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Issues in Mental Health Nursing
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20
Postpartum Depression Among African-American Women
Linda Clark Amankwaa
To cite this article: Linda Clark Amankwaa (2003) Postpartum Depression Among African-American Women, Issues in Mental Health Nursing, 24:3, 297-316, DOI: 10.1080/01612840305283
To link to this article: http://dx.doi.org/10.1080/01612840305283
Published online: 09 Jul 2009.
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Issues in Mental Health Nursing, 24:297–316, 2003 Copyright c© 2003 Taylor & Francis 0161-2840/03 $12.00 + .00 DOI: 10.1080/01612840390160801
POSTPARTUM DEPRESSION AMONG AFRICAN-AMERICAN WOMEN
Linda Clark Amankwaa Virginia Commonwealth University, Richmond, Virginia, USA
The purpose of this qualitative study was to describe the nature of postpartum depression (PPD) among African-American women. Twelve women, who had experienced PPD within the last three years, were interviewed for approximately one hour at two intervals. Nudist-4 software and the constant comparative method were used to analyze the data. Five themes “Stressing Out,” “Feeling Down,” “Losing It,” “Seeking Help,” and “Feeling Better” represented aspects of PPD as experienced by the participants. The last theme, “Dealing with It,” represented the cultural ways in which African-American mothers managed their depression. These included Keeping the Faith, Trying to Be a Strong Black Woman, Living with Myths, and Keeping Secrets. Suggestions for future directions in nursing research are included.
Giving birth can be characterized as a social event as well as a tremen- dous physical and psychological event in a woman’s life. Normally signaling a time of great joy and immense happiness, birth may also bring sadness and pain. For a large number of American women, birth brings with it one of the common mood disorders. Postpartum depres- sion (PPD), in particular, often is unrecognized by family members and health care professionals (Beck & Gable, 2000, 2001). PPD severely
This article was prepared by the author from her dissertation completed at Georgia State University. The author’s chair was the retired Dr. Phyllis Johnson. Drs. Sandra Hewell and Denise Donnelly were members of the dissertation committee. Supportive funding for coursework and the dissertation was received from the ANA Ethnic Minority Fellowship Program.
Address correspondence to Linda Clark Amankwaa, Virginia Commonwealth University, 1220 E. Broad St., P.O. Box 980567, Richmond, VA 23298. E-mail: [email protected]
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affects a mother’s ability to care for her newborn, herself, and her fam- ily. It affects approximately 10–15% of new mothers and is characterized by debilitating changes in a woman’s emotional health during the post- partum period, although the symptoms are not as severe as psychosis (O’Hara & Swain, 1996). Symptoms such as tearfulness, feelings of inadequacy, suicidal ideation, sadness, lack of appetite, and feelings of helplessness and hopelessness are identifying factors of PPD (Kendall- Tackett & Kantor, 1993). Depression is termed postpartum depression when it occurs and is diagnosed after the birth of a baby (American Psy- chiatric Association, 1994). It can have numerous devastating effects on the mother and her new family that can last several weeks to many years.
Biological, psychosocial, and cultural factors have been implicated in PPD. Biological factors that have been investigated include a change in postpartum hormones, such as estrogen and progesterone, thyroid hormones, prolactin, and others. Other studies have focused on family history, previous psychiatric history, and genetics. While some of these factors seem to explain women’s risk for PPD, researchers continue to look for a biological basis of PPD, especially because all women experience a shift in their hormonal levels after birth. Consequently, a biological basis for PPD has not been established thus far (Hendrick, Altshuler, & Suri, 1998).
Psychosocial factors associated with the cause and consequences of PPD have been posited, but this thesis remains unsubstantiated as well (O’Hara, 1986, 1995; Beck, 2001). These factors include stress, social support, marital difficulties, and others. However, women who have social support and who appeared not to be stressed also develop PPD.
Cultural factors also have been investigated in relation to PPD. Re- searchers suggest that mothers of different cultural backgrounds may exhibit culturally explicit behaviors and actions when suffering from de- pression (Lazarus & Folkman, 1984). Some cultural differences include the expression of anxiety, presentation of symptoms, and the reporting of depression and depressive symptoms. There appears to be some cul- tural variability in the conditions under which it is appropriate to express one’s feelings and in the patterns of outward expression such as crying and laughing (Lazarus & Folkman, 1984).
