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Social Science & Medicine 57 (2003) 1783–1795
Solutions forgone? How health professionals frame theproblem of postnatal depression
Beverley Lloyda,*, Penelope Haweb,c
aSchool of Public Health, University of Sydney, Building A27, Sydney 2006, AustraliabDepartment of Community Health Sciences, Faculty of Medicine, University of Calgary, 3330 Hospital Drive NW,
Calgary, Alta., Canada T2N 4N1cSchool of Public Health, La Trobe University, Australia
Abstract
Our interest is in how particular solutions in postnatal depression have a tendency to be adopted at the expense of
alternative solutions. One aspect of the answer may lie in how people in positions of authority think about problems.
‘Framing’ refers to the way particular causalities, consequences and moralities are contained within the ways in which
people communicate concepts, in particular in language and in metaphor. Naming the way problems are framed and
identifying alternative frames, (i.e., ‘reframing’) may provide an opportunity to set problems more effectively and to
identify solutions that will solve the problem more effectively. A framing analysis was conducted, drawing on interviews
with senior researchers, policy makers and practitioners in the field of postnatal depression. Seven principal ways in
which the problem of postnatal depression was framed were illuminated. These fitted into three broad approaches to the
problem: individual therapeutic approaches, social competence approaches and societal approaches. Participants in our
study were comfortable and articulate in describing the problem of postnatal depression—whether they were focused on
the individual or societal levels of analysis. However, they were less well versed and comfortable in discussing what they
felt might be important social or societal-level solutions, lacking in both language and schema to do so. The history and
hierarchy that is carried by people from the helping professions may be hindering new avenues to help mothers with
new babies.
r 2003 Elsevier Ltd. All rights reserved.
Keywords: Postnatal depression; Problem framing; Maternal health policy; Australia
Introduction
Cultural images of the birth of a baby in western
societies present it as an event occasioning joy and
celebration among women and their families. Approxi-
mately 13% of childbearing women, however, will
experience an episode of minor or major depression,
referred to as postnatal depression (O’Hara & Swain,
1996). While the overall prevalence of postnatal depres-
sion may not differ from that of depression among
women of childbearing age generally (O’Hara, Zekoski,
Philipps, & Wright, 1990), there is some evidence that
the rate of onset of depression is elevated up to three-
fold in the months after childbirth (Cooper & Murray,
1998). The significance of depression at this time lies in
the potential negative consequences on women and
families. An episode of major depression may have
detrimental consequences for family formation, erode
already difficult marital relationships, and reduce con-
fidence in parenting. Postnatal depression may impact
on children’s cognitive and emotional development,
though this association may be more strongly associated
with factors such as poverty (Murray & Cooper, 1997).
Depressive symptoms may be of greater severity than
with depression experienced at other times in women’s
lives, as a result of the psychological and social demands
ARTICLE IN PRESS
*Corresponding author. Tel.: +61-2-935-15-424; fax: +61-2-
935-17-420.
E-mail address: [email protected] (B. Lloyd).
0277-9536/03/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0277-9536(03)00061-3
of infant care (O’Hara et al., 1990). Furthermore, if not
appropriately managed, an episode of major depression
may result in chronic or recurrent depression (Philips &
O’Hara, 1991).
Recent reviews of aetiological factors for postnatal
depression stress the significance of complex interactions
of social factors, for example, the quality of the marital
relationship and social support, with individual factors
such as personality style, history of depression, and
cognitive style (Boyce, 1996; Cooper & Murray, 1998;
O’Hara & Swain, 1996; Pope, 2000). However, what is
given the status of an independent variable in an
aetiological analysis, begs the question of how the
‘problem’ of postnatal depression is being framed in the
first instance. Similarly, what is targeted as an amenable
factor in a health policy, presupposes particular
conscious or unconscious assumptions. Framing refers
to the ways particular causalities, consequences and
moralities are contained within the ways in which people
communicate particular concepts, in particular in
language and in metaphor (Entman, 1993; Goffman,
1974; Schon, 1983; Schon, 1987). According to Schon
(1987), individuals who frame the same problem in
different ways are paying attention to different features.
