Future Research
Gender, Pregnancy, and Mental Health

Framing the Issue 
Pregnancy is a gendered experience. But we may not know as much as we think we do about the gendered experience of pregnancy when we take into account into account the diverse identities of women through an intersectional lens. 

In our technologically advanced, information society, there is a plethora of information available to expecting women. There are books ranging from the best-selling What to Expect When You Are Expecting to self-authored books by celebrities. Medical information is readily available on the internet from hospitals to sites such as WebMD. There are pamphlets and literature given by health care providers. But there are also a mass of internet sites aimed at expectant moms. They include not only articles about pregnancy and child issues, but message boards, where women ask and give advice (and at times “police” each other). What does this have to do with pregnancy being a gendered experience? 

We need to take into account the cultural messages about gender that this information advocates in addition to the cultural messages women are given by friends and family. In this sense, these sources define what a good mother is in relation to gendered expectations.  It also might be the case that  they point to how a good mother is from a white middle class perspective.

Yet, my inquiry into pregnancy as a gendered experience is not just about understanding if the cultural mandates proposed about the experience lack an intersectional focus. Moreover, I seek to understand mental health issues, in particular depression and anxiety, as they relate to the gendered pregnancy experience. Thus, this research has roots in various fields within sociology and feminist studies. These include sociology of gender, intersectionality, medical sociology , the medicalization of pregnancy, and welfare state issues. 

In the past, the focus on mental health in relation to pregnancy has been on post-partum depression, often called the “baby blues.” In the academic realm, Verta Taylor’s book, Rock-a-bye Baby: Feminism, Self-help and Postpartum Depression, discusses this issue in depth through though an analysis of self-help groups of women experiencing post-partum depression. Post-partum depression is often characterized as a time of melancholy as new mothers, lacking essential sleep and adjusting hormone levels, feel isolated and sad as they care for a new infant. Although post-partum depression is still a concern, a new issue is being discussed. This is depression during pregnancy.

It is estimated that one in ten women experience pregnancy during depression. Yet, this statistic might not tell the whole story, which is part of my interest in this subject. The number might be low because do all women who experience depression during pregnancy report this? Why would they report it or not?  Which women are more likely to repot this? These questions are central to my interest in this research.

Stemming from reading the medical literature given to pregnant women by providers, a concern of untreated depression during pregnancy is that women who are depressed may be more likely to engage in “risky” behaviors such as substance abuse that might harm the growing fetus. But now that the issues of depression during pregnancy has came to light and there are numerous pharmaceutical remedies for treating depression, a new concern has arose. That is, is it safe for women to use anti-depressant medication during pregnancy? 

There seems to be an increase in medical studies detailing the effects of using anti-depressants medications during pregnancy. However, like most medical studies, there are some methodological issues. First, the sample sizes in the studies tend to be low, making generalizability an issue. But moreover, the studies lack adequate control or comparison groups. For example, studies usually only look at the effects of mothers who took anti-depressants (and hence we assume they were depressed) versus mothers who did not (we do not know if they were depressed, but might assume they were not). Thus, the results show how medication affects the fetus of mother who was depressed compared to women who may not have been depressed. Not the best comparison, especially when health professionals are beginning to discuss how stress, depression, and related ailments of the mother affect the fetus. A better comparison would be to compare mothers who are all depressed who did and did not take the medication. Granted, there are some studies that show that certain anti-depressants, such as Prozac, have caused heart abnormalities in the fetus/baby. Therefore, there is needed information stemming from these studies. Yet, the studies on other anti-depressants, such as Zoloft or Buspar, have not shown the same extreme effects and this is where the comparison between depressed women and those who are not seems crucial. 

Why does this matter and how does it link to this proposed study? First,  there are debates about if medications should be used to treat depression at all and if the use of anti-depressants is the result of pharmaceutical companies push for profits.  The purpose of my study does not focus on this debate and I take the stance that depression is real and medication can help . Even so, this debate does link to ideals of a good mother (and hence gender). For some, a good mother would not ingest anything during her pregnancy that might harm the fetus. Moreover, this also relates to the  question of why a woman would be depressed during pregnancy? If you are depressed, you are not fulfilling the womanly, mother role. Our culture tells us that expecting women have a glow, should be happy about expecting, and at all costs, do everything they can to ensure the best life for the new child.

