Postpartum Depression Theory



Postpartum Depression Theory 


M. Katherine Maeve






CREDENTIALS AND BACKGROUND OF THE THEORIST


Cheryl Tatano Beck graduated from the Western Connecticut State University with a baccalaureate in nursing in 1970. She recognized during her first clinical rotation that obstetrical nursing was to be her lifelong specialty. After graduation, Beck worked as a registered nurse at the Yale New Haven Hospital on the postpartum and normal newborn nursery unit. By 1972, Beck had graduated from Yale University with a master’s degree in maternal-newborn nursing and a certificate in nurse midwifery. In 1982, she received a doctorate in nursing science from Boston University.


Beginning at the rank of instructor in 1973, Beck has held academic appointments with increasing rank at several major universities, including University of Maryland, University of Michigan, Florida Atlantic University, University of Rhode Island, and Yale University, and as professor at the University of Connecticut, where she holds a joint appointment in the School of Nursing and the School of Medicine. Beck has served as consultant on numerous research projects for universities and state agencies in the northeastern United States. During her career, Beck has received more than 30 awards, including Distinguished Researcher of the Year from the Eastern Nursing Research Society in 1999. She was inducted as a fellow in the American Academy of Nursing in 1993.


A prolific author and disseminator of her research, Beck has authored more than 100 journal articles and given scores of research presentations locally, nationally, and internationally. She has served on the editorial boards of many nursing journals, including Advances in Nursing Science, Nursing Research, and the Journal of Nursing Education. Beck served on the executive board for the Marce Society, an international society for the understanding, prevention, and treatment of mental illness associated with childbirth, and on the advisory committee of the Donaghue Medical Research Foundation in Connecticut.


Beck has written several articles regarding statistical analysis strategies and approaches to qualitative analysis strategies. Many in nursing will recognize the classic Polit and Hungler research text, a fixture in countless graduate nursing programs. Beck became coauthor of Polit’s seventh edition (Polit & Beck, 2003), reflecting Beck’s research expertise.


Although Beck conducted seven major studies regarding educational and caring issues with undergraduate nursing students, for over three decades she has contributed to knowledge development in obstetrical nursing. Fittingly, her research career began by studying women in labor, examining their responses to fetal monitoring (Beck, 1980). Beck’s research focus eventually became the postpartum period and specific studies of postpartum mood disorders.


This body of work has resulted in a substantive theory of postpartum depression (Beck, 1993) and the development of the Postpartum Depression Screening Scale (PDSS) (Beck, 2002c; Beck & Gable, 2000) and the Postpartum Depression Predictors Inventory (PDPI) (Beck, 1998, 2001, 2002b). A time line of Beck’s research is outlined in Table 34-1, demonstrating the logical progression of her work.



Table 34-1


Time Line of Beck’s Perinatal Research




























































































































Year Focus of Research
1972 Women’s cognitive and emotional responses to fetal monitoring (master’s thesis)
1977 Replication of master’s thesis
1982 Parturients’ temporal experiences during labor (doctoral dissertation)
1985 Mothers’ temporal experiences in postpartum period after vaginal and cesarean deliveries
1988 Postpartum temporal experiences of primiparas
1989 Incidence of maternity blues in primiparas and length of hospital stay
1990 Teetering on the edge: a grounded theory study of PPD
1992 The lived experience of PPD
1994 Nurses’ caring with postpartum depressed mothers
1995 Screening methods for PPD
1995 PPD and maternal-infant interaction
1995 Mothers with PPD perceptions of nurses’ caring
1996 The relationship between PPD and infant temperament
1996 Predictors of PPD meta-analysis
1996 Mothers with PPD and their experiences interacting with children
1996 Concept analysis of panic
1997 Developing research programs using qualitative and quantitative approaches
1998 Effects of PPD on child development
1998 Checklist to identify women at risk for PPD
1999 Maternal depression and child behavioral problems
2000 PDSS: development and psychometric testing
2001 Comparative analysis between PDSS and two other depression instruments
2001 Item response theory in affective instrument development
2001 Ensuring content validity
2002 PPD—metasynthesis
2002 Revision of PDPI
2002 Mothering multiples
2003 PPD in mothers of babies in NICU
2003 PDSS—Spanish version
2004 Birth trauma
2004 Posttraumatic stress disorder after childbirth
2004 Benefits of internet interviews
2005 DHA in pregnancy
2005 Birth trauma and breastfeeding
2005 Mapping birth trauma narratives
2007 PDSS-Internet
In progress Subsequent childbirth after previous birth trauma
In progress Mother’s caring for child with brachial plexus injury
In progress PDSS—telephone version

NICU, Neonatal intensive care unit; PDPI, Postpartum Depression Predictors Inventory; PDSS, Postpartum Depression Screening Scale; PPD, postpartum depression.



