Postnatal Depression: When Reality Does Not Match Expectations

ten that give us important information about epidemiological, biological, clinical and psychological aspects of common mental disorders during pregnancy and in the postnatal period. Some of the issues covered in this book are: detecting postnatal depression using different instruments at the right time, which is very important to avoid the negative effects on the children of depressed mothers; understanding the impact of anxiety and depression during pregnancy and in the postnatal period; biological issues of perinatal anxiety and depression; epidemiological information about perinatal mental health problems among minorities, like immigrant population and underserved rural women. Some information is also provided on postnatal depression in men, which is frequently overlooked.


Introduction
In popular imagery and discourse, the concept of motherhood is a mythical, magical and powerful role; however, the documented reality of many mothers' lives indicates that early parenthood does not consist solely of positive experiences (Harwood, MacLean & Durkin, 2007;Nicolson, 1999).Nevertheless, the myths of ideal mothering still prevail in contemporary society.'Good' mothers are seen to be fulfilled in their new social role and as selflessly, happily attending to infant tasks.This dominant ideology does not reflect the typical realities for most mothers (Barr, 2008).Indeed, for many mothers, reality involves sleepless nights, anxiety, stress, feelings of being overwhelmed and difficulties in coping.Yet women feel compelled to fit into the socially constructed mould of the good mother.Therefore, experiences that differ from the dominant perspective are often considered to stem from personal shortcomings and are perceived both by society and by women as constituting failure.Harwood et al. (2007) found that unrealistic expectations of parenthood often led to greater difficulties adjusting to the experience itself.The discrepancy between anticipated and real outcomes becomes problematic for parents in terms of their psychological adjustment and acceptance of their new reality.
The conflict between expectations and reality has been noted in the literature on motherhood and postnatal depression (Alici-Evcimen & Sudak, 2003;Beck, 2002;Mauthner, 1999;Nicolson, 1999).The incongruity between expectations of happiness and depressive symptoms-at a time that is typically regarded as joyful-further increases maternal guilt and isolation (Alici-Evcimen & Sudak, 2003;Hall & Wittkowski, 2006).Women question themselves and their worth as mothers and as individuals when their mothering experience is not what society has conditioned them to believe is acceptable.There is, therefore, a discrepancy between what is experienced and the perception of what the experience ought to be like.Hall and Wittkowski (2006) report that women perceive a need to be perfect as mothers.However, good intentions may have little impact in regard to the subjective and unpredictable realm that is motherhood.Mauthner's (1999) research on postnatal depression found that all mothers in the study experienced some kind of conflict between their views of the mother they felt themselves to be and the mother they wanted to be.Similarly Dennis and Chung Lee (2006) found that all mothers in their study struggled to fulfill their ideal perception of motherhood while at the same time concealing their needs.They surmised that motherhood is plagued by the damaging effects of cultural norms, ideals and expectations.Consequently, mothers experiencing postnatal depression are hesitant to disclose their true feelings out of shame and perceived stigma as well as a fear of being deemed unfit for motherhood (Alici-Evcimen & Sudak, 2003;Dennis & Chung Lee, 2006).Mauthner (1999) indicates that knowledge in regard to postnatal depression has been developed largely from within a medical model and approaches using quantitative methodologies which conceptualize postnatal depression as a disease or an illness.Research efforts have been devoted to describing, predicting, preventing and treating it.Yet Nicolson (1999) has argued that there is little empirical support indicating a biological basis for postnatal depression.McMullen and Stoppard (2006, p. 276) similarly suggest that the medical model focuses on fixing women by altering their biochemistry, personality or life circumstances; such an approach is deemed problematic: The consequence of such a conceptualization is that attention is not directed to what, from feminist-informed perspectives, are the sources of the problem-specifically, the structural (economic and political) conditions that affect women and how these conditions, along with gendered expectations, are brought to bear on our understandings of women's distress.
Feminist approaches seek to create theory grounded in women's experiences, language and concepts.Some authors advocate for research focused on the socially constructed, gendered values and norms that create or sustain postnatal depression (Edhborg, Friberg, Lyndh, & Widstrom, 2005;Leung, Martinson, & Arthur, 2005;Mauthner, 1999).Based on this approach, the postnatal period is similar to a period of metamorphosis for women.As women adapt to their new social roles, they also shed part of their former selves, relationships, roles and activities which are incompatible with motherhood (Van Gennep, 1960).
A common belief is that depression renders women incapable of conveying meaningful insight into their experience or of generating trustworthy accounts of their feelings (Mauthner, 1999).In contrast, within the current study, the meanings that women attribute to their experiences and daily lives can provide clearer, first hand accounts of postnatal depression and generate a more holistic understanding of subjective lived reality.The purpose of this study was twofold.The first objective was to examine women's descriptions of postnatal depression and their stated needs in order to inform the development of a peer support program.The second objective was to explore the women's perspectives on postnatal depression given their location in northern and rural contexts since much of the published postnatal literature involves women residing in large urban settings.

Data collection
Ethical approval was obtained from the sponsoring university in northern Ontario.The topics used to guide semi-structured individual and group interviews were related to their postnatal experiences, their support needs, and barriers and solutions to peer support in postnatal depression.Each interview lasted 30 to 90 minutes and took place in a location most convenient for participants.All interviews were audio-recorded and transcribed verbatim.

Data analysis
Using the anonymized data sets, a thematic analysis was undertaken (Buultjens & Liamputtong, 2007;Creswell, 2007).From the transcripts of interviews, data excerpts associated with experiences of PPD and needs were identified and extracted.Feminist analysis was employed to assist in examining postnatal depression within the context of gender relations and socially constructed expectations.As Buultjens and Liamputtong (2007, p. 78) state, The myth of the maternal instinct can create feelings of inadequacy in mothers who do not feel overwhelming joy and love for the new child and for those who find mothering tiring and stressful.Feminist writers have challenged society's double standard where on the one hand motherhood is idealized and on the other hand it is trivialized and undervalued.
Motherhood remains a benchmark for femininity yet it is characterized by a patriarchal array of assumptions, expectations, stereotypes and impositions that dictate the dynamics of that role.Feminist analysis yields a description of social relations acknowledging genderbased oppression by identifying female experience within a social and political realm viewing women in the context of their relationships, families and communities and does not accept the status quo values and assumptions about women (Kelly, Bobo, Avery, & McLaughlin, 2004).To this end, the text was repeatedly read to code the data into categories, then group similar categories into themes.The process involves reading the verbatim transcripts, creating themes and sub-themes, aggregating the sub-themes into theme clusters and comparing the theme clusters to the original transcripts.
To address credibility, the authors regularly articulated and discussed the constructions of their perceptions of the data in an effort to check on the evolving analysis and the group decision-making processes pertaining to the identification of themes and subthemes (Creswell, 2009).Additionally, negative case analysis was employed in an effort to identify negative or disconfirming evidence.

