Applied & Preventive Psychology 6: 169-178 (1997) Cambridge University Press. Copyright © 1997
ALICE K. LOCICERO AND DIANNE M. WEISS
Private Practice, Belmont, MA
Social science research and clinical literature concur with our experience as providers of psychoeducational and clinical services: Postpartum depression results from the interplay of a multitude of individual and contextual factors. In light of the extensive literature on postpartum depression, it is surprising that models for prevention have not been established. We propose a model for prevention through integrated care and support, in which a wide range of existing services are used. This model is similar to comprehensive prevention models proposed by advocates of integrated service systems, such as community mental health and family support. The article includes illustrative case material.
Key Words: Prevention, Depression, Postpartum, Family, Health promotion, Social support, Service delivery
Postpartum depression poses significant challenges to families
and the community at large. Considerable research and
clinical attention has been paid to this complex phenomenon
(Campbell, Cohn, Flanagan, Popper, & Meyers, 1992; Collins,
Dunkel-Schetter, Lobel, & Scrimshaw, 1993; Comport,
1990; Hamilton & Harberger, 1992; Harkness, 1987;
Kendall-Tackett & Kantor, 1993; Kitzinger, 1994; Kruckman,
1992; Lim, 1993; LoCicero, 1993; Madsen, 1994;
O'Hara, 1995; Romito, 1989; Sheppard, 1994; Trotter, Wolman, Hofmeyr, Nikodem, & Turton, 1992). This attention is
justified, as it is estimated that between 10 and 20% of new
mothers suffer from postpartum depression within the first
several months after birth. 1O'Hara & Engeldinger, 1989;
Weissman & Olfson, 1995).
Despite burgeoning research and clinical literature on this subject, there is no universally accepted definition of postpartum
depression. The American Psychiatric Association's
DSM-IV (1994) does not have a specific diagnosis for any
postpartum- or pregnancy-related disorders. We have found
various descriptions and lists of symptoms for postpartum
disorders and distress to be useful (Dunnewold & Sanford,
1994; Harberger, Berchtold & Honikman, 1994; Kendall-
Tackett & Kantor, 1993; Kleiman & Raskin, 1994). The
wide range of symptoms described by various authors include
many types of physical and emotional difficulties that
can be mild or severe. Some examples are mild depression,
irritability, inconsolable sadness, suicidal ideation, oversensitivity,
sleep and/or appetite disturbance, physical symptoms,
loss of interest in activities usually enjoyed, excessive
worry, feelings of inadequacy and anxiety (Dunnewold &
Sanford, 1994; Harberger et al., 1992; Kendall-Tackett &
Recent literature on postpartum depression has identified
numerous etiological factors at the cultural, social, psychological,
and biological levels. These factors include social
isolation or lack of social support: (Collins et al., 1993;
Cutrona, 1984; Enkin, Keirse, Renfrew, & Neilson, 1995;
Kitzinger, 1994; Oakley, 1980); disharmony in the primary
relationship, (O'Hara, 1995; Sheppard, 1994); recent life
stresses (Casoni, David, & Berthiaume, 1993; Grossman,
Eichler, & Winickoff, 1980); lack of culturally determined rituals, support, and recognition to the new mother (Harkness,
1987; Kruckman, 1992; Stern & Kruckman, 1983);
adverse economic conditions (Ballard, Davis, Cullen, Mohan,
& Dean, 1994; Grossman et aI., 1980); the mother's
perceptions of the birth experience as problematic, or one in
which she was helpless and disempowered (Edwards, Porter,
& Stein, 1994; Greene, 1995; Oakley, 1980); vulnerability to
depression (Campbell et al., 1992; O'Hara, 1995); difficult
infant temperament (Casoni et al., 1993; Gelfand & Teti,
1990; Hopkins, 1984); and adverse reactions to biochemical and
hormonal shifts (Hamilton & Harberger, 1992; Parry, 1992).
Causes _____________ ___ ____Treatments______
Interaction of Causal Factors
Psychodynamic..............................Psychotherapy (usually psychoanalytic)
Recent Life Stresses (Life Events).. .Supportive,Directive Counseling,Professional Guidance
Figure 1. Older models of causality and treatment of postpartum depression.