Certain aspects of the problem are then accorded more
salience. Schon (1983) argues that professionals frame
problems in ways that reflect their training, and the
techniques of their discipline. Certain ways of framing
problems come into vogue at certain times, reflecting
shifts in knowledge brought about by research within
disciplinary domains. Frame analysis is an increasingly
familiar method in health research. It has been used, for
example, to understand the outcome of policy con-
troversies in environmental health and in tobacco
control (Chapman & Lupton, 1994; Menashe & Siegel,
1998; Vaughan & Seifert, 1992).
Schon argues that professionals pay too great atten-
tion to solution finding, at the expense of ‘problem
setting’, i.e., asking the question ‘what is this problem
about?’ (Schon, 1983). Naming the way problems are
framed and identifying alternative frames, i.e., ‘refram-
ing’, may provide an opportunity to set problems more
effectively and to identify solutions that will solve the
problem more effectively. In this study, we sought to
investigate the different ways in which postnatal
depression is framed. Our purpose was to uncover the
dynamic of how postnatal depression framing might
influence health policy. The study was undertaken at the
end of a decade in which postnatal depression had been
identified as a priority health issue in Australia (Carter,
1994; NSW Health, 1994; Lumley, Small, & Yelland,
1990; Pope, 1995) although clear evidence-based recom-
mendations for the alleviation of the problem were not
apparent (Pope, 2000). We conducted an interview study
of senior-level professionals involved in research, policy
and services in maternal mental health. This allowed us
access to a broader range of perspectives, positions and
assumptions than may be available if we had simply
reviewed emerging policy documents. Framing analysis
was used as the vehicle to identify these perspectives in
the interview text, and to give clues to alternative
approaches to solving the problem of postnatal depres-
sion (Entman, 1993).
Methods
A series of one-to-one semistructured interviews were
conducted. The participants were academics, clinicians
and bureaucrats in two Australian cities who met the
criterion of having a track record in at least one of the
following three areas: research, policy development and
services at a senior level in maternal mental health.
Sampling proceeded by the snowball method. Interviews
with 10 professionals were included in the analysis. The
sample included individuals whose professional role at
the time of the interview included one or more of the
following: senior management (health services), acade-
mia (research and/or teaching or postgraduate student),
policy (at local or state level), health services policy,
health professional education and clinical practice. All
but one of the participants has professional training in a
health-related area. Three participants trained in psy-
chiatry, two in psychology, three in nursing, and one in
general medicine. Several of the respondents have
research experience in postnatal depression or related
issues as an academic and/or in postgraduate study, and
some had published on the topic in peer-reviewed
journals.
The study was described as an opportunity to
contribute to finding solutions for the problem of
postnatal depression by exploring how health profes-
sionals, academics and bureaucrats think and talk about
it. The interviewer began by stating that she was
interested in understanding ‘what is postnatal depression
about?’. After referring briefly to a number of current
models and theories of postnatal depression, the
interviewer then asked the interviewee to discuss his or
her view of postnatal depression, and its perceived
strengths and weaknesses. The interview was piloted
with one health professional who met the inclusion
criteria. As no significant changes were made to the
interview schedule after the pilot, this interview was
included in the analysis.
The interviews were transcribed in full. The qualita-
tive analysis package NUD*IST 4.0 was used to code,
organise and retrieve segments of text. Open coding was
undertaken with the explicit intention of identifying
topic categories within the themes of the interview
(Strauss & Corbin, 1990). Subsequently, additional
codes were added to include other issues generated by
the interviewees. The categories are listed in Table 1.
ARTICLE IN PRESSB. Lloyd, P. Hawe / Social Science & Medicine 57 (2003) 1783–17951784
Throughout this procedure general themes that could
contribute to the frame analysis were noted as memos.
