Investigating Postpartum Depression in the Adolescent Mother Using 3 Potential Qualitative Approaches.

Adolescent mothers are twice as likely as their adult counterparts to have postpartum depression (PPD). Left undiagnosed and untreated, PPD can have significant consequences for the mothers, infants, families, communities, and society. Although the epidemiology has been well studied, there is a scarcity in the number of qualitative research studies being conducted to study this unique group of young women. Qualitative research is a perfect match to elicit the voices of adolescent mothers having PPD because the qualitative approach offers a way to gain insight, meaning, and understanding of a phenomenon that is still largely misunderstood and unaddressed. This article will discuss 3 major qualitative approaches (phenomenology, ethnography, and participatory action research) that may be employed to study PPD in the adolescent mother.

Postpartum depression (PPD) is a common and growing public health concern that affects women across the globe. A widely accepted definition and criterion for PPD includes depressive symptoms that are present every day for at least 2 weeks within 1 year postdelivery that significantly interferes with daily life.[1] Postpartum depression is a devastating disorder that affects not only the mother but also everyone around her. While most women experience the postpartum blues immediately after birth, studies show that approximately 10% of women experience PPD, a more severe variant that has short- and long-term consequences.[2-4] Postpartum depression has been studied extensively in adult women but has been less explored in adolescents.[5] Adolescent mothers are found to be at higher risk for developing PPD than their adult counterparts with studies suggesting adolescent PPD rates between 15% and 50%, whereas adult rates are approximately 10%.2,5

In 2013, in the United States, more than 450,000 adolescent girls became pregnant before age 20.[6] Of these pregnancies, 37% ended in legal abortions. According to Kingston et al,[2] adolescent mothers are twice as likely as adult mothers to experience PPD. These staggering statistics signal a critical need to study this vulnerable population of adolescent mothers with PPD. As will be described below, a complex interplay of developmental and situational factors predispose adolescent mothers to developing PPD.

Antecedents and Consequences

The transition to motherhood carries with it many biological, developmental and psychological changes. Learning the new role of motherhood along with the physical exhaustion, sleep deprivation, decreased financial resources, and isolation are inherent stressors that all new mothers face. For some mothers, the upheaval during this pivotal time can be so challenging that they are ill-equipped to handle the stressors.

Compounding the issue are certain risk factors that are unique to adolescents and predispose them to developing PPD. Adolescence in itself is a time period of significant developmental and behavioral changes.[7-9] As adolescents mature and develop, their brains undergo significant changes.[8] These developmental changes place adolescents and especially adolescent mothers at increased risk for developing depression.[10] With the arrival of an infant, adolescent mothers must quickly learn to adapt to their new maternal role in addition to their other life roles (ie, daughter, student, girlfriend, etc). The physical, emotional, and mental demands imposed by motherhood can be overwhelming even to the most accomplished, well-supported woman. However, to adolescents who are still negotiating their role in society, the drastic and permanent changes can be crippling.

Aside from their young age, developing cognition, and underdeveloped coping skills, other risk factors have been found to contribute to developing PPD in adolescent mothers.[11] Other contributing factors include history of prior depression, low socioeconomic status, lack of social support, low education, poor body image, inadequate maternal competency, and family dysfunction.[5,11,12]

If not addressed, PPD in the adolescent mother can have serious and devastating results. These complications include poor parenting skills, delayed infant development, low self-esteem, substance abuse, suicidal ideation, and persistent mental illness beyond the postpartum period.[5,10] To prevent long-term effects of untreated PPD on the mother, infant, family, and society, the voices of the suffering adolescent mothers should be elicited to gain insight into their experiences and to develop appropriate interventions through health care provider and family collaboration.

Healthy People 2020 has established several national goals related to adolescent mental health. Specifically, 4 objectives pertaining to adolescent depression, pregnancy, and suicide include the following: (1) reduce the proportion of adolescents aged 12 to 17 years who experience major depressive episodes, (2) increase the proportion of children with mental health problems who receive treatment, (3) reduce the suicide rate, and (4) reduce the rate of suicide attempts by adolescents.[13]