Our experiences as providers of psychoeducational and clinical
services to childbearing and adoptive families are
consistent with the findings reported in recent literature: a
multitude of factors contribute to the development of postpartum depression and early family stress. It is clear from our experience, as well as from the case studies explored in the clinical literature (Dunnewold & Sanford, 1994; Kendall-Tackett & Kantor, 1993; Kleiman & Raskin, 1994)
that the factors contributing to postpartum depression are likely to interact thereby increasing the risk of postpartum depression.2 For example, financial problems may contribute to marital disharmony; life events, such as a job change
necessitating a move, may contribute to social isolation. We
have observed, however, that despite literature by both researchers and clinicians suggesting multiple, interacting factors in the evolution of postpartum depression, many practitioners continue to base their work on older models
that identify a single etiological factor as "primary" and
provide treatments which address only that factor.3 The variety
of causes thought to be "primary" fall readily into five
categories of experience: biological, psychodynamic, cognitive, developmental and life events. As Figure 1 illustrates, each model identifies one area as primary, and thus prescribes a course of action designed to address that area.
There is little likelihood of attending simultaneously to several etiological factors, or to the interactions among factors. The following situation is illustrative of the results of these older models.
Rosalie was 4 weeks' postpartum when she began to experience insomnia, loneliness, uncontrollable weeping, and anxiety about her baby's health and her own adequacy
as a mother. She and her husband had been having marital difficulties prior to conceiving the child, but had believed these to be normal adjustment issues. Rosalie first consulted
Psychiatrist A, who suggested regular psychotherapy sessions
to explore her relationship with her mother and her feelings about being a woman. Although she felt comfortable talking with Psychiatrist A, Rosalie's symptoms did not abate and she sought a second consultation. Psychiatrist
B told Rosalie that although he had no objection to her seeking psychotherapy, she would not recover from postpartum depression without medication, which he prescribed.
Rosalie's physical symptoms decreased, but she continued to be lonely, and to experience marital distress, concerns about her ability to mother, and worries about her baby's health.
The new mother who has symptoms of depression is often treated in ways that do not take into account the complex factors that are a part of her life. The mother is either
seen as a depressed woman who also has a young baby, or as a woman with a chronic depressive illness whose current episode was precipitated by giving birth. This diagnostic
approach is reflected in the DSM-IV, which does not provide a diagnosis for postpartum depression, though it does allow the addition of a specifier for "postpartum onset" if
an episode of a mood disorder occurs within 4 weeks' postpartum(American Psychiatric Association, 1994). Though each of Rosalie's psychiatrists defined the problem differently,
and prescribed a different course of treatment based on this definition, neither course of treatment included attention to issues specific to her situation as a new mother. Context was not explored in the evaluation process and was
therefore absent from diagnoses and treatments. Attention to contextual factors did not playa part in the recommendations
or treatments provided by these care providers because
they assumed that the primary cause of Rosalie's difficulties was either biological (Psychiatrist B) or psychodynamic
(Psychiatrist A). Each of the psychiatrists Rosalie consulted identified one etiological factor-within Rosalie-as primary and prescribed treatment to address that factor alone.
Another common, limited approach to postpartum depression is to attribute the difficulty, even when severe, to
the normal stress associated with the transition to parenthood. This is illustrated by Martha's case.
At 8 weeks' postpartum, Martha attended a new mothers'
support group at a community-based family resource center. When Martha shared some of her concerns about her ability to care for her baby, about marital problems, and about
her increasing impatience with her colicky baby, the other mothers, as well as the group leader, validated her concerns
and reassured her that such concerns were a normal aspect
of the transition to, motherhood. These reassurances continued despite Martha's complaints of ongoing anxiety and growing detachment from her baby.
In Martha's case, those who provided support also used a one-dimensional model to explain and respond to postpartum
distress-a model that normalizes mothers' concerns, attributing even serious concerns to developmental and transitional processes. This model ignores both internal and contextual factors specific to Martha's situation.
The group members and leader with whom Martha had contact saw only her status as a new mother when considering
what contributed to her difficulties. In contrast, the psychiatrists who saw Rosalie focused on one aspect of her life history, (either biological or psychodynamic) and her current
depression, and barely acknowledged the importance of her ongoing experience as a new mother. Our work as service
providers indicates that effective assistance for a new mother who has symptoms of depression must include both attention to her status as a new mother and to her depression.
