Methodology

The methodology we chose to use is meta-study with a particular focus on meta-findings and synthesis of those findings/ themes [9]. Beck (2002) describes a meta-synthesis as an interpretation of a large body of qualitative work; whereas, a metaanalysis is more of a collection of data. Though both Munhall and Beck espouse caution when using meta-synthesis, as it calls for an interpretation of a researcher’s findings, which are, in themselves, interpretations [10,11]. Having said that, they both agree that there are ways to avoid distorting the original meaning or intent. One way to do this is to have individual researchers become familiar with and interpret each primary study individually and then meet to discuss their findings until there is a harmony of ideas [9,11]. As outlined in the data analysis section of this paper, this is the path we followed while analyzing the findings of the seven primary studies in an attempt to remain as true to the original meaning as possible.

Paterson (2001) points out that, not only does metasynthesis work to find similarity in existing qualitative data, but by searching for the “kernel of a new truth” (p. 111) in order to gain a deeper knowledge of a phenomena, it also allows the consumer to see new possibilities that could engender a more responsible and holistic health care response [9]. It is for this reason that meta-synthesis, if done properly, is thought to produce strong and compelling research findings. In fact, Beck (2009) points out that for certain clinical situations, including the treatment and care of women with PPD, meta-synthesis of qualitative research can be more appropriate than quantitative research.

Methods

Originally, we aimed to explore the experiences of breastfeeding mothers with PPD. We used online databases such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Ovid, and Google Scholar to search the key words postpartum depression, mothers, expectant mothers breast feeding, postpartum, support, perception, women support, selfconcept, self-efficacy, infant bonding, infant care. This search yielded 7 studies, few of which were appropriate or valuable to our original area of inquiry. Therefore, the PICO question was re-worked to focus on the lived experiences of women with PPD through the primary work of Beck. Once again, the online databases mentioned above were used to search for Beck’s primary qualitative research on PPD from the years 1991 through 2000. Key words such as postpartum depression and Beck (as author) were used (Appendix A).

The inclusion criteria for the meta-synthesis was that PPD was the primary focus of the article, that it was a primary research study, that it was authored or co-authored by Beck and that the research design was qualitative. The initial retrieval process yielded 18 studies. Through further inspection of the 18 articles retrieved only 5 were identified as qualitative research studies. PubMed was used to search under the author Cheryl Tatano Beck, Cheryl T. Beck, Cheryl Beck and Beck; this yielded 65 articles. From those, two additional qualitative studies were found and chosen for the metasynthesis. Additional methods used to ensure that all of Cheryl Tatano Beck’s primary work was considered for the meta-synthesis included consultation with the university’s librarian, consultation with the course professor and reference chasing from “Bringing visibility to an invisible phenomenon: A postpartum depression research program” out of Routledge International Handbook of Qualitative Nursing Research (Beck, 2016, p. 128). Of the 18 references identified through reference chasing only 5 were primary qualitative studies and they had already been gathered through the online database search.

The 7 articles chosen for the meta-synthesis were appraised using the Critical Appraisal Skills Program (CASP) Qualitative Research Checklist. Each study was appraised and scored out of 10. These studies all gained high CASP scores and were considered appropriate for inclusion in the meta-synthesis. Essential data from the studies and CASP scores were then extracted into a table (Appendix B) in order to readily assess each study’s findings.

Data analysis

Thematic analysis by Braun and Clarke (2006) was used to analyze the data for the meta-synthesis. Their approach consisted of six phases:

To identify the initial codes, we went to the local college and used their library’s study rooms and large white boards. From there, we created a table that included each study’s year, purpose and findings, along with several original quotes from mothers to help identify where the researchers developed their final themes. We reviewed each study and highlighted impactful statements and reoccurring thematic imagery. We constantly referred to the original articles to gain more insight as to the context of the findings and we reviewed the actual interview statements frequently throughout the process. From there, we began to write down initial codes. Our initial codes were included in a map of our thought processes and it was from this that we derived our sub-themes:

1. Foggy, a decrease in functional abilities, struggling to survive, overwhelmed
2. Desperation/nightmare, haunted by fear, suffocated
3. Loss of normalcy, loss of self, like a robot/zombie, mechanical, going through the motions
4. Resentment and guilt, anger, no joy in motherhood; guilt about negative feelings/thoughts
5. Misunderstood, shame, keeping secrets, hiding, wearing a mask, social isolation
6. Shocked and alarmed at their negative feelings/thoughts
7. Regaining control, asking for help, fighting for their baby, health and well-being.