Frame analysis
The frames were identified with respect to four
functions of framing suggested by Entman (1993), to
provide a framework for the analysis of the particular
concerns of this research. This framework encourages
the analyst to look for particular features or elements of
the frame and the connections among them. The
functions pertain to
* Definition of the issue as a problem, identified with
respect to its costs, i.e., How the problem is defined
as a problem, i.e., what is it about this condition
postnatal depression that makes it problematic. What
are its costs?* the source of the problem, i.e., what brings it about.* the evaluation of the source, i.e., evaluation of the
source of the problem and its effect.* the remedies or solutions that follow logically from
the definition, source and evaluation.
The frame analysis began by interpreting the topic
category ‘problem definition’ in terms of the four
functions of frames. The first two sub-categories of this
topic category were examined to identify recurring
words and phrases. From these sub-categories skeleton
frames were identified. Other sub-categories and cate-
gories were then examined. As the analysis proceeded,
there was increasing overlap of topic categories, because,
as one would expect, categories contributed to more
than one frame. Other topic categories that would
contribute to the framing were then examined. Topic
categories that did not address how postnatal depression
is framed were excluded from consideration.
Five frames were identified in this manner. Text that
could be representative of two frames was included in
one only by considering common words and phrases,
and its relation to the four framing functions. Two
additional frames were identified at this stage. The topic
category reports were then re-read to identify further
instances of text that were consistent with each frame.
Finally, the quotations were re-read in the transcriptions
to check that de-contextualising them did not change
their meaning from that suggested in the full flow of
each participant’s text.
Results
Seven frames were identified in the interview data.
The frames were identified with respect to common
words and phrases, and salient ideas. The framing
process was relatively smooth. By this we mean that the
functions were easily used to categorise segments of text
to identify separate frames. We found, however, that
‘evaluation of the source of the problem’ the third
function of framing suggested by Entman (1993) did not
allow us to include our text that covered our question
about the strengths and weaknesses of the participant’s
view of postnatal depression. In addressing this part of
the interview schedule, participants provided their view
of the consequences of framing the problem in a
particular way. They often called upon alternative views
of postnatal depression to illustrate their views. Thus the
third function was extended to include both an
evaluation of the source of the problem, and the
participant’s evaluation of the consequences of framing
the problem in particular, sometimes competing, ways.
Each of these seven frames will now be presented and
explained.
Innate vulnerability to depression is exposed by childbirth
The focus of this frame is vulnerability to depressive
illness, and it is endorsed largely by participants with
training in psychiatry. This frame is causal in its
orientation, and concerns correct diagnosis and appro-
priate management of women.
I confine postnatal depression for those people who
will meet diagnostic criteria for major depression,
ARTICLE IN PRESS
Table 1
Topic categories
Category no. Category name Description
1 Problem definition The interviewee’s conceptualisation of postnatal depression
2 Advantages Advantages of defining the problem in a particular way
3 Disadvantages Disadvantages of defining the problem in a particular way
4 History How the interviewee came to his/her view of PND
5 Solutions Solutions to PND
6 Do not work Solutions that do not work
7 Foundation ‘What’s the foundation of an approach to PND?’
8 Issues Issues generated by the interviewee
9 Risks Interviewee references to ‘risk’
B. Lloyd, P. Hawe / Social Science & Medicine 57 (2003) 1783–1795 1785
either ICD 10 or DSM-4. So I seem to be fairly rigid
in that. (2: 313–315)1
The costs of postnatal depression are discussed in the
context of treatment approaches and their potential for
success.
Ah, well if it’s untreated we know that women can
very often have very long-term depressions, um,
which means their self-esteem and self-confidence are
severely damaged, and it’s very hard to get restora-
tion of self-esteem. (2: 200–202)
Causality in this frame focuses on the susceptibility of
some women to depression.
It’s to do with vulnerability. I mean we’re looking,
the women who get depressed have a vulnerability
that will come out whatever life stress that they have.