Wenger (1995), in an article on cultural context, discussed factors and influence of culture when making health care decisions. Wenger submits “other groups . . . who havebeen in the United States since the 17th century, quietly find culturally congruent ways to promote health and respond to illness episodes that fit their cultural context but usually
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are not understood by health care professionals” (p. 3). Therefore, studies focused on cultural differences may add to the scientific knowledge base of PPD.
While many studies exist on the manifestations of PPD among European-American women, few exist which focus solely on African- American women who have had PPD. Preliminary findings by Hall (1996) suggested that there were differences in the manifestation of PPD between African-American women (AAW) and European-American women. An early study by Kane, Lachenbruch, Lokey, Chafetz, Auman, Pocuis, and Lipton (1971) investigated PPD among southern African- American women. In this study, 126 African-American participants and 132 European-American participants completed a demographic survey and the Neuroticism Scale Questionnaire on the second or third post- partum day. These investigators found that African-American women reported less anxiety during this time but the total neuroticism score was greater than for European-American women. This study was con- ducted during the first several days after birth, a time when most women experience postpartum blues. More recently, Logsdon, Birkimer, and Usui (2000) examined the link between social support and postpartum depressive symptoms in African-American women with low incomes in a sample of 57 AAW. They found that symptoms of depression were pronounced in the sample, that the participants received more support than they considered important, and that the importance of support was related to symptoms of depression. No study was located that elicited the experience of PPD using a qualitative approach. The purpose of this study, therefore, was to explore and describe the nature of PPD among African-American women from their point of view.
METHODOLOGY
A qualitative approach was used to examine PPD among African- American women. The questions devised for the research were re- viewed and evaluated by four nursing professionals for clarity prior to conducting the interviews. In the interview, the participant re- sponded to this main statement: “Tell me about your postpartum de- pression and what you went through.” Each participant completed two separate one-hour interviews with demographic information re- quested after the first interview. Interviews were conducted over several months.
Ethical considerations such as protection of human subjects were accomplished by acquiring IRB approval from two institutions.
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Participants signed a consent form prior to being interviewed. Code names were used within the manuscript to protect the identities of the subjects and assure confidentiality. Finally, during any discussion of the participant with peer reviewers and debriefers, the participants’ cho- sen code name was used instead of their given name. (Note: The peer debriefer was an AAW who consulted with the researcher after each interview. The peer reviewer was a PhD-prepared AAW who consulted with the researcher after all of the interviews were completed.)
Sampling
Potential recruits were obtained from professional and personal col- leagues. Over a nine-month period, participants were accepted into the study if they reported that they had been diagnosed as having PPD by their health care provider or by self-report of depression after childbirth. Criteria for inclusion also included being over 18 years of age, English- speaking, an African-American woman, and a mother who had had PPD during the first year of a child’s birth. Recruitment and interviews con- tinued until saturation of the data occurred. Each participant received a gift certificate and a letter thanking her for participation in the study.
The sample for this study consisted of 12 African-American women. Participants were interviewed after their last episode of PPD. All of the African-American women who participated in this study self-reported that they were middle-class and had health insurance with private health care providers. Education of the participants ranged from completion of high school to completion of the doctorate degree. Their ages ranged from 22 to 40 years at the time of their postpartum depression.
Analysis of the Data
The constant comparative method was used to analyze the data (Glaser & Strauss, 1967). Data analysis began with the first transcript that was received from the court reporter who was commissioned to transcribe the interviews. The participant read each transcript after each interview. The process of refining the codes and constantly comparing each piece of data with every other new piece of data continued until all of the transcripts were coded. As the themes emerged, early connections between the codes appeared. Revisions of the themes and subthemes were made upon further review of the data. The peer reviewer read the final themes and findings for congruence and trustworthiness.
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FINDINGS
The six themes that emerged from the data included Stressing Out, Feeling Down, Losing It, Seeking Help, Feeling Better, and Dealing with It. The basic psychosocial process emerging from the data was Enduring. One mother reported, “For me . . . I had a lot toendure and I did it alone, I didn’t have any help. I didn’t have any idea what to do next.” For these mothers, to endure meant to hold up under pain and fatigue, to undergo distress, and to survive the distress of the depression after the birth of a baby.