THEORETICAL AND PHILOSOPHICAL SOURCES


Although Beck does not address caring as a theoretical or philosophical construct specific to her research, she has conducted several studies that evidence her belief that “caring is the essence of nursing” (Beck, 1999, p. 629). Beck’s use of the ideas of Jean Watson with regard to caring theory endorses caring as central to nursing, while acknowledging Watson’s concern that quantitative methodologies may not reflect adequately the ideal of transpersonal caring. It is obvious throughout Beck’s writings, including research reports using both quantitative and qualitative methods, that advancing nursing as a caring profession is desirable and achievable in practice, research, and education.


Because many of the studies used to develop Beck’s Postpartum Depression Theory were qualitative in nature, various theoretical sources have been cited by Beck reflecting the philosophical and theoretical roots of methodologies that were important for the kind of knowledge developed in each study. Phenomenology was used in the first major study of how women experienced postpartum depression, using Colaizzi’s (1978) approach. In her next study, Beck used grounded theory as influenced by the theoretical and philosophical ideas of Glaser (1978), Glaser and Strauss (1967), and Hutchinson (1986). Throughout all of Beck’s work and consistent with feminist theory, there is explicit valuing of the importance of understanding pregnancy, birth, and motherhood through “the eyes of women” (Beck, 2002a). Furthermore, Beck acknowledges that childbirth occurs in many simultaneous contexts (medical, social, economic), and that mothers’ reactions to childbirth and motherhood are shaped by their responses to these contexts.


An unusual theoretical source came from the work of Sichel and Driscoll (1999), who developed an earthquake model to conceptualize how interactions between biology and life result in what they term biochemical loading. Over time, with constant chemical challenges related to stressors, women’s brains may develop a kind of “fault line” that is less likely to remain intact during critical moments in women’s lives, such as the challenges women face around childbirth, resulting in a kind of “earthquake.” Beck understood Sichel and Driscoll’s model to “suggest that a woman’s genetic makeup, hormonal and reproductive history, and life experiences all combine to predict her risk of ‘an earthquake’ which occurs when her brain cannot stabilize and mood problems erupt” (Beck, 2001, p. 276). Although it is easy to understand the physiological and hormonal challenges of pregnancies for women, Sichel and Driscoll’s earthquake model was important in helping Beck holistically conceptualize the phenomena that might affect the development of postpartum depression for women. Although Beck states that she never experienced postpartum depression after the birth of her own children, those who have may relate to the earthquake metaphor complete with tremors culminating in postpartum depression or, worse, postpartum psychosis.


Beck has identified Robert Gable as a particularly important source in her work. Now Professor Emeritus at the Neag School of Education, University of Connecticut, Gable coauthored an important text called Instrument Development in the Affective Domain (Gable & Wolf, 1993). After developing a wealth of knowledge about postpartum depression, the next logical steps for Beck became developing instruments that could predict and screen for postpartum depression. Gable assisted Beck with theoretical operationalization of her theory for practical use. Gable has remained directly involved through the step-by-step development of the PDSS, including the Spanish version (Beck & Gable, 2003).



MAJOR CONCEPTS & DEFINITIONS


Beck’s major concepts have undergone refinement and clarification over years of work on postpartum depression. The first two concepts, postpartum mood disorders and loss of control, are conceptualizations that Beck developed utilizing phenomenology and grounded theory methods.


CONCEPTS 1 THROUGH 2



1. Postpartum Mood Disorders


Postpartum depression and maternity blues have become better delineated over time, as has the understanding of postpartum psychosis. Two other perinatal mood disorders, postpartum obsessive-compulsive disorder and postpartum-onset panic disorder, have been identified, as has how these disorders are different and how they are interrelated (Beck, 2002c).








2. Loss of Control


It was identified as the basic psychosocial problem in the 1993 substantive theory of Beck’s early work. This descriptive theory captured a process women go through with postpartum depression. Loss of control was experienced in all areas of women’s lives, although the particulars of the circumstances may be different. The concept of loss of control fit with extant literature and left women with feelings of “teetering on the edge” (Beck, 1993). The process identified consisted of the following four stages:




CONCEPTS 3 THROUGH 9


The conceptual ideas and definitions described above were used to develop specific foci for testing. Initially, Beck (1998) identified eight risk factors for postpartum depression. Many studies have expanded areas where Beck determined that more conceptual clarity was needed. For example, through her own study and meta-analysis of other studies, infant temperament was identified as a separate risk factor and predictor for postpartum depression (Beck, 1996b).


Another important change is marriage. Through subsequent research, it was noted that there were two marital factors of concern: marital status and the nature of the marital relationship satisfaction (Beck, 2002b). Two other risk factors identified were socioeconomic status and issues of unplanned and unwanted pregnancies.



