed having suicidal thoughts (Recto & Champion, 2018a, p. 113).
Cultural Stigma as a Powerful Roadblock
Black and Hispanic women of color all expressed the strong presence of culturally based stigma regarding mental illness that hindered them from seeking help for their PPD. In Iturralde et al.'s study (2021), some Hispanic mothers shared their concerns admitting they were depressed because that would make them seem ungrateful for motherhood or crazy as one Hispanic woman described if you go to the psychologist or something. It's not well seen. It's like you're ah, like a crazy person (p. 4).
Black women shared they kept secrets about their PPD due to shame and embarrassment associated with Black culture that labeled depressed persons as crazy (Amankwaa, 2003). One Black mother described in her blog that The stigma surrounding mental illness in the Black community is strong. So strong doing so means you're crazy. Black women shared that their cultural community believes that strong women do not catch postpartum depression (Sampson et al., 2014, p. 47).
Complicating Barriers to Seeking Much-Needed Professional Help
Complicating the cultural stigma of mental illness for women of color were a multitude of additional obstacles hindering efforts to seek professional help. Lack of education and misunderstandings of PPD by the women themselves and their families were further barriers. Mexican adolescents disclosed the difficulty in recognizing that PPD was what they were experiencing (Recto & Champion, 2018a). Some felt that depression after childbirth was normal. This quote illustrates this misconception: it's like somebody saying, ah, you have contractions while you're in labor (Recto & Champion, 2018a, p. 115).
Other barriers to professional treatment women of color experienced included difficulty navigating health care services, lack of transportation, distrust of health care providers, involvement of child protection services, fear of discrimination of PPD, and time commitment. Mexican American adolescents recalled how lack of transportation was a barrier to their seeking professional help (Recto & Champion, 2018a). A Black mother in Iturralde et al.'s (2021) study shared that she was afraid of discrimination if her PPD was on her medical record. She feared it could increase the cost of her life insurance and affect her employment. Another Black woman recounted her multiple attempts to navigate the maze of social service and welfare systems that contributed to her PPD. Some Black women in Sampson et al.'s (2014) study feared that they may have warrants and that the law and Child Protective Services could get involved. Black and Hispanic women explained that strict constraints on their maternity leave and time off from work were other barriers (Iturralde et al., 2021).
Some, but not all, women of color had negative experiences with their health care providers. When describing her obstetrician this Black woman recalled I didn't feel supported with my depression with her at all (Iturralde et al., 2021, p. 5). A Hispanic mother in this same study admitted, My first OBGYN treated me like a statistic, a number...Here take this [antidepressant] medication and go away (p. 5). Some Mexican American adolescents recounted their distrust of health care providers. For example, some feared they would be lectured by clinicians because they got pregnant as adolescents. Other Mexican American adolescents felt clinicians were impersonal and rushed through their appointments.
Support as a Lifeline or "Just Pulling Yourself up by Your Bootstraps"
Black and Hispanic women stressed the importance of support from family, friends, and other women experiencing depression after giving birth. Support also came in a variety of forms such as prayer, chat rooms, or blogs. A Black mother in her blog posting described the strong support she received from her husband. It took me another month to tell my husband how I was feeling - my sweet, wonderful, patient husband who made the call to our insurance for me so I could get help for my PPD. One Black woman turned to the internet. I lived on Postpartum Progress searching for hope stories and hanging onto them for dear life. Black and Hispanic women shared that bonding over similar PPD struggles with other mothers in their church helped them feel supported (Keefe et al., 2016).
Not all women of color received the benefits of the lifeline of support from others. Low-income women of color in Abrams and Curran's (2009) study recounted the loneliness and lack of support they felt mothering alone when the fathers were absent or marginally involved in child care. Some Black mothers described that instead of needed support they received constant criticism. It seemed like the whole world is on your shoulders pushing you down (Sampson et al., 2014, p. 46). A strong theme for Black women centered on pulling themselves up by their bootstraps as relayed in blog posts. One Black mother in Amankwaa's (2003) study recounted the African American culture's belief is that women are strong; You pull yourself up and you know, you keep going (p. 311). In her blog posting this Hispanic mother explained that in her culture women are raised with the cultural ideal of "Marianisma" in which a woman puts the needs of her family ahead of her own...Seeking help is often frowned upon by family members. Family must come first before a mother's struggle with PPD.