Results and discussion
For the women in this study, the core theme was the stigma of being considered "crazy".Their struggles in the initial postnatal period were negatively influenced by fear, loss, guilt, isolation and being overwhelmed.In response to their perceived vulnerability, some sought support from within their social or professional networks.Unfortunately, this often resulted in further disengagement as they perceived being judged as "bad" or "unfit" for motherhood.Such experiences were in contrast to their expectations, as Patricia explained: The reason, well one of the reasons, I didn't go to my doctor and let him know is because I thought I was going nuts.And I thought that as soon as I went to my doctor and told him how I was feeling, the symptoms I was experiencing, they would take my baby away.So I had that fear that my baby was going to be taken away.I wasn't thinking rationally.Gross (1998) proposes that Western romanticized ideologies of motherhood have an enormous impact on how women are stereotyped.Such images characterize women as sacrificing themselves for the sake of their children and husbands.Postnatal depression, defined as a personal defect and individual dysfunction, creates a 'cloak and dagger' context in which women feel the need to hide their symptoms and repress their feelings for fear of social repercussions.Mauthner (1999) found that postnatal depression occurs when women are unable to experience, express and validate their feelings and needs within supportive, accepting and non-judgmental interpersonal relationships and cultural contexts.Women feel trapped in their experience as a result of being unable to express themselves; consequently they strive to present themselves according to social and cultural expectations.
The sense that postnatal depression was something that needed to be hidden was a common experience for many of our study participants.The perception is driven by many different factors but mainly the fear of what others in society would think based on the stigma that continues to be attached to mental illness and specifically mental illness among mothers.Joanne expressed her fear of being diagnosed with postnatal depression: "I don't want to have that label because then you're associated with that behaviour."Patricia felt isolated in her experience and stated, "It would have been nice for me to know that there are other women out there feeling the same way.I am not the only, you know, crazy one.Um because at the time I did feel like I was crazy." In the public mind, postnatal depression is associated with mental illness.Hence a diagnosis of postnatal depression stamps a woman with "craziness" which society uses to judge women as mothers and as individuals.Kristen expresses this view: I didn't really fit in with anything, you know.I kind of thought, well you know, [I'm] not mentally ill, but even though it is a mental illness obviously.But when you, you kinda get that stigma and that, you know, I didn't really want to fit in there I guess.
Several other participants expressed similar feelings in regard to their assumption that there would be negative public perceptions of them.Carole stated "After I found out I had it [postnatal depression] I was going to worry about what people would think of me."Patricia recalls, "People are perceiving you as, nuts, out of control, not in control of yourself, not in control of your feelings, immature.' Like grow up, snap out of it'." The stigma attached to the diagnosis of postnatal depression appears to dissuade women from identifying their struggle, acknowledging their needs and seeking help for their symptoms.Kristen explained this idea: I think it was just um, a fear of what's gonna happen you know?Like, I pretty much knew it was postpartum depression-I kinda self-diagnosed.And um, I was afraid of you know what kind of medications I might have to take and I'm breastfeeding this baby.I didn't want to take the meds.And I was getting into breastfeeding almost.There were a few of us at work that had babies all within a few months of each other.I didn't want to be the one that has postpartum depression.I was wanting to fit in with the mom and baby group thing.
Women appear to hide their feelings and experiences but often secretly hope that someone will notice and help them.Brenda stated that she was "very afraid that people could tell from the outside.Yet, I don't think they could because nobody really reached out to me." Alexandra corroborated this feeling in stating that "… nobody really asked too many questions and details about how I was really coping."Nicole explained that she attempted to manage on her own and wanted help from her husband.However, she felt guilty about asking for help and subsequently resented him for not assisting her.She states: He [husband] actually adds to my anxiety.Like almost 50% of my anxiety is added from him.And that's the most important support that I really want.I was doing everything but I had the supermom syndrome where [I thought] 'I can do it, I can do it.'And it took for his mom to come down and say [to him], 'What is wrong with you?' To kinda say [to him], you know, 'You gotta help here.'It took for me to have almost a total meltdown.Riley had similar difficulties and also experienced resentment.She states, "I just felt like [I was] crazy.I was this psycho woman who wanted her house clean and her husband was just a jerk."Dobris and White-Mills (2006) reviewed a variety of implications which may stem from popular media presentations of pregnancy and childrearing.Specifically, they looked at the What to Expect series, a series of publications for mothers that details the expected progression of pregnancy and early childhood.These authors noted that the patriarchal positions embedded in these texts reinforce gender stereotypes of disengaged fathers who have a diminished role in the practice of childrearing.Women, therefore, are led to expect that they must sustain the role of primary caregiver to their children.Further, they argued that patriarchal positions are often so embedded in discourse that they appear invisible to the rhetorical audience.Consequently, patriarchal knowledge and assumptions continue to dictate the norms and values of motherhood.
The stigma of postnatal depression prohibits its prevalence from being known and thus sustains the myth that it is a rare and strange occurrence usually experienced by women who have some form of emotional or personal deficit.Brenda states, You don't hear too many stories because people like me just keep quiet.… We need to make it more comfortable for women to talk about and to share their labour stories with anybody … you don't really share your postpartum story with anybody.
As the data from this study show, women generally do not talk about their postnatal depression experiences and thus maintain the cloak of secrecy around a phenomenon that occurs more commonly than is perceived.Feminist analysis unveils postnatal depression as being exacerbated and sustained by a patriarchal discourse and culture that individualizes and vilifies the postnatal experiences of women.As such, women feel compelled to keep their experiences hidden.As explained in the following section, this was motivated by fear.

Fear
Like many women in the current study, Nicolson (1999) notes that the women in her sample did not admit to experiencing postnatal depression and referred to their experience using other terms such as feeling fed up, upset, and down.Nicolson (1999) believed that this phenomenon was indicative of women's efforts to gain personal distance from postnatal depression as a pathology discourse.The current research found that women express a variety of fears in regard to both acknowledging their experiences and seeking assistance.Once again, many women attempt to hide their struggle from the world.Kristen states that "having them know what's going on is a scary thing."For her, public knowledge of her depression created a fear that she would be perceived as a bad mother and would be forced to relinquish motherhood.Kristen stated: You don't want to give up that role.I am the child's mother and I think a lot of times women are afraid that if people know that they have postpartum depression, they're just going to try to step in and take over.I know that's happened to a lot of women.
Kristen's concerns are legitimate.Society has developed standards which dictate an acceptable level of parenting.Should a parent be considered sub par to that standard, child welfare agencies are mandated to intervene if the safety and well-being of a child is considered at risk.Adverse impacts of maternal depression have been found in children virtually from infancy to adolescence (Smith, 2004).Maternal mental health has been linked to child risk across cognitive, social, emotional and physical developmental areas (Cleaver, 1999;Coiro, 1998).Therefore, mothers with issues of mental health are often scrutinized in terms of their ability to provide a safe and nurturing environment for their children; there is a real possibility that children will be apprehended by child welfare services if mothers are deemed incompetent due to such issues.Women are aware of this social reality and often strive to disguise their experience for fear that their children will be removed from their care.Linda underscores the experience of fear: I didn't seek any community resources or anything like that so I just tried to deal with it on my own.I was afraid of saying too much and that I was going to be labelled as such and have to kind of get put through a [child welfare] system.Thus, a primary fear of mothers in the current study was related to potential intervention by child welfare authorities.As explained above, this fear was linked to the association between postnatal depression and the stigma of mental illness.Supporting this finding, Hall and Wittkowski (2006) noted that mothers had difficulty admitting their depression and that this difficulty was further exacerbated by fears of perceived consequences that they would be admitted to a psychiatric unit or that their children would be apprehended by child welfare services.Further, Mauthner (1999) found that while women realized that motherhood was a challenging and devalued activity for which many received little support, they struggled to understand their extreme reactions and feelings of deep depression.They felt they were going mad and feared that they might one day find themselves in the local mental hospital.It appears then that women experience a fear not only of what they are feeling but also a fear in regard to the consequences that may be imposed upon them should they allow anyone to have knowledge of those feelings.The basic notion according to Mauthner (1999) is that women who suffer from postnatal depression have not been able to experience their sadness and most importantly have not been able to experience it in a context of empathetic and validating relationships.As such, many women struggle with their postnatal depression in silence and battle their symptoms in isolation.