[y] That vulnerability is going to be there, if it isn’t
having a baby, it might come out in some other way.
(2: 434–445)
This vulnerability may be ‘triggered’ by certain risk
factors.
So we found [a number of risk factors that] all
increased the risk for vulnerable women getting
depressed. (2: 241–242)
In this frame, remedies are discussed in terms of
health service provision with primary and secondary
(screening) approaches as the starting point.
yif you’re going to have a depressive illness the
chances are that you’ve got other things happening in
your life which makes you vulnerable, or that you’ve
got the gene for the illness. So we should be able to
pick out the people who are going to have the illness,
if we’re very careful. (4: 69–73)
Thus early intervention programs may be offered to
women whose risk factor profile indicates they may need
support.
(Interviewer: But what about women who don’t
have a history?) Yeah that’s right. I mean those
women are much harder, but again there are a
number of factors that if they’re kept in mind, they
probably are additive, so if there’s, you know, several
risk factors as opposed to one or none, then we need
to look at that woman more carefully, and certainly
again try and minimise any stresses at the time, as
much as that can be done. Or optimise the supports.
(1: 206–210)
The pivot around which remedies revolve is correct
diagnosis. Women who do not meet this criterion are
not the business of mental health services.
I believe we need to put a plimsol line saying if you
don’t get up to here, you’re not really a case that
requires treatment, you’re distressed and that’s
unfortunate, but from my point of view it’s only
the cases that should be the proper business of
psychiatry. So that’s why I take a fairly rigid point of
view on that. (2: 302–323)
The frame promotes the improvement of management
strategies for postnatal depression within current health
services arrangements.
We certainly recognised here that postnatal depres-
sion was an important and serious issue, and that
women did need to be able to access some services to
help them overcome postnatal depression, knowing
the long-term consequences of postnatal depression.
(2: 28–32)
Crises in coping are played out in different ways, for some
it shows as postnatal depression
This frame concerns women’s ability to cope with the
task of parenting, emphasising the behavioural and
social competence approaches of psychology.
How do I see the big picture? I mean the big picture is
thatysomewhere between say seven and fifteen
percent who don’t cope once they’ve had a baby.
(10: 66–70)
In contrast to the innate vulnerability frame, postnatal
depression is considered a broad condition. Diagnosis is
therefore diffuse.
I don’t think it is [a discrete condition]yClinically
you end up saying ‘Is this person coping as well as
they would like to be coping?’ And the fact that they
might not quite fit into a [diagnostic] box doesn’t
really matter. (10: 276–281)
The source of the problem in this frame reflects the
problem’s definition—the source is open, unspecified.
I think about it as a heterogeneous kind of condition.
That there’s a really broad spectrumyand various
different ways about you can get it and various
different forms of severity, um, which require
different approaches in terms of service provision.
(5: 36–39)
The evaluative judgement here concerns identifying
the outcome, i.e., impaired mental well-being, rather
than focusing on a broad range of causal factors.
According to this frame, a focus on strict diagnosis and
on causal factors may obscure the main issue, i.e.,
ARTICLE IN PRESS
1Denotes study participant followed by transcript line
numbers.
B. Lloyd, P. Hawe / Social Science & Medicine 57 (2003) 1783–17951786
improving women’s ability to cope with their situation.
Observing stringent criteria for caseness may create
barriers to assisting women:
I don’t think caseness is a good way of at looking
this. I think it’s a continuous condition. I think if you
want to see if something works you’ve got [to use]
continuous measures. Do those people get a bit
better, or whatever? And, in fact if you look at
caseness you may obscure effective work, or you may
say there’s effective work and there isn’t. (10: 289–
294).
