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Purpose of the Study

This study focuses on the socio-cultural experiences of depressed Mexican American mothers. For instance, Gosdin (2005) found that stigmatization and the lack of accurate postpartum depression information prevented Hispanic adolescent mothers from seeking mental health care. The narrative compare self-reported depressed Mexican American mothers (i.e. adolescents and adults) to understand the complexities of barriers, beliefs, traditional healing systems; and views of depression. The following are goals of this study; (1) to identify cultural and age specific postpartum depressive symptoms, which could apply to various race/ethnic groups; (2) to identify the lack of detection of Mexican American postpartum depression by mainstream medicine, and thus increase awareness of Mexican American postpartum depression; (3) to suggest culture specific postpartum behavioral interventions and (4) to explore the consequence of postpartum depression in regards to breastfeeding and mothers’ perceptions of their babies.

Significance

This research is important and significant. First, Hispanics are the fastest-growing ethnic group in the United States and are expected to comprise 25% of the U.S. population within the next 40 years (Aguilar –Gaxiola et al., 2002). The recent increase in Hispanics accounts for approximately half of the United States population growth in five years (Hakimzadeh, 2005). Specifically, Mexican Americans, the largest ethnic subpopulation, comprise more than 60% of the Hispanic community in the United States. The influx of Mexican immigrants has led to institutionalized discrimination including being denied access to health care, a livable wage and educational opportunities, this negatively impacting one’s overall health (Escobar, Nervi & Gara, 2000). Therefore, an understanding of Mexican American mothers’ mental health issues is important societal concern.

Second, because Hispanics comprise a large portion of the lower socioeconomic class, they experience high levels of stress, which has been linked to anxiety and depression (Abrams & Curran, 2007; Lopex, 2002). Third, Hispanic mothers, compared to other ethnic and racial groups, have higher fertility rates. As a result, they are at an increased risk (47%) of developing postpartum depression, compared to non-Hispanic Whites (31%). Hispanic mothers are also at a slightly higher postpartum depression risk compared to African Americans (45%) (Howell, et al., 2005). However, few studies have examined the postpartum experiences of racial/ethnic women. Moreover, fewer studies have explored Mexican American adolescents’ beliefs and perceptions, symptom experience, and postpartum help-seeking behavior. Research has suggested, however, a link between level of acculturation and depression among Mexican American teens (Escobar, Nervi & Gara, 200). Explicitly, acculturation often creates intergenerational conflict, leading to depression. Thus, the need to further explore postpartum depression among Mexican American adolescents is crucial.

Fourth, approximately one million U.S teens get pregnant each year with 500.000 babies born to teenage parents (Birkeland, Thompson & Phares, 2005)and for the first time in 15 years, the teen pregnancy rates remains unknown, therefore the focus on mothers of all ages is not only significant, but also urgent.

In addition, although mental health disparities among Hispanics are well established, to my knowledge, there are no mixed methods comparative studies that focus on the experiences of self-reported depressed Mexican American mothers across age groups. This research is unique because it considers the overall experiences of Mexican American mothers of all ages, which is imperative to understanding the overall quality of maternal health. The qualitative portion of this study seeks to understand Mexican American postpartum depressive experiences, which may be applied to other racial/ethnic groups. exploring postpartum depression from a holistic perspective, the quantitative phase of the study emphasizes the negative impact of maternal depression on the mothers’ perceptions of their child’s physical health along with breastfeeding behavior.

The quantitative portion of the study is significant and crucial because postpartum depression is associated with adverse maternal and infant/child outcomes (Logsdon, 2006; Lusskin et al., 2007). for instance, postpartum depression often prevents maternal/infant bonding, prohibits breastfeeding; and often leads to child emotional and behavioral problems, resulting in child abuse or neglect (logsdon, 2006). Studies have extensively documented a positive association between postpartum depression and child behavioral problems such as aggression, hyperactivity, anxiety and depression; as well as missed days from school (Lusskin, et al., 2007). Therefore, a qualitative and quantitative research design is significant and timely to explore depression among Hispanic mothers, and its influence on breastfeeding behavior and health perceptions.

The study employs a qualitative and quantitative research design. The major focus of this study is the qualitative in-depth interviews of Mexican American adolescents, using a comparative sample of adult Mexican American mothers, a within ethnic qualitative design. It explores postpartum depression within the context of pregnancy and motherhood to understand the socially constructed identities of self-reported depressed Mexican American adolescents and the meanings attached to depression compared to that of a Mexican American adult sample. While the qualitative analysis focuses on meanings attached to everyday experiences, the quantitative research uses a national sample of self-reported depressed Hispanic mothers to identify breastfeeding behavior and mothers’ perceptions of the physical health of their babies.