Sense of loss -identity, autonomy and the physical self
A view of motherhood as a joyous and fulfilling life experience has been perpetuated over time and across various cultures.In Western societies, the planning of a pregnancy, the excitement of the revealing lines on the pregnancy test stick, the baby showers, the fuzzy stuffed animals and the ritual d e c o r a t i n g o f t h e b a b y ' s r o o m i n p i n k o r b l u e a r e a l l behaviours designed to promote motherhood as a whimsical and beautiful time.However, the colour of motherhood is often not pretty pink or soft blue but more shades of grey and sometimes black; the latter is often experienced as a rude awakening from a glorious dream.Although most new parents realize that raising a child will pose challenges, it appears that many are not fully prepared for the scope of change that a baby will bring to their lives.Isabelle describes her experience as follows: So I found just the life changes, uh, were such a fundamental shift for me.And then pile on the fact that you're not sleeping either.And then pile on the fact that you're now completely responsible for a creature and it is your job to make sure that they're not totally messed up in life.That is an overwhelming responsibility.
What Isabelle describes is a feeling that her entire life has changed.It is interesting that she uses the words "pile on" several times to describe the pressures she feels to manage these new changes in her life.It appears that, for Isabelle, the stressors are cumulative and take over the life she once knew.Isabelle further states that it would have been helpful if she had been more fully aware of the realities of motherhood prior to her first hand experience so that she could have been better prepared for it.She was somewhat resentful that other mothers participate in the perpetuation of the motherhood ideal while knowing that the reality is different.She indicates that the media also play a key role in defining motherhood: "It may have been comforting to have someone say 'being a mom is not easy.'Women have been sold lies through the media about how wonderful it is your first time and second time".
Isabelle is candid and honest in expressing her shock and surprise and the feeling that she was ill informed about the experience of motherhood.Nicolson (1999) explains that women experience pleasure and pain in caring for others; the giving and receiving of love takes place alongside isolation and the resentment that they are not able (or sometimes not willing) to put themselves first.It appears that there is a sense of betrayal in terms of the social construction of motherhood in the face of its reality.Isabelle states: "I wasn't depressed.It was just that I felt like I really had the wool [pulled over my eyes]-the rug pulled from under my feet.It was based on a lie from my mother from a very young age.So I felt like I had been lied to my entire life." The magnitude of this new role is such that women are required to immerse themselves into an alternate reality and expected to develop an altruistic existence in relation to their infant.Gross (1998) discussed the ideology of intensive mothering which promotes mothers as the ideal, preferred caretakers of children and the notion that labour intensive childrearing is best.Again, embedded within the current structure of patriarchal society, gendered roles are circumscribed and perpetuate the discourse of mother as primary caretaker and father as, at best, being in a supporting role.Nicole believes that the media contribute to the presumption that couples will take on gendered roles and promote unrealistic expectations.She states: One of the things I think is problematic is that there is this idea that the media puts forward-this glowing idea, golden idea, of motherhood.And then, I was waiting for it to come.And some days it still doesn't come.Like when is this supposed to arrive?
The media also perpetuate the notion that women can and should "have it all" in terms of their ability to balance motherhood with an exciting lifestyle as well as a career.Having a baby is portrayed as a milestone that will make women's lives complete.It is conceived as the epitome of fulfillment.Dobris and White-Mills (2006) found that, while some women may experience negative consequences of pregnancy and childbirth, ultimately the general consensus of mainstream society, perpetuated in part by mainstream media, is that this time in a woman's life will be perceived as perhaps the pinnacle of their lives.Parenting magazines, a source of information for many new mothers, tend to gloss over the negative, stressful and tedious aspects of motherhood and promote the wonderful joys a baby can bring to a woman's life.Although this may be the case for many, it is not always so and there are many times when the role of mother interferes with one's ability to enjoy aspects of life established prior to the birth of a baby.
For some women, a baby does not bring about a sense of completion but rather varying degrees of loss.Nicole speaks about how television mothers are portrayed in a manner that is nowhere close to the real experience.She notes that television promoted "the idea that you just wake up looking gorgeous.The baby sleeps all the time.Television does not show the screaming episode and the endless nights that you don't sleep because the child is colicky for three months." Our participants expressed the view that women do not often wake up looking like the attractive women portrayed in magazines.New mothers often wake up with black circles under their eyes from lack of sleep.Many women considered it to be an accomplishment to have showered and dressed at some point during the day.Media representations do not reflect who most women perceive themselves to be and subsequently they begin to become unrecognizable to themselves.An array of reality programs document a couple's journey through pregnancy, culminating in the birth and the first few days following.These programs typically denote the amazing, breathtaking experience of new life and foreshadow a world of beautiful new beginnings.They do not depict sleep deprived, tense parents and crying, sleepless babies who begin to howl when they are placed in their cribs.Olivia corroborates this realization: Nobody talks about bad things in regard to pregnancies.Nobody talks about it you know.It is like pregnancy and motherhood or fatherhood or parenthood is supposed to be beautiful but the reality is, it is life.It is not beautiful.It is not pretty.
The transition to parenthood and the demands of caring for a newborn infant may be destabilizing forces that elicit associated psychological effects (Horowitz, Damato, Duffy, & Solon, 2005).Adapting to the changes that a baby brings is difficult because the changes are so drastic (Nicolson, 1999).Not only are parents adjusting to their new responsibilities, new roles and new lifestyles, they are usually doing so on very little sleep.Initially at least, parents' lives revolve around their new baby.No longer are they responsible only for themselves; now they must consistently place the needs of their child or children before their own.Gruen (1990) describes the postnatal period as transitional in nature and characterized by great changes.It is a time where roles, patterns, and relationships are renegotiated.She likens this change to culture shock, where former coping mechanisms are no longer applicable and new ones have not yet been developed.The fears surrounding this unfamiliar state of self and lack of trust in the new roles can be alarming.For people who are accustomed to being in control of their time and lives, the unpredictability of new infants and their own affective states can be disconcerting.
Alici-Evcimen and Sudak ( 2003) describe childbirth as a decisive biological, social and psychological event with concomitant physiological, interpersonal and intrapsychic demands.When defined in this manner, one can understand the all encompassing nature of this life event.Women expect to feel that their lives are now complete and not as though life as they knew it is over.Chen, Wang, Chung, Tseng, and Chou (2006) indicate that depression in the postnatal period may be seen as a problem of adjustment to new social and personal circumstances.Women must redefine themselves in relation to their children.