Stressing Out
Stressing Out was the first theme of the study. It was defined as the difficulties that participants experienced prior to the stage of Feeling Down. A word search of the transcripts for the word “stress” revealed that 10 out of 12 mothers used this word in their interview. Subthemes of Stressing Out included Caring for My Children, Feeling Alone, Feel- ing Out of Shape, Worrying about My Finances, and Having Many Stressors.
Two major stressors for mothers of newborns going through the post- partum period are: (1) recovering from the immediate physiological changes of delivery and (2) returning to functional status (which rarely returns to normal prior to six weeks) during the days and weeks after delivery (Fishbein & Burggraf, 1998; Tulman, Fawcett, Grobleski, & Silverman, 1990). Discussion of new mothers’ stressors during the nor- mal postpartum period must encompass the immediate recovery period and their postpartum functional status.
Stressors, other than the immediate recovery period, were reported by the participants and could be divided into three categories. The first of these categories consisted of physical stressors such as pain, surgery, infection, complications of pregnancy and delivery (such as pregnancy- induced hypertension and Cesarean-section delivery), and the mothers’ current health problems. The second category consisted of mental stres- sors such as loneliness, unmet expectations, birth plan disappointment, and abandonment. The third category of stressors included external stres- sors such as colicky newborns, sibling care, lack of support, partner con- cerns, employment, and financial concerns. African-American mothers’ experiences with PPD may be influenced by the type and number of stressors they experience within this time frame.
While mothers did not encounter all of the stressors at once, most mothers encountered many of these stressors at the same time.
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Experiencing multiple stressors during the postpartum period led to sleeplessness, fatigue, and irritability, which eventually led to declin- ing physical health and energy. Research on PPD supported mothers’ experience of Stressing Out. In a review of the literature, Albright (1993) found those mothers with depression often perceived their col- icky babies as stress producing. Wood, Thomas, Droppleman, and Meighan (1997), in a qualitative study of 11 mothers with PPD, found a common theme of “Demanding Infant” and found that mothers felt unable to soothe their crying infants. They also found that the depressed mothers in their study felt trapped, angry, and afraid be- cause of their demanding infants. In other studies, researchers have found that obstetrical complications, unhappy marital relationships, child care stress, and life stress were risk factors for PPD (Beck, 1996; O’Hara & Swain, 1996). Similarly, these stressors were evi- dent from the analysis of the data from participant interviews. Mul- tiple difficulties were encountered after the birth of the baby. These difficulties included physical, mental, and external stressors. After experiencing the stressors, mothers reported Feeling Down about their inability to adequately fulfill their role after the birth of the baby.
Feeling Down
Feeling Down was the second theme of the study. Feeling Down was defined as the sadness, uncontrollable crying, lack of energy, and de- creased level of satisfaction described by the mothers. Feeling Down followed the “pile-up” of stressors that African-American mothers ex- perienced after the birth of their babies. McCubbin, Thompson, and McCubbin (1996), in a compilation of inventories that were used for measuring resiliency, coping, and adaptation, described a similar “pile- up” of demands. These researchers suggested that stress adversely af- fected families, especially when there was a “pile-up” of stressors and that the outcome may be maladaptive behaviors. This was pos- sibly true for the participants in this study. Once the stressors piled up, the mothers seemed to progress to a stage of Feeling Down. Feel- ing Down represented the transition phase between Stressing Out and Losing It.
Mothers reported a change in their feelings and a change in their be- havior during this stage. Although mothers recognized that they were changing, some mothers were not able to identify or recognize the problem.
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Losing It
Losing It was the third major theme of the study. Losing It is defined as the time when mothers reported losing control of all or some of their ability to care for themselves, the baby, or their family after the birth of their newborn. Some incidents seemed to border on psychosis.
Losing It was associated with the lowest and most difficult point of PPD for AAW. At this point, mothers were unable (at differing levels) to control their environment, to manage their activities of daily living, and to control negative or harmful thoughts. There were three subthemes associated with this theme: Losing Control, Thinking Harmful Thoughts, and Losing My Self.