CONCEPTS 3 THROUGH 15


These are major concepts found to be significant predictors or risk factors for postpartum depression (Beck, 2002b). The most current interpretation of effect size was assigned from a meta-analysis of 138 extant studies and is at the end of each concept definition (Beck, 2002b).
















CONCEPTS 16 THROUGH 22


These final concepts represent the distillation of all predictor and risk factors that are used to screen women for symptoms of postpartum depression in the PDSS (Beck, 2002c).











USE OF EMPIRICAL EVIDENCE


When Beck began to examine postpartum depression in 1993, she noted that only two qualitative studies contributed to the knowledge base of the disorder. Most studies were based upon knowledge developed in disciplines other than nursing. Beck’s background as a nurse midwife undoubtedly gave her a view of women throughout the postpartum period not commonly available to those in other disciplines involved with women during the perinatal period.


In 1993, after four major studies regarding women in the postpartum period (see Table 34-1), Beck developed a substantive theory of postpartum depression using grounded theory methodology. The substantive theory developed was entitled “teetering on the edge,” with the basic psychosocial problem identified as loss of control (Beck, 1993). Since development of the substantive theory, Beck has designed 14 other studies to refine the theory by examining the experiences of postpartum depression on mother-child interactions, postpartum panic, posttraumatic stress disorder (PTSD), and birth trauma to tease out differences among postpartum mood disorders (postpartum depression, maternity blues, postpartum psychosis, postpartum obsessive-compulsive disorder, postpartum-onset panic disorder). Meta-analyses were conducted on predictors of postpartum depression, the relationship between postpartum depression and infant temperament, and the effects of postpartum depression on mother-infant interaction. In addition, two qualitative meta-syntheses were conducted on postpartum depression and mothering multiples.


Beck used ten qualitative studies of PPD in women from a wide variety of geographic locations and cultures. Women represented in these studies included Black Caribbean women, Irish women, Indian women, Hong Kong Chinese women, Hmong women, middle eastern women (living in the UK), Asian women, Portuguese women, Australian women, Canadian women, and African American women. These new data were used to compare Beck’s original teetering on the edge grounded theory with women in other cultures. Beck found that the theory’s modifiability was in keeping with theoretical expectations of a relevant substantive grounded theory. Therefore, the theory of “teetering on the edge,” with “loss of control” as the basic psychosocial process, has functionally expanded to women in other cultures (Beck, 2006a, 2007).



MAJOR ASSUMPTIONS


Nursing


Beck describes nursing as a caring profession with caring obligations to persons we care for, students, and each other. In addition, interpersonal interactions between nurses and those for whom we care are the primary ways nursing accomplishes goals of health and wholeness.






THEORETICAL ASSERTIONS


The theoretical assertions within Beck’s theory are well represented throughout her writings. She acknowledges the importance of Sichel and Driscoll’s (1999) work related to the biological factors involved in postpartum depression in the following assertions:



image The brain can biochemically accommodate various stressors, whether related to internal biology or external events.


image Stressful events (internal or external), particularly over long periods, cause disruption of the biochemical regulation in the brain. The more insults to the brain, the more chronically deregulated the brain becomes. Because an already deregulated brain is again challenged with new stressors (internal or external), it is likely that serious mood and psychiatric disorders will result.


image Women’s unique and normal brain and hormonal chemistry result in a vulnerability to mood disorders at critical times in their lives, including after giving birth.


image Postpartum depression is caused by a combination of biological (including genetic), psychological, social, relational, economic, and situational life stressors.


image Postpartum depression is not a homogenous disorder. Women may express postpartum depression with a single symptom but are more likely to have a constellation of varying symptoms. This is related to varying life histories of internal and external stressors.


image Culturally, women are expected to feel happy, look happy, act happy, understand how to be a mother naturally, and experience motherhood with a sense of fulfillment. These expectations make it difficult for women to express genuine feelings of distress.


image The stigma attached to mental illness increases dramatically when a mental illness is related to the birth of a child, leading women to suffer in silence.


image Within a level of prevention framework, postpartum depression can be prevented through identification and mitigation of risk factors during the prepartum period. Postpartum depression can be identified early with careful screening and can be treated effectively. Prevention can alleviate months of suffering and decrease the harmful effects on women, their infants, and their families.


image A number of biological, sociological, and psychological issues and challenges are entirely normal in all pregnancies. These may include fatigue, sleep alterations, questioning one’s abilities, and the like. Comprehensive prenatal and postnatal care can eliminate troublesome pathological symptoms and help women normalize expected symptoms, thus reducing the degree of stress they actually experience.

Feb 9, 2017 | Posted by in NURSING | Comments Off on Postpartum Depression Theory
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