The idea that not all women are happy during pregnancy is not new. For example, take Naomi Wolfe’s book “Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood”. Or, when talking to expecting women, there are some common complaints about the fatigue, the weight gain, and other physical ailments that can take a toll on their mental health.  Doctors, partners of the expectant, and even the books state that a pregnant women’s hormones change during pregnancy, which may affect a women’s mental state. Medical providers do acknowledge that women who have experienced depression in the past are more likely to experience it during pregnancy. So, pregnancy may not be a happy experience due to chemical issues, social expectations, or both. 

Yet, if a pregnant women is depressed, if she has or has not experienced depression before, will she admit this and seek help?  This is where I would like to bring in what I think may  be a contradiction with the medical sociology literature and feminist/sociological literature on reproduction.   

Social Status, Gender, & Pregnancy Expectations  
While previous research has looked at mothering, post-partum depression, teenage pregnancy, and high fertility rates among certain groups, few seem to look solely at the experience of pregnancy and mental health. Building upon my graduate coursework in the sociology of health and medicine, my foundation in the gender and reproduction literatures, and my prior work experiences in the mental health and disability field, I will explore mental health and pregnancy through an intersectional gendered analysis. Looking at pregnancy through this framework shows the different ways diverse women experience this time and how social institutions and other actors involved view and construct this experience for diverse women in different ways.

My interest is in comparing how diverse social statuses, such as race, class, religion, and other social factors and institutions, such as welfare, social networks, and medical providers, impact how women experience pregnancy and mental health during this time. What cultural and gendered discourses do women use to understand their pregnancy experience? How does this relate to which women are more likely to suffer depression during pregnancy or how depressive symptoms might escalate for women with chronic depression? Who is more likely to admit their difficulties and seek help? Why might this differ across diverse women? This is important research because not only is mental illness stigmatized in society, but it is even more so during pregnancy because of gendered expectations to be happy, self-sacrificing, and a good mother while pregnant. While the medical sociology literature shows that in general those who are white and higher status have better mental health because of access to health care and social networks, does this hold true during pregnancy because of the increased attention to gender and motherhood as social statuses?  Are diverse women held up to the same “perfect motherhood” standards that begin when women are pregnant? Are higher status women less likely to admit feelings of depression and not take medication if needed because they see it as a potential risk to their social standing and ideas of being a good mother? How do social support networks that may buffer depression vary during pregnancy among diverse women, particularly when we take into account not only race, ethnicity, and social class, but age, educational background, and career status?

As discussed previously, new medical discourse states that depression and a mother’s stress can have a negative effect on the fetus. Yet, the medical studies on the effects of mothers’ use of anti-depressants during pregnancy are limited in a few ways. Thus, how do the few medical studies on the effects of anti-depressants during pregnancy on the fetus affect medical providers’ recommendations and/or  pregnant women’s decisions to take medication if needed? How might these decisions about medication, or even conversations about medication with care providers, be affected by women’s differing social statuses?  How does this relate to gendered discourse about the self-sacrificing good mother who should not ingest anything that might be harmful to the baby, even if the mother’s mental health might be in question and affecting the fetus? 


Proposed Methods & Data Collection

This will be a qualitative study consisting of interviews with both women and medical professionals, observations of support groups and other events if possible, and content analysis of both the literature presented to pregnant women concerning mental health and websites where pregnant women seek and discuss information on pregnancy. 

Importantly, the methodology presented here is a proposed one. This study would need to be approved by an institutional review board and I am aware of the sensitive nature of studying mental health issues and pregnancy. Thus, this is a proposed methodology that would be revised in regards to these factors.

In thinking about recruiting women for interviews, I would like to talk with women who both have experienced depression during their pregnancy and characterized it as such and pregnant women in general. I would like to include the latter category as not only a comparison, but also to discern if women across the two groups may have had similar feelings and struggles, but may have characterized it differently (i.e. not attesting that they had/have depression) because of how mental health issues are stigmatized in general and possibly more so during pregnancy. Again, because of the sensitive nature and unique category of women I would like to speak with, possible ways of recruiting people would be advertisements about the study in places where pregnant or new moms go, such as medical offices, WIC offices, and related sites depending upon IRB approval.

Possible Interview Questions
I  provide here tentative questions that could be asked during interviews with different respondents

Health Care Providers
How often do your pregnancy patients discuss mental health concerns with you?
How do they discuss with you? Are they nervous? Shy? Embarrassed?
Do you provide information to all your patients about depression or mental health during pregnancy? Why or why not?
How do you discern mental health might be an issue for a patient?  How do you approach the patient? What resources do you recommend?
Have you ever prescribed anti-depressants for a pregnant patient?  What factors influenced your decision to do this?
How do you view the risks and benefits of using anti-depressants during pregnancy?
Do you feel other providers you know or work with are concerned about depression  during pregnancy?
From what sources do you learn about mental health during pregnancy?
Why do you think depression is an issue during this time period?
Why would you not recommend medication for depression for a pregnant woman?
When do you think depression during pregnancy became a concern in your field?
Are there certain criteria of your patients that would promote you to discuss mental health concerns with them?
Do women characterize their experiences with terms such as depression or do they talk in general about struggles they are facing?