Losing Control, the first subtheme, depicted extreme emotional and behavioral changes for African-American mothers. Mothers reported losing the ability to control their emotional and their physical selves. During this time, the mothers reported having trouble functioning and managing their day-to-day activities. Not all of the mothers reported the same level of severity in Losing Control. Mothers seemed to experience mild, moderate, and severe forms. Mothers who experienced the mild form did not seek support or discuss thoughts of harm. Mothers who experienced the moderate form had thoughts of harm and sought help to prevent them from harming others. Of the mothers who experienced the severe form of Losing Control, two attempted suicide, two had family members that recognized that something was bizarre about their behavior and obtained help for the mother, and another mother recognized within herself that something was terribly wrong and sought medical help.
The African-American women in this study reported Losing Con- trol at two distinct intervals—within the first two weeks and around six weeks. Most noticed the beginning of PPD while they were at home, alone, trying to care for their newborns. Others noticed that something was wrong even before they left the hospital. Mothers described PPD as being in a daze, feeling distant, seeming as if a “cloud descended on me,” “everything looking cloudy and distorted,” and as “being on a mental roller coaster.” The four most commonly acknowledged signs of PPD for this group of AAW were uncontrollable crying, insomnia, loss of appetite, and tiredness. Participants reported having trouble concen- trating, making decisions, and staying focused. Several of the women spoke of having low energy, being fatigued, and being irritable. They de- scribed panicky feelings, anxious feelings, and emotional mood swings. Kendall-Tackett and Kantor (1993) and Whiffen (1991) reported similar findings.
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Mothers spoke of withdrawing from their family members and friends. They also reported finding little interest in the things they used to do, such as shopping. Mothers reported a disinterest in dressing fashion- ably, along with styling and combing their hair. Many women discussed how their hygiene suffered as well as their housework because of the de- pression. One mother reported a loss of her libido during this time. Many of the AAW noted that it was difficult, during this time, to do the things that they used to do. Some of the mothers stayed in bed much of the day, did not cook or clean and only minimally took care of themselves.
Mothers spoke of not being able to function, not being able to carry out their activities of daily living, and not being able to care for the baby in some instances. Similarly, Beck (1996) suggested that mothers in the midst of PPD had difficulty interacting with their children, feared their ability to cope, separated themselves from their infants, and failed to respond to cues of their children. In the novel,Willow Weep For Me (Danquah, 1998), Meri spoke of the difficulty she had in taking care of her daughter while she was in the midst of depression. She also notes that it was not that she did not want to care for her child, but she was mentally unable to care for the baby and herself while she was feeling sad.
A participant in the present study described this inability to function:
But there were times it was like the baby was crying. So what, I can’t deal with this. Can’t deal with it. I said to my mother, this is after—I was just like totally overwhelmed, and overwhelmed feeling. I said, you are probably going to have to get the baby, so—I don’t think I can take care of this baby. I just can’t do it. . . . Sobetter for me to let that baby cry and hopefully, you know, God help her, because I can’t. . . . Sofinally, I broke, and I would sob. And I said, Lord, Lord, Jesus, Jesus, what is it, what is it, why is this happening to me? I can’t believe that you let me have these three girls, and I am not going to be able to take care of them. Is it something that I have done? I put it on the altar, just please help me. I can’t, I understood that I could not live like that, not eating, not sleeping.
This mother remembered the date she lost it, how she felt, and where she happened to be at the time. She was so disabled, she was unable to wash her face. In both interviews she recounted the episode of Losing It.
I had to walk—I’d try to get a mental grip. Okay. Go over and pick up the soap, you know, the routine. It is like we have a routine of doing things, and I couldn’t really remember what the routine was. It was like, well, wow, I must really be, you know, out of it. I can’t even wash my face.
When the mothers were in the midst of Losing Control, they withdrew from their families, friends, and others—disconnecting, alienating, and
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isolating themselves. Disconnecting from others produced a change in the mother’s communication pattern. As they lost control, mothers be- came disinterested in their environment, more self-absorbed, and soon found that they spent many hours alone. As the participants withdrew, they became disconnected psychologically and experienced a disinte- gration of self. Many of the mothers also experience a period where they misinterpreted reality. Thoughts of harm, the second subconcept, appeared during this time—one mother reported wanting to baptize the baby, another mother reported thoughts of shaking the baby to stop the crying, and still others attempted or contemplated suicide. Of suicide and African Americans, hooks (1993) wrote:
In black life, suicide, like so many other illnesses and behaviors related to the realm of psychological breakdown, tends to be seen as the gesture of a “weak” person. For years, many black people perpetuated and believed the myth that black folks did not commit suicide. That is a myth that is now brutally shattered by the overwhelming evidence that black folks— women, men and children—are killing ourselves daily. Still, in a context where suicide is still seen as a sign of weakness, a character flaw, it is difficult for individuals to “confess” suicidal states and suicidal feelings. (p. 105)
In this study, mothers did reveal their thoughts about suicide and harm, something that would have been extremely taboo in years past. It may be that the potential threat to their families as a result of feeling suicidal and thinking harmful thoughts, coupled with increasingly more acceptable professional psychological care, enabled the mothers in this study to “confess” thoughts of harm.
