The average age of our 13 female participants was 31.0 ± 4.0 years old and the average length of residence in the United States was 27.1 ± 16.6 months. All women participants were married, had health insurance, and their educational attainment was a bachelor's degree or higher. The age of the five spouse participants was 31.0 ± 6.0 years old and their average length of residence in U.S. was 28.6 ± 18.7 months, and each had at minimum a bachelor's degree.
Eleven of the 13 women had nuclear families only in the US; 10 had a household annual income less than $60,000. Their primary daily supports during pregnancy involved their husbands (n=5), themselves (n=4), their mothers (n=3), and their mother-in law (n=1). In contrast, primary postpartum support included their mothers (n=7), mothers-in law (n=5), and husband (n=1). (See Table 1)
Table 1
SAMPLE CHARACTERISTICS (N = 18)
Characteristics
|
N
|
|
WOMEN (N = 13)
|
MEN (N = 5)
|
Age (in years)
|
|
|
Mean (SD)
|
31±4
|
31±6
|
Range
|
25-38
|
25-40
|
Marital Status
|
|
|
Married
|
13
|
5
|
Employment status in the perinatal period
|
|
|
Employed
|
5
|
2
|
Unemployed
|
8
|
3
|
Education level
|
|
|
4-year college degree
|
7
|
0
|
Master’s degree
|
2
|
1
|
Doctoral level degree
|
2
|
2
|
Current graduate student
|
2
|
2
|
Months lived in the US
|
|
|
Mean (SD)
|
27.1±16.6
|
28.6±18.7
|
Range
|
1-50
|
13-60
|
Main caregiver throughout pregnancy for the woman
|
|
|
Her mother
|
3
|
NA
|
Mother-in-law
|
1
|
NA
|
Husband
|
5
|
NA
|
Herself
|
4
|
NA
|
Main caregiver for the woman during the postpartum
|
|
|
Her mother
|
7
|
NA
|
Mother-in-law
|
5
|
NA
|
Husband
|
1
|
NA
|
Herself
|
0
|
NA
|
Whether adhere to the tradition of " Doing the month "
|
|
|
Yes, for all my children
|
3
|
NA
|
Yes, for my children born in China only
|
1
|
NA
|
No
|
7
|
NA
|
Other
|
1
|
NA
|
Whether adhere to the tradition of " Doing the month "
|
|
|
Yes
|
6
|
NA
|
No
|
7
|
NA
|
Way paid for the delivery services
|
|
|
Entirely on her own
|
13
|
NA
|
Partly by medical insurance
|
0
|
NA
|
Family annual income during the most recent pregnancy
|
|
|
< $60,000
|
10
|
4
|
≧$60,000
|
3
|
1
|
Whether have children born in China
|
|
|
Yes
|
3
|
4
|
No
|
10
|
1
|
Whether have children born in the US
|
|
|
Yes
|
10
|
1
|
No
|
3
|
4
|
Family structure
|
|
|
Nuclear family
|
9
|
4
|
Dyadic nuclear family
|
1
|
0
|
Live with own parents
|
2
|
0
|
Live with parents-in-law
|
0
|
1
|
Live with child only
|
1
|
0
|
NA:used to mean “not applicable”. |
Note: To aid the readers' comprehension of the results, all quotes presented below, shown in italic, identify the speaker's participant identification number for each focus group, followed by the focus group (FG) number. Themes were defined as arising in multiple groups, in addition to being expressed by multiple members of the same group only.
Experiences of perinatal depression
Emotional distress was a theme that emerged in both mother focus groups. Whether the pregnancy was planned or not, the women interviewed generally were happy to learn that they were pregnant: It wasn't in the cards, but I was especially happy when I found out I was pregnant. (04,FG1) However, with the onset of pregnancy, the physical discomfort made it difficult and even depressing for some women: Serious pregnancy symptoms made me sick, even gave me that depressed feeling. I would vomit when I smelled anything or just drank water. (01,FG1) Most of the women interviewed reported frequent feelings of stress, fear, and anxiety during the perinatal period due to worrying about the baby: I suffered from sinusitis ten days after delivery. The doctor advised me to do a CT scan, but I thought CT had radiation and I was really worried that it would influence the breast feeding so I insisted on an MRI at that time. I didn’t feed my baby breast milk when I used antibiotics until the half-life of the antibiotic was gone. The radiation, the antibiotic, everything led to my anxiety. (02,FG2). Some women become emotionally sensitive during the perinatal period, especially concerned about others’ appraisal of them, contributing to unhappiness, irritability, unprovoked tears or anger: During pregnancy, I think I became more sensitive and sometimes when someone said something, I would feel like it was directed at me and it upset me. And I would want to cry.(05,FG1) Well, I just didn’t feel well at all. My whole state was not very good. I guess I was just very irritable, and it was irritable. I felt down when my baby made noises. But It was really not because of it. I just felt down for no reason. (07,FG2) Several expressed the view that women with baseline depression could suffer greater depression during pregnancy. Two women with a history of depression before pregnancy had suspended their antidepressants during pregnancy because of concerns about their adverse effects on the fetus: I stopped taking them(antidepressants) right after I got pregnant…then I felt like my depressive symptoms worsened. (04,FG2)
Perceptions of perinatal depression
Partial understanding of perinatal depression.