The less dominant phase of this mixed methods study consists of a quantitative component, specifically a secondary analysis of the National Survey of Children’s health, 2003 national data set. The National survey of Children’s health, 2003 is a module of the State and Local Area Integrated Telephone Survey Program, which uses the National Immunization Survey’s sampling frame. The findings from the quantitative phase of this research assist in the interpretation of the dominant qualitative findings as suggested by Tashakkori and Teddlie, (2003) by providing insight into breastfeeding behavior and child health perceptions held by Hispanic mothers.

This research presents a sociological approach to postpartum depression, which is most often viewed solely as a medical issue. Specifically, social and structural factors associated with the onset, diagnosis and treatment of postpartum depression have been largely neglected in previous studies. Therefore, unlike prior studies, this research explores the depressive experience and consequences of postpartum depression among Mexican American mothers while considering the role of culture, myths of motherhood, stigma and the medicalization fo childbirth. This study also explores pregnancy as it relates to the depression experience. Research indicates the need for further exploration into the link between anxiety and depression, both during pregnancy and postpartum (Ross, et al., 2003).

Justification for Mixed Methods

This research frame work was chosen because it is best suited for exploring new phenomenon and has the capability to test theory grounded in the qualitative data (Takhakkori and Teddilie, 2003). This study incorporates a parallel relationship between the qualitative and quantitative samples(Collins et al., 2006).

A mixed methods design frame work was chosen for several reasons. First, the quantitative phase increases confidence in the qualitative findings (Cathain, 2007) by providing an examination of the effects of untreated materials depression among Hispanics. Specifically it focuses on how the child’s physical, emotional and behavioral health is impacted by maternal depression. The second reason for mixing methods in this study is to neutralize biases (Johnstone, 2004) inherent in each method. Employing a mixed methods design provides a means to cross check the qualitative findings with the quantitative results (Kinn and Curzio, 2005). According to Denzin (2007), Morse (2007) and others, a true mixed-method design utilizes separate samples (i.e. Qualitative research Conference, Indiana, 2007).

Organization of the Dissertation

This study will be organized into seven chapters. Chapter 1, consists of an introduction or overview of the study. Specifically, the first chapter examines the socio-cultural dimensions of postpartum depression, why the research is significant, and a description of postpartum depression as a major health concern, along with research questions guiding both the qualitative and quantitative phases of the study.

Chapter 2, reviews the literature and includes definitions of terms related to and symptoms of postpartum depression, an overview of mental health issues facing Mexican American women, a comparison of postpartum depression among Mexican American adolescent and adult mothers, a synopsis of adolescent pregnancy,

Chapter 3 includes an explanation of the methods including the design, hypotheses, procedures, data collection techniques, data analysis, validity procedures and limitations for the quantitative portion of the study.

Chapter 4 consists of the results from the quantitative portions, statistical analyses and tables summarizing the quantitative findings.

Chapter 5 encompasses qualitative findings from the narratives of adolescent and adult Mexican American mothers. Specifically, sample characteristics, key distinctions between the two groups and major themes are included.

Chapter 6 reveals and applies a theoretical framework for understanding the experiences of both groups of participants, which is grounded in the qualitative data.

A discussion of the findings, implications for future research and public policy are included in chapter seven-the conclusion.

CHAPTER 2

REVIEW OF THE LITERATURE

Postpartum depression, as a social phenomenon, is virtually absent from the literature. Very few studies examine meta health as it relates to motherhood, culture, gender and age. To accurately understand postpartum depression it is first necessary to consider the experiences of depressed Mexican American adult mothers. Comparing the two groups highlights the knowledge gap in the literature. Specifically, this study delves into pregnancy and motherhood while also considering the socio-cultural explanations of depression including its relationship to and perpetuation of socially constructed myths of motherhood. First, the definition of postpartum depression is examined along with specific symptoms and risk factors among both adolescents and adults. Additionally, pregnancy and motherhood are explored within the context of the Mexican American culture and adolescence. Consequence of untreated postpartum depression and its impact on the mother, baby and family is also investigated. Socio-cultural explanations of depression and specific barriers to mental health care are examined among both groups of mothers.