Attention to Context: An Ecological Framework
Attending to the new mother both as a new mother and as a
person who is depressed is not even sufficient. In order to
provide adequate care for women with postpartum depression,
providers must also recognize that postpartum depression
evolves within a complex life context.4 Bronfenbrenner's
(1979, 1995) perspective on human development offers a broad-based, multidimensional framework in which
to conceptualize postpartum depression. He suggests that
individuals must be seen within the context of the systems
in which they are active participants-for example, within
the family, community, workplace, society, and culture. All
of these systems interact with one another, while the individual
plays an active role in shaping his or her experience.
Each of the factors known to contribute to postpartum depression can be located within one of the levels identified
by ecological theory. For example, relationship disharmony takes place within the level of the family; lack of ritualized
support and recognition reflects a failure on the cultural level. Furthermore, every one of the levels identified by the
theory contains one or more of the factors known to contribute to postpartum depression. For example, there are factors
within the mother, such as a prior history of depression, as well as outside factors involving the family (e.g., lack of support), the community (e.g., social isolation), and society (e.g., socioeconomic conditions).
Ecological theory has been applied to both individual and
family development (Moen, Elder, & Luscher, 1995). We
highlight the applicability of this theory to the understanding and prevention of postpartum depression: the interconnections among factors at various levels affect the mother's well-being.
Ecological theory addresses the real-life context of the
person studied. The realities of life in anyone community or
society shift over time, however. In the next section we
describe some factors specific to contemporary American life, which, as we conclude from research and clinical experience, are likely to increase new mothers' vulnerability to
Contemporary American Families at Risk
Comparing our own case studies with literature on childbirth and family development (Belsky & Kelly, 1994; Cohen & Estner, 1983; Davis-Floyd, 1992; Elkind, 1994; Gaskin, 1990; Grossman et aI., 1980; Harkness, 1987; Kruckman, 1992; LoCicero, 1995; Mutryn, 1993; Panuthos, 1984; Peterson, 1991) we found considerable agreement on several factors in contemporary American society that have
a potentially adverse effect on maternal well-being and
healthy family development. These factors include the lack
of universally accepted traditions or rituals around childbearing, the American ethic of individualism, contemporary
economic conditions, the expectation or need faced by most families to have both parents work full time before and after
bearing or adopting children, the mobility of families, the medicalization and technologizing of childbirth practices,
and the advent of managed medical care.
The lack of universally accepted traditions or rituals regarding childbearing results in multiple, often conflicting, cultural practices and expectations regarding the ways pregnant women and new parents should be treated and should treat themselves and their babies. For example, parents receive conflicting advice regarding whether to pick up a baby who is crying during the night, whether the baby should sleep in the same room with the parents, and whether to breast-feed exclusively. In the absence of expected and even
ritualized practices, many American mothers and families find themselves uncertain as to what to expect, and are on their own to invent ways to meet the challenges of parenthood. Those women and families who do come from backgrounds with rich traditions and rituals regarding childbearing seldom find medical care providers who are willing to
integrate these practices into standard perinatal care.
The American ethic of individualism causes many women to be unwilling to admit to a need for support or to accept prescribed or ritualized kinds of support. Anthropologists have suggested that in cultures where there is a more collective ethic that supports a prescribed structuring of the postpartum period, there is less postpartum depression (Harkness,
1987; Stern & Kruckman, 1983).
When motherhood is viewed as only one of several important life roles for women, there tends to be a decrease in the extent to which young women are expected to have contact with babies and children. This leaves many new
mothers with little experience, few internalized role models, and little sense of self-efficacy in the mothering role. The high proportion of women who are working also means that
fewer experienced mothers are available in neighborhoods or communities to give informal support, advice, and guidance
to new mothers. In addition, a dual commitment to
career and motherhood tends to increase the amount of stress experienced by some new mothers, who will try to"do it all" well, only to learn that this is not possible for most women.
The mobility of families has led to women giving birth in communities in which they have no relatives or old friends.
Thus, fewer women benefit from naturally occurring, longstanding,
informal social-support networks. In addition, family mobility eliminates some possible buffers for economically stressed new parents, such as the availability of grandparents as babysitters. The medicalization and technologizing of childbirth practices
leads many women to feel disempowered during childbirth and increases the likelihood that many will need to
grieve actively the loss of the anticipated birth experience. One in four births takes place by cesarean section and the vast majority of vaginal births include invasive interventions, such as epidurals and episiotomies. These procedures
particularly when unplanned, lead many women to feel both physical and psychological distress (Greene, 1995; Mutryn, 1993).