After identifying these seven sub-themes, we analyzed and discussed them at length and came to a mutual consensus as to what the sub-themes represented and how they were interrelated. By doing this we helped ensure that the original themes, findings and theoretic imagery were accurately interpreted and represented in our final themes. We combined similar sub-themes and four overarching themes emerged:

1. Buried alive: Tormented by endless negative emotions
2. Enslaved by the role of mother: Numb to joy and fulfillment
3. Self-inflicted isolation: Masking the chaos
4. Emerging from the darkness: Unearthing inner strength Findings

Buried alive: Tormented by endless negative emotions

Throughout all seven studies chosen for this meta-synthesis, resentment, guilt and desperation were repeated often; women described living in a “nightmare” mired in sadness and fear [6]. Women often felt as though there was no way out and the thought of death actually acted as a comfort to them as it offered them a way to end their suffering [6,12,13].

“I was living constantly with these terrible thoughts that I was a horrible person, a horrible mother, and questioning what’s wrong with me.” [14].

Many of the women in the studies also expressed negative emotions towards being a mother. The following phrases were used to describe these feelings, “being on the edge of insanity” (Beck, 1992); “petrified” (Beck, 1995); “living nightmare” (Beck, 1992); “suffocating” (Beck, 1992); “uncontrollable anger” (Beck, 1995), and “panic” (Beck, 1996, 1998) [15,16]. From our review of the articles, as well as interview statements, we used the powerful descriptions to elicit the overarching theme of being buried in a deep, dark pit consumed by distressing thoughts and feelings; these women were unable to see their way through these negative emotions. The women described their experiences with postpartum depression as being condemned, and that they would do anything in order to feel good again. All of this led us to conclude that mothers’ with PPD had their visions of what motherhood would be ripped away only to be replaced with a terrifying new reality.

Enslaved by the role of mother; numb to joy and fulfillment

The women in the seven studies consistently identified themselves as “zombies or robots’, describing themselves as “just going through the motions [13, p. 5]. They went on to say that they had “foggy” thinking patterns and a significant decrease in their functional capabilities.

“Oh, I tried to do something - go out for a run, visit a friend, or take the baby to the mall - but it didn’t work … I could not concentrate to read a book. I had been a very avid reader and could comprehend well I lost all that in my postpartum depression. People would talk to me and all I would see was their lips moving.” [14, p. 45].

These women described no longer feeling like themselves, stating that they had difficulty even doing the bare minimum in order to just get by. Throughout the research the loss of self and the loss of normalcy was rampant. PPD stripped away the person the mothers thought they were and, understandable, they grieved over this loss:

“Every hour, every day, every night was the same [8]. The cycle would start all over again” (Beck, 2002, p. 601).

Other women described their loss of self as feeling “like my body was abused” and “like being a servant to very demanding people” (Beck, 2002, p. 600). This sense of lost self was reported in 5 out of the 7 studies reviewed and made a striking impact on the development of our final themes. The inability to reconcile who they used to be with the husk of a person they had become, these women felt caged by their new role and deprived of the joy customarily experienced with a new child.

Self-inflicted isolation: Masking the chaos

Many of the women were able to identify the negative emotions they felt towards the role of mother. The women would describe feelings of shock and alarm at the depth of their anger, frustration and rage (Beck, 2008, 1998, 1995). The women also described a fear of being misunderstood, as they felt shame for feeling the way they did, and would therefore hide their feelings from loved ones or health care providers (Barr & Beck, 2008; Beck, 1995, Beck 1998; Beck, 1992). In one study, one woman was experiencing a panic attack and went to her local emergency department to seek care, only to be told that “[she] [was] abusing the emergency room” (Beck, 1998). A self-imposed isolation was donned as the mothers struggled alone with their fear of judgement; they were terrified of divulging the truth of their reality to anyone. Many of the women experienced suicidal ideation, but did not disclose this information to their GP or psychiatrist; they would simply state that “things are bad” (Barr & Beck, 2008, p. 1717). Loneliness prevailed, as these women exhausted themselves in order to keep their reality a secret, even from those they loved the most (Beck, 1992, 1998).

Comfort was only felt once another individual “took the time” to have a conversation surrounding the woman’s feelings surrounding their role as mother (Beck, 1995). It was as though the women were depreciating themselves, while also convincing themselves that they were the only ones to have ever experienced negative emotions towards their child.

“The nurse did not pass judgment. She tried to understand what I was experiencing” (Beck, 1995, p. 823.).