Our participant, Isabelle, believes that there is a need for women to be fully informed about the realities of motherhood in an effort to increase their ability to adjust to the experience.She states, "I just think that there is a real awareness required at large about what it means to be a mom.We just have very unrealistic expectations about motherhood and what that means."In general, it appears that the social construction of motherhood which permeates contemporary society sets women up to develop a sense of failure when reality does not meet expectations.Women are socialized to anticipate the gains and positive aspects that infants will bring to their lives and this anticipation clouds any thoughts about the losses that may also ensue.
Fatima recalls her experience of being bothered with the responsibilities of motherhood.She states, "I remember just being tired of having to pack a diaper bag every time I went somewhere.I was getting really annoyed with being a mom."Fatima resented aspects of the obligation to provide child care.The day to day activities of child care can become tedious and time consuming.Whereas previously one was generally able to make decisions and leave the home without notice or forethought, having a child requires planning, preparation and accommodation that can often be exhausting.For some, the adjustment to this new lifestyle and the imposed losses are among the most daunting tasks of motherhood.Isabelle reinforces this view: I have to wonder how many of my symptoms would have cropped up if I was getting eight hours of sleep at night and there was no change to my restrictions in terms of my freedom.Because, all of a sudden, you have a baby and you can't go places that you would want to go when you can go because they're sleeping again so you can't leave.So I found such a huge adjustment in my life.All of a sudden I couldn't even decide when I could go to the grocery store.
These sentiments are understandable given that first time mothers have often lived an egocentric existence prior to the birth of the child.Then, instantly, they are thrust into the position of provider and caregiver to a child-not temporarily as perhaps they had done when babysitting in the past-but on a full-time basis, 24 hours a day, seven days a week.The added reality is that this job, and their commitment to it, will prevail for at least the next 16 to 18 years.In essence, life as they knew it is over and they must now adjust to their new life.Therefore, within the context of expectation versus reality, there is also, in many cases, a sense of loss over one's autonomy and identity.A new mother must face the reality that the person she once was is gone.Mothers must now shift and mould themselves into the role of mother, in many respects abandoning their former identities.
The current data also showed that women experienced both a sense of loss in terms of social identity and independence and in terms of physical self.For many women, the physical changes to their bodies during and after childbirth are a significant source of stress.Weight gain and stretch marks are but two of the many possible physical repercussions of pregnancy.In a society focused on beauty and the feminine ideal, many women struggle with their changing bodies and altered physical appearance.Georgia had a difficult time feeling confident about her appearance because of the changes that her body had endured.She became very self-conscious about her physicality and a sense of lost beauty added to her unhappiness with motherhood.Georgia recalled being uncomfortable with her appearance and becoming self-critical.She struggled with finding things to wear stating, "Oh well, I don't look good in that because I am still dealing with a belly and everything seems to be leaking."There is social pressure to gain a set amount of weight during pregnancy which is deemed acceptable within a limited, prescribed range.Comments made to pregnant women such as "you are all belly" are meant as a compliment to the woman for gaining only the socially acceptable amount of weight.After the birth, there is an expectation that women need to work hard to regain their pre-pregnancy figure.Women strive to lose their baby weight in a race to fit into their old clothes, a goal which is not easily achieved.However, the expectation is that this is what a woman must do.Women's worth is measured in terms of their ability to fit into a socially constructed mould and this expectation adds to the pressure and stress experienced by new mothers.
Unfortunately, the power of social acceptance is strong and, at a time when women are feeling tired and vulnerable, the pressure to conform can elicit an array of negative self thoughts.Women look at themselves and they look at other women and their perceptions are registered at face value failing to take into consideration external factors and varying circumstances.As a result, women may lose their self-esteem, become self conscious and internalize feelings which perpetuate a negative experience of motherhood.Dobris and White-Mills (2006) propose that women may often compare their own lived experiences to those ideals promoted by mainstream culture and they may attempt to restructure their experiences more similarly to what they perceive to be the norm.Further they suggest that, for these women, such restructuring may reaffirm their choices and subsequent actions or create a situation of alienation as women construct themselves as "less than."Georgia describes her experience at a mother's group as serving to increase her negative self thoughts.She compared herself to the other mothers and ultimately felt inadequate.Georgia states that she observed other mothers and subsequently developed a negative selfassessment: Like [seeing] a perfect mom going in there with a perfect baby and being like, completely made up and happy, happy, happy and everything great.And me feeling like crap and looking at her and thinking 'Ok now I feel really, really badly.' Melissa describes a similar experience of comparison with other mothers, stating that: Everyone else has it all together.You know, [I asked] 'what is wrong with me?' Those conversations tend to be in that group and they seem so in tune with their baby.On the other hand, me and my baby clash with them and you have a sense that you are not holding it together.
The struggle to maintain the self while sustaining an infant's life was common throughout much of the data.Fatima states that "It seems that I hadn't brushed my teeth for like a few days.Self-care was falling behind."New mothers often become so focused on caring for the infant that they do not take the time to care for themselves in even the most basic of ways.Additionally, within the current gendered society, fathers are not expected to take an extensive role in childrearing but are commended if they choose a supportive role.The task of childcare typically rests almost exclusively on the shoulders of women.Melissa found that her mental and physical resources were exhausted."I was so emotionally and physically exhausted that I hit the pillow and was out.Then the next day I woke up and I was just [feeling] no energy.I was just like a zombie."She also expressed a fear that her former self was lost forever: I never thought my mom would be able to go back home.She, you know lived [a far distance] away.She didn't think she'd ever be able to go home and I never thought I'd be able to work again.I just, you know, I just didn't think I was going to be myself again.
Many new mothers exist in an isolated world characterized by a routine involving feeding the baby, changing the baby, soothing the baby and attending to the baby's every perceived need.Often the needs of the mother fall by the wayside and this situation ultimately serves to increase the intensity of her struggle with the adjustment to motherhood.Nicole questioned "How do you take time for yourself?How do you get motivated to do that?"According to Nicolson (1999), motherhood alters women's lives socially, emotionally and economically.With any change comes the need for adjustment and since the human experience is subjective in nature, one's response to change will also be subjective.Women adjust to motherhood in differing ways and within differing timeframes.Not every mother has the same constellation of circumstances and adaptive factors.Therefore, adjustment is also contingent on a variety of personal and social variables.While individual stress may not solely affect a woman's psychological well-being, the cumulative effect of multiple daily stressors potentially affects a woman's adaptability in the larger context of her environment (Page & Wilhelm, 2007).
Feminist research, and qualitative research in particular, has found that the postnatal losses of autonomy and time, along with transformations in personal and occupational identity, body image and appearance, sexuality, and relationships all figure prominently in the experience of postnatal depression (Beck, 2002;Nicolson, 1999).Nicolson (1999) theorized that social prohibitions preventing women from openly grieving the losses and changes that accompany their transition to motherhood underlie postnatal depression in Western cultures.The postnatal period can be a time during which women struggle to reconcile the past and the present.