We’re doing, we’re in the middle of doing some
screening work at the moment. We’ll be starting
antenatally. And the idea is to do it before we
discharge, then at the six week visit. Um I’m not sure
about screening. There is a danger with screening, I
mean the concept is fine, I’ve no problems with it, the
concept of screening. You can pick people up who
are at risk and we’ve got the resources to follow
them, that’s great. But I think there’s a couple of
issues that we have to remember that people who
aren’t at risk may have a very hard time and what the
danger is that if you forget about them, well they’re
not at risk. Now we’ll provide an intervention for
these people who are at high risk, you leave out all
these people. So there’s a problem there. (10: 610–
622)
Remedies are construed within extant health services,
but differ from the previous frame about innate
vulnerability because they take account of the broader
conceptualisation of postnatal depression in the frame,
and are thus not confined to a particular passage
through health services.
Its not going to be one size fits all. Just like postnatal
depression is not a single disorder. It can manifest in
a number of different ways and really vary quite
significantly in the degrees of severity. So for some
people they might need various services and for other
people they might need a little bit of support and
some more community style interventions. (9: 17–29)
I’ve seen heaps of women. Their social support
networks are so poor once they’ve had a baby, if one
can try and improve that by just getting people in
touch with each other, I think [it can] make a
significant impact for a number of women. (10: 507–
510)
[Setting up neighbourhood networks of mothers] I
think that will make life a lot easier for a lot of
people. Having someone to talk to and someone who
can say, ‘I have got exactly the same problems. I
don’t know whether he should sleep longer during
the day or not.’ (10: 533–536)
The chain of negative consequences that flow from
postnatal depression is the real problem
In this frame, postnatal depression is identified in
terms of its consequences for women, families and
society. This frame crossed professional boundaries. The
frame is illustrated by this comment:
I would pick it [postnatal depression] in the big
picture, um, as a condition which affects you know
the mother, and as a result her infant, and the rest of
her familyyso it’s got really broad impact on a
number of people. (1: 16–20)
The primary focus of this frame is the costs of
postnatal depression, i.e., distress for women and for
families in the short term and in the long term:
Postnatal depression can have an enormous impact
on both the mothers and the child and the family
functioning and well being. (9: 43–45)
The relationships can often go on a downhill spiral,
and I see a lot of relationships breaking up. (2: 202–
203)
The potential costs for children are considered
profound and long-term.
I see quite a few children who are starting school who
clearly have suffered because of their mother’s
depression, they have difficulty separating, going
off to school, they show behavioural disturbances
when they’re at school. (2: 211–213)
ythere’s increasing evidence that it also impacts on
children in all sorts of ways be it cognitive and
behavioural development. (5: 87–88)
Postnatal depression has the capacity to cross
generational boundaries—the future parenting skills of
the children of women who currently have postnatal
depression maybe impaired.
ypeople are, um, I suppose the fact that skills are
laid down in the way a child thinks and therefore
what the way a parent thinks, is laid downy[In-
t:yat a very early age.] At a very early age in the first
sort of two or three years. (8: 208–221)
Thus the consequences become more than the
consequences for a woman and her family. They are
more broadly social, they affect the ability of women to
parent in general, and have implications for the whole
social fabric.
In this frame, the cause of postnatal depression is
largely unrepresented and consequently various causes
may be assumed. Postnatal depression is subjectified, it
is the cause of other, possibly more significant,
problems. Postnatal depression is both cause and
ARTICLE IN PRESSB. Lloyd, P. Hawe / Social Science & Medicine 57 (2003) 1783–1795 1787
effect—it creates a potentially ceaseless chain of
consequences. Due to the centrality of costs to families
and society in this frame, the remedy involves treating
women to solve the problems for infants, children,
partners and so on.
You can’t separate the well-being of children from
the well-being of mothers. So if you don’t have
adequate responses for mothers you’re not going to
meet the needs of children either. (9: 97–100)
I really think that if we can look after women and
their families at this stage then we’ll have a much
better society. (8: 697–699)
Postnatal depression is an understandable result of
parenting in a hostile world
This frame concerns the social and economic circum-
stances in which parenting takes place. This frame too
crossed professional boundaries. It focuses on the source
of the problem and its potential remedies.
