Elsevier

Social Science & Medicine

Volume 49, Issue 12, December 1999, Pages 1651-1661
Social Science & Medicine

What makes new mothers unhappy: psychological distress one year after birth in Italy and France

https://doi.org/10.1016/S0277-9536(99)00238-5Get rights and content

Abstract

The aim of this report is to present results on the factors associated with psychological distress in 724 Italian and 629 French women 12 months after birth. The prevalence of distress was ascertained by the 12-item Goldberg Health Questionnaire (GHQ), using a cut-off score of >5. Results show that, in both countries, after controlling for previous psychological health, the variables significantly associated with mothers' distress were: an unsatisfactory couple relationship; lack of a confidante; a baby with serious health problems, financial worries. In Italy, also being an older mother and a discrepancy between actual and desired employment status were associated with a high GHQ score. These results point out to the high prevalence of mothers' psychological distress in Latin countries too, and stress the role played by family and social factors.

Introduction

Being depressed is a painful experience. A depressed person may feel unhappy, inadequate and worthless; every-day activities become insuperable tasks; life becomes meaningless, wearisome and, depending on the intensity and duration of the suffering, sometimes unbearable. For a new mother, being depressed can be even more painful. On the one hand, a baby demands a tremendous amount of attention, love and care; whether the mother feels mentally or physically fit or not, our society expects her to assume most of the responsibility for this. On the other hand, the arrival of a baby is usually considered joyful; indeed, in some languages, such as French and Italian, a common metaphor for the birth is ‘the happy event’. A new mother is supposed to be delighted; if she happens to be unhappy or depressed, she may feel guilty, and again she is to blame for not living up to what society expects of her role (Marshall, 1991).

Depression after birth, or postpartum depression, has been studied extensively in the last 20 years. Research methodology has been perfected in the process and many of the limitations of early works have been overcome (see Romito, 1990a): nowadays, studies tend to be longitudinal and investigate large, randomized samples, and several validated indicators of mental health are used.

Many mothers are distressed after childbirth. In an Australian study, the point prevalence of depression 8–9 months postpartum was 15% (Astbury et al., 1994), while in a longitudinal study in Holland, 21% of mothers experienced depression in the 8 months after childbirth, the highest prevalence being at 10 weeks postpartum (14% of depressed) (Pop et al., 1993). These figures are consistent with the results of a meta-analysis, which showed a prevalence of postpartum depression of 13% (O'Hara and Swain, 1996).

Meta-analysis has made it possible to synthesize the results of numerous studies. According to a recent work based on 59 studies (O'Hara and Swain, 1996), stressful life events, lack of social support, marital conflicts and previous psychiatric or psychological problems are significant predictors of depression in the first few months after childbirth; economic factors and obstetrical complications show small but significant associations, while most demographic factors (age, parity, education, marital status) show no consistent association with the mothers' mental state. On the other hand, qualitative studies have documented the subjective experience of new mothers, their feelings of loneliness and isolation, the repetitive nature of their daily work, their worries about not being a good mother, and their frequent conflicts of role (see Oakley, 1980, Romito, 1990b, Small et al., 1994, Mauthner, 1995).

There are many important questions still unanswered. Many recent studies have been aimed at exploring one specific domain of mothers' experience or at testing one specific hypothesis. Few have tried to take into account all the potential variables involved in mothers' psychological well-being. For instance, studies aimed at analyzing the effect of returning to work have not considered factors such as obstetrical complications or the baby's health (Hock and DeMeis, 1990, Shibley Hyde et al., 1995). On the other hand, studies principally designed to analyze the consequences of birth events and experiences may leave out the indicators of the couple relationship or of the mothers' employment status (Hannah et al., 1992, Astbury et al., 1994).