The advent of managed medical care has led, in many cases, to restrictions on choice of care providers and place of birth and to restrictions on direct referral from one perinatal
care resource to another. Managed-care policies rarely
have provisions for doulas for labor support, despite the fact that research has shown that the presence of doulas has
many beneficial effects, such as decreased likelihood of cesarean sections and other interventions, and increased success in breast-feeding and postpartum adjustment
(Klaus, Kennell, & Klaus, 1993). Furthermore, most managed-care policies also restrict coverage of postpartum home-care services.
Recently there has been tension between managed-care organizations and consumer advocates regarding the number of hours a woman stays in the hospital following birth. There has also been disagreement over who makes this decision in each individual case. It seems to us that the
discussion should also include how to best use the time spent in the hospital, rather than focusing exclusively on the
number of hours spent. During the hospital stay, families
and providers should collaborate to determine the specific
needs of the family, both in the immediate hours postpartum
and after discharge. Services available should include, at
minimum, screening for risk of postpartum depression, lactation support, basic education in infant care and postpartum care for the mother, identification of community resources, and discharge planning and referral.
Our society has, unfortunately, never instituted the practice
of universal provision of professional home-care services
for new families. Such home care is routine in countries
such as the Netherlands, Britain, Ireland, Costa Rica,
and Belgium. Hewlett (1991) regarded home-visiting services
and other community-based supports as both humane
and highly cost-effective, especially in relation to the public costs of treatment and remediation for babies and families
whose postpartum needs have been neglected.
New parents in the United States too often are left essentially
on their own with their infants. Our experience suggests that this contributes to the incidence and severity of postpartum depression and other serious disruptions in the functioning of new families, as shown in the following case
Barbara's circumstances reflect some previously discussed contemporary issues. A 35-year-old corporate attorney, Barbara reluctantly discontinued unsuccessful treatment for infertility, due to growing evidence that the treatments might pose health risks. A year later, she was
surprised and delighted to discover that she was pregnant.
The birth was by cesarean section; it was followed by a 24-
hour separation of Barbara and her baby. During the separation,
Barbara's baby was bottle-fed, and this led to later
difficulties in breast-feeding.
Barbara had resigned from her job in order to be at home
with her baby; however, Barbara became overwhelmed
when her husband returned to work. Barbara had few
friends in the community, having recently moved across the
country. When Barbara's baby was 2 weeks' old, the pediatrician
noted that her baby was not gaining weight at an
adequate rate. Barbara's mother came to help, and, although
the baby did better, Barbara's sense of adequacy as a mother
plummeted. Soon she began to have difficulties sleeping
and was anxious and uneasy caring for her baby. She was
troubled about the birth; she felt that she had been cheated
of a normal birth experience. She alternated between feeling
that her body had failed and feeling that her doctor had
performed a cesarean unnecessarily.
Barbara's situation is illustrative of the various contextual factors that interact and contribute to the development of postpartum depression. For example, having a cesarean left
Barbara physically exhausted. In addition, breast-feeding
difficulties following the cesarean made Barbara feel that
she was inadequate to the task of mothering her baby. Being
new to the community, Barbara had no friends to call on
who might have been able to offer help, refer her to the La
Leche League for breast-feeding support, or give her advice
from their own experiences.
Integrated Care and Support Network: A Model for Prevention
We have seen that the complexities of women's postpartum
emotional experience, including depression, are such that no
simple model of causality or treatment can be considered
adequate. As noted above, a variety of factors have been
shown to contribute to postpartum depression: social isolation
or lack of social support; recent life stresses; lack of culturally
determined rituals, support, and recognition of the
mother; disharmony in the primary relationship; adverse
economic conditions; difficult birth experiences; vulnerability
to depression; difficult infant temperament; and
adverse reactions to biochemical and hormonal shifts.
Despite an existing, rich body of knowledge about the
evolution of postpartum depression, prevention efforts have
not become widespread. In the remainder of this article, we
propose a model for prevention of postpartum depression,
which we call an "Integrated Care and Support Network."