Participants of all three focus groups had heard the terms "postpartum depression" or "perinatal depression." Nearly all identified some symptoms: Sometimes I was unable to control my emotions and suddenly cried for no reason. And it was hard for me to fall asleep. (04,FG1)
Four out of five male respondents mentioned they had noticed their partners’ reluctance to communicate as an important sign of depression: I think the salient feature of the depression is that she didn’t want to talk to you. (02,FG3) However, they had difficulty distinguishing between normally expressed uncertainties and emotions arising during perinatal period and symptoms indicative of significant perinatal depression: I could distinguish the differences when it (my wife’s mood) had big changes, but I was not sure whether it could be regarded as depression or not. (03,FG3)
Describing factors associated with perinatal depression.
The respondents identified several potentially important factors that could contribute to the development of significant depression—based on both their own experiences and what they had observed with others. They described depressed feelings related to being an immigrant—i.e., having a small social circle, a sense of isolation, and difficulty adjusting to living far from home: I have heard from my wife that one of her friends lived in an apartment, and there were few friends to communicate with in the perinatal period. She said she felt depressed at that time. (03,FG3) They also reported that conflict with mothers-in-law can be associated with depression: I don’t want to recall the first weeks after delivery. My mother-in-law refused to take care of me and my baby. She didn’t help during nighttime as she said the baby didn’t seem happy to be cared for by her at night. So, I had great conflicts with her during that time. (01,FG2). Women participants additionally described depressive symptoms associated with conflicts with the elders, especially involving "doing the month ": If I thought ‘doing the month’ was a good idea, and others suggested that I should do so, that’s fine. However, if I didn’t like the idea, and my mother-in-law kept saying I should, I would feel depressed. (07,FG2) The men uniformly expressed the same view: I support my wife, and she can do everything she wants. She can follow what the elders say if she wants it (doing the month), or ignore it if she thinks it's wrong. If she keeps happy, she would recover better. If she is not happy, then even taking ginseng wouldn’t help. If I don't support her, she would be more depressed, (02,FG3) Lastly, the gap between ideal expectations of parenthood and the realities of caring for a newborn may be related to depression. Some of the women interviewed thought to have a baby was a wonderful thing before pregnancy, but after the birth they found themselves struggling to cope with problems: When I saw pictures of other moms breastfeeding their babies, I thought ‘what a happy scene’. But with the baby in my own arms, screaming hard as if I was abusing him, then all the happy scenes you imagined in the past seemed to just turn into big struggles. (03,FG1). And: I thought the baby would be born knowing how to suckle but he didn't do so until two weeks after delivery. I felt so bad about it that I just fell apart. (04,FG1)
Screening for perinatal depression.
All women participants approved of universal screening for perinatal depression by their obstetrical providers. They reported depression screening is more acceptable when partnered with other routine prenatal testing, such as general bloodwork, glucose monitoring, or ultrasound exams: Yeah, they gave me a questionnaire to fill out in at the hospital. I didn’t pay much attention as there were plenty of exams and blood tests anyway during the prenatal visits. It’s just another task in the whole thing. (03,FG1)
General preventive and coping strategies for perinatal depression
Solve within the family first.
Due to a lack of understanding or distrust of mental health professionals, as well as the stigma associated with the traditional Chinese concept of minimizing mental illness, respondents tended to address any mental health concerns first within their family: People always think that seeing a doctor is a very sensitive matter, especially when you go to see a doctor for depression. You really don’t want others to think that you have problems. (02,FG3) Participants reported trying to identify strategies to improve their emotional state, such as learning about coping skills or posting their thoughts on virtual forums such as WeChat: I had some (depressive) symptoms. But the book I read suggested that it had something to do with hormonal changes and it would fade away slowly. So, I just tried to think in a positive way. (04,FG1). Women identified distraction as a common strategy: I would choose to work when I am pregnant again because I think I need some distraction. Focusing entirely on the baby may make the pregnancy seem longer and I’d feel worse. Therefore, I preferred working and I was pretty happy working. (02,FG1) Social support also was identified as protective. Husbands, especially, can help alleviate their wives’ distressed emotions, by providing emotional support or by sharing housework and child care: It’s comforting that my husband was good at talking. He would talk to me when I was not happy. The role of husband was very important. He talked a lot to me and made me feel that some conflicts in the family can be solved through communication. He was nice to me and I felt peaceful in the perinatal period (01,FG2) Similarly, sharing feelings with close or trusted family members, such women’s parents, was valued by both women and men. To solve this problem (depression), I will find her parents to talk to her if they were around. I think she would like to talk to people shecan trust. (02,FG3)
Seek outside help later.
