Discussion
Key findings from this study reveal mothers in this study felt cultural expectations that mothers be the glue that holds families together and that mothers suffer and sacrifice their own needs for their children. Taken together with feeling they will be judged if they have PPD and must hide their emotions, findings illuminate the need for prioritising and centring mothers experiences and needs in the postpartum phase. Listening to mothers’ voices, we learnt that they view the experience of PPD as one that can be isolating, entail judgement by the community, and potentially threaten one’s usefulness to her own family. Participants in the focus groups had varying awareness of PPD and shared stories of misinformation or negative assumptions of what it means for a mother to have PPD. All mothers had heard of depression after childbirth, many had experienced it, and most remarked that the personal experience and community acceptance of it vary by family. Acceptance and support from their community and family were highly valued and desired. Negative views of depression during or after pregnancy may be stemming from a lack of information about the causes, variation in severity and treatment. Mothers felt judged by their communities (eg, family, neighbours, church). Stigmatising community beliefs and misconceptions about the causes and progression of PPD within Latino communities are not uncommon.46 Beyond the stigma, it was also evident that mothers were unsure of how to know the difference between a sadness that passes and depression symptoms that require professional help. Providers should be aware of a need for dialogue about the continuum of emotions from baby blues to severe PPD.
Affiliation with cultural values was woven through the discussions. The prioritisation of family over the individual needs and the cultural value in focusing on the family (familismo) is common in Latino families.44 Some cultural beliefs such as familismo seemed to provide great support to mothers, while others such as maternal self-sacrifice (marianismo) or traditional gender roles resulted in mothers feeling ashamed, incompetent and alone. Data from these focus groups reveal that suffering and sacrifice are expected in motherhood as mothers tend to put their children first and put her own happiness aside. Parenting by teaching cultural values of family, religion and respect was discussed by most mothers in the current study and supported by Calzada, Fernandez and Cortes' qualitative study among Mexican-born and Dominican-born mothers.47
The shared experience of not feeling useful when having PPD should be interpreted within the context of the high value of the mothers’ role in their family as reported by participants. Our focus group participants worried that if they could not perform their duties as a mother, they would feel incompetent and might lose their family if they succumb to depression. Qualitative studies among Mexican-American immigrant women describe how the mothers view themselves as serving a central role in the home, responsible for the children’s moral education, and the primary source of teaching children how to get along in the world.48 49 Based on the findings in this study and other qualitative studies among Latinas, mothers are likely to feel a great sense of responsibility to stay well and be the leader of socialisation for the family. This expectation may prohibit the admission of depression symptoms and or help-seeking behaviours. As stated by one of the participants, ‘I keep my feelings to myself…’, the admission of depressive feelings could be seen as an admission that the mother can’t handle her ‘job’.
The point that the community says ‘she must not have any help’ when they see a depressed mother brings up a valid perspective that is often not discussed enough in mainstream research and media in the USA. Childbirth can result in physical trauma from which it takes time and rests to recover. Effective recuperation is not possible if a mother has no help from family or friends. In Latin American countries, traditional customs are performed to help and support new mothers. For example, peers who are also mothers, sisters and grandmothers assisted the new mother with household duties, newborn care, and enforcing periods of rest for the new mother.29 These customs are not universally practised in the USA, and it is worth exploring strategies that non-native Latina mothers use to get the help they need and avoid feeling alone in their experience. There are likely many strengths that exist interpersonally and at the community level that can be leveraged to support their maternal well-being. Increasing awareness that pregnant women may need extra help and time to care for own mental well-being after childbirth could result in increased community and family level support.
Social support and instrumental support are known buffers of PPD.50 In focus groups with Spanish-speaking mothers, husbands have been cited as the primary support system followed by mothers, cousins and friends.45 However, in the cited study by Negron et al
45 mothers also reported that they expected their husbands and family to implicitly understand that new mothers need help with the care of the baby and need positive emotional support. Mothers said they would often not ask for help from family for fear of having their parenting criticised or feeling like a burden to others.