Definition of Postpartum Depression

Postpartum depression is a mood disorder that affects approximately 10-15 percent of adult mothers yearly with depressive symptoms lasting more than six months among 25-50 percent of those affected (Beck, 2002). Approximately 48 percent of adolescent mothers experience depressive symptoms (Clemmens, 2002). Postpartum depression often occurs between a few months to a year; studies report postpartum depression four years following birth (Mauthner, 1998). Postpartum mood disorders are classified into three categories according to the severity (O’ Hara et al., 1990) The first, postpartum blues, which is the least severe from typically lasting a few days to a couple of weeks after giving birth and affects approximately 50-85 percent of all new mothers and according to some studies is a precursor to postpartum depression (Watanabe at al., 2009). The second postpartum mood disorder, postpartum depression, is more severe, causing a great deal of problems for the mother. If left untreated postpartum depression often results in bouts of crying, guilt, feelings of inadequacy and detachment from the baby. A third type of postpartum mood disorder, postpartum psychosis, affects less than 2 women per 1,000 births, causes delusions, rapid mood swings, confusion and hallucinations (Leitch, 2002) and is most likely to occur during the first three months following delivery (O’Hara et al., 1990).

Symptoms and Treatment of Postpartum Depression

Previous research suggests that mothers suffering from postpartum depression do not always appear depressed rather some exhibit more visible warning signs including anxiety, insomnia, irritability and confusion (Dalton et al., 2005); Leitch, 20020). Other symptoms maybe obvious, for example, depressed mothers may experience uncontrollable crying spells and fear.

Mothers also learn to mask symptoms, thus making early detection difficult. Other latent symptoms of postpartum depression include guilt, inadequacy, changes in appetite and fatigue, which can led to medical misdiagnosis, or no diagnosis. Women and physicians do not always recognize subtle symptoms of postpartum depression (Chaudron et al., 2005). Mothers who are unable to recognize or identify depression often cannot articulate their feelings, thus postpartum depression persists untreated. Therefore, research strongly suggests screening for postpartum depression especially among racial and ethnic minority women because depressive disorders are often underestimated in such populations (Howell et al., 2005). Lack of detection of postpartum depression can also be attributed in part to insufficient screening during the medical encounter. Fewer than 40 percent of depressed mothers seek help (Hayes, 2007) and estimates show that only 13 percent of women exhibiting signs of postpartum depression are under a physician’s care, despite the fact that the condition is easily treatable (Thio et al., 2006). The recovery rate for women who seek professional help is between 80 and 90 percent (Hayes, 2007). Although women have increased contact with healthcare providers during the postpartum period few of the encounters center around the mother, thus overlooking her needs.

Also, the onset of depression is often gradual, thus making postpartum depression screening at various points postpartum critical. Screening should begin during pregnancy as studies show a possible link between antenatal depression and anxiety and postpartum depression (Romans-Clarkson et al., 1991). Some studies report antenatal depression rates up to 50 percent (Bozoky and Corwin, 20010).

Adolescent Pregnancy

Teen pregnancy rates have increased in 2008 for the first time in more than 15 years (Center for Disease Control, 2006) and remain five times higher in the United States than any developed country (Clemmens, 2002). In the United States, Hispanic teens have the highest pregnancy incidence rate (8.2 percent in 2004) compared to 2.7 percent of White adolescent mothers (Nadeem et al., 2006; Heavey et al., 2008). The consequences of teen pregnancy are great, not only for the mother, but for her child. Teen mothers tend to have lower educational attainment, lifelong poverty and an increase risk of child and substance abuse (Center for Disease Control, 2006). Such social factors increase their susceptibility to depressive symptoms.

Mental Health of Hispanic Women

One out of every 10 people in the United States suffers from depression and women are twice as likely to be depressed as men (Hayes, 2007). Furthermore, research indicates that Hispanic women have higher rates of depression compared to non-Hispanic women (Chaudron, 2005). According to the literature, Hispanic women experience numerous social stressors, while some are acute others are chronic and have the potential to jeopardize their mental health. These stressors include acculturation, intergenerational conflict (particular for Hispanic adolescents), intercultural competency and the language barrier. Chronic stressors include poverty, racism and sexism faced by many Hispanics, particularly women. The literature indicates a strong association between the s socioeconomic status, racism and health status (Williams and Collins, 1995). Studies have found that low socioeconomic status is a predictor of elevated rates of psychiatric conditions (Williams and Collins, 1995).

Postpartum Depression and Hispanic Adolescent Mothers

The prevalence of depression among adolescent mothers compared to adult mothers is significant. In general teen mothers are more depressed than adult mothers and more likely to develop chronic depression later in life (Lanzi et al., 2009). Hispanic adolescent mothers, specifically Mexican Americans, are at highest risk of moderate to severe depression compared to all other racial and ethnic groups, minority adolescent mothers are least likely to report symptoms of depression to healthcare professionals (Nadeem, 2006). Studies have found that approximately 26 percent of adolescent mothers experience postpartum depression.