To answer the call put forth by Healthy People 2020, several quantitative projects were completed to study PPD in the adolescent mother. However, there are a disproportionately few number of qualitative studies found in the literature. Using databases CINAHL, Cochrane Systematic Review, PsycINFO, PubMed, and Scopus, along with truncated keywords “post*” “depress*,” “teen*,” “adolesc*,” and “mother*,” 69 articles surfaced from the literature search. After article review, 67 articles utilized a quantitative or mixed methodology leaving only 2 qualitative studies (see Figure 1 for PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] diagram illustrating search strategy and results). Most of the quantitative articles focused on predictors and risk factors of PPD in adolescents (ie, abuse, history of depression, lower socioeconomic status, and limited social support), long-term consequences of PPD for mother and child, and effectiveness of interventions aimed at preventing or improving PPD.[5] The skewed propensity for quantitative methods is unfortunate because the best way to elicit the true experiences of adolescent mothers with PPD is to conduct qualitative studies where their voices are heard and their stories are told.[14] Qualitative approaches which gain the input of the key stakeholders, the adolescent mothers, could yield valuable information useful in creating more effective interventions and services.[14,15] This critical step is being overlooked and could result in unnecessarily ineffective interventions for adolescent mothers having PPD.[15,16]

Figure 1.

PRISMA diagram for literature search strategy and results. PRISMA indicates Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Of the 2 qualitative articles identified through this review, one used an unspecified qualitative descriptive approach,[16] and the other used a grounded theory approach to analysis.[14] Boath et al[16] did not note a specific qualitative methodology. The methods they described most closely aligned with a qualitative, descriptive approach.[17] Boath et al[16] conducted semi-structured, private interviews with 15 adolescent mothers aged 15 through 19 who had previously been diagnosed with PPD using the Edinburgh Depression Scale. The purpose of the study was to elicit the voices of adolescent mothers having PPD. The authors chose to use thematic framework analysis to analyze the qualitative data captured in the interviews.

The adolescents in this qualitative study identified several themes unique to their struggle with PPD including (1) stigma and judgment, (2) social and professional support, (3) knowledge about PPD, and (4) barriers to using support.[16] The adolescents reported the compounding stigma that resulted from being a young mother and also having PPD.[16] Overall, the adolescents had very little knowledge about PPD, and when they started having symptoms, they felt as though something was wrong with them. The fear of judgment and stigma caused many adolescents to wait to seek treatment until their symptoms were severe. Social support from parents, significant others, or health care providers was a significant source of strength and increased the likelihood that the adolescent mothers discussed their PPD and received treatment.[16]

The second qualitative study by Muzik et al[14] used a community-based exploratory qualitative research approach to examine desired perinatal health services among a group of minority adolescent mothers. Two focus groups with a combined total of 19 participants and 21 individual semi-structured interviews were conducted. The authors reported that they used a grounded theory approach to data analysis; however, on critical appraisal, it is evident that this study was, in fact, not a ground theory study because no theory explaining the adolescent behaviors or experiences was presented.[18] Thematic analysis was also used to analyze and interpret the qualitative results of this study. Overall, the participants desired to access comprehensive services to improve their perinatal experience, but there was a lack of accessibility and adequacy of services.[14]

Although these 2 qualitative studies that emerged from the literature search can help the scientific community understand the perspectives of adolescent mothers, more research is needed to fully understand their experiences and create the most effective interventions for this population. This article will discuss 3 different qualitative approaches that can aid in the process of understanding and further studying this misunderstood phenomenon in a vulnerable population of adolescent mothers.

Three Qualitative Approaches

While there are several different extant qualitative methods that could be employed to examine PPD in adolescent mothers, 3 were thoughtfully selected that have not yet been conducted in current literature to sequentially explore PPD in the adolescent mother. These are phenomenology, ethnography, and participatory action research. If completed in the proposed sequential order, PPD in the adolescent mother will be better elucidated and addressed. First, the voice of the adolescent mother should be elicited via phenomenology. Second, the coping strategies and behaviors should be examined via ethnography. Finally, after hearing their stories and observing their daily lives, key stakeholders will be better informed to generate change to serve the needs of this marginalized group of young women through participatory action research.