Preferences for Help with Postpartum Depression
Nonprofessional Preferences. For many women of color their first choice to seek help for their PPD was not medical professionals but instead family members or friends. Some Mexican adolescents in Recto and Champion's (2018a) study stated they would rather confide in family and other persons who had experienced depression because some feared their infants could be taken from them if they opened up about being depressed. Mexican adolescents preferred nonpharmacological methods to treat their PPD due to fear that medications would affect their infants or impede their ability to care for their infants.
Black and Hispanic women turned to prayer and attending church for help when experiencing PPD. In Black culture, PPD is viewed as a weakness and believed to be overcome by prayer (Iturralde et al., 2021). In Keefe et al.'s (2016) study, faith in God helped women feel less alone and more hopeful. Prayer and belief in God prevented some women of color from harming themselves as this quote illustrates, I believe in God, I have a higher power. There's been days where I broke down...and can honestly say I wanted to take my life, but I prayed so hard. There was never a day where that praying did not work (Keefe et al., 2016, p. 729).
Professional Preferences. In their blog postings, some Black women described their treatment experiences of PPD. Two of the women started on antidepressants but stopped taking them due to side effects but once their depression reared its ugly head again, the women went back on the antidepressants and their depression lifted. This Black mother shared in her blog posting I am so happy and blessed to be able to say that taking those meds saved me!
In a couple of the blogs, Black women described how counseling helped them. As one woman wrote, I can remember feeling such relief after talking to the intake counselor and explaining why I needed help. I had no idea how heavy a burden I was carrying until I had to detail out the thoughts and feelings I was having. She was prescribed an antidepressant and this mother reported the medication really helped her feel more like her normal self. In Iturralde et al.'s (2021) study, some Hispanic mothers revealed that they would be willing to take antidepressants, whereas other Hispanic women were concerned about being pressured to take antidepressant medication.
Discussion
Both Black and Hispanic women are represented in the five themes and experienced the stigma attached to mental illness in their cultural communities. Women experienced typical symptoms such as crying, guilt, loneliness, sadness, and irritability. Especially concerning were suicidal thoughts that were revealed by Black mothers in Amankwaa's (2003) study, in blog postings, and by Hispanic and Black women in Keefe et al.'s (2016) study. This serious finding alerts clinicians to the critical need for early PPD screening so women struggling with this mood disorder can receive appropriate treatment as soon as possible.
As this current review revealed, these are some different cultural perceptions among Black and Hispanic mothers that can affect their experiences seeking mental health services for PPD. In the Black culture, Pulling oneself up by their bootstraps and in the Hispanic culture Marianisma were strong cultural beliefs that hindered mothers from seeking the help they needed to overcome PPD. Low-income women of color described how their stressful economic conditions exacerbated their PPD symptoms (Abrams & Curran, 2009; Iturralde et al., 2021). The theme, struggling with an array of distressing symptoms, confirmed Liu et al.'s (2016) study where Black and Hispanic women who reported high financial and relational stress also reported higher PPD symptoms compared with White women.
The barriers that prevent women of color from seeking and obtaining mental health care are complex as described in all the themes. Both contextually relevant stressors such as, lifetime poverty and trauma, and culturally relevant stressors can complicate PPD in women of color (Lara-Cinisomo et al., 2016). Clinicians, researchers, and policy makers all need to work together to remedy this complex situation for women of color struggling with PPD.