Losing My Self, another subtheme, depicted the participants’ descrip- tion of losing something within themselves—the person they used to be before the pregnancy and the depression. This subtheme is consistent with previous research. Nicholson (1999), in a qualitative study of loss and postpartum depression, found six themes of loss while interviewing 20 women. Themes included loss of autonomy and time, loss of appear- ance, loss of femininity and sexuality, and loss of occupational identity. African-American mothers in this study reported similar losses of the self as they went through PPD along with feelings of loss that related to their identity and independence.
Seeking Help
Seeking Help was the fourth theme revealed in the participant tran- scripts. This theme was associated with three subthemes: Trying to Help
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Myself, Getting Professional Care, and Counting on Family and Friends. Nine mothers received medical attention. Three mothers did not seek a medical intervention. One AAW described how she helped herself through PPD.
Trying to Help Myself
Trying to Help Myself was described as the strategy that the mothers used to get themselves through their experience with depression. Two mothers used their internal resources to help themselves feel better.
And if I thought about something, I would just cry more and more and more until eventually I had to make myself stop. And I just had to sit down and stop, you know, try to just take a deep breath and just calm myself down and think about good things and just relax. I would put the baby in the crib, and let her cry a little bit until I—you know, she would cry in the crib, and I laid there in that bed and cried until we both kind of like had enough. And we both—I would get her and put her in the bed next to me, and we would just go to sleep for a while.
One mother who self-diagnosed her PPD considered mental illness a personal affair and suggested that she was responsible for Seeking Help for herself. She turned to those professionals that she knew personally, in the medical community, to help her rather than going through formal channels to receive mental health treatment.
I never got any help, really. I would just call people that I knew. I had received counseling, marriage counseling prior to the birth of my second baby. . . . And I would call my—my—she was a psychiatrist. I would call her occasionally during the course of that first year.
Getting Professional Care
Seeking Help represented when and from whom the mothers received help (professional health care) for their PPD and also described how mothers performed their own self-help. Most of the participants decided to get help for their mental discomfort of their own free will. Some of the participants faced difficulties obtaining professional medical care, while others were able to garner support without difficulty. Three of the participants did not receive formal medical treatment, but were able to get through this period with the assistance of persons in their own personal networks, family members, and their own self-treatment. Nine of the participants sought medical care for their sadness, received professional medical care, and were diagnosed with PPD. The process of Seeking
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Help for their sadness was difficult for the participants in many cases. Frequently, their signs of symptoms were given only cursory attention thus perhaps serving as a barrier to obtaining treatment.
Regional differences are significant in help-seeking behavior for African Americans according to Taylor, Hardison, and Chatters (1996). African Americans from the southern United States were more likely to choose kinship networks than were northern African Americans accord- ing to these researchers. This observation was true also in the present study and is supported by Mays, Caldwell, and Jackson (1996) who found that African-American women living in the south were less likely to use private therapists than women in other regions in the United States.
Several African-American women in this study reported thoughts of shame about being depressed when they were supposed to be strong. Shame was also identified in a study by McIntosh (1993), which found that postpartum mothers who had not sought help felt like failures, felt ashamed, felt inadequate, and ultimately were too embarrassed to tell anyone about their inability to cope. The McIntosh study did not in- clude any African Americans in the sample. Clearly then, these feelings of embarrassment, shame, and inadequacy may cross racial and ethnic lines.
