"The Association between Depressive Symptoms and Social Support in Taiwanese Women During the Month" (2004), by Shu-Shya Heh et al.

In 2004, Shu-Shya Heh, Lindsey Coombes, and Helen Bartlett studied the association between Chinese postpartum (post-childbirth) practices and postpartum depression in Taiwanese women. The researchers surveyed Taiwanese women about the social support they received after giving birth and then evaluated the depression rates in the same women. Heh and her colleagues focused on the month following childbirth, which according to traditional Chinese medicine is an important period that warrants a set of specialized practices to aid the woman's recovery. Collectively called zuoyuezi (doing the month), the postpartum practices require the help of someone else, typically the woman's mother or mother-in-law, to complete. Heh and her colleagues found that, generally, Taiwanese women with more social support displayed fewer postpartum depressive symptoms, and concluded that the practice of doing the month helped prevent postpartum depression in Taiwanese women.

According to traditional Chinese medical theory, health is the result of a balance between two opposing forces called yin (shady) and yang (sunny.) Traditional Chinese medicine maintains that women experience an imbalance after giving birth, becoming too cold, or yin, during pregnancy, and needing more heat, or yang, during the month after childbirth. Through the practices of zuoyuezi, women restored the balance by staying indoors, avoiding cold water, and eating foods that are considered hot, hypothesized as an intrinsic quality of the food, not its temperature. Because of the various rules of the practices, anthropologist Barbara Pillsbury has stated that traditionally, a family member accompanies the woman during the month after childbirth. However, in the late twentieth century, doing-the-month centers have developed in Taiwan and China to provide zuoyuezi services to new mothers.

Many investigations of zuoyuezi have addressed the physical benefits or detriments of the Chinese postpartum practices. However, Heh and her colleagues studied the link between the practice and postpartum depression, which is associated with the six-week period following childbirth and characterized by episodes of irritability, guilt, exhaustion, anxiety, and sleep disorders. Heh was a professor at the Department of Nursing at Fu-Jen Catholic University in Taipei, Taiwan, and collaborated with Coombes, a professor at Oxford Brookes University in Oxford, UK, and Bartlett, a professor at the University of Queensland, in Brisbane, Australia. The team explored the types of social support that Taiwanese women received during zuoyuezi, how those women perceived the support, and whether the women's satisfaction or dissatisfaction had an effect on their postpartum depressive symptoms.

To begin their study, Heh and her colleagues described the social support systems and postpartum depressive symptoms of a sample of Taiwanese women. They selected participants from two teaching hospitals in Taipei, Taiwan, stipulating that the participants had to be married, between the age of twenty and thirty-five, and following the zuoyuezi practice after delivery. They only included women who had normal, spontaneous deliveries with a full term healthy infant, who were the first children of the women. The researchers excluded women who had complications before and immediately after giving birth, women who had a previous psychiatric history, and women who were not following the zuoyuezi practice.

After obtaining approval from hospitals' research committees, Heh and her colleagues sent letters to three hundred women who met the selection criteria. In the letters, the researchers explained the purpose and procedure of the study and assured the women that their responses would be kept confidential and would not affect the medical treatment they received at the hospital. The researchers then sent three surveys to the participating women four weeks after giving birth. The first survey was a questionnaire requesting demographic information and data relating to zuoyuezi, such as the place and person that helped the woman do the month.

The second survey that Heh and her research team sent to participants was the Postpartum Social Support Questionnaire. The Postpartum Social Support Questionnaire (PSSQ) consists of eighty-one questions asking about the types of support that women receive from their spouse, family, and others after delivery. The support is separated into two types: emotional support and instrumental, meaning physical or tangible, support. Women answer the questionnaire by rating their answers on a seven-point scale, with seven being the most support, and one being the least.

The third survey the researchers sent was the Edinburgh Postnatal Depression Scale. The Edinburgh Postnatal Depression Scale (EPDS) consists of ten questions relating to how women feel and respond to certain situations. Like the PSSQ, the questions on the EPDS have graded answers, such as "yes," "sometimes," "not very often," and "not at all." The researchers scored participant responses at the end of the questionnaire, with a maximum score of thirty and any score over ten indicating possible depression.

Heh and colleagues translated the two scales into Mandarin Chinese. Following data collection, the researchers used statistical tests to analyze whether the Edinburgh Postnatal Depression Scale scores were positively correlated to the women's demographic variables and if the Edinburgh Postnatal Depression Scale scores were positively correlated to the Postpartum Social Support Questionnaire.

