Date of Award
Open Access Dissertation
Health Promotion, Education and Behavior
Deborah L Billings
Background: The World Health Organization (WHO) and the United Nations Population Fund (UNFPA) highlight education and training for healthcare providers and the development of a policy framework as core strategies to address maternal mental health in low- and middle-income countries. This research critically examines these strategies with respect to postnatal depression in Mexico. The research 1) addresses how healthcare providers in Mexico conceptualize postnatal depression, and 2) assesses the policies that exist in Mexico regarding postnatal depression, which will inform the next steps for policy development. The research informs appropriate healthcare provider education and training, as well as the next steps for policy development. The research aims are 1) to understand the conceptualizations of postnatal depression among physicians, nurses, social workers, and psychologists in primary, secondary, and tertiary levels of care in public-sector healthcare facilities in Mexico City and Yautepec, Morelos, Mexico as well as to understand how healthcare providers apply their understanding of social and behavioral antecedents in their conceptualizations of postnatal depression; and 2) to ascertain whether and how postnatal depression is addressed in policies at federal, state, and local public-sector healthcare facility levels in Mexico. Key components of Kleinman's (1980) Explanatory Framework of Illness, Entman's (1993) functions of framing, the Theory of Planned Behavior (Ajzen and Madden, 1986), and a typology of symbolic versus material policies elaborated by Howlett (2000) and Hood (1986) were used to examine healthcare providers' conceptualizations of postnatal depression and whether and how postnatal depression is addressed in policies.
Methods: In-depth, semi-structured interviews were conducted with physicians (n=19), nurses (n=18), social workers (n=17), and psychologists (n=10) from five public-sector healthcare facilities in primary, secondary, and tertiary levels of care in Mexico City and Yautepec, Morelos, Mexico. Healthcare providers were also presented a reality-based vignette that was written based on data from semi-structured interviews with seven Mexican women from Mexico City and Yautepec, Morelos, Mexico who had experienced postnatal depressive symptoms identified based on a score of 12 on the Edinburgh Postnatal Depression Scale. Follow-up questions followed the presentation of the vignette. National health plans, national action plans, federal and state laws and regulations, clinical practice guidelines, and public-sector healthcare facility policies were collected and evaluated through qualitative content analysis according to whether they included a statement of intent and/or actions related to the care and management of women who experience or who are at risk of experiencing postnatal depression.
Results: Results from the first aim revealed two frameworks that healthcare providers use to conceptualize postnatal depression: biochemical and adjustment. An emerging model illustrates how social and behavioral antecedents influence both frameworks, as well as how symptoms of distress represent a possible case of postnatal depression and how postnatal depression is perceived as affecting responsibilities associated with motherhood. In the second aim, six clinical practice guidelines out of 597 were relevant to postnatal depression and were included in the analysis. Laws (n=3), regulations (n=1), national health plans (n=1), national action plans (n=1), and public-sector healthcare facility policies (n=1) were also evaluated, for a total of 13 policies. Postnatal depression and other synonymous search terms were not mentioned in 38% (n=5) of policies. In the remaining 61% (n=8) of policies postnatal depression was mentioned in some way, but in only 46% (n=6) of policies was a statement of intent or actions included relating to the care and management of women who experience or who are at risk of experiencing postnatal depression. These policies are the mental health law of Mexico City and its regulation, the clinical practice guidelines on pre-eclampsia, HIV, and prenatal care, and a policy from a tertiary level, public-sector healthcare facility.
Implications: The results of the first aim may also be useful in the development of training materials which build on providers' existing conceptualizations of postnatal depression to enhance women's quality of care. They also provide a foundation for future study of how healthcare providers' conceptualizations of postnatal depression may affect detection and treatment practices. The results of the second aim identify possible areas to focus future policy development efforts. Policy makers should consider building on the mental health law of Mexico City by identifying specific actions to prioritize the care of women who experience postnatal depression, as well as establishing clinical practice guidelines that specifically address maternal mental health problems. Future research can examine the rationale behind policy-makers' choice of the particular actions or lack of actions identified to address postnatal depression in Mexico.
Place, J. S.(2013). Postnatal Depression In Mexico: Healthcare Provider Conceptualizations and Policies In the Public Health Sector. (Doctoral dissertation). Retrieved from https://scholarcommons.sc.edu/etd/2570