For midwives only
Do you think midwives deal better with women’s mental health concerns during pregnancy?
How do you deal with women who are struggling?
What do you recommend to these women?

For Pregnant Women in General:
Please describe your pregnancy experience. What did you enjoy about it? What was difficult or problematic? Physically? Mentally?
Are you partnered or married?  Do you have other children? Do they live with you? Do you have family that live near? Do you have trusted friends?
Did you work during your pregnancy? Did you go back to work after? What type of work did/do you do?  Was your work supportive of your pregnancy?
Was this a planned pregnancy? Please describe what you mean.
Did you have ideals about what pregnancy would be like? Where did these stem from?  
Did your experience match your ideals? Why or why not? How did this make you feel?
From whom or where did you get advice on pregnancy related issues? Did you trust the advice?  Did you use the advice? How did it make you feel when you received advice?
Would you characterize pregnancy as a mentally challenging time? Why  or why not?
How did others’ expectations of you while pregnant affect you? (i.e. did people assume  you were happy about being pregnant or say you were glowing?)

For Pregnant Women Who Were Treated During Pregnancy for Depression
Was depression something you experienced before or just during pregnancy? Was it worse  during your pregnancy? Why do you think it was?
Who do you think was supportive of you during this time? (i.e. doctors, partners, friends). Who did you talk to? Why?
Did you express your concerns to your doctor/midwife?  How did they react?
Did you take medication for depression during your pregnancy? How long? Why did you decide to take it?  Who prescribed it for you? Did you ask for it or was it recommended? How did you weigh the potential risks and benefits?
Why do you think you were depressed during pregnancy? What stresses or social factors might have impacted this?
Do you think the medication helped you? Were you judged by anyone for taking medication?
If you told people you were depressed, did they try to explain why you were depressed?  How so? (i.e. its hormones, etc).
Would you have more children after this experience? Why or why not? If yes, what would you do differently?
How would you characterize your pregnancy experience? Is it what you expected? Do you think other people have similar experiences or yours is unique?
Do you think your behaviors were scrutinized more by people (i.e. med professionals, friends, etc) because of your depression (or other social statuses such as race, class, welfare, etc)?
What pregnancy recommendations or ideals were hard for you to follow? Why?
How did you cope with your feelings during the pregnancy?
What advice would you give to other pregnant women who are similar to you?  What advice would you give to women who experience depression during pregnancy?
Did you use the internet for information during your pregnancy? What sites? How did you use the information? Did you feel that the information applied to you?
Did you read and/or participate on message boards regarding pregnancy? Ones about depression? What was said? How did you feel about the information?
Have you ever experienced or struggled with depression or other mental health concerns in the past? How did you deal with this?  Did these manifest during your pregnancy?


Support Groups
I would also like to conduct ethnography at support groups for women suffering depression during pregnancy or post-partum (i.e. as many are devoted to women in both categories) and/or at similar events. From some preliminary general research on this, support groups for women experiencing depression during pregnancy or post-partum are sponsored by hospitals and medical providers in some geographic areas. Other avenues might be general support groups for women suffering depression.  I would like to conduct research in these settings to see not only what type of women would attend these groups and why, but also how the women talk about their experiences in this type of setting, how the medical professionals who run the group act and how the women interact with each other. Is it unique because the women all have suffered depression? Are they supportive? How so? How does the group foster a vision of gender?


Websites
The following is a sampling of websites that provide context to my interest in this study and could be used for content analysis. I am particularly interested in the websites aimed at expecting mothers and parents where message boards are present. These capture the interaction of mothers discussing pregnancy issues and hence cultural messages about gender and motherhood.  It is important to note that discerning social class or other social statuses of the women who post would not a completely accurate measure, but can be discerned by the content of the comments and  information we have on internet use. But it is also important to note that all of the websites are important in that these are publically accessible sites that women are able to access via search engines on the internet.