Feeling overwhelmed
As stated above, often women become so focused on caring for the child that the remainder of their existence becomes pressed to the background.Their entire being revolves around the baby and begins to consume them.Yet challenges are inevitable and, as our current research shows, feelings of inadequacy perpetuated by an unattainable social standard of the motherhood ideal lead women to feel pressured to conform to established standards; this in turn leads to feelings of being overwhelmed by the scope of the responsibility.Brenda reports the following: I started having real anxiety over being alone with [my infant child] and feeling very overwhelmed with the care.I really just needed somebody with me all the time.It was a real anxiety panic attack kind of feeling-just huge feelings of being overwhelmed and not knowing what to do, where to go.
Similarly, Alexandra describes her experience of being overwhelmed as follows: At the beginning it was a lot of intrusive thoughts about my health.I would have a headache and then ask myself 'What's going on?'There must be something really wrong.Then that would just escalate.Then it would be just you know a stomach pain.Then I would just get anxious about that.So that was the first emotional thoughts I had.After that it went into just being very fatigued, being depressed and crying for nothing.I was just being really anxious; like going out was a difficulty and having people over was difficult.And just feeling I needed help or couldn't do what I needed to do for my child.
The reality is that mothers are typically the primary caregivers to their children for at least first year after birth.Although some fathers fill a primary role and even take parental leave from their employment, this is often not the case.Generally, fathers and extended family members are expected to take on a supportive role in assisting the mother with the overall caregiving and go about their daily business with relatively little interference, disturbance or additional tasks.However, mothers at home caring for their infants often feel alone and unassisted while devoting themselves to an alternate reality.The expectation is that mothers are to go about their daily business and, at the same time, take on the all encompassing task of childcare.Georgia recalls her experience as follows: "You hear stories from way back when.Moms just did it.They had no choice.They did it all with six or seven kids on their hips.They didn't have a choice whether they felt bad or were crying."Dennis and Chung-Lee (2006) found that the rationale for women's lack of disclosure in regard to their depression was their assumption that they were expected to cope with it.Our participant, Olivia, made a similar observation stating that: I had no time for anything.I remember there were moments I would walk into the bedroom and just wake him [husband] up by crying because I was so overwhelmed with the demanding physical work of taking care of my child.Barr (2008) notes that being depressed interferes with a person's functioning ability and, therefore, the moments of happy mothering can be infrequent for mothers who have a mental health disorder.Our participant, Patricia, states: I remember a lot of the negative aspects in his first year of life.I feel I was cheated out of his first year of life because I was there but I wasn't there.And I did [care for the child] like I bathed [the child], I changed [the child's] diaper; [the child] never went a day without being fed.I would go out on occasions with [the child] in the winter time, although it was very difficult.But I can't remember the good things.I can't remember the good times; I can just remember me in the bathtub in a foetal position crying.
Women are pulled in all directions.They are expected to care for their new babies while maintaining all other areas of their lives.The expectation is that the role of mother is a natural transition easily incorporated into women's everyday lives.However, the reality is that motherhood often involves many new tasks which ultimately become priorities for which women must find additional time and energy to fulfill.Leung et al. (2005) found that women felt frustrated and suffered from a strong sense of failure because they considered themselves incompetent.Yet there is little sympathy or empathy for the unrealistic expectations that define motherhood.The expectation is that women just need to do it without complaint because that is what women do.The social construction of motherhood and the role of women in a gendered, patriarchal society prevail and subsequently set the stage for many women to become overwhelmed.
Throughout the data, there was an indication that the feeling of being overwhelmed was perpetuated by a sense that motherhood brings about a new and often challenging reality.Patricia states: After [my child] was born I started seeing commercials on the television and it talked about like you're in a maze and you're trying to climb these stairs to get out of the maze and you can see the light but you can't.Whenever you get close to it, it's not there.You have to turn again and you just can't get out.And that's exactly how I felt.
Georgia questioned whether "it was going to get better" while Melissa describes her experience as having a "sense of hopelessness."Nicole reiterates this sentiment stating that "you feel as hopeless as you can in your life."Women become so consumed by managing the many new facets of their lives that they wonder when they are going to have time to breathe again.Riley states, "You feel like you are in a hole and there is no grip.You just keep falling."Motherhood is a juggling act and women are thrown more and more balls that they must attempt to keep in the air.Isabelle expressed uncertainty in not knowing "how much of depression is heightened by the fact that everything in your life is turned upside down?"What develops for many women is the sense that they need to pick up the pieces of their lives; except now, they are unsure where many of those pieces go and this adds to their feelings of being overwhelmed with their new reality.

Guilt
The stigma of the bad mother, of not being good enough, and the guilt of somehow failing as an individual evolved as a significant theme within the data.Mauthner (1999) found this in her research as well stating that her participants each experienced a different set of conflicts reflecting their own notions and constructions of the "good mother."In their study of depression, McMullen and Stoppard (2006) found that women implicated gender-based expectations of what constitutes a "good woman, wife and mother" in their understandings of depression.They discussed the burden of expectations to be a 'perfect' woman, wife or mother; it was often understood that these expectations were unrealistic but women still attempted to achieve them even to the point where they could no longer do so.The characteristics of the 'good mother' varied between cultural and interpersonal contexts depending on the beliefs, values and norms that had been internalized in each participant.For some, a good mother is one who stays home and cares for her children full-time, taking them to playgroups and mother-infant yoga; for others, a good mother is one who breastfeeds her child; while for others, a good mother is one who is able to strike a balance between career and home life.The perception of a "good mother" is subjective and shaped by culture, interpersonal interactions and life experiences.Mauthner (1999) found that each mother experiences a different set of conflicts reflecting her own notion and construction of the good mother.Within the current study, Fatima describes her mothering experience as follows: I had a bit of shame when I was first going through it.I felt like I was failing as a mother and there was something wrong with me.And even when I had feelings that I wasn't bonding with [the child] I was feeling guilty for it.Cause I'm like um, 'I'm not a good mom.'I saw it as a weakness as a mom to be going through what I was going through.You know I don't feel like I'm connecting with [the child].I don't feel that connection with [the child].
Women receive messages both verbally and non-verbally in regard to the nature of social expectations surrounding motherhood.Kraus and Redman (1986) state that, even if the family realistically anticipates the stresses of parenthood, the cultural context holds yet another layer of potential contributors to postnatal depression by defining appropriate feelings and behaviours for new mothers.Women develop an ideal notion of motherhood and subsequently place extreme expectations upon themselves in measuring their circumstances according to the socially constructed standard.Behaviours and circumstances which portray anything less than this ideal are perceived to reflect weakness and failure both as a mother and as a woman.When they experience difficulty managing, women feel as though they have failed themselves, failed their children, failed their families and failed society.Isabelle states that "there's definitely a fear of letting people down and being called a bad mother." Women carry guilt in relation to their perception that they are not good enough.Mauthner (1999) describes her understanding that mothers seem caught between two opposing voices.One set of voices reflects mothers' expectations of themselves and their interpretations of cultural norms and values surrounding motherhood while another set of voices seems to be informed by the mothers' actual, concrete, everyday experiences of mothering their particular children and in the particular circumstances in which they find themselves.When they experience depression, mothers find it difficult to accept these grounded feelings and experiences.Because the latter conflict with their expectations, they feel they must be doing something wrong and they try to change themselves in order to live up to the ideals of the good mother.Patricia explains that she had expectations which she placed upon herself but that were essentially imposed by her perception of society's expectations.She further states, "I was going through a lot of emotional challenges.I was crying a lot.I was basically just taking care of my child's basic needs and that was it.I found myself wanting to sleep a lot [and] just feeling like I was a rotten mother."Additionally, there is guilt in regard to what women perceive they should feel and the actuality of what they are experiencing.Linda states that "I believed I must be a terrible mother to be having these feelings.'Why am I not so happy about it [motherhood]?'Gruen (1990) proposes that depression in response to death, divorce, or job loss is culturally acceptable, whereas depression in response to the arrival of a child is not culturally approved.The social stigma and resulting shame, embarrassment, and fear prevent families from seeking help when they experience symptoms of depression.The guilt then surfaces when women do not feel the way they expected to feel and when they do not feel the way that society expects them to feel.Buultjens and Liamputtong (2007) found that Western culture stipulates that women are to have babies, that they should want to have babies and that mothering is happy experience.If a woman disrupts this assumption by being unhappy and depressed, she challenges the fundamental societal understanding of femininity and maternity.Such understandings affirm a patriarchal vantage point for assessing both the "good" and the "bad" mother, according to Dobris and White-Mills (2006).