Counting on Family and Friends
Counting on Family and Friends encompassed support from friends and family. Family support for the mothers was more than adequate in some instances and inadequate at other times. Most of the AAW in this study identified their mother as the person most relied upon to provide support. The second person was her spouse, followed by sisters, and other friends and neighbors. Two AAW noted that God gave them the major support, and two AAW said that their children also gave them support. The participants spoke of having “too much” support, not having their mothers when they wanted them to be there, and being alone without their family as being stressors. For most of the participants it seemed that the support they received was not always adequate nor what they wanted or expected. Most of the participants had spouses at home at the time of the PPD, but it appears that the spouses’ presence did not buffer the effects of PPD. Lack of social support was found in the literature to be a major risk factor of PPD (O’Hara & Swain, 1996). Therefore, having the right kind of support and the support expected seems to be more important. Warren (1997) suggested that stressful life events and lack of social support in middle-class African-American women might cause depression.
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Feeling Better
Feeling Better was defined as the stage where mothers regained their strength. It was the time after the delivery when the participants reported that they were able to function normally again. Here a mother discusses how she started to feel.
She is 11 months. [And so are you feeling better?] Somewhat, yes, I am back on the medicine . . . I wasweaned off actually; but I got back on and I started taking something about, oh, almost two months ago. I am feeling better . . . Not like I would like to feel, but I am feeling better. [Do you think you will be able to go back to work?] Actually I have gone back. I went back—it’s been almost a month and a half now. I went back part-time and I am not doing what I used to do. I am doing something that is pretty—I don’t want to say it’s easy, but, yeah, I guess it is pretty easy compared to what I used to do. I don’t—I am responsible for me. So I am back . . . Idon’t feel like my old self, but at this point I am—I am wondering if that’s even realistic, because I am not the same . . . I am mommy now.
Beck (1993) reported a theme of Regaining Control. In this stage, mothers reported their sense of recovery from the PPD and documented how they felt after experiencing depression. African-American mothers in this study reported similar responses as the participants in the study by Beck (1993). Most of the mothers reported that they did feel better at the time of the interview but that things were different. Most of the symptoms such as crying had stopped according to the participants, although some mothers reported that there continued to be occasions when they feel like crying. None reported that they continued to have negative thoughts. All 12 of the participants slowly returned to their normal routines and were able to care for their children.
Dealing with It
Dealing with It, the final theme, represented the strategies African- American mothers used to handle sadness after the birth of their babies. Associated subthemes include: Keeping the Faith, Trying to be a Strong Black Woman, Living with Myths, and Keeping Secrets.
Keeping the Faith
Keeping the Faith characterized the use of religion by the mothers during the time when they were going though PPD. A woman, who
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chose her code name because of her great faith, explained her deep religious grounding.
If I were not African American and Christian, it wouldn’t be so hard, because there are some things that I believe that are unique to—well, see, that would be a whole, another story. I don’t know. I believe the church is the church—but we know the black church as it exists, you know, in African-American communities. Okay. But so two things, in African- American culture, the idea of being able to handle your own problems and black women being strong and able to, you know, you do what you need to do and no time to talk about being depressed.
In almost all of the transcripts, there was some discussion of reli- gion. A word search revealed that all of the participants used the word “prayer” in their transcripts. Other words related to spirituality included “Jesus,” “God,” and “Lord,” although most of the participants did not use these terms as much as they used the word “prayer.” Typical religious statements that were reported by the women in this study were: “The Lord will not put more on you than you can handle.” “All you need to do is pray,” and “All you need is faith.” These phrases, which their moth- ers often repeated to them, were handed down through generations of African-American women. Many of the participants’ mothers counseled them to pray about their sadness.
AAW reported that they relied on prayer and faith to help them through their mental pain. Others thought that they were being punished for something that they may have done in the past. Religious affiliation seemed to be an important coping mechanism for the participants in this study. Many of the participants suggested that it was their faith that got them through this period, even though the participant received professional medical care.
Broman (1996) found that African-American women used prayer more often than African-American men as a coping strategy. Prayer may be used in response to personal problems such as physical health, interpersonal health, emotional health, and death, according to Broman. Mays, Caldwell, and Jackson (1996) found that reli- gious affiliation was supportive for African-American women ex- periencing emotional problems. They suggested that those women who were connected with religious community-based resources sought fewer mental health services and that this may be an important pre- ventive strategy for serious mental illness among African-American women.