The network that we are proposing includes a wide range
of services and resources available to meet the needs of
childbearing families, such as sensitive perinatal and pediatric
health care, prenatal and postpartum exercise classes,
home-visiting services, parenting education and family support
programs, and breast-feeding support. Additional services
for families with special childbearing needs include
mother-baby psychiatric units, Depression after Delivery (a
mutual support group), pregnancy loss groups, and postcesarean
support. All of the elements of the network we are
proposing already exist in many communities5; however,
they currently exist as separate, free-standing entities, rather
than as an integrated network. The network would emphasize
collaboration among the providers of those resources
and services, many possible points of entry into the network,
and freedom of movement within the network from
anyone service to any other, as needed.6 Figure 2 illustrates
such a network. We will describe the network and discuss
changes among professionals and the community at large,
which we believe necessary in order for such a network to
Description of an Integrated Care and Support Network
Each resource of the care network we are proposing addresses
an area known to put women at increased risk for
postpartum depression. For example, postpartum motherbaby
groups, the La Leche League, and self-help groups
address isolation and lack of social support; childbirth education
and sensitive perinatal care address the disempowerment,
helplessness, and overmedicalization that lead to
dissatisfaction with the birth experience; perinatal psychotherapy
addresses contemporary life stresses and past life
events that affect childbearing. Although this network can
serve many purposes, we are focusing on the preventive
benefits of such a network.
Use of the Network
The many services available to childbearing families
have not evolved naturally into a network. Nor has the
existence of various services led to a diminution in the
incidence of postpartum depression. Unless the network is a
visible and ordinary part of everyday community life, it will
be underused, particularly as a form of prevention.
It is surprising that support for a common life event such
as childbearing is not a part of the fabric of normal everyday
living. Rather, each family has to create its own system of
Figure 2 illustrates a network of perinatal care and its
entry points. The content and entry points alone do not
define the network, however. Below are some functional
aspects of the network that allow it to serve as a means of
1. The set of services available should be commonly
known among members of the community, both professional and nonprofessional. This would increase
the likelihood that a childbearing family would reach
appropriate services as needed, and before a crisis evolved.
2. Prospective parents should be encouraged to explore
the network prior to conception. This, too, would
increase the likelihood of crisis prevention by allowing
early use of services.
3. Childbearing families should be welcome to enter the
network at any point in time and through any of
a variety of referrals, including self-referral. This
would allow both preventive efforts and early intervention
by reducing any red tape.
4. The network should be an open system: movement
from one service to another should be easy with or
without formal referral. This would allow families to
receive services that address more than one causal
5. Providers should communicate readily with other
providers about services offered. This would facilitate
6. Network providers should include professionals and
volunteers, in both formal and informal caregiving
contexts. This would expand the consumer base, including
those who are more comfortable with professionals,
as well as those more comfortable with volunteers.
7. The network should include services and resources
appropriate from preconception through early family
Transition to Integrated Care
8. A continuum of care should be available, ranging
from universal access to childbirth preparation, parenting
education, community resources, and social
support, to more intensive mental health services and
preventive interventions for women who need them.
Although all of the elements of the network we are proposing already exist, we find it distressing to note how few
providers of conventional perinatal care are aware of the
existence of services other than their own. It is our observation
that even when some awareness exists, providers make
referrals infrequently, and that when referrals are made,
they are more likely to come following a crisis, rather than
as a means of prevention. Although integration of existing
services may appear to be a straightforward task, it would,
in fact, require radical changes in our society's approach to,
and understanding of, family formation and development. In
the United States, pregnancy and childbirth are currently
defined as momentous, medical/technological events
(Davis-Floyd, 1992; Martin, 1987), with minimal attention
to psychological, social, or cultural perspectives on pregnancy
or birth, and almost no attention at all to the postpartum
period and its challenges.
Recommendations for Change
In order for care-and-support networks to be established
and to serve a preventive function in the area of postpartum
depression, the following changes in professional practice
and philosophy must occur:
1. Care providers must recognize that the factors contributing
to postpartum depression are complex, interactive,
and may be manifest at any point in time,
from preconception through early family development.
In order for this recognition to occur, there
must be a change from seeing birth as a unitary,
isolated medical event to seeing it as an important
point along the continuum of personal and family
development. In addition, this continuum must be
recognized as an organic, ever-changing system,
wherein a change in one part will reverberate through
the entire system.
2. Professionals and community members must be educated
regarding the range of available choices in prevention
and treatment of postpartum depression including
mainstream care, such as medication and
psychotherapy, and alternatives such as acupuncture
and self-help groups.