Medical Websites About Depression, Anti-Depressants and Pregnancy
Mayo Clinic
http://www.mayoclinic.com/health/antidepressants/DN00007

WebMD
http://www.webmd.com/baby/guide/pregnancy-depression

Organization’s Websites About Mental Health and/or Depression During Pregnancy
Mental Health America Maternal Depression Guide
http://www.mentalhealthamerica.net/go/maternal-depression

March of Dimes
http://www.marchofdimes.com/pnhec/188_15663.asp

World Health Organization: Gender and Mental Health
http://www.who.int/mental_health/prevention/genderwomen/en/

International Association for Women’s Mental Health
http://www.iawmh.org/about.htm

National Asian Women’s Health Organization
http://www.nawho.org/site/c.ipILKTOCJsG/b.3522897/

African American Women’s Mental Health
http://www.blackwomenshealth.com/2006/articles.php?id=56

National Latino Behavioral Health Association
http://www.nlbha.org/

Scientifically Focused Sites on Studies About Anti-Depressants During Pregnancy
Science Daily
http://www.sciencedaily.com/releases/2008/11/081124081150.htm

US Department of Health and Human Services
http://www.ahrq.gov/research/may08/0508RA8.htm

Healthy Place
http://www.healthyplace.com/other-info/mental-illness-overview/antidepressants-during-pregnancy-and-nursing/menu-id-198/

Parenting Websites Including Article, Commentary, and Message Boards About Depression, Anti-Depressants, and Pregnancy
Babycenter.com
http://www.babycenter.com/404_is-it-safe-to-take-antidepressants-during-pregnancy_2343.bc

I-Village
http://messageboards.ivillage.com/iv-pppregndep

I-Am_Pregnant.com
http://www.i-am-pregnant.com/encyclopedia/D/Depression-during-pregnancy/

Berkeley Parents' Network:
http://parents.berkeley.edu/advice/pregnancy/antidepressants.html

Parents.com
http://www.parents.com/pregnancy/my-body/is-it-safe/taking-antidepressants-during-pregnancy/
http://www.parents.com/baby/health/postpartum-depression/how-depression-affects-your-family/
http://www.parents.com/dgroups/index.jsp?plckForumPage=Forum&plckForumId=Cat%3a464c6917-7212-40cf-af32-063fa4981ccbForum%3af1cba18c-6712-4888-bf7e-bb9ea8c27e22

 
Importance of Study and Funding
My research will make important contributions to the growing fields of the medicalization of pregnancy and illness and mental health and gender. This research is timely and fundable because of the current debates centering on the risks and benefits of using any medication during pregnancy, but particularly anti-depressants. Because of its links with the medical field, this study has potential to be an interdisciplinary, collaborative project with those interested in gender, reproduction, and/or mental health. Hence, possible fields for collaboration might include Gender and Women’s Studies, Anthropology, Social Work,  Nursing, Psychology, Psychiatry, and other medical fields and specialties such as Obstetrics and Gynecology. Thus, the results of this study would be of use not only to sociologists and other social scientists, but also to medical professionals who have increased their attention to this issue, which augments this study’s fundability.

Potential Funding Sources and Places to Look for Funding  
Below, I list potential places to seek funding for this study. Most of the ones listed are national or larger agencies. I will also search for and seek funding from local or state organizations in the area I will be located when I begin this project. For example, there may local women’s organizations that provide funding for research on these issues. With these different funding sources, I would  apply for the most relevant ones to this project. I list these different sources to highlight the range of funding that is potentially available, and in particular for women’s mental health during pregnancy and post-partum.  

National Institute on Mental Health
http://www.nimh.nih.gov/research-funding/grants/index.shtml

National Institute on Drug Abuse
http://www.drugabuse.gov/funding/resfundslist.htm

United State’s Governments Health and Human Services:
Women’s Health
 http://www.womenshealth.gov/fund/

Agency For Health Research and Quality
*to note is that they have funding for research on depression during pregnancy and post-partum (see second link). Even though this may not be 
available at the time of my proposed research, it is important to highlight this area as a concern of potential funders
.*

http://www.ahrq.gov/fund/grconix.htm#process
http://grants.nih.gov/grants/guide/pa-files/PA-09-175.html

National Mental Health Information Center
http://mentalhealth.samhsa.gov/funding/

Substance Abuse and Mental Health Services Administration
http://www.samhsa.gov

Grant Makers in Health
http://www.gih.org/topics3985/topics_list.htm?attrib_id=8497

American Medical Women’s Association
http://www.amwa-doc.org/index.cfm?objectid=FFA1FB0A-D567-0B25-5F6567CDF851D6B9

Foundation Center
* a site to search for funding opportunities*
http://foundationcenter.org/

Women Grants
*a listing of funding sources for women and research about women and girls*  
http://www.fundsnetservices.com/women.htm


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