Our participant Olivia finds it finds it difficult to reconcile her feelings and experiences with her reality and recalls that, "it didn't make sense to be with this healthy, beautiful child.And he did nothing wrong.'What's going on with me?Why does this not make me happy?Why is it unfulfilling?' Hall and Wittkowski (2006) found that women often felt unjustified in their depression which was confusing for them and often led to increased feelings of guilt and low mood.Kraus and Redman (1986) found that some of the common cultural myths about motherhood contend that it is a woman's ultimate fulfillment associated with an indescribable joyfulness, that a woman will immediately feel love for her baby and that a woman will intuitively know how to parent.Yet, women appear to feel as though they are being judged when they do not share these experiences.
Our participants feel as though they are under scrutiny and are measured against an unattainable standard of perfection.Riley states, "you feel like everyone is looking at you.You're crying over something.'Oh my God she's crying again.'We're so hard on ourselves too [expecting] to be the perfect mom."Helen discussed her postnatal depression experience and advised that, her perception was that "you're not supposed to have these problems.Good mothers don't have these problems."She describes postnatal depression as a vicious cycle and believes that feelings of guilt experienced by women when they perceive that they do not meet the ideal mother standard lead directly to feelings of depression.She states: The guilt actually makes you do stuff that you wouldn't [otherwise do]… you get more upset because you're upset and then the ball gets rolling.[I believed that] the guilt somehow caused it [postnatal depression].If I was better at this or that or the other thing I wouldn't have this problem.
Patricia individualized her experiences as well and internalized the negative connotations of her feelings.She states that: I felt that like I was inadequate as a wife and mother.I felt like I was weak because everyone I knew that had babies never had any problems.They had a good pregnancy, they had nice babies.They were healthy, they went back to work and everything was fine.A woman's worth is measured against a socially constructed ideal based in patriarchal ideology that defines women's existence.Unfortunately, this ideal is institutionalized within society promoting a social climate where the expectations placed on mothers create a skewed reality.When reality does not meet the expectation, guilt is internalized and breeds a variety of negative self thoughts which in turn can create or increase feelings of depression.Helen states: "I believe a positive sense of self is from within.No matter how often everyone is telling you, 'You're a good mom' it is irrelevant if you don't think you are." These findings support those of Mauthner (1999) who found that, during their depression, women found it difficult to let go of their images and ideals of motherhood and criticized themselves on moral grounds.There was a pervasive sense of what they should be feeling, what they ought to be experiencing versus what they actually felt were, respectively, the right and wrong ways to mother.Some researchers have found that maternal self-efficacy protects against the development of postnatal symptomology (Coleman & Karraker, 1997;Seguin, Potvin, St. Denis, & Loiselle, 1999).Research conducted from a feminist perspective has related postnatal depression to the challenges women face in achieving a sense of maternal competency or realizing idealized expectations of motherhood (Beck, 2002).Rubin's (1984) seminal qualitative study of pregnant and postnatal women described how the gap between the realities of motherhood and women's idealized expectations of maternity result in self deprecation and depression.Subsequently, a woman's sense of competence as a parent, satisfaction with parenting, her focus on the infant and the amount of experienced life change will either strengthen or weaken her feelings of self-efficacy during the postnatal adaptation (Horowitz et al., 2005).Patricia corroborates these sentiments and states: I told my husband that I was going to leave him.I said, 'I am not a good enough wife.I am not a good enough mother.'I was literally going to go to the bank to get enough money for bus ticket and just take a bus anywhere.And I didn't know what I would do when I got wherever I was going.I just wanted to get out of their life cause I thought he would be better off marrying someone else and someone else would be a better mother and a better wife.
In addition to guilt in a general sense which was experienced by many of the women in the current study, guilt was also described in more specific expectations of mothering.Breastfeeding appeared to be an area in which a number of women experienced a variety of negative and stressful emotions.The medical community actively promotes breastfeeding with slogans such as "Breast is best" and community agencies such as La Leche League are organized to assist women and their babies in ensuring that successful breastfeeding is sustained.Breastfeeding is a behaviour that is considered preferable within the scope of good mothering.However, as some of our participants stated, women may choose not to breastfeed or decide to do so but struggle with the process.Alexandra indicated that breastfeeding was challenging.It appears that, for her, breastfeeding was yet another stressor in her new motherhood experience and an opportunity for her to feel guilt because she was struggling.Helen states, "It seems like the rule of thumb is to really stick to it [breastfeeding] for four months or six months.At six months it's like, 'That's it, you are done.You are done.You did good job."This is another area in which women feel compelled to place expectations upon themselves and to comply with social values that may not be conducive to their own emotional well-being; yet these expectations are perceived by them to be essential to their ability to conform.Women may not breastfeed their babies because they want to do so but proceed with it because of social pressures.Patricia states: I have nothing wrong with breastfeeding you know.All the more power to you if you breastfeed.I choose not to, not because I can't [but] because I don't feel comfortable with it.And they basically, in a nut shell, they said everything but you're a rotten mother because you choose not to breastfeed.They have a La Leche League and it's a group to support women that breastfeed.I feel like there should be a group supporting parents that decide to give formula to their kids.I feel like going up on a stage and screaming, 'You know what?I am still a good mother even though I decide to give formula to my child.'I found this played a role too in how I perceived myself as being a mother.I felt like the society shunned me because I was feeding my baby formula.I was going through depression.I was just a rotten person all in all.
Nicole also expressed the view she felt pressure to breastfeed and that this added a negative dimension to her experience.She states: I saw this little drop of colostrum so I'd pump, pump, pump, pump, pump and then still pumping when I got home.I pumped whenever I felt full.In the back of my head I felt guilty because I thought I might have to bottle feed.And I felt this, and that added a lot of stress.I knew the benefits of breastfeeding but what if you can't do it.Don't stress about it.
Breastfeeding was equated with coming closer to that ideal mother.Instead of breastfeeding being a comfortable choice, it appeared that some women felt pressured to breastfeed despite the fact that the practice added to their stress.They felt an obligation based on the socially dictated theory that a good mother breastfeeds.
