1. Social Determinants of Postpartum Depression
A Mixed Method Multilevel Theory Building Study

2. Background and Aims
It is increasingly recognised that major adult public health issues, related to development, behaviour and lifestyle have their origins during pregnancy, infancy and early childhood.
The aim of this study is to utilise mixed methodology to build a conceptual framework, theory and model describing the mechanisms by which multilevel factors influence the developmental and life course outcomes with a focus on perinatal depression.

3. Methodology and Methods
We used a critical realist approach to social epidemiology theory building.
Emergent methods included: key informant interviews, focus groups, thematic analysis, conceptual mapping, situational analysis, factor analysis, logistic, linear, and Bayesian spatial and multilevel regression studies.
Explanatory theory building utilised abductive Inference to the Best Explanation.

4. Critical Realist Theory Building

5. Mixed Method Design

7. Study One: Overview of Literature
Peri-natal adversity impacts on child development and life-course outcomes
Biological Programming
Permanent alteration of phenotype
Stress impact on HPA axis
Accumulation of risk
Attachment patterns and emotional deprivation
Breast feeding and cognitive attainment
Childhood SES shapes adult disease risk

8. Study One: Overview of Literature
Peri-natal Depression – Quant studies
Prevalence percent
Past history of depression
Low social position (SES)
Less partner support
Hx of family psychopathology
Lack of social support
Stress

9. Study One: Overview of Literature
Impact of depression
Foetal sequelae of cortisol crossing placenta
Preterm labour
Foetal Development affected
Infant temperament affected
Insecure attachment
Breastfeeding
Shaken baby

10. Study Two: Qualitative Individual Level
Three focus groups plus practitioners
Coding, concept mapping, situational analysis
Support and nurturing of mothers
Support networks and mothers groups
Access to services
“Loss of control”
“Expectations Lost”
Conflicting advice

11. Study Two: Qualitative Individual Level
Isolation
“not belonging”
Stress
Marginalisation
Social position and Class
“Being Broke”

13. Study Two: Qualitative Individual Level
Expectations and Dreams
Marginalisation and “being alone”
Loss of Power and Control
Support and Nurturing

17. Study Three: Quantitative Individual Level
Cross sectional study SWS
2-3 weeks postpartum
N=15, 389 mothers
64 item survey
Exploratory Data Analysis
Non-linear PCA (CatPCA)
Binary Logistic Regression
Exploratory CFA

18. Study Three: Quantitative Individual Level

20. Study Three: Quantitative Individual Level

22. Study Four: Qualitative Group Level
Three focus groups plus practitioners
Coding, concept mapping, situational analysis
Community level social networks
Social capital
“Depressed Community”
Access to services
Big Business
Social Policy
Ethnic segregation

23. Study Four: Qualitative Group Level

24. Study Four: Qualitative Group Level

26. Study Five: Quantitative Group Level
101 suburbs
46 ecological variables
26 selected after EDA and EFA
Six latent variables identified in EFA
Ecological linear regression
Spatial Bayesian linear regression
Spatial Bayesian Multilevel Logistic Regression

27. Study Five: Quantitative Group Level
Six latent variables were called:
Disadvantaged Communities
Social Cohesion
Health Behaviours
Housing Quality
Access to Services
Support Networks – Social Capital

29. Study Five: Quantitative Group Level - Ecological
Final linear and spatial models agreed:
No Support
Ethnic Diversity
No Regret Leaving
But ?compositional effect

31. Study Five: Quantitative Group Level - Multilevel

32. Study Five: Quantitative Group Level - Multilevel

33. Study Five: Quantitative Group Level - Multilevel

34. Study Five: Quantitative Group Level - Multilevel
Migrant mothers only where no group level support lack of group level support was protective Group No social support was protective in the southern suburbs of Blairmount, Claymore, Rosemeadow, Airds and St Helen’s Park Group Social support was detrimental in West Hoxton, Panania etc.

35. Study Five: Quantitative Group Level – Factor 61 2 3 4 5 6
SCHOOL YEAR 8 OR LESS %
-.567
-.406
NOT SUPPORT %
-.679
NO PRACTICAL SUPPORT %
-.589
DENSITY
-.452
-.493
DIFFERENT ADDRESS 5 YEARS
.349
.395
MALY INDEX
.308

36. Study Five: Quantitative Group Level – Factor 6
poor schooling
no support
no practical support
density
-ve different address
-ve Maly index (low diversity)
? Weak Social Capital
Opposite is Strong Social Capital

37. Factor Six is Positive in North and Claymore
Factor Six is Negative in South
Weak social capital is protective to migrant mothers
Social capital is detrimental to migrant mothers

38. Study Five: Quantitative Group Level
Migrant mothers only Factor Six – weak social capital – is protective Why: Strong community “bonding” social capital excludes minorities

40. Building a Theory

43. Conclusion
Drawing on the call for theory building approaches to social epidemiology I have utilised critical realism and a mixed method design to construct an explanatory theory of maternal depression and context.
The study will contribute to the increasing role that both realism and mixed methods are playing in explaining the social distribution and social determinants of health.

44. Conclusion
The study found accumulating evidence that maternal stress, during and after pregnancy, is a cause of maternal depression and altered developmental trajectory of her infant. The focus of this study has been on the social context that initiates or conditions maternal stress.
Global, economic, social and cultural mechanisms were identified that explain maternal stress and depression within family and neighbourhood contexts. There is a complex intertwining of historical, spatial, cultural, material and relational elements that contribute to the experiences of loss and nurturing.

45. Conclusion
Emerging is the centrality of expectation lost as a possible trigger of stress and depression not only for mothers but also others who have their dreams shattered during life’s transitions. In these situations social and cultural context can either nurture and support or marginalise and isolate.
The challenge for policy and practice is to support mothers and their partners during the transition to parenthood within a challenging global-economic context.