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Trying to Be a Strong Black Woman
African-American mothers reported that the image of their mothers of being a “strong woman” made an impression on them. The symbol of being a strong woman was perpetuated by their mothers and significant others with whom they interacted socially, especially their family mem- bers. Participants discussed being socialized to be strong and handle whatever life hurled at them, without regard for their physical or mental well-being. AAW reported how the message of being strong was relayed to them. This message was seen in several phrases that appeared in the women’s interviews. Examples of phrases that symbolized strength and moving forward despite the odds were: “keep on going,” “get over it,” “pick yourself up,” “brush yourself off,” “snap out of it,” “just go on,” “get back on track,” “pull yourself up,” “do what you are supposed to do,” and “handle your problems.”
The idea of being a “Strong Black Woman” may have hindered some of the participants from getting the treatment that they needed. In other cases, it may have prevented mothers from accepting the diagnosis of depression as legitimate. Warren (1994) reported that:
Research has suggested that African-American women may internalize their role designation and the media’s portrayal of African-American women into an unobtainable superwoman or matriarch image (Carrington, 1980; Collins, 1991). This internalization combined with nurturing responsibilities may be in direct opposition to African- American women’s need to participate in “self-enhancing activities, either professionally or personally, that do not directly or indirectly include their families” (Carrington, 1980). Failure of the African-American women to achieve this superwoman/matriarch image may produce a sense of failure and frustration for the women—as well as precipitate the development of guilt, hostility, depressive symptoms and conflicts in interpersonal rela- tionships (p. 31).
African-American women reported that their mothers appeared to be “superwomen,” and they struggled to emulate their predecessors. They seemed to struggle between who they really were (the real self) and who they thought they were supposed to be (the ideal self). This symbol of strength and the mothers’ attempt to attain this superwoman stature seemed to cause distress for the mothers in this study. The “superwoman syndrome” also may have caused feelings of failure and frustration. Being a superwoman meant that mothers adapted to caring for babies, work, homes, families, husbands, and themselves without complaining of the pain or discomfort during their postpartum period. One mother
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spoke about not being in the “olden days” where mothers “dropped” (delivered) their babies and continued to work in the fields. Participants remarked about seeing their mothers doing it all and the sadness they felt about not being able to fulfill this role as their mothers had done in the past.
Chisholm (1996) suggested that for African-American women to “ad- mit feelings of weakness and vulnerability is to expose one’s vulnera- bility and to be perceived as a failure to live up to the tradition set by previous generations of women” (p. 74). In other words, mothers of the past set the gold standard by which African-American women of today try to judge themselves. Unfortunately, the time and the circum- stances have changed, but the mothers continue to try to uphold these ideals.
Additionally, African-American female children, according to one of the participants, are socialized at an early age to portray strength of character as well as physical strength and stamina to “do what they need to do” without asking for help and in spite of the situation. This message, it seems, may have been internalized and carried over into motherhood and the postpartum period, as shown in the following quote from a transcript:
But so two things, in African-American culture, the idea of being able to handle your own problems and black women being strong and able to, you know, you do what you need to do and no time to talk about being depressed. And you just go on, you can do it. And you know, you pull yourself up. And you—you know, you keep going. You may have to cry for a while, but, you know—and that’s part of life from family, having observed other women in my family over the years.
Living with Myths, Stereotypes, and Stigmas
This subtheme represented common misconceptions about mental illness in the African-American community. There were two myths surrounding depression for the mothers in this study. Some African- American women did not believe that they could get PPD and reported they thought only “white women” got depression. These misconcep- tions helped form the basis for denial and their delayed or apprehen- sive behaviors toward the treatment of their PPD. The myth in some African-American communities, is that depression is a sign of weak- ness and not a legitimate illness. Depression, according to the myth, symbolizes internal weakness, lack of mental capacity, and lack of con- trol of your senses, rather than an illness that requires medical atten- tion. Having depression, of any kind, decreased respect for a person in
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the African-American community. Participants apparently internalized these cultural taboos.
Acceptance of myths may have caused the mothers to fail to seek help, not take their prescribed medication, and/or rendered them unable to recognize the signs and symptoms of depression when faced with it. The National Mental Health Association’s survey of African-American attitudes about clinical depression may have some bearing on the findings of this study. Findings from that study suggested that African Americans fear seeking help for mental illness, that 60% believe prayer and faith will successfully treat depression, that they were embarrassed about seeking help, and that they refused help because of denial (Mitchell, 1998).
