Research report
Confinement and other psychosocial factors in perinatal depression: A transcultural study in Singapore

https://doi.org/10.1016/j.jad.2005.09.004Get rights and content

Abstract

Background

To investigate the prevalence, socio-cultural and psychosocial risk factors for perinatal depression in Singaporean women.

Method

A prospective cohort of 559 women was interviewed antenatally and at six weeks' postpartum at a tertiary hospital. Women were interviewed for diagnosis of depression using a two-stage design, with a screening questionnaire and diagnostic interview.

Results

Postnatally, a negative confinement experience was associated with depression. Other independent factors included poor emotional support, a past history of depression, unplanned pregnancy and perceived potential conflicts with relatives over childcare antenatally and dissatisfaction, poor instrumental support postnatally. The prevalence of depression antenatally and postnatally was 12.2% and 6.8%, respectively.

Limitations

Measures of satisfaction with social support were based on self-report; there were high dropout rates at six weeks' postpartum; and other modulating social factors such as pre-existing interpersonal conflicts were not studied.

Conclusions

Perinatal depression in Singaporean women is common. Contrary to expectations, a negative ‘confinement’ experience is a significant risk factor for postnatal depression, and is not universally welcomed by women. Depression is modulated by dissimilar sets of psychosocial factors antenatally and postnatally.

Introduction

Psychosocial factors play a large part in depression (Brown et al., 1996), perhaps even more so during the perinatal period than at any other time in a woman's life. Perinatal depression, defined here as depression encompassing pregnancy and the first postpartum year, has potentially profound negative effects on mother and child (Murray and Cooper, 1997). Pillsbury (1978) has pointed towards the protective effects of close social networks and forms of culturally sanctioned social support such as the ritual of confinement or “doing the month” in some Asian cultures, though recent studies have highlighted that ethnoepidemiological factors must also be considered (Lee et al., 2004). Singapore is a small South-East Asian island–nation that presents the opportunity to study a population with easy geographical access to extended family, as well as to traditional social support through confinement practices.

In particular, we were interested to study the confinement experience and its relation to perinatal depression. Singapore is a melting-pot of South-East Asian cultures and influences. It has a predominantly ethnic Chinese population with significant Malay and Indian minorities. The majority of Chinese and Indians of childbearing age are third- or fourth-generation Singaporeans whose ancestors migrated from Southern China and Southern India respectively. The Malay population is indigenous and shares the same culture as their counterparts in Peninsular Malaysia and part of the Riau islands of Indonesia.

In this study, we defined “confinement” to encompass not only the Chinese traditional practice also known as peiyue, but also the local Malay and Indian traditions which are intended to increase social support for the mother and to aid her recovery from childbirth. Chinese confinement traditions dictate that the mother is in a state of depletion and needs “warming” tonics and food to redress this imbalance. Special dietary prescriptions and proscriptions may include food that is cooked with ginger, and avoiding “cooling” things such as cold water or drinks. For some women, confinement practices may even include bathing in warm water to which certain herbs have been added or not washing one's hair for the entire month! In addition to or other than having a female relative help with infant care, some Chinese women may hire a “confinement nanny” for the express purpose of cooking the requisite postnatal diet and looking after the physical needs of the baby. There is booming cottage industry of middle-aged Chinese women with practical experience in peiyue who have successful careers staying with families a month at a time to care for them. Anecdotally, there have been reports of clashes between confinement caregivers and the new mother over issues such as, say, whether or not to breastfeed the child in which both parties may come with different sets of cultural beliefs and expectations.

In addition for the woman to not leave the house for the first forty days postpartum or so, it is common for Malay women to hire a masseuse who provides postnatal massage, apply traditional herbs and perform abdominal binding designed to aid involution of the uterus and return to the mother's prenatal weight and figure. Indian Hindu women are likely to have certain dietary restrictions during the postnatal period, together with having special prayers and ceremonies designed to protect mother and child from spiritual harm. Owing to the assimilation of such practices across cultures, various elements of these confinement practices have been adopted across the different ethnic groups to varying degrees. For example, it is not uncommon for Chinese or Indian women to hire a Malay masseuse who will come to the house during the confinement month to do the postnatal massage and abdominal binding during the first few weeks post-delivery. We thus sought to study the socio-cultural factors associated with and prevalence of perinatal depressive disorders in Singaporean women.

Section snippets

Method

The study design was of a longitudinal cohort study of women delivering at a university-affiliated teaching hospital in Singapore between July 2002 to December 2003. Inclusion criteria included all pregnant women who were available for the 6-week follow-up period after delivery. Potential subjects were approached during their antenatal appointments in the obstetric clinic and written informed consent was first obtained from potential subjects prior to recruitment. Women who were subsequently

Results

During the first phase of the study when 724 mothers were approached antenatally for recruitment into the study, 128 (17.7%) declined to participate in the study and 37 (5.1%) were excluded because they would not be available during the follow-up period. The remaining 559 (77.2%) patients were recruited into the study. Limited information about the refusals was obtained from their patient registration data. However, comparison of baseline data between refusals and subjects showed that the two

Discussion

To our knowledge, this is the first study to show that confinement practices can be a risk factor for postnatal depression, a form of culturally sanctioned support which is widely practiced in South-East Asia among the Chinese, Malay and Indian populations. Furthermore, a third of women surveyed did not consider confinement a positive experience. In our sample, a positive confinement experience was also not associated with a lower risk of developing a depressive disorder in our study

Limitations

One limitation of the study was the high dropout rate during the second phase of the study. This is perhaps not surprising, given that high rates of refusals in excess of 50% and dropouts of up to 36% were also seen in other studies of perinatal women (Morris-Rush et al., 2003). These dropout and refusal rates may thus reflect a widespread problem in the perinatal period where there are extra demands placed on the woman's time due to preparing for the arrival and caring for the new infant.

Conclusions

Perinatal depression in Singaporean women is common, though it appears that antenatal and postnatal depression are modulated by dissimilar sets of psychosocial factors. Some of these factors are well known, such as poor marital satisfaction, unplanned pregnancy and a past history of depression. Clinicians should thus be alert to enquiring about women's emotional as well as instrumental support during the perinatal period, bearing in mind that different aspects of such support may emerge as

Acknowledgements

We would like to thank Mrs R. Rajaram for her generous assistance in recruiting and following up with patients for the study. The authors acknowledge the Medical Publications Support Unit of the Medical Affairs Department of National University Hospital, Singapore, for their assistance in the preparation of this manuscript.

Declaration of Interest: This work was funded by the National Healthcare Group of Singapore (NHG grant no. STP-02021).

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