Moreover, while meta-analysis can be a powerful tool for making a synthesis of disparate studies, it also obscures the differences existing between results. Examples of such conflicting issues are the role of economic factors and of obstetrical complications. For instance, lower social class was found to be associated with maternal distress at 6 weeks and at 6 months postpartum by Ballard et al. (1994), but not by Paykel et al. (1980) (6 weeks postpartum) or Astbury et al. (1994) (8–9 months after the birth). A different indicator, low family income, was found to be significantly linked with mothers' depression in some studies (Stein et al., 1989, Gjerdingen and Chaloner, 1994) but not in others (Murray et al., 1995). As far as childbirth is concerned, some studies found evidence of a significant relationship between type of delivery, mother's subjective evaluation and postpartum depression at different times in the postpartum year (Hannah et al., 1992, Astbury et al., 1994, Ryding et al., 1998), while others found no association (Paykel et al., 1980, Stein et al., 1989, Gjerdingen and Chaloner, 1994). Methodological aspects are unlikely to fully explain these differences, and the role of contextual factors should be considered. Being poor or belonging to a low social class, having a caesarean section or having a disappointing birth experience can mean different things in different cultural and social contexts. Studying these differences in results and their links with a broader context could be very useful for a better understanding of mothers' mental distress.

None of these studies has been carried out in Latin countries, however. The aim of this report is to analyze the factors associated with psychological distress in Italian and French women 12 months after birth using data drawn from a longitudinal study carried out in the two countries with the same protocol.

Section snippets

Sample and procedure

All women who had delivered their first or second child were eligible for the study. Exceptions were: mothers of twins, those whose baby was stillborn or had died after the birth and those unable to speak the national language. In Italy, five hospitals were involved in the study, all in the north-east (three in an urban and two in a rural area); in France, three hospitals were involved (two in the Parisian region and one in the Champagne–Ardennes). Mothers answered questionnaires at three

Psychological distress

The principal measure of psychological distress 12 months after birth is the General Health Questionnaire (Goldberg, 1972), in its 12-item version. It is a screening instrument, used extensively with new mothers (see Nott and Cutts, 1982, Watson and Evans, 1986, Cooper et al., 1988, Stein et al., 1989, Cox et al., 1993, Viinamaki et al., 1997). The 12-item version has been validated internationally (Goldberg et al., 1997, Piccinelli and Simon, 1997). While a cut-off point of >2 is generally

Strategy of analysis

A bivariate analysis was carried out using the same variables in Italy and France, while logistic regression analysis was performed entering only those variables significantly associated with the GHQ score; therefore, two distinct models were constructed for the two countries.

The χ2 test, and when appropriate Fisher's exact test, were used for comparison of percentages; a p value equal or inferior to 0.05 was considered statistically significant. In logistic regression, adjusted odds ratios

Indicators of psychological distress

Table 1 shows the relationships between different indicators of psychological distress. The proportion of mothers with a GHQ score >5 was 9% in Italy and 11% in France. With a cut-off point of >2, 33% of Italian mothers and 34% of French ones showed some distress. In both countries, all indicators of psychological distress correlated strongly with the GHQ score.

Characteristics of the samples

The characteristics of the samples can be inferred from Table 2. Italian women were more likely to be older and to have had their first

Discussion

The aim of this longitudinal study was to examine factors associated with psychological distress in two samples of Italian and French women, 12 months after the birth of their first or second child. Although samples were not nationally representative, mothers' sociodemographic characteristics correspond to those of national samples in France, and to those of mothers of the centre–north in Italy. Moreover, the response rate 1 year after birth was over 85% in both countries.

Between 9 and 11% of

Acknowledgements

The Italian survey was funded by the Region Friuli–Venezia–Giulia and by the IRCCS Burlo Garofolo, Trieste. The French survey was funded by a contract CNAMTS-INSERM 1992. The collaboration between the Italian and the French team was supported by a grant from the Italian CNR (Comitato Nazionale delle Ricerche) and the French INSERM (Institut National de la Santé et de la Recherche Médicale) for 1997–1998. The authors would like to thank the mothers who participated in the study, the women who

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