Emerging from the darkness: Unearthing inner strength

In each of the seven studies reviewed, all participants were struggling internally to regain control. Each study depicted the women’s fight against her own thoughts and feelings, dragging herself through the trenches, every waking moment. Women described themselves as being terrified of what they might do if left alone with their child to the point that they developed strategies such as “organizing paid help”, or “delaying bath time until their partners came home”, while others “fled outdoors for a breath of fresh air” (Barr & Beck, 2008, p. 1717.e3.; Beck, 1998, p.134). It was also apparent through the research that women experiencing PPD often attempted to ask for help. The women experiencing PPD reported that they would try to speak to their husbands, loved ones, and friends, but their attempts would fall on “deaf ears” as they were told to “snap out of it” (Beck, 1992). Consumed by negative emotions, many of the women changed their lifestyles, avoiding all activities that would prompt negative feelings or thoughts, further isolating themselves to prevent harm (Beck, 1992, 1998). For the women who did seek care, their efforts were very delicate, but on the inside, they were screaming!

Discussion

Review of C. T. Beck’s primary work revealed the women experiencing PPD are trapped in a conscious state, and silenced by the inability to embody what they believe to be as “mother”. The review also revealed that women experiencing PPD are screaming for help in the most subtle ways, desperately waiting for someone to take notice. One of the reigning themes identified through this meta-study is the constant struggle to gain control, with each woman coping in their own unique way to prevent harm to their child, or themselves (Beck, 1992, 1998, 2008). Moreover, it is impossible to fathom the constant, daily struggle that these women face. It is only possible through qualitative work such as C. T. Beck’s that provides a glimmer into the lives of women suffering from PPD.

Women in the postpartum period need to be screened, assessed, and engaged in conversation at each and every clinic visit, as postpartum depression can present as an evolving process after a continuum of non-depression (Clemmens, Watson Driscoll & Beck, 2004, p. 184). Furthermore, research on postpartum depression is now expanding to include diagnoses such as “anxiety disorders” and “post-traumatic stress disorder” under the postpartum depression terminology umbrella, in hopes of earlier recognition and intervention (Coates, Visser, & Ayers, 2015). Education is vital in teaching all women that we are complex, unique creatures, and that we do not fit into a box; just as new mothers do not need to be “depressed” to be suffering from PPD (Coates, Visser, & Ayers, 2015). More research is needed to be able to better support mothers and their families through the postpartum period. Through early education and awareness, as well as improved screening tools, health care practitioners will be better equipped in preventing the negative outcomes associated with PPD (Thomas, Scharp, & Paxman, 2014, p. 374).

Tables

References

1. Patel S, Wittkowski A, Fox JRE, Wieck A (2013) An exploration of illness beliefs in mothers with postnatal depression. Midwifery 29: 682-689.
2. Thomas LJ, Scharp KM, Paxman CG (2014) Stories of Postpartum Depression: Exploring Health Constructs and Help-Seeking in Mothers’ Talk. Women Health 54: 373-387.
3. Coates R, Visser Rde, Ayers S (2015) Not identifying with postnatal depression: a qualitative study of women’s postnatal symptoms of distress and need for support. J Psychosom Obstet Gynaecol 36: 114
4. Miller WR (2010) Qualitative Research Findings as Evidence: Utility in Nursing Practice. Clin Nurse Spec 24: 191-193. Beck CT (1992) The lived experience of postpartum depression: A phenomenological study. Nurs Res 41: 166-170.
5. Clemmens D, Watson Driscoll J, Beck CT (2004) Depression as profiled through the postpartum depression screening scale. MCN Am J Matern Child Nurs 29: 180-185.
6. Beck CT (2002) Releasing the pause button: Mothering twins during the first year of life. Qual Health Res 12: 593-608.
7. Paterson BL, Thorne S, Canam C, Jillings C (2001) Meta-study of qualitative health research: A practical guide to meta-analysis and meta-synthesis. Nursing in Critical Care 8: 162.
8. Munhall PL (2012) Nursing research. Sudbury, MA: Jones & Bartlett Learning 5^TH
9. Beck CT (2013). Routledge International Handbook of Qualitative Nursing Research. New York: Routledge 1^st
10. Barr AJ, Beck CT (2008) Infanticide secrets: Qualitative study on postpartum depression. Can Fam Physician 54: 1716-1717. e5. Beck CT (1995) Perceptions of nurses’ caring by mothers experiencing postpartum depression. J Obstet Gynecol Neonatal Nurs 24: 819-825. 13. Beck CT (1993) Teetering on the edge: A substantive theory of postpartum depression. Nurs Res: 42: 42-48.
11. Beck CT (1998) Postpartum onset of panic disorder. Image J Nurs Sch 30: 131-135.
12. Beck CT (1996) Postpartum depressed mothers’ experiences interacting with their children. Nurs Res 45: 98-104.
13. Postpartum Support International. Cheryl Tatano Beck, DNSc, CNM, Retrieved.