Postpartum Depression: A Case Report of Bedapu From Aceh Singkil.

BACKGROUND: Postpartum depression is a commonly occurring psychiatric disorder. Prevalence of postpartum depression varies across cultures and countries. Many factors affect, trigger, or aggravate post-partum depression, including sociocultural factor. Bedapu is a unique tradition from Aceh Singkil on post-partum mothers. CASE REPORT: We reported a case of two women with postpartum depression who performed Bedapu tradition on themselves. Edinburgh Postnatal Depression Scale (EPDS) was conducted for screening and DSM-5 as the determinant of diagnostic criteria.
CONCLUSION: Postpartum depression has varying symptom spectrum, and Bedapu affected it by aggravating the symptoms of postpartum depression. Copyright:

Introduction

Bedapu is a tradition in Aceh Singkil, in which postpartum mothers placed in the kitchen and were made “Bale-Bale” of 1 x 2 m [1] as a bed. Beside it, a furnace is made from a type of wood. This was performed since the child is 6 days old to 60 days old for the first child and 40 days for consecutive children [2]. Bedapu ritual that should be performed by a mother after giving birth is heated herself in the morning and the afternoon by the fire of the furnace. The ritual is started using heated brick, or young coconut, wrapped in fabric and Noni leaves placed on the mother’s stomach. Meanwhile, she is not permitted to drink mineral water, only certain herbal water, and she is only permitted to eat boiled vegetables and grilled fish. With rapid era development, this tradition is starting to be abandoned. However, in several regions, this tradition is still performed. There are several components of Bedapu tradition that contradicts the principle of health, which is burning wood in a furnace inside a room which causes smoke-filled air that lead to difficulty breathing [3].

Giving birth and being a mother is a physiological occurrence. This event brings different meanings for every woman and their family. For many women, this event has a positive meaning and a delightful transition phase to a new stage on their life cycle. However, it can mean negatively and create various emotional disorder during the postpartum period. One of the variations of an emotional disorder is postpartum depression [4], [5].

Postpartum depression is a mood disorder occurring after birth which reflects psychological dysregulation and a sign of major depression symptoms [5]. Depressed mood, loss of joy in performing activities, loss of appetite, sleeping disorder, physical agitation or psychomotor decline, weakness, worthless feeling, difficult to concentrate, and suicide desire are the symptoms often found in mothers with postpartum depression [5]. Other study stated that severe postpartum depression occurs in approximately 25% of new mothers and 20% in mothers giving birth to a second child or more [4], [5], [6].

Case Report

A 24-year-old Pak Pak woman, M, who had given birth to a first child in the primary healthcare facility was taken by her family to Psychiatry Department of Aceh Singkil Hospital with depression, lack of energy, fatigue, lack of concentration and awareness, gloomy and pessimistic future vision, sleeping disturbances, loss of appetite. EPDS test on the patient showed a score of 19. It is known that the patient experienced postpartum depression which was established by the doctor in a primary healthcare facility right after giving birth. The patient was allowed to go home after three days of care due to family demand for postpartum care at home. While at home, she performed Bedapu tradition which was performed from sixth day postpartum. After a month, the family brought her back to the healthcare facility with a complaint of depression which was aggravated by difficulty breathing of the infant during Bedapu ritual after interview through alloanamnesis to the family of the patient, i.e. the husband and her parents.

A 42-year-old Pak Pak woman, N, had given birth to her eight-child helped by a midwife, and taken by her family to Aceh Singkil Hospital with a complaint of depression, loss of interest, fatigue, loss of self-awareness and confidence, thought of guilty and worthlessness, sleep disturbances, and loss of appetite. EPDS test showed a score of 20. After anamnesis, these symptoms were felt a few days after giving birth and worsen in the last 3 weeks. The patient stated that she felt these symptoms because she remembered her sixth child’s death after birth while performing Bedapu tradition and was diagnosed bronchopneumonia by the doctor. The patient felt anxious that the event would repeat because the family still performs Bedapu.