One topic of conversation in the focus groups that has potential for future research is the question, ‘is suffering and sacrifice part of being a good mother?’ Keefe et al suggest that a narrow conceptualisation that ‘good mothers’ do the majority of child rearing and sacrifice their own needs contributes to women feeling they do not measure up and, therefore, being more at risk for depression after childbirth.30 From a strengths-based perspective, Keefe et al recognised definitions of what it means to be a good mother in the mothers’ stories, such as being resourceful, strong and able to juggle multiple responsibilities and seek self-care when depressed.30 Our participants spoke of suffering and sacrifice as a natural part of motherhood. They discussed the transmission, internalisation and passing down cultural values as a strength in group interviews. Similar to the findings reported in a Child Trends research brief,51 the mothers in our group spoke with pride of their sacrifices for their children. According to the Child Trends report, understanding and incorporating cultural values such as respeto, familismo and sacrifice is vital to engaging Latino parents in early childhood education. Their findings are transferable to ours in support of incorporating a maternal strengths-based approach that is aligned with cultural values when working with foreign-born mothers.51
For example, sacrifice could be seen as a strength, and within the context of experienced trauma history and immigration trauma, resiliency. Many of our mothers live in the intersections of immigrant, poor and Latina. Practitioners and researchers must ask themselves: how can we centre the resiliency and strength born from this intersectional identity versus continuing to simply report poverty, immigration and ethnicity as risk factors for depression? More qualitative research is warranted to explore how behaviours and beliefs such as sacrifice for children can co-exist with behaviours such as self-care of one’s own mental health. Left unchallenged, beliefs and expectations that mothers should sacrifice their own needs for the needs of children can be a dangerous set up for untreated depression. Living in poverty and being an immigrant are known to be factors that exacerbate depression yet also, act as barriers to help seeking.7 14 22 If a mother experiences ongoing depression symptoms and yet she does not feel permission to share her struggles, she is unlikely to admit symptoms, let alone, seek professional help.52 Our findings indicate that programme developers should consider family-focused education and intervention efforts.
Family plays a central role in providing emotional support for Latinos.47 In our study, mothers felt useful when performing household duties and emotional support for the family. Husbands and life partners could play a vital role of ‘witness’ if they were educated to be more vigilant about the mother’s mental health. The current study expands what we know from smaller focus groups with Latina immigrants who spoke of their cultural beliefs of PPD.13 In both Sampson et al ’s study and the focus groups presented in this paper,13 mothers spoke about not knowing (within themselves and when observing others) how to distinguish the normal range of suffering from a level of emotional and physical suffering that requires professional help. Although there was not enough discussion specifically about lack of information contributing to difficulty in distinction, several women mentioned a lack of clear and consistent information about what PPD looks like, feels like and how to know when to ask for help.
With national PPD prevalence in the USA higher among Latinas than non-Latina Whites,6–9 there remains a need for more accurate screening and intervention. Progress toward the goal of decreasing PPD and negative outcomes is only possible with more inclusive research. Researchers and practitioners must be careful not to ascribe a ‘one size fits all’ mentality when inquiring about symptoms or offering interventions for mothers with PPD. As research on perinatal mood disorders such as PPD broadens in its breadth and depth, it is apparent that we must decrease the stigma of PPD and apply more understanding of culturally specific norms and practices that prevent or exacerbate depression. We must also explore how the experience of foreign-born mothers living in the USA is characterised by clashes in cultural expectations and norms about how a mother adjusts after childbirth.D'Anna-Hernandez et al observed that the US values of independence and self-reliance was a risk factor for increased depressive symptoms among Mexican-Americans during the pregnancy.53 This information can only be gleaned from PPD-related research that centres Latina women. Innovation in awareness building and intervention implementation is needed. Researchers have demonstrated success with recruitment for a randomised trial of PPD intervention among US-born and non-US-born Latinas by using online recruitment methods aimed at a global audience.54 55 Le et al successfully recruited over 100 women through internet marketing and substantiated efficacy for an evidence-based intervention of Curso Mamás y Babés.56
This study has several limitations. First, it only represents a sample of 133 Latinas, some US-born, some foreign-born with similar demographics but unknown amount of variation in ethnicity differences. One danger that research among Latino populations face is the homogenisation of a population with a large amount of ethnicity variation. More research needs to be done to disaggregate qualitative and quantitative data within Latino populations. Second, given that it is a qualitative study, we cannot generalise our findings to broader populations. Although external validity is not a goal or a promise of qualitative research, we hope our results could inform practice and research on mothers with similar cultural norms and demographics. Third, our community partner gathered the demographic data before the focus groups, so we missed an opportunity to get more precise data in demographics such as whether they had ever had a positive PPD score, numbers of years in the USA, and specific country of origin. Lastly, despite our efforts to ensure the trustworthiness and rigour of this study, such as keeping it embedded in communities, having bilingual facilitator and having diversified reviewers during the data analysis, it is possible that research reactivity and researcher bias still existed.