When efforts within the family fail to improve perinatal depression, respondents would consider seeking outside help through new social connections or professionals. Participants were encouraged to attend tea parties for mothers in the community and vent their emotions to new friends in US. Through communicating with peers, they learned about parenting and got support and comfort by other mothers who also experienced mood fluctuations during the perinatal period: If it was a friend of mine who was experiencing perinatal mood swings, I'd share my own experience with her, and I thought it might be helpful. Because I had a similar experience, I was more likely to understand what she was feeling. (04,FG1) For those who still find themselves struggling after talking with friends or family, the women might seek help from a mental health professional if their mood remained distraught or uncontrollable: I feel like the depression ... If it gets so bad that it becomes unmanageable, I'd probably go to a doctor. (04,FG1) Participants noted that if a deeply distressed woman continued to resist seeing a psychiatrist, her family could try having a psychologist or psychiatrist talk with her outside the clinic: Right, if it comes to the point of looking for a doctor, my idea may be to say for example, well, getting a psychologist or psychiatrist to meet with my wife and me in places like a café…mainly because I'm afraid she might feel ashamed of her illness in the setting of clinics. (02,FG3). Respondents generally were not interested in medication treatments: Maybe the drug is not the best way to cure her, maybe she(my wife) should change the whole way of life. (03,FG3)
Attitude towards using mobile health technologies during the perinatal period
Receptivity to mobile health.
Respondents generally reported that they would be trusting and receptive to educational information published on social media platforms by authoritative organizations or individuals: I followed what she (a gynecologist from Beijing) said in Weibo (a social media platform), because she is very famous in China. I can learn how to take care of babies there. (04,FG2) Nearly all of the respondents have used perinatal apps or obtained perinatal health-related information through social media platforms. They expressed a positive attitude toward implementing mobile health strategies during the perinatal period: It’s good to spread mental health information through such social media platforms. (03,FG3) The apps they accessed cover a wide range of topics, providing pregnant women and their spouses with information including: pregnancy care, estimated due date, post-natal rehabilitation, mental health, and infant feeding. They were described as helping inexperienced mothers and fathers navigate these novel tasks more comfortably. My wife was confused about many things in the perinatal period, and she could get a great deal of useful information from these apps. (04,FG3) However, when the women and their spouses were experienced with newborns and related postpartum challenges, their use of apps lessened: The app would be useful with your first child. But after one or two weeks, you gradually work out what to do and when to do them. At that time, you would not rely on the app to take care of the baby anymore. (02,FG3) Language was an obstacle for some when using local resources—whether apps or talking to her doctor: My wife’s does not speak very good English. She may have trouble telling her doctor the changes in her mood during the perinatal period. So, it’d be hard for her doctor to understand her condition. (03,FG3)” Thus some respondents followed the accounts of specific Chinese doctors through social media platforms to obtain needed the information or to ask questions in Chinese: I followed the Weibo account “I work in hospital” which often publishes some useful information such as, “What should I do if the baby is choking?” (04,FG2) Additionally, many women joined the mother’s communication groups on WeChat to gain useful parenting tips or encouragement from other women.
Expect personalized service.
Respondents described a desire to have access to a range of options to learn about perinatal depression: Every person has her own preference. When she needs the information, you need to give them choices of how such information is conveyed…(otherwise)the health messages you send out would be disposed of as junk text messages or junk Email (02,FG3) Women respondents generally reported they preferred social media platforms over text messaging because the former gave them more sources of information to follow, who to follow, when to view it, and greater anonymity: Text messages make me feel I am a passive recipient. If it's something on Weibo or WeChat(social media platforms), I can decide whether to read it based on my need. If the information on perinatal health comes from these authoritative sources, I will selectively read it. (04,FG2) The male respondents indicated that health education information about perinatal depression should be sent directly to mothers, interspersed with infant feeding information: I think husbands are usually careless, they wouldn’t read (the mental health messages). So, it is better to send the messages directly to the cell phones of the moms. It’d be best giving some parenting tips at the same time. Actually, moms care a lot about their babies’ health conditions. (04,FG3)