Numbers factors place Mexican American adolescent mothers at risk for postpartum depression, including; low maternal competency; antenatal depression; conflicted social networks; poor body image; self esteem; single parenthood; unmet emotional and physical needs; no or limited partner support; turbulent partner relationship; and stigma associated with teenage motherhood (Gosdin, 2005).

Transitioning into motherhood during adolescence often presents additional challenges for many Hispanic teens. For instance, an intergenerational conflict between Hispanic teens and their parents, caused by what some researchers refer to as an “acculturation gap” creates interpersonal tress and perpetuates conflict. Lags in acculturation occur when teens adopt ideas and behaviors typical of American culture while abandoning certain aspects of Hispanic culture. Alienation and misunderstanding develop when children acculturation at a faster pace than their parents (Pasch et al., 2006). Research indicates a link between acculturation and depression among Hispanic teens. For instance, Mexican Americans born in the United States have higher rates of depression compared to their non-native counterparts (Gonzales et al., 2004). Increased rates of depression found among Mexican Americans can also be explained through discrimination and prejudice attitude often experienced by Mexican American youth *Gil, Vega, and Dimas, 1994). Institutionalized racism and discrimination should be considered when considering postpartum depression because studies highlight the relationship. “Women who report any kind of discrimination are more likely to have depressive symptomatology” 9Surkan et al., 2006). Second, acculturation can also negatively impact body image among Hispanic mothers (Gosdin, 2005). Studies indicate that eating disorders are increasingly common among Hispanic teens. Media representations of ideal beauty emphasize smaller figures, therefore pressuring Hispanic females to drop weight. Studies show that Hispanic teens are progressively influenced by such media images becoming less comfortable with their body (Donnelly, 2005). Gaining weight during pregnancy can contribute to depressive feelings postpartum among adolescent mothers (Godsin, 2005).

Postpartum Depression and Adult Hispanic Mother

Hispanic women have higher rates of postpartum depression, but are less likely to be identified as depressed compared to non-Hispanic women (Chaudron, 2005). Risk factors associated with postpartum depression among Hispanic adult mothers are similar to that found among adolescent mothers, and include maternal incompetency, antenatal depression, unplanned pregnancy, infant with the colic or other health problems, single parenthood, having several children at home and unmet needs both emotional and physical (Prodromidis and Abrams, 1994). However, few studies have examined how Hispanic adult mothers experience depression, and seek help compared to comparable adolescents.

Gender and the Hispanic Culture

Hispanic females, especially second generation immigrants, are often torn between two cultures. While they are bound to cultural norms and values, they are also expected to assimilate into American society. Therefore they experience an identity crisis, which often leads to depression (Turner et al., 2002). This is common among adolescent Hispanic females who report feeling torn between family and friends. Studies report that American Hispanic females who report feeling torn between family and friends. Studies report that American Hispanic females desire to be autonomous, which often poses a threat to traditional cultural and family values (Turner et al., 2002). Hispanic adolescent females are particularly vulnerable to “intergenerational conflict,” which occurs when the adolescents’ values clash with those of their parents (Turner et al., 2002).

As a result, teenage Hispanic females often are caught between the traditions of their culture and the desire for independence, commonly idealized in America. Such conflict places Hispanic adolescent mothers at risk for depression, and often suicidal behavior (Turner et al., 2002).

Hispanic adolescent mothers’ stressors are enormous, and adversely affect their mental health postpartum. Hispanic women are socialized within “a highly traditional, gender-specific, patriarchal system” (Flores et al., 2006p. 49). The contrast between traditional roles and the push for gender equality create conflicting expectations among many Mexican American women (Goodkind et al., 2008). Disagreements concerning dating and career choices have been cited as major sources of intergenerational conflict, *Turner et al., 2002). Thus, understanding gendered experiences within the Hispanic community is an essential component of the meaning of the Hispanic postpartum depression experience.

Social Construction of Motherhood

Motherhood is constructed around traditional gender roles which create role strain and conflict (Edhborg e t al., 2005). Pregnancy and motherhood are often viewed as battles in the gender equality fight. The motherhood role may be viewed as negative since mothers are often expected to delay personal and professional gratification, often neglecting their own needs. Additionally, motherhood is idealized, which often make women feel they are expected to do it all (house work, primary care taker, etc.) and retain their femininity. For example, myths of motherhood incorporates an ideology of intensive mothering thus creating and perpetuating the idea that mothers are solely responsible for the nurturing and well-being of their children (Hayes, 1996). Women who have children are expected to give up their individual and fully devote themselves to motherhood, a fully time and often devalued job. Mothers are constantly policed and those who do not fit the socially constructed profile of a “good mom” are socially sanctioned (Johnston and Swanson, 2003). Such expectations set women up for failure, especially those outside who lack access of social, economic and political capital, particularly Hispanics and adolescent mothers. “Mothers are under pressure to conform to societal standards and is not necessarily best for mothers or their children” (medina and Magunson, 2009 p. 93).