Women also felt guilt in regard to the impact that their postnatal depression had on both their immediate and extended family.They felt as though they were failing their families and burdening them with their personal difficulties.Helen felt guilt in regard to her husband and states: My husband is at a loss.This is not what he expected either.We were both kind of um trying to deal with it.He is trying to deal with me as well as the baby and everything.I'm trying to deal with me, the baby and him.He is trying to deal with the rest of the world and his job and all these other things that ah he has a life too.
Ellen also spoke about a similar experience and states: I felt a lot of guilt toward my husband.This made it hard for me to just let go of the bad feelings and just let myself feel bad until I could start to feel better.[I would have benefitted from] a lot of physical support-relieve my husband so that I wouldn't feel so guilty.
Many of our participants acknowledge that postnatal depression has far reaching effects on the majority of their social relationships.Georgia felt guilt about how her experience would impact on her own mother and states "I was nervous about letting her know [mother] because then I knew she'd be more worried about me."Although spouses and extended family can be strong sources of support for women experiencing postnatal depression, the data indicates that they can also directly or indirectly add to the guilt and stress experienced by women.
Postnatal depression can be adequately managed and women can experience reduced symptoms through the use of anti-depressant medication.However, the data in the current study indicate that many women are opposed to taking medication to address their needs for a variety of reasons.Fatima states that she "saw it as a sign of weakness to go for help or to go on medication".She had difficulty acknowledging that her experience was beyond her control and that recovery would require assistance.For others, such as Isabelle, the idea of proceeding to take medication and accept intervention was equated with a sense that she would lose control of her affect.Isabelle stated that "maybe I think I'm all powerful but I don't want to have to go the medication route."She worried about the loss of self-control: Part of it is you want to control your own life, your own world.As soon as you introduce drugs into this, you question, 'Will it change me?' 'How will it change me?' 'Am I going to be the same person?' 'Am I going to become a drone?' 'What's going to happen to my highs and lows?' Maybe I don't really want to lose my highs.
Most people prefer not to rely on pharmaceutical assistance for their day to day functioning.There is also stigma attached to the need for anti-depressive medication.Thus not only is there stigma in regard to the condition of postnatal depression, there is stigma in regard to one of its effective interventions.As such, many women are opposed to addressing their experience through medication.Melissa states that: "As soon as he said medication I was just like "Whoo!" Up went the wall."She did not want to discuss the matter as the stigma of medical intervention precluded her ability to consider its benefits.

Isolation and the need for support
One of the most evident experiences disclosed by study participants was the positive impact of access to support in increasing their ability to manage while struggling with postnatal depression.Women spoke about various forms of formal and informal supports both within group settings and in one-on-one interactions.It appears that support was highly valued and beneficial in assisting women both in concrete ways and on an emotional level.Seagrist (2008) found that there is substantial evidence that participating in a support group has a positive effect on well-being.The group can serve as a resource for overcoming isolation and expanding informal support networks.It also may provide a sense of hope to counterbalance situational depression arising from losses and other traumatic experiences and encourages sharing feelings of intense emotional reactions as well as new ways of coping with problematic life events.Paris and Dubus (2005) found that new mothers experienced isolation and loneliness that often led to disconnection.Our participant, Patricia, stated that: "I felt so isolated and thought I was the only one going through this."Because mothering often occurs within the walls of the home, women sometimes feel alone and separated from the rest of the world.For women experiencing postnatal depression the current data indicate that support groups allowed women to feel less isolated in their struggle and allowed them to develop an openness to revealing their experience.Involvement alleviated some of the stigma associated with postnatal depression and facilitated discussion in regard to managing.Donna had not yet participated in a support group but expressed an opinion about this: Support would be a place that you can go where people understand what's going on and um telling you that you're not crazy…[It would also be a place that would] give you coping strategies… the biggest thing though is just knowing that you're not crazy and that there are other people that are like you that are going through [it].The biggest thing would be other women who understand.This sense of relief experienced by women in terms of their newfound ability to talk about how they were feeling and to obtain some validation of their feelings within an environment of acceptance was both enticing and beneficial for many of the study participants.Alexandra felt support groups helped her: The best thing for me was just to open up about it as I was feeling anxious a lot.I always found that after I talked to someone, anybody, I just felt less anxious.I felt better about it.It was actually a good way to help other moms open up and say 'Yeah, you know what, I can relate or I think I went through the same thing.'Brenda also experienced the benefit of support groups and stated that it was comforting to her: "Other people had pretty similar stories and that was a big help because it still feels like a lot of stigma with mental illness.I wanted to deal with my depression within a group of like-minded people".Support groups then appear to remove some of the sense of stigma of postnatal depression and reduce feelings of isolation.As well it allows the opportunity for women to share their stories of coping.Participation allows them to work through various strategies and provides a sense of hope where perhaps there had been little or none.Carole states that support groups were beneficial for her: "Just hearing that someone else has gone through it and hearing other people's stories.You come to realize that you are not as bad off or as alone as you thought".
Ellen also expresses this sentiment: "I guess that I'm not alone.Just to hear other people's coping skills is helpful."In a sense, support groups are often effective because they can normalize emotions and experiences by exploring commonalities.By normalizing postnatal depression, those related experiences that women described as guilt, fear or shame are minimized.Joanne stated that attending support groups "made it more manageable, almost more normal for you.You didn't feel like you were going crazy."Helen indicated that support groups helped her realize that: "… you're not the only one.… There really are people out there and they do have the same problems that I have.They're really functioning and some of them are functioning better".
What Helen found within the group was a glimmer of hope that she was going to survive her postnatal experience.This realization had an impact on Melissa as well, as she recalled that "you know from the mothers who were kind of in recovery, they've gotten over it.You get a sense that it does get better."For some women, involvement in a support group assisted them in addressing the experience within their families.Helen enjoyed speaking to the women in the support groups because she could see "that some of them have the same symptoms as you do and some of them have different ones.There is no right answer or wrong answer."She further stated that the support group allowed her to realize that postnatal depression can remain "a family secret if you want it to be but, if you don't want it to be, it doesn't have to be anymore."For some, support groups offer hope and provide optimism.Kristen states that the groups: "just kinda normalize it for the family.If it normalizes everything and maybe you wouldn't feel so weird talking about it with your family-maybe".Linda concurs stating that, "you see a normal woman with a normal family, a job, and everything.It is just something that happens sometimes."Abrams and Curran (2007) found postnatal depression is negatively correlated with social support thus supporting the theory that postnatal depression is related, to a large extent, to psychosocial and environmental stressors.However, because of the on-going stigma, misinformation and secrecy that envelopes postnatal depression, women often struggle alone; loneliness can sustain itself and become a dark place where women cannot find their way out.Support groups afford the possibility of shedding some light on the experience, opening the door to communication and offering a path to recovery.