Phenomenology

The research question, “What is the lived experience of adolescent mothers with postpartum depression?” is best answered by employing a phenomenological approach. Phenomenology’s philosophical foundations emphasize that knowledge and understanding about the world is only possible by being and living in it rather than thinking and rationalizing about it. Those who ascribe to phenomenology posit that perceptions present the evidence of the world—not as it is thought to be, but as it is lived.[19] Furthermore, existence is being in the world. Thus, people are in their worlds and are understandable only in their contexts.[19]

The strengths and benefits of using phenomenology to answer the aforementioned research question are as follows: (1) it provides a complete description of a human experience or phenomenon and (2) it epitomizes the holistic underpinnings of nursing.[20,21] Founded in the early 20th century by Edmund Husserl, phenomenology has evolved over the past century with continued use by philosophers and nonphilosophers who find the phenomenological tenets valuable and fitting for their distinct discipline. Phenomenology has also evolved from Husserl’s original approach of descriptive phenomenology to his successors’ view of using interpretive phenomenology where the researcher is more interested in the participant’s interpretation of the world they live in rather than a description of their world.[20,21] The nursing profession quickly adopted phenomenology both as a philosophy and a research method because of its congruence with the profession’s worldview of holism, relativism, and multiplicity.

In studying adolescent mothers with PPD, their lived experiences are sought out by completing in-depth interviews to gain a better understanding of their situated truths and their polyvocality in perspective.[21] Each of their experiences with PPD will be unique, yet themes are likely to emerge that make their individual journeys meet on common ground. However, the weaknesses and challenges that researchers may face while completing in-depth interviews with adolescent mothers with PPD involve the very characteristic that make them unique, their young age. In addition to their age, another difficulty in conducting research with this population is their lack of life experience. This contributes to many adolescents being unaware of the research process. The critical and sometimes intangible component necessary in the success of qualitative research is the establishment of trust between the researcher and the participant. Without trust, the validity and credibility of the study are jeopardized. Adolescent mothers may view the researcher’s questions as intrusive and not offer the true depth and breadth of their PPD experiences. On the contrary, adolescents may also skew their stories to achieve social desirability in the researcher’s eyes. At this developmental stage, adolescents vacillate between their desire to be accepted as “pseudo-adults” and their need for continued parental protection and provision. This is a confusing time made even more so by virtue of tackling a new role as a mother.

Interpretive phenomenology is an appropriate approach to use to elicit the lived experience of adolescent mothers with PPD. To better serve this population, their stories have to be told and heard. Ethical questions may arise related to safety and comfort for both the researcher and participants. Procedures for handling severe emotional distress and suicidal ideation should be established prior to the onset of the project. As suicide is the second leading cause of death among adolescents aged 15 to 24 years,[22] their safety and well-being are primary and research goals are secondary (see Table 1 for table summarizing the 3 qualitative approaches).

Table 1.

Summary of the three qualitative approaches.

	Phenomenology	Ethnography	Participatory action research
Philosophical foundations	Perceptions present us with evidence of the world—not as it is thought to be, but as it is lived. Existence is being in the world. People are in their worlds and are understandable only in their contexts.	Ethnography is used to explore cultural groups in their naturalistic setting. It is holistic, contextual, reflexive, and presented in the emic perspective.	Pragmatic and democratic in nature, it focuses on both process (research) and outcome (change) to address oppression.
Strengths and benefits	It provides a complete description of a human experience or phenomenon. It epitomizes the holistic underpinnings of nursing.	Using thick descriptions, it provides a powerful account of cultural nuances to better understand the group.	It warrants researchers to work with and for the participants (rather than on). They are vehicles for change and work intimately with the participants to effect changes.
Weaknesses and challenges	It requires in-depth interviews with adolescent mothers who may not be open to “intrusion” into their lives.	It may be difficult to gain entry into the cultural group, and researcher may not be able to proceed through the phases of data collection. Complete bracketing may be challenging.	Gaining entry and trust may be difficult. Researcher must be able to work with all stakeholders.
Usefulness	Its use is appropriate to elicit the lived experience of adolescent mothers with postpartum depression.	Its use is appropriate to obtain the patterns of coping in the daily lives of adolescent mothers with postpartum depression.	Its use is appropriate to ascertain ways for adolescent mothers with postpartum depression to regain control of their lives and achieve self-actualization.
Ethics	Questions related to safety and comfort for both participant and researcher may arise.	Questions related to balancing role of “outsider” and “insider” may arise.	Boundaries between the researcher and participants are blurred; thus, questions related to rigor and validity may surface.

Ethnography

The research question, “What are the patterns of coping that adolescent mothers with PPD use to function in their daily lives?” is best answered by employing an ethnographic approach. Ethnography’s philosophical foundations emphasize that to truly capture the essence of a cultural group’s beliefs, values, norms, and behaviors, research must be completed in their naturalistic setting.[19] Ethnography is holistic, contextual, reflexive, and presented in the emic perspective.[21] The philosophical underpinnings of ethnography are again congruent with nursing’s tenets of viewing the person not only by its parts but also by its whole. This whole goes beyond that of the person alone, but the person’s impact within family, community, and society.