I think that just the African-American community needs to get over the myths that black people—that African-Americans don’t become de- pressed, because we do. And I think we need to seek help. I think that it just needs to be talked about more and not presented as, you know, a subject that’s off-limits. But we need to know that depression, you know, it cuts across racial lines. People all over the world become depressed, and we need to accept that and to not be afraid of the treatment that is offered. More education about what antidepressant medication is. Lots of people are afraid that it’s addictive.
Keeping Secrets
Keeping Secrets was reported by the mothers in this study and meant that the mothers did not “tell” or talk about what they were going through after the birth of the baby or their circumstances. An example from one of the mothers was quite clear:
And as an African-American woman, we, in order to survive, historically, have learned how to wear the mask. And I was able to, especially the second go around—you know, I could get through the day, you know, smiling. But I had deep circles up under my eyes.
It appears that the participants did not want to disclose their thoughts, feelings, and actions to others during this time. According to the mothers, they were afraid and possibly embarrassed about having a “mental ill- ness.” “Secrets keep us sick”—one mother suggested. Words and phrases that women used to denote their propensity to keep secrets about PPD were: “not talking about it,” “don’t mention it,” “not telling,” “hiding the crying,” and “keeping the emotions to themselves.” AAW kept these fears to themselves because of the shame and embarrassment associated with being crazy or being labeled as crazy.
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The finding, Keeping Secrets, is supported by the literature. Chisholm (1996) described nondisclosure among African-American women and suggested that it is taboo to talk about experiences such as depression to others on the “outside.” In this case, some husbands, partners, and family members as well as health professionals and others were per- ceived as outsiders. Mothers in this study did not disclose, immediately, to their family and friends that they were experiencing difficulties dur- ing the postpartum period. This behavior also may be seen as culturally sanctioned (Marsella et al., 1985), and thus family and friends may have entered into a subconscious agreement whereby neither the mother, nor the family and friends publicly acknowledged the depression. Nondis- closure can also be seen as repression. In the past, AAW survived by repressing their feelings (hooks, 1993). Slavery socialized black people to contain and repress their emotions (hooks, 1993). hooks suggested:
The practice of repressing feelings as a survival strategy continued to be an aspect of black life long after slavery ended. Since white supremacy and racism did not end with the Emancipation Proclamation, black folks felt it was still necessary to keep certain emotional barriers intact. And, in the world-view of many black people, it became a positive attribute to mask, hide, and contain feelings and came to be viewed by many black people as a sign of strong character. To show one’s emotions was seen as foolish. Traditionally, in Southern black homes, children are taught at an early age that it was important to repress feelings (hooks, 1993, p. 133).
The findings suggest that Dealing with It was an important theme for the African-American mothers in this study. This theme has important implications for nursing and other health professionals who care for women during the postpartum period.
CONCLUSION AND NURSING IMPLICATIONS
PPD is a devastating problem for the new mother, the baby, and family. Literature and current news reports suggest that PPD should not be taken lightly due to the potentially fatal nature of this mood disorder. At a time when mothers are most vulnerable, they are responsible for the care and nurturing of a newborn baby, their homes, themselves, and their families. It comes as no surprise then that some mothers have difficulty managing the multiplicity of roles and the responsibilities that accompany each of them, all of which are additive for PPD during an important life transition for the new family.
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Mothers seem to be crying out for help during the postpartum period. Although their physical needs seem to be met by our current medical policy and institutions, their mental health needs may not be recognized. It seems that African American mothers are reluctant to expose any frailty, thus making it difficult for professionals to provide adequate diagnosis and treatment. Findings of this study may assist mental health clinicians to sensitively assess African-American women for PPD.
Based on the findings from this research, nursing research might in- clude development of a questionnaire/screening tool which incorporates (1) questions addressing African-American mothers’ perceived stress immediately postpartum, (2) questions about AAW’s perceived and re- ceived levels of family and social support, (3) perception of being over- loaded or overwhelmed, and (4) thoughts of baptizing, negative dreams, thoughts of harm, and suicide. Future directions for nursing research also include studies related to the themes that the participants discussed, such as seeking help and losing control.
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