Hispanic mothers also cope with the stressor of paid labor force participation. Women confront demands associated with working outside of the home. Such stressors include finding affordable quality daycare, inflexible work schedules, the wage gap, etc. the role stain experienced by mothers can lead to depression when they fail to meet family and social expectations (Edhborg et al., 2005). The demands of motherhood, experienced by those who are limited by structural constraints are overwehelming and are likely to contribute to postpartum depression (Gaschler, 2008).

Medicalization of Childbirth

The medicalization of childbirth is directly linked to the social construction of motherhood. The United States has a long history of regulating the reproductive health of women including defining childbirth as a medical issue. Although the medical profession posits that hospital birth minimize health risks for both the mother and child. There is a plethora of research suggesting that giving birth in sterile hospital environment is not only unnecessary but actually alienate women from an otherwise natural and normal occurrence (Cahill, 1999). Medical dominance over child birth disempowers women in several ways thus increasing their risk of depression (Oakley,1980). First, the medical setting is rarely patient centered; instead the needs or medical professional are given priority. Medical intervention, for example, scheduling cesarean deliveries are often a matter of convenience for the obstetrician with little regard give to the best interest of the women. Although, to my knowledge, there re no definitive studies linking cesarean birth to high rates of postpartum depression, research have found correlations between medical intervention postnatal mood disorders (Oakey, 1980). However, the issue warrants further exploration.

Second, hospital births are often impersonal and mundane giving women little control over their birthing experience, limiting individuality and comfort (Oakley, 1980). The medical setting is not always conductive to bonding with her partner or the baby during the process of labor. Numerous studies have found that depressed mothers have difficulties bonding with their infant (Fiori-Cowley at al., 1996, Gelfand et al., 2000), however it is not known there or not insufficient bonding contributes to depression.

Socio-Cultural Barriers to Mental Health Care

A number of barriers prevent depressed mothers from seeking mainstream treatment for postpartum depression. The literature identifies socio-cultural barriers such as attitude toward mental illness and treatment, partner support, social support, family, poverty, social capital, education, lack of recognition of depressive symptoms and language barriers (Chaudron, 2005). There are also structural barriers, including lack of transportation, childcare, health insurance, knowledge regarding where to seek care, regular source of care and proximity to treatment centers (Lopez, 2002).

The nature of the typical medical encounter can also serve as a deterrent to treatment. For instance, the average medical encounter last approximately 18 minutes (Mechanic, 2001). Condensed medical visits can lead to patient dissatisfaction and insufficient time spent understanding patients’ needs therefore increasing the number of medical misdiagnosis. For example, when a mother seeks care for depression her symptoms are often minimized by health care professionals (Dennis and Chung-Lee, 2006) or dismissed as temporary resulting in a misdiagnosis 50% of the time (Godfrey, 2005).

Psychosocial barriers can also prevent Hispanic mothers from seeking care. For example, poor body image and unrealistic expectations for beauty, particularly among adolescent mothers (Gosdin, 2005) can create barriers to mental health care. Cultural ideals of modesty must also be considered, particularly among Hispanic adolescent mothers. Because Hispanic adolescents have a higher fertility rate, compare to other ethnic groups, it is significant and crucial to explore socio-cultural barriers which prevent quality mental health.

Additionally, the Hispanic culture does not encourage open discussion about mental health and depression s considered by many a personal issue that should be kept private (Haynes, 2007).

Consequences of Postpartum Depression

There are numerous consequences of untreated postpartum depression. Not only is the mother’s mental and physical health in jeopardy, but also the child’s. For instance, the literature reveals a link between maternal depression and prevalence of early breastfeeding termination, reporting an inverse relationship (hatton, 2005). Other studies have reported similar finding suggesting that problems associated with breastfeeding and postpartum depression should be addressed (Henderson et al., 2003). Specifically, breastfeeding among Mexican Americans appears to be impacted by levels of acculturation (Kimbro, Lynch and McLanahan, 2008). Studies indicate that the “Hispanic paradox’ can be applied to breastfeeding behavior, thus less acculturated Mexican immigrants are more likely to breastfeed and for long period of time compared to more acculturated Mexican Americans (Kimbro, Lynch and McLanahan, 2008). The importance of breastfeeding is well documented as is known to have a positive effect on the mother’s mood while also lowering stress levels in both the mother and child (Kendall-Tackett, 2007).