Of the two hundred forty women who initially agreed to participate in the study, only one hundred eighty-six women responded to the surveys, which they received in their fourth week after giving birth. The average age of the responders was twenty-eight years old. About seventy-four percent of the women were employed, and sixty-seven percent of the women reported that the pregnancy had been planned. According to the questionnaires, forty-two percent of the women experienced depressive symptoms after giving birth, including anxiety, sleep disturbance, depression, crying, anger, shouting, weakness, and stress. The women indicated that the majority of symptoms occurred in the first week after discharge from the hospital.

The researchers first compared the demographic information from the first, short questionnaire with the EPDS results. They did not find statistically significant relationships between demographic variables like maternal age, education, working status, and family income with postpartum depressive symptoms. However, they did find that unplanned pregnancy, the location of doing the month, and the key person who helped the woman during the month, correlated with postpartum depressive symptoms. Specifically, women who stayed at their parents-in-law's homes and had their mothers-in-law as their key helpers had higher EPDS scores, indicating a higher degree of depressive symptoms, while women who stayed in their parents' homes and had their own mothers as key helpers had lower EPDS scores, indicating a lower degree of depressive symptoms.

Heh and her colleagues then analyzed the results of the Edinburgh Postnatal Depression Scale with the answers from the Postpartum Social Support Questionnaire, which measured the types and amount of social support that women received. They found that women who reported high levels of instrumental parental support had low EPDS scores. Women who reported high levels of total emotional support from their spouse, family, and friends, also had low EPDS scores. Conversely, Heh and her colleagues found that women who were dissatisfied with their parents' support, especially instrumental support, had high EPDS scores. Based off those results, the researchers concluded that Taiwanese women who were more dissatisfied with their social support were more likely to have a greater degree of depressive symptoms. Overall, women were less likely to have postpartum depression if they received higher levels of instrumental and emotional support from family and friends, and if they were satisfied with that social support.

In their published paper in the International Journal of Nursing Studies, Heh and her colleagues presented four major themes from their data collection and analysis. Firstly, they argued that their findings show that social support can help to mitigate depressive symptoms during the month after delivery and lessens some of the stresses associated with childbirth.

Secondly, the researchers suggested that, contrary to the arguments of other studies, postpartum depression does not vary significantly across cultures. According to their results, about nineteen percent of the women had EPDS scores over ten, which according to the EPDS protocol indicates depression. A 2001 comparative study of postnatal depression in women from Britain and Taiwan found that the prevalence of postnatal depression in both groups was almost equal, around eighteen percent. Heh and her colleagues argued that their findings similarly showed that postpartum depression was not a culture-bound phenomenon.

Thirdly, the researchers highlighted the correlation between Taiwanese women's postpartum satisfaction and the source and type of social support that they received. According to their data analysis, Taiwanese women who received support from their own parents had a lower EPDS scores, and women who had little emotional support from their in-laws and parents were more dissatisfied and more likely to have high EPDS scores. Thus, Heh and her team suggested that zuoyuezi helps to insulate postpartum women from the risk of postnatal depression, but only if the women were satisfied with the support they received. Heh and her research team also suggested that women seek help from their own family, and especially their own mother, after childbirth.

Lastly, Heh and her colleagues discussed how changes in society have affected the correlation between social support and postnatal depression. Specifically, they addressed the EPDS scores of women who stayed at doing the month centers, which provide commercial zuoyuezi services. They noted that the twelve women who stayed at the centers had an average EPDS score over ten, indicating depressive symptoms. The researchers pointed to other studies suggesting that women who stayed at the center felt little support from their own families, little emotional connection to the center staff, and felt more depressed.

Heh and her colleagues concluded that the zuoyuezi practice may provide valuable social support for women after giving birth, helping to alleviate postnatal distress and depression. However, they added that researchers should consider the perspectives of the women to ensure that the support they received satisfied and benefitted them. They suggested that health policy makers consider how postnatal care should be provided to women who had just given birth after their discharge from the maternity unit.

Into the twenty-first century, the zuoyuezi practices continued in Hong Kong, China, and Taiwan, with government agencies estimating over a hundred doing the month centers in Taiwan. Similar centers opened in the United States to cater to immigrant women whose mothers or mothers-in-law are not in the United States. Heh, Coombes, and Bartlett's study of postpartum depression in Taiwanese women confirmed the theory that the zuoyuezi practice has not only physical, but mental and emotional benefits for Taiwanese women after childbirth.