3. Interdisciplinary communication, referral, and coordination
of services should be improved. Practitioners
in fields such as mental health, childbirth and parenting
education, pediatrics, family support, self-help, alternative
health care, and informal support services
must develop both formal linkages and informal collaborative
relationships with providers of obstetrical
care.7 These alliances can be strengthened through joint planning activities, collaborative partnerships
among private practitioners, multidisciplinary conferences,
and professional development organizations
4. Screening for risk of postpartum depression (including
adequacy of social support) should become a
standard part of prenatal and postpartum health care,
childbirth education classes, hospital discharge routines,
home-visiting services, and pediatric practice
(Placksin, 1994). Dunnewold and Sanford (1994)
and Kleiman and Raskin (1994) have constructed
self-assessment tools for use by women who are in
distress during the postpartum period. Though not
meant for prenatal or for professional use, they might
provide starting points for construction and evaluation
of a tool for perinatal care providers. Because
risk may be indicated by the presence or interaction
of multiple factors, a systematic approach to assessment
is needed. Krauss and Jacobs (1990) describe
such an approach to assessment of families.9
5. Providers must acknowledge the rights of women
and families to choose the interventions that are most
consistent with their own values and preferences, and
to have access to information that will assist them in
making comfortable and wise choices.
6. Finally, the transition to an effective system of preventive
care must be accompanied by significant improvements in women's basic access to perinatal health care, including mental health services and
Partial Integration of Services: A Transitional Step
Integrated perinatal care has not yet become commonplace. However, we have case studies illustrating the benefits
of partial integration of care. Presently, such integration>
occurs only when individual providers or families are persistent
in seeking to collaborate and integrate care. One such case is Eve, whose primary care provider, a midwife, initiated
and coordinated varied services. Eve had several risk factors for postpartum depression.
The most dramatic was Eve's sister's sudden death when Eve was in the first trimester of her first pregnancy. Concerned
that the resulting anxiety and depression would place
Eve at risk for postpartum depression, her midwife referred her for psychotherapy. The midwife chose to refer Eve to a
perinatal specialist who frequently collaborates with, and
consults to, the midwifery practice. The midwife also provided Eve with names and numbers of other postpartum support services such as the local La Leche League, support
programs for new mothers, drop-in groups, and home-care
Eve was seen for short-term therapy. Sessions included
grief work, as well as psychoeducation and support around mothering, breast-feeding, and infant development. The
therapist reinforced the midwife's suggestion that Eve attend La Leche League meetings and postpartum groups. She also referred Eve to a home-visiting program run by a colleague
of the therapist, so that Eve could have a veteran
mom visit her weekly to help her adjust to motherhood.
Eve followed the recommendations of the midwife and perinatal psychologist. She made supportive connections with other mothers. Her depression and anxiety lifted and
her grief became manageable. Eve benefitted greatly from integration of care. The services she received were complementary
in nature. Despite risk factors including her sister's
death, Eve did not develop postpartum depression. We
cannot know, of course, whether Eve's use of partially integrated
care was the crucial factor in her avoidance of postpartum
depression. We do, however, believe that widespread
availability of adequate, varied services and the
encouragement to choose services consistent with personal values is likely to reduce the incidence and severity of postpartum
depression. Eve was referred to various resources by her midwife. In our integrated care-and-support model, however, the direction could easily have been reversed: friends, neighbors, or
others in a prenatal support group might have referred Eve to a particular midwife or perinatal therapist. In fact, Eve
could have referred herself to any of the resources in the network, or moved from one resource to any other, based on
her own perception of need.
Support for Fully Integrated Care
It has long been recognized that women such as Eve
could benefit from integration of care and support services. An integrated care-and-support network such as the one we propose parallels service integration models in the fields of
health, mental health, child welfare, and education. Early in
the community mental health movement in Massachusetts,
in fact, a similar model was proposed by Bibring and Caplan
(Bibring, Dwyer, Huntington, & Valenstein, 1961; Caplan,
1954/1974). Our recommendations are fully consistent with those of
the Carnegie Task Force on Meeting the Needs of Young
Children (1994) and other initiatives that emphasize collaboration
and coordination of community resources for families
(Bruner, 1994; Dunst, Trivette, & Deal, 1994; Harberger
et al., 1992). We agree with those family-policy
advocates who believe that widespread social change in the
way new mothers and families are supported by the community
is necessary (Hewlett, 1991; Kagan & Weissbourd,
1994). We see prevention of postpartum depression as one
of the objectives of such change.