Additionally, depressed mothers exhibit difficulty bonding and interacting with infants, which is associated with developmental problems. Maternal depression, during the first year postpartum, is associated with aggression, hyperactivity and depression among children at age three (Lusskin et al., 2007). There is also evidence suggesting that chronic maternal depression can result in poor vocabulary skills among children (Leitch, 2002). Postpartum depression, if left untreated, negatively impacts the mothers’ ability to parent, thus negatively affecting her self-esteem while putting the child at unnecessary risks, both physical and mental (Perfetti, et al., 2004).

Untreated postpartum depression can also lead to physical and mental impairment, lifelong depression, infanticide or suicide. Although postpartum depression can have devastating effects on the mother and the child, it also has the potential to disrupt the family resulting in lower quality of life and dysfunction (Logsdon, et al., 2006).

Conclusion

While previous studies have examined socio-cultural aspects of mental health few have been applied to postpartum depression thus a significant gap in the literature remains. The relationship between society, culture and postpartum depression is examined throughout this dissertation. Focusing on the unique experiences of self-reported depressed Mexican American adolescent and adult mothers contributes to the postpartum literature while also suggesting cultural interventions necessary to treat this specific population.

Postpartum depression cannot simply be reduced to a chemical imbalance or hormonal abnormalities. Rather, depression after childbirth can be understood as a social phenomenon that exists and is maintained through existing social structure found outside of the individual mother. The social construction of postpartum depression, including possible causes and affects must be explored through the experiences of motherhood, pregnancy and birthing all of which are typically examined through the lens of white, middle-class America, ignoring a variety of socio-cultural factors and structural constraints unique to Mexican American mothers.

Consequence of untreated postpartum depression, among a national sample of Hispanic mothers, is analyzed through three types of regression analyses and is addressed in the next chapter. The quantitative findings are then integrated within the qualitative framework provided in chapter 6.

CHAPTER 3

DATA AND METHODS

Research Design

A mixed methods study including qualitative phases was implemented utilizing separate samples, both from the same underlying population – self reported depressed Mexican American mothers. The qualitative portion explores how the pregnancy, motherhood and depression experience shape the social identities of self-reported Mexican American adolescent and adult mothers; while the quantitative piece examines consequences of untreated postpartum depression, specifically breastfeeding behavior and perceptions of the physical health of the child.

A mixed method design was implemented because it is bet suited for exploring new phenomenon and has the capability to test theory grounded in the qualitative data (Taskhakkori and Teddilie, 2003). Theory derived from the dominant qualitative phase will assist in the interpretation of the quantitative findings by providing insight into breastfeeding behaviors and perceptions of children’s health among self-reported depressed mothers.

Data were collected in two distinct phases; the first phase is the qualitative portion, and phase 2 is the quantitative portion, which provides assistance to understand the effects of maternal depression of health perceptions and breastfeeding behavior. The qualitative and quantitative methods were integrated during the interpretation stage of the research process (Taskhakkori and Teddlie, 2003)

Institutional Review Board

The study was approved, after a few minor changes regarding specific terminology included in the minor assent forms, on April 16, 2009 by the Institutional review Board at the University of North Texas. I was contacted by email regarding the approval of the study, including the use of public secondary data specifically the National Survey of children’s health, 2003. Minor assent forms were signed and dated by both adolescent participants and their legal guardians prior to the interviews, Participants were guaranteed that all information shared during the interviews would be kept confidential and that no identifying information would be used. The approval letter and consent forms are located in Appendices A and b. Recruitment began immediately after receiving final IRB approval.

Qualitative Phase

Procedures

Six Mexican American adolescent mothers and sic Mexican American adult mothers were interviewed twice using two distinct semi-structured interview guides totaling 24 interviews. Mothers were interviewed twice due to the sensitivity of the topic and the length of time needed for each question. Participants from both groups were recruited from the DFW metropolitan areas.

Recruitment

Recruiting qualified participants was a challenging and time intensive process. The combination of specific recruiting criteria, sensitivity of the subject matter and language barrier complicated the recruiting process. I began recruiting adult mothers in May 2009 with assistance from a key informant who is a native-Spanish speaker, health educator and active member of the Denton Hispanic community. The key informant arranged several public speaking engagements where I presented current literature and my previous research on postpartum depression while actively recruiting at churches, community health fairs and health clinics. Several recruitments strategies were employed including: creating and disseminating flyers, calls and emails to various pregnancy centers, schools and health clinics throughout the DFW areas, a radio interview, online and print ads, list serves, church bulletins and personal and professional contacts, Print ads in local newspaper, in both English and Spanish, and the radio interview proved most successful in recruiting adult participants while a personal contact assisted with accessing a teen parenting program at a local public high school, which led to adolescent participation.

