This highly selected group of women with depression during pregnancy engaged fully in this research which appeared to have great salience for them. For the women in this study, becoming the best mom that I can was a complex process requiring that they recognize the problem, deal with their shame and embarrassment, identify an understanding healthcare provider, and consider the consequences of the depression and its management in order to reground the self and regain control of their lives.
There are some similarities and major differences between the findings of this study and those that have examined PPD [22
] and other postpartum disorders [48
] Depressive symptoms, the resulting loss of control, altered perception of self, and doubts about maternal ability described by the women in this study, appear similar to the findings generated by Beck's [22
] metasynthesis of qualitative studies of PPD. The themes that emerged from her analysis, "incongruity between expectations and the reality of motherhood, spiraling downward, and pervasive loss" suggest that the experience of the depression itself may be similar for the two groups. The findings from Beck's [22
] metasynthesis have drawn attention to the women's sense of loss (of control, self, relationships, and voice) as being a pervasive component of PPD. This knowledge has provided new perspectives for understanding women's experiences, [49
] and prompted the use of loss and grief frameworks "in designing interventions for postpartum-depressed women" [22
The women in the sample sought care from mental healthcare providers who were experts in the field of reproductive mental health. For some women, this was facilitated by their obstetric care providers. For others, particularly those with a pre-existing depression, seeking expert care was of their own volition. They considered that only a psychiatrist experienced in the care of pregnant and postpartum women was acceptable. This is similar to the findings of Robertson and Lyons, [48
] who reported that women in their study identified themselves as needing "specialized forms of treatment" outside of that offered "within a general psychiatric service".
Finally, the women in the current study all needed to hear that "they were not the only one", in order to normalize their experiences and to gain hope for the future. For many women, the idea that depression could occur during pregnancy was antithetical to their vision of the pregnant self. Consequently, they felt embarrassed and ashamed. Goffman [50
], in his essay on stigma, notes that a known discrepancy between one's expected and actual identities, "spoils" a person's "social identity", causing that person to withdraw from society and from the self (p. 31). This may explain the women's shame and inability or unwillingness to talk to friends about how they were feeling.
Having a confidante has been shown to be an important aspect of emotional support [51
]. However, none of the women in this study had a confidante outside of their partner, occasionally their mother, and their mental healthcare provider. Berggren-Clive [52
] noted that postpartum support groups play an "integral part of the help seeking process and important role in the creation of hope" for women with PPD. Conversely, for the women in the current study, there were no support groups. Prenatal classes currently focus on preparing the expectant mother for the birth; those classes would be an ideal venue for the provision of information and education on the possibility of mood disorders during pregnancy. Indeed, increasing depression literacy, that is, improving community awareness and understanding of depression during pregnancy, may result in the successful implementation of prevention, intervention and treatment programs for these women.
Many of the women in the current study reported stable marital relationships that strengthened after having gone through counseling. This is inconsistent with the findings of Beck [53
] and Robertson & Lyons [48
] who reported that the women in their studies experienced a loss of relationship with the partner. It may be that the high SES of the women in the current study protected the relationship and of partner support. Alternatively, it may be that the outcomes of depression during pregnancy and those of the postpartum differ. During pregnancy the husband may feel a particularly strong need to protect his wife and coming child. This protective role may be unsustainable by the husband when he encounters the stress and demands of a new baby and a wife who herself is not coping. This suggestion is supported by the findings of one study that has examined PPD from the perspective of the male partner [54
]. Those authors report that the men's experiences of their partner's PPD was overwhelming, isolating, stigmatizing, and frustrating. Those feelings may contribute to the deterioration in the interpersonal relationships that has been reported in PPD. If this is so, appropriate and efficacious interventions for perinatal depression should include both partners.
Constructivists frequently encounter the charge of relativism: if all meanings are co-created, how can one researcher's meaning be any more important than any other meaning. However, by interpreting "a
reality" (p.523) [24
] the substantative theory developed in this study begins the process of representing the voices of the women, illuminating their perspectives and how their perspectives influence action. The theory "constitute(s) not a new truth, but a sort of tentative truth claim" about the process of managing depression during pregnancy [55
]. It is context specific and thus limited in that it was developed with Canadian women. Additionally, the women in this study were all of relatively high SES, the majority in stable relationships with supportive husbands. Whether depressed obstetric patients with different characteristics would tell the same story is an area that requires further investigation. Also, it must be kept in mind that the pregnancy of interest, that is the pregnancy during which the woman was depressed, occurred on average 1.0 years (range = 0 to 2.5 years) prior to the interview. For some women this long recall time, and the events in the intervening period, may have affected their memories.
Finally, the women were recruited through a reproductive mental health program located in a tertiary hospital. Including only such women may have influenced the findings in a number of ways. First, women were in possession of knowledge, or had access to others with the knowledge, that enabled them to access such a resource. It is unlikely that the majority of obstetric patients with this disorder, especially those living within a rural setting, would have the same opportunity and therefore the same outcomes. Second, psychiatrists who see many obstetric patients may manage the disorder more confidently, that is, they may be more likely to prescribe antidepressants for pregnant women than would family physicians. Third, it is likely that there is a high degree of unrecognized and untreated depression during the obstetric period, however, the proportion of pregnant women who suffer without treatment are unknown [21
]. Women who remain undiagnosed may have very different experiences than the women who participated in the current study. High quality care for women can only begin with the recognition of symptoms and an accurate diagnosis of the disorder.
Like all grounded theories, the current findings may or may not be transferable [56
]. However, information has been provided so that the reader can determine whether the findings are applicable to a new situation [45
]. The major strength of the grounded theory approach is that it allows for a "fuller use of highly contextualized research for ongoing discovery" [57
]. Through the "continued use of emergent fit, the theory can be expanded, revised, and adjusted to maintain its usefulness" [56
] in explaining the process of managing depression during pregnancy.