The strengths and benefits of using ethnography to study the coping patterns employed by adolescent mothers with PPD include the thick descriptions that result from immersion into the cultural group. For instance, if the researcher were to complete the study in an inpatient behavioral center for adolescent mothers with mood disorders, the researcher’s multimodal strategies for data collection would include fieldwork with participant observation, interviews, and document and artifact review. This immersion process is one that cannot be hurried and requires patience.

Alongside the long period of time spent doing fieldwork, another weakness and challenge that the researcher may face is the successful navigation through the 4 phases of data collection: (1) negotiating entry, (2) becoming better acquainted with the routines of the setting and participants becoming comfortable with the researcher, (3) establishing trust, and eliciting cooperation and acceptance by the group, and (4) withdrawing from the group.[19] Complete bracketing may be challenging as a result of the relationships formed. This is the main ethical concern when using ethnography as a method. The researcher must learn to balance the role of “outsider” versus “insider.”

Ethnography is appropriate to use to obtain the patterns of coping in the daily lives of adolescent mothers with PPD. The ethnographer not only elicits the voice of the mothers with PPD but also extracts how they cope with the mental anguish in their day-to-day activities (see Table 1 for table summarizing the 3 qualitative approaches).

Participatory action research

The research question, “How can adolescent mothers with postpartum depression regain control of their lives and achieve self-actualization?” is best answered by employing a participatory action approach. Self-actualization is operationally defined as resuming and/or finishing school, while also becoming a competent, confident, and loving parent to the infant. The philosophical foundations of participatory action research include pragmatism and democracy to generate change.[21] This approach focuses on both the process (research) and the outcome (change) to address oppression.[21] To better serve this group of marginalized young women, their experiences are heard and shared, their coping patterns are elicited, and their input for change is acquired.

The strengths and benefits of using participatory action research to help adolescent mothers with PPD regain control of their lives and self-actualization are as follows: (1) the researcher works with and for the participants rather than on the participants and (2) the researcher becomes a vehicle for change and works intimately with the participants to promote changes. The researcher empowers these young women to arrive at solutions for their own problems.

The weaknesses and challenges of using participatory action research include the potential difficulty of gaining entry and building trust between the researcher and participants. More importantly, the researcher must be able to work with all stakeholders. Stakeholders include the mothers, their families, teachers, school staff, health care providers, mental health facilities, support groups, and policymakers. In order for researchers to be effective in completing the participatory action project, they have to be dedicated and passionate about the plight of adolescent mothers with PPD. Finally, ethical concerns related to boundaries between the researcher and participants may arise. Because of their intimate work, their professional margins may be blurred which could lead others to question the rigor and validity of the study. Participatory action research is undoubtedly a labor-intensive process that yields immense reward (see Table 1 for table summarizing the 3 qualitative approaches).

Contrasts and Comparisons

The 3 qualitative methods (phenomenology, ethnography, and participatory action action) discussed above have similarities and differences. All 3 require an inductive approach, are highly contextually laden, and necessitate intimate collaboration between the researcher and participant. Yet, there are differences that set each one apart as outlined in their respective sections above. In studying PPD in the adolescent mother, phenomenology focuses on the individual lived experience, whereas ethnography focuses on the group’s cultural dynamics. In contrast, participatory action research considers both the individual and group voices to achieve tangible results for the plight of adolescent mothers with PPD. To date, no studies have examined PPD in adolescent mothers using the 3 qualitative methodologies proposed in this article. It is paramount that researchers use both qualitative and quantitative methodologies to understand this vulnerable population. Using the proposed sequence of research approaches may better elucidate the lived experiences, coping strategies, and ongoing needs of adolescent mothers with PPD.

Conclusions

Adolescent mothers with PPD are a vulnerable group who require specialized care that considers their unique needs and attributes. From the myriad of quantitative studies already completed, it is widely accepted that PPD is more common among adolescent mothers than adult mothers.[5] The epidemiology is clear; however, their stories are not. Now is the time to reverse the paucity of qualitative studies on a phenomenon that is truly best suited for more inductive, holistic, contextual work offered by phenomenology, ethnography, and participatory action research.