The key informant previously mentioned also assisted with translating the interviews and served as a reference to increase cultural competency, specifically, she proofread both interview guides and the demographic questionnaires providing feedback regarding wording and culturally specific concepts. A second native Spanish speaker assisted with recruitment by translating recruitment flyers from English to Spanish while also serving as a contact person for interested Spanish speakers. She was also included in the interview process with the adult mothers by translating interviews with two adult non-English speaking participants while also building report. The rationale for translating during the interview was to: (1) build trust and to establish comfort among participants: (2) to ensure the most accurate data by having participants speak their native languages; (3( to ensure that sensitive information was communicated accurately and not subjected to a language barrier. The translator was not needed for the interview =s with the adolescents because (1) they were fluent English speakers and (2) the parenting teacher, whom the students trusted and confided in, was nearly, putting the participants at ease and building report between the researcher and the teens.

Qualitative sample inclusion: Mexican American adolescent mothers were recruited based on the following criteria: (1) 18 years of age or younger; (2) self-reported depression; (3) eight weeks to a year postpartum, to distinguish depression from the more common "baby blues” (4) have never sought care from a mainstream healthcare professional for depression,; and (5) have never taken medication to treat depression, Mexican American adult mothers were included based on the same criteria expect for age which was 19 years or older.

Qualitative sample exclusion: Mexican American adolescent and adult mothers were excluded from the study based on the following: (1) participants over the age of 18 were excluded from the adolescent group and mothers under the age of 19 from the adult group; (2) non-self –reported depressed mothers; (3) less than 8 weeks postpartum; (4)have sought care from a mainstreams health care professional for depression; (5) have taken medication for depression.

Identifying Postpartum Depression

The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening instrument for postpartum depression. The EPDS consists of 10 questions with a maximum score of 30 and a score of 10 indicating possible depression. This particular screening instrument has been tested among women of many cultures, including Hispanics. Also, the EPDS is closely correlated with other depression scales and is extensively used in both research and clinical studies (Boyd et al., 2005; Mason, Linda and Poole, Helen, 2008). While the purpose of a screening instrument is not to diagnosis postpartum depression, it identifies women who are at risk. Identifying mothers who are at risk of developing postpartum depression is extremely important considering approximately half of all cases go undetected (Abrams and Curran, 2007; U.S. Department of Health and Human Services, 2000). To determine if the scores on EPDS and the respondents’ narratives of depression match, each respondent completed the EPDS scale.

A Spanish version of both the demographic questionnaire and the EPDS were available for the participants who felt more comfortable reading and writing in their native language, although only two of the adult mothers chose to do so.

Data collection

Qualitative data collection began in July 2009 and was completed February 2010. In-depth interviews serves as the primary method of data collected, while a secondary data analysis supplements the qualitative findings. Data were collected through in-depth interviews of two groups- self reported depressed Mexican American adolescent mothers and self-reported depressed Mexican American adult mothers.

The qualitative portion of this study consists of twenty-four semi-structured in-depth interviews resulting in 230 pages of transcripts. Group 1 consists of 6 self-reported depressed Mexican American adult mothers, the interview guide was divided into two separate parts, thus participants were interviewed twice. The in-depth interviews lasted approximately one hour. Adult mothers were interviewed in either their home or a nearby public library while adolescent mothers were interviewed on the campus of the high school where the parenting program was based. Interviews with adolescent participants were conducted in a private area of the school library.

Each interview was audio recorded and transcribed verbatim; the tapes were stored in a private location for the duration of the study. No identifying information was revealed to anyone other than the researcher. Three of the interview transcriptions were contracted out, while I transcribed the remainder.

Interview Guide

The two groups of participants were asked questions from two different semi-structured interview guides. Both were geared to answer the same research questions, but varied slightly. The main difference concerns the wording and addition of two questions created specifically for adolescent mothers. The supplemental questions were designed to uncover perceptions of stigmatized identity commonly expressed by teenage mothers (Gosdin, 2005). Specifically, adolescent mothers were asked to describe how parenting as a teenager differs from adult motherhood and how well people in general understand teen mothers.

Both interview guides categorized question into four distinct sections; (1) pregnancy experience, (2) motherhood experience, (3) depression experience and (4) socio-cultural explanations of depression and social barriers to mental health care. I began each interview with an ice breaker to establish more of an open dialogue rather than a formal interview. For instance participants were asked to share some thing about themselves or their baby and what they do for fun. The first interview focused on the experience of pregnancy, motherhood and depression. For example, to elicit feelings that arose during pregnancy participants were asked how they felt when they first learned that they were pregnant, who told first, to describe a typical day during their pregnancy and how they would describe their pregnancy experience.