A review of research and clinical literature, combined with
our experience as providers of psychoeducational and clinical
services, strongly supports the position that postpartum
depression results from the interplay of a multitude of factors
on various levels. This is consistent with an ecological
model of human development, with attention to the levels of
the individual, the family, the community, and the society.
Given the knowledge currently available, it is surprising
that the focus of care providers continues to be on diagnosis
and treatment, rather than prevention of postpartum depression.
Furthermore, the care commonly provided for postpartum
depression fails to take into account all of the individual
and contextual factors known to contribute to its development.
Both individual and contextual factors vary for each
woman and her family. Several factors in contemporary
American society have frequently been cited as having an
adverse effect on maternal well-being and early family development.
These factors include contemporary economic conditions, expectation or need for both parents to work full time, mobility of families, and the medicalization and technologizing
of childbirth practices. Such contextual factors
must be taken into account in designing strategies for prevention.
We propose a model for prevention that we call an "Integrated
Care and Support Network." The proposed network
includes a wide range of formal and informal services and
resources available to meet the needs of childbearing families.
Collaboration among all providers, easy access to the
network, and ease of movement among the various resources
in the network are crucial elements of its functioning.
Our integrated care- and support-network for childbearing
families, with an emphasis on prevention of postpartum
depression, parallels service integration models used in related
fields that focus on comprehensive prevention, such as
community mental health and family support.
Despite the fact that a wide range of resources and services
for the care and support of childbearing families
already exist, and despite the fact that our integrated care-and-
support network model is similar to comprehensive
prevention models proposed by advocates of service integration
in related fields, the transition to an integrated care-and-
support network serving childbearing families would
require major changes in care provision and in popular perceptions
of the process of childbearing and family development.
We propose some steps toward the establishment of an
integrated care-and-support network, such as the development
of local, multidisciplinary planning councils on meeting the needs of childbearing and adopting families; integrated referral systems; joint training and professional development
programs; public education and empowerment;
and the coordination of perinatal services and supports
through both formal linkages and informal collaboration
among professionals, agencies, and community groups.
We wish to thank Margery Davies, Karen Greene, Jane Honikman, Fran
Jacobs, Kathleen Kendall-Tackett, and Rae Simpson for helpful feedback
and suggestions regarding earlier versions of this manuscript. We also wish
to thank Richard Carter and James A. Crawford for assistance with preparation
of Figure 2. This article is based on a presentation made at the 104th
Annual Convention of the American Psychological Association, August
1995, in New York, NY. Case material is based on composites of many
cases known to the authors.
Send correspondence and reprint requests to: Alice K. LoCicero, Department
of Education, Rivier College, Nashua, NH 03060. E-mail may be sent
1 Estimates vary among studies, but the ranges suggested by Weissman
and Olfson (10%-15%) and O'Hara and Engeldinger (10%-20%) are
2 Earlier work on depression (not necessarily in the postpartum period)
by Brown and Harris (1978) also suggests that factors interact to cause
3 In fact, we have noted that practitioners are often at pains to argue that the causal factor they favor is more primarty than the causal factor faavored by some other practitioner.
4 This point is made strongly by Kendall-Tackett and Kantor (1993),
particularly in describing the experience of the new mother they call
5 A recent directory of resources available to childbearing families in
Massachusetts (Massachusetts Friends of Midwives, 1996) lists approximately
280 individuals and institutions offering many types of care.
6 It has been reported that in some communities there is movement
toward integrated perinatal care (L. Butterfield, personal communication,
November 1996; Placksin, 1994).
7 Kagan, Goffin, GoJlub, and Pritchard (1995) have developed a comprehensive
analysis of strategies that facilitate movement from fragmented
services to integrated systems of care.
8 Postpartum Support International (PSI), founded by Jane Honikman, is
an example of a group that supports multidisciplinary conferences and
professional collaboration, and publishes an extensive bibliography of
research on postpartum mood and anxiety disorders (Kruckman, 1994).
9 Krauss and Jacobs (1990) recommend a risk-assessment model that
includes multiple strategies to assess the balance between stressors and
supports, such as structured interviews, observations, and standardized
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