Conclusion
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) of the American Psychiatric Association does not describe postnatal depression as a category but it is listed under the broad spectrum of general depression.Yet postnatal depression, viewed as a separate condition, often remains undiagnosed and untreated (Dennis & Chung Lee, 2006)."Risk factors for postnatal depression that are commonly reported in the literature include maternal characteristics such as being single, younger, of low socio-economic status, being anxious, having a history of depression and exposure to recent life stress" (Howell, Mora, & Leventhal, 2006, pp. 149).These variables are static factors.They are, for the most part, unchangeable in the short term.However, when we look beyond an individualistic understanding of women's experiences and specifically of postnatal depression, we discover an array of situational factors.Nicolson (1999) states that clinical practice and popular knowledge in this regard appear to be based on belief, myth and a body of contentious empirical evidence; however, the nature and definition of postnatal depression remains largely unknown.Nicolson (1999) proposes that perhaps postpartum depression is a normal response to the fundamental changes a woman experiences as a result of pregnancy, childbirth and mothering.Abrams and Curran (2007, p. 292) make a similar argument: Feminists have argued that the medical model tends to pathologize women's negative postpartum affective experiences instead of recognizing that these experiences are normative and potentially inevitable.They have maintained that the physical trauma of and recovery from childbirth, sleep deprivation, new responsibilities, and the need to quickly master new skill sets would produce emotional disturbances in anyone.
When viewed through the lens of feminist standpoint theory, it is plausible that the current social and cultural climate serves to thrust upon women unattainable expectations while promoting a skewed reality in regard to the experience of motherhood.It generally sets women up to fail and then condemns them for their apparent failures.However, Mauthner (1999) argues that consideration of postnatal depression as a normal response to motherhood trivializes and minimizes feelings which mothers themselves experience as terrifying and abnormal.
In light of the current findings, it appears that, on some level, both theories are relevant.It is not surprising that many women experience postnatal depression given the context of their experiences.However, in terms of normalization, it appears that it is not the condition of postnatal depression that is normalized but the structure of society that perpetuates its existence.There is currently an acceptance of the status quo which allows women's lives to be defined by values and norms which are not their own but those created by dominant discourse that fails to acknowledge the realities of women's experiences.Buultjens and Liamputtong (2007) state that the overall recognition of depression is an indication of change in societal acceptance of a mother's inability to cope automatically with the life-altering transition associated with motherhood.However, the myth of blissful parenthood is still embedded in a large proportion of our society, stigmatizing anxiety and depression after childbirth.
The findings of our study are similar to those of Abrams and Curran (2007) in terms of the notion that nearly all mothers experiencing postnatal depression symptoms hesitated to disclose their feelings to others due to fear that they will be judged, labelled as "crazy" or rejected by family and friends.Abrams and Curran (2007) also state that shame and guilt associated with the failure to fulfill idealized maternal expectations make mothers less inclined to seek help for postnatal depression.Additionally, the current study is consistent with prior research conducted by Haslam, Pakenham and Smith (2006) who found that social support and maternal self-efficacy are inversely related to postnatal depression and appear to protect against the development of postnatal symptomology.Our findings also corroborate the notion put forward by Howell et al. (2006) that the negative impact of the functional limitations of postnatal depression on mothers' emotional states can be reduced by a supportive social environment and self confidence in carrying out daily activities.Overall, the findings of the current study indicate that women's experiences of postnatal depression extend beyond a medical model of individual pathology and are best understood in relation to the social and cultural climate in which they occur.

Implications for practice
When expectations lie in contrast to reality, not only are women's realities often surreal, the characterization of the experiences associated with postnatal depression can be identified as significant barriers to both diagnosis and treatment.It can be assumed that the prevalence of postnatal depression is not truly known as many women do not acknowledge or report their experiences in relation to the perceived social repercussions of their disclosures.In terms of adequately assessing and subsequently serving women with postnatal depression, health care professionals and community service providers must obtain a holistic understanding of women's lives looking beyond a medical model towards a thorough awareness of those social and cultural influences that constitute a woman's lived reality.
When we observe, within the findings of the current study, the experiences of loss, guilt, shame, stigma, fear and inadequacy with which many women struggle postpartum, it is evident that the impact of such experiences can be debilitating and often paralyzing for women and have far reaching effects on their personal and social functioning.When reality does not match expectations and the expectations are not realistic, women struggle to redefine their reality but must do so under social and cultural pressures which serve to destabilize them.The instability can result in an internal battle with the self and the context of one's life.There is a need to foster awareness in regard to the experience of new mothers, the pressures placed upon women entering motherhood and the social and personal expectations which create and sustain a reality that contributes to impairments in individual and family functioning.Society in general needs to be educated about the nature of postnatal depression in order for the related stigma to be removed, thus allowing women's struggles to become less isolated.In removing the cloak of secrecy and shame around the experience of postnatal depression, the opportunity may arise for women's realities to be unveiled and their needs addressed in a manner that is timely, appropriate and beneficial to the overall health and well-being of women and families.
Lastly, the current findings evidenced the benefit of support programs for women experiencing postnatal depression.Overwhelmingly, women expressed their view that their postpartum symptomology-such as feelings of isolation and guilt and fears that they were going crazy-were reduced through their ability to share their experiences with individuals who were understanding and to whom they could relate.The availability of postnatal support groups may be an effective community intervention which can have a positive impact on the ability of mothers to express their feelings and develop coping strategies that can assist them in navigating their way out of their depression.Unfortunately, access to postnatal support groups is not universal.For many women residing in rural, remote or northern communities, the reality is that such services simply do not exist.In light of the current findings, the benefit of postnatal support groups must be highlighted and promoted in an effort to obtain resources and develop initiatives which may allow these quality services to be available to all women despite geographical location.
In viewing postnatal depression through from a feminist standpoint, it is logical that interventions should be based on feminist principles supporting women within the context of their lives through strengths-based interactions and strategies designed to empower women in all regards.Ultimately, the research findings have contributed to knowledge in regard to understanding their perceptions and providing information to guide meaningful direct service to women and families.Only when postnatal depression is understood holistically can positive change be effected for those struggling in the shadow of this phenomenon.

Implications for future research
It is noted that postnatal depression is often assessed using the Beck's Depression Inventory (BDI) and/or the Edinburgh Postnatal Depression Scale (EPDS).These are self-report scales in which women's responses determine a diagnosis.Should women choose not to disclose their struggles out of fear, shame or guilt, they may not be forthcoming in their responses to the administration of these instruments; consequently, the reality of postnatal depression is dismissed.Additionally, it is noted that the majority of the themes found in current qualitative research related to postnatal depression are not reflected in or quantified within the EPDS or BDI.It is notable that, within these standardized scales, there is no reference to feeling overwhelmed, fearful, isolated or experiencing loss.Therefore, it is proposed that those tools do not adequately measure the breadth of postnatal depression.Beck (1992) indicates that "even though a woman does not need to exhibit every symptom of postnatal depression to be diagnosed as experiencing the disorder, quantitative instruments should include the gamut of possible behavioural manifestations from which a mother can rate her symptomology" (pg.170).Qualitative studies such as the current one can be used as a starting point for methodological research focused on developing a qualitative instrument to assess postnatal depression.In an effort to improve future methodology on the topic of postnatal depression, the development and promotion of qualitative research in this area of study is considered essential so as to provide a holistic understanding of the subjective experience of this social phenomenon.

Strengths of the study
The findings of the current study based on a sample of women in Northern Ontario are strengthened by the similarity to those found in prior research in terms of the experience of postnatal depression.Specifically, the findings were consistent with past research which