Questions directly related to motherhood were aso asked and included: “Describe a typical day now that you have had the baby” and “In what ways is motherhood similar to and different from what you imagined?” To best understand how self-reported depressed Mexican American mothers make sense of depressive symptoms questions such as “In what ways do you express sadness?” and “Do those closest to you understand why you get depressed?” the second interview focused on the relationship between the mother and her child and help seeking behaviors. Participants were asked to describe the interaction with their baby and how their depression affects their bonding. Also, questions pertaining to the culturally influenced perceptions of mental health such as “how is depression viewed in the Mexican American Community?” and “What would prevent a depressed Mexican American mother from talking to a healthcare professional about depression? Were included.

To supplement the qualitative data I wrote reflective memos immediately following the interviews. The purpose of memo writing in qualitative research is to further theoretical thinking strengthening the relationship between the researcher and the data (Birks, 2008). The memos include my own reflections, expectations, feelings and preconceptions toward the research.

Data Analysis

Qualitative data were analyzed using a grounded theory approach based on a multi step technique developed by Strauss and Corbin *Eaves, 2001). Each of the 24 transcripts and depression scales were hand coded by the researcher. After an initial read of each transcript, 29 codes were assigned based on emergent common themes. Codes include normalizing and controlling depression, pregnancy complications, social support, childcare stress, conflict within interpersonal relationships, perceptions of baby, body image, etc.

A separate codebook for the adolescent and adult mothers was created based on the same 29 open codes which then collapsed into categories. For example, the code pregnancy related complications was deconstructed and grouped based on specific issues indicated by participants such physical and emotional difficulties. Upon categorizing codes, subcategories were created through the process of linking code with specific statements illustrated in the data, which created through the process of linking code with specific statements illustrated in the data, which led to the development of themes, thus generating theory explaining how postpartum depression is socially constructed among Mexican American adolescent and adult mothers. Specifically this study examines how the experience of pregnancy, motherhood and depression differ among these two groups of mothers.

Also, data obtained from the Edinburgh Postnatal Depression scale (EPDS) were hand scored and are displayed in Tables 11 and 12. The scale encompasses a maximum score of 30 with a score of 10 or greater indicating possible depression. Participants’ scores were compared to their corresponding demographic information completed at the beginning of each interview. The purpose of this comparison is to (1) determine the severity of the participants’ depression, and (2) to determine if the severity matches the qualitative in-depth-interviewing narratives.

Table 1

Summary of Qualitative Study

Adolescents Adults

6 self-reported depressed Mexican 6self-reported depressed Mexican

American adolescent mothers American adult mothers

18 years & younger 19 years and older

Demographic Questionnaire Demographic Questionnaire

EPDS scale EPDS scale

Two Interviews each Two Interviews each

Total 12 Interviews Total 12 Interviews

Reflexivity

I became interested in studying postpartum depression after learning about the 2002 Andrea Yates court in Houston, Texas. I was perplexed by the media’s portrayal of postpartum depression and society’s response to mental illness in general. Why are we so quick to blame the victim? I felt that this question was never posited; instead it was questions of how could a mother commit such a horrible act and what would be the most fitting punishment. As Andrea Yates’ story became public, including her long history of depression with psychosis, it became clear to me that this case centered on an American sentiment based on revenge, misogyny and ignorance of mental illness, specifically postpartum depression. Postpartum depression, an issue typically reserved for psychiatry and psychology, can and should be analyzed through a Sociological lens, thus leading me to the research topic.

Studying postpartum depression from a sociological perspective required re-thinking motherhood as a social construction, which rarely favors women. Having witnessed numerous friends’ transition into motherhood and dedicating much of my adult life to studying sociology I thought I has a good idea of the challenges facing mothers. In many ways I, like many of the women interviewed, thought that depression after childbirth was normal. Who wouldn’t be depressed being a mother in a society that devalues women while de-emphasizing the importance of motherhood? Although I had long realized that American society sets mothers up to fail by not providing the needed infrastructure required for a quality life, I had not fully realized the extent to which Mexican American mothers are negatively impact or the direct effects that untreated postpartum depression has on the family.

Ethical Considerations

All participants were informed of the possible risks, which were minimal. Due to the sensitivity of the subject matter participants were referred to a culturally competent community mental health clinic in Dallas, Texas that provides both counseling and medical treatment to the indigent. Several mothers stated that they would seek mental health care upon receiving the information. Several of the adult mothers cried during parts of the interviews but also expressed emotional relief that they were able to openly talk about their feelings.

The remaining three chapters focus on key findings derived from qualitative interviews with self-reported depressed Hispanic mothers in general. The social construction of postpartum depression as highlighted throughout this dissertation also calls attention to policy and clinical implications while considering future areas of research.