In the theme complicating barriers to seeking much-needed professional help, women revealed both their own and their family's lack of education and misunderstandings about PPD. Jones (2022) reported that mental health literacy was positively related to attitudes toward professional psychological help-seeking in postpartum women. Mental health literacy for women of color, their families, and their cultural communities needs to be addressed by nurses and other health care providers. There are multiple components of mental health literacy regarding PPD. These include a person being able to recognize a specific mental disorder, in this case, PPD and have knowledge and beliefs of its risk factors and causes, self-help interventions, professional help available, and how to seek mental health information (Jorm, 2000).
The theme, preferences for help with PPD, supported Bodnar-Deren's et al.'s (2017) results that found Black mothers were less likely to accept prescription medication and mental health counseling and more likely to accept spiritual counseling than White women. This theme also confirmed Dagher et al.'s (2021) finding in a national survey that Hispanic mothers had significantly lower odds of seeking postpartum mental health consultations than White mothers.
In this integrative review, blogs for Black and Hispanic women provided much needed emotional and informational support during their PPD. This finding confirmed what Moore et al. (2020) reported in their meta-synthesis of women's experiences of online forums for perinatal mental illness and stigma that blogging helped provide a safe place to talk, a virtual support system, and to not feel so alone.
Limitations
Limitations of this integrative review include its small number of studies and the lack of published studies on U.S.-born women of color other than Black and Hispanics. Research is needed with other groups of women like Native Americans, Asians, and Native Hawaiian/Pacific Islanders to address this glaring absence from the literature. Another limitation of this integrative review is the scant inclusion in the research reports of participants' demographic and obstetric characteristics.
Clinical Implications
Women of color in Keefe et al.'s (2016) study provided recommendations for health care providers in caring for women of color with PPD that clearly have implications for nursing practice. Most important was the ability of nurses and other clinicians to develop strong therapeutic alliances with their patients by listening carefully to the mothers' concerns, empathizing with them, and developing a trusting relationship. Black and Hispanic mothers in Iturralde et al.'s (2021) study offered additional recommendations such as making mental health care more convenient for women of color by offering telemedicine and having on-site childcare, and using peer health workers to go out into the community and spread awareness of PPD. Women also suggested that patient advocacy groups for specific ethnic groups can be formed and consulted with to guide health care agencies to develop culturally appropriate interventions for PPD.
Nurses need to provide culturally relevant community education about perinatal mental illness to help decrease stigma and increase mental health literacy. As women of color preferred informal support of family, friends, and their church communities over formal professional support, it is critical that their significant others receive correct information about PPD. Pastors and priests should not be forgotten when planning educational sessions on perinatal mood and anxiety disorders. Black women in Amankwaa's (2003) study stressed the need to teach people in their community that crying and sadness are not the only symptoms of PPD. Anxiety can also a debilitating symptom.
Nurses should be vigilant in ensuring that women of color are being routinely screened for perinatal mood and anxiety disorders. Sidebottom et al. (2021) reported women of color were significantly less likely to be screened for PPD than White women during the first 3 months after birth. This disparity in screening can potentially lead to under reporting and women with PPD falling through the cracks of the health care system. Women of color in this integrative review shared thoughts of suicide and of harming themselves that supports the need for early PPD screening. Compounding the cultural beliefs of pulling oneself up by your boot straps and Marianisma were the economic stressors surrounding women of color. Nurses and other health care providers need to assess and monitor women of colors' social and economic concerns and make any necessary referrals to social work and community resources.
Acknowledgment
The author would like to express her appreciation to Anne Reeder, MPH, BSN, RN for reviewing and confirming the results of the content analysis.
CLINICAL IMPLICATIONS
* Health care providers and policy makers need to acknowledge that PPD in women of color is complicated and can be situated in their financial hardships.
* Nurses need to be vigilant in screening women of color for PPD and for their social and economic concerns.
* Educational outreach efforts should include communities in churches because spirituality is often a focal point in recovery.
* Nurses can inform women of color about the benefits of perinatal mental health blogs.
* Providing educational sessions in the community on PPD that are culturally relevant are needed to increase mental health literacy.
INSTRUCTIONS Experiences of Postpartum Depression of Women of Color
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References