Discussion

Postpartum depression generally related to the psychosocial problem (marriage problem, social support, cultural tradition, difficulty during childhood) and factors related to pregnancy, and all of them interact with personality. Postpartum depression is dangerous for both the mother and the baby which may lead to suicide. On the other hand, children whose mother had postpartum depression symptoms had been shown to have a higher vulnerability to behavioural and emotional problems. Several studies had identified several risk factors that may be related to postpartum depression symptoms, including young age, low education, smoking during pregnancy, history of depression, poor marital status, poor economic status, negative life events, antenatal depression and anxiety, and sociocultural factor [4], [5], [6], [7].

Psychosocial problem is one of the factors that can aggravate postpartum depression. As an example, an uncomfortable and depressing sociocultural tradition performed by a mother can lead to a condition worse than before [4], [5], [6].

The focus of this case report is to explore that cultural tradition can affect the psychological problem of postpartum mothers. Furthermore, the results showed that the negative experience of postpartum mothers could cause postpartum depression worse than the previous one. These results were clinically relevant because the mother felt the depressed and uncomfortable situation and felt that the condition was not what she expected. They felt guilty and anxious about their children’s health.

Therefore, postpartum depression can affect the capacity of a woman to care for her child and can lead to an inability to act as a mother, which are nursing and caring for the baby [5], [6].

To determine the diagnosis of a disorder, several diagnostic criteria of the disorder should be noted. Therefore, in this case, diagnostic criteria from DSM-5 and ICD 10 were chosen and was reinforced by the Edinburgh Postnatal Depression Scale (EPDS), screening for postpartum depression [8], [9].

To establish the diagnose of depression, the symptoms should be experienced for at least 2 weeks, whether mild, moderate, or severe.

EPDS screening test has a score range of 1-30. Score 1-9 showed that there is no risk of depression, 10-12 showed moderate risk of depression, and score 13-30 showed severe risk of post-partum depression. There are 10 question items with four answer choices. Code S = Often is scored 3, KK = sometimes is scored 2, SJ = very rarely with score 1, and TP = never with 0 [9].

According to case report above, after complete psychiatric anamnesis, clinical interview, and examination of mental status and referring to the diagnostic criteria shown in Table 1 and Table 2, it was determined that both patients met the diagnostic criteria of postpartum depression.

Table 1

Diagnostic criteria of depression according to DSM-5 [8]

Complaint	Main	Others
1	Depressive affect	Concentration decline
2	Loss of interest	Decreased self-awareness
3	Loss of energy	Feeling guilty
4	Fatigue	Pessimistic
5		Desire to die
6		Loss of appetite
7		Decreased sleeping frequency
Mild	Moderate	Severe
2 main complaints	2 main complaints	3 main complaints
2 other complaints	3 other complaints	4 other complaints

Table 2

Edinburgh Postnatal Depresion Scale Depresion (EPDS) [9]

No	Item	S	KK	SJ	TP
Value		3	2	1	0
1	I laugh when encountering funny events
2	I found the future full of hope
3	I feel worthless because of past mistakes
4	I am interested in and not anxious for clear reasons
5	I feel anxious and scared for an unknown reason
6	I feel I was right for certain things
7	I feel sad which causes sleeping difficulty
8	I feel sad
9	I feel very sad that I cry
10	I feel a failure or a loss

When classified into postpartum depression classification, both patients experienced severe postpartum depression, where the symptoms are observed from the results of the Edinburgh Postnatal Depression Scale (EPDS) for diagnosing postpartum depression with a score above 13.

Overall, these cases had unique characteristics of common postpartum depression. Even with limitations, these results showed relevant clinical value. Therefore, we suggest improving the regulation that sociocultural tradition should be by the principle of health, giving the mother a comfortable condition and paying attention to the nutritional value of the food taken. This case report found a correlation between the sociocultural tradition factors that aggravates the psychological condition.