A great deal of illness is psychosocially constructe-
dy, it’s related to where you fit and your circum-
stances and where you fit in the overall scheme of
things and how much power and influence you’ve
got, and how much money you’ve got, you know.
And how much stress. (5: 201–204)
The significance of the social and economic context in
which women parent is demonstrated by the following
quotation, in which it is suggested that even women who
are generally well able to manage a variety of situations
can become depressed as a result of challenging
circumstances.
Yeah. Well I guess you have to conceptualise as an
individual, but that individual is not divorced from
her social context. Um she may be very adaptive and
able to do lots of things and be a very resilient
woman, but if she’s got a partner or social
circumstances impinging upon her, providing her
with no support um, that, increases the difficulty for
her, and may make her depressed. (2: 104–108)
Thus the frame highlights the potential for any
woman to become depressed if parenting in adverse
circumstances. The source of the problem may be
financial stress.
ylook there’s a woman that has to go back to work
after three months. The baby’s twelve weeks old. It
breaks their heart. I’d get depressed about thatyit’s
often the most stressful time when you have a baby
because you lose one income. (11: 471–473)
Or postnatal depression may be associated with other
issues, for example, domestic violence.
One of the things that we’ve found out by taking the
screening approach was that there’s higher levels of
domestic violence than expected, and this was the
picture of a lot of key young family dysfunction and
mental health problems. (9: 165–168)
The judgment inherent to this frame concerns the
necessity for ‘society’ to do something about the
problem, and not leave it in the hands of the health
system.
yperhaps I can point out what I see as the
disadvantages of seeing ityfrom a social perspective.
I think there’s very little we can do sociallyyI
suppose I’m fairly cynical about what governments
can do, what health services will actually do in real
terms. I mean, you know, there’s often, there’s a lot
of (pause) a lot of people will say things but they
don’t actually act on it in the long run. (1: 43–51)
The remedy for depression in this frame involves
changing social structures to support women and
families. One participant suggested an approach invol-
ving changes in the workforce that reduce the economic
pressures faced by some families.
I think we should give paid leave, twelve months.
Because it’s often the most stressful time when you
have a baby because you lose one income. (11: 474–
476)
Or it might involve health services working with other
sectors to build better community structures.
I think we need to do a lot of work around rebuilding
communities and that the community structure
doesn’t revolve just around the shopping mall, so
it’s a matter of urban planning, it’s a matter of
health, housing, community services. (9: 276–269)
But for some participants, the difficulties involved in
modifying social structures were a major issue. It is
easier to locate a potential solution than to intervene.
This led to a sense of defeat or frustration among some
participants.
yhow much can we do about social dislocation,
about poverty, unemployment (pause) they’re very
much causal factors in a particular woman’s depres-
sionybut there’s not much one can do about those
social risk factors. I’m, rather, you know, pessimistic
about that. (1: 63–71)
I’m interested in health services being able to provide
those more extended services. I think it’s hard. I
don’t think it’s a strength [having a broad view of the
antecedents of postnatal depression]. I think it’s
hard. (5: 207–209)
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One way of dealing with social circumstances is to
help women to deal with their adverse circumstances
psychologically.
ythe best way to help them is from the base that I’m
coming from, very much that psychologicalytrying
to get them to accept their circumstance if they have
difficult circumstances. (1: 110–115)
Finally, the solution involves more than helping
women to cope, it concerns empowering women to face
adversity independently.
ythe word that comes to mind is empowering those
women. And giving them a sense of they can help
themselves, that they don’t need to rely completely
on other people. (1: 439–442)
Postnatal depression results from role conflict
This frame concerns the expectation that in post-
industrial society women take on multiple roles, and an
expectation that at least some women ‘do it all’.
Postnatal depression is seen as a response to the
difficulty of managing a number of possibly conflicting
roles.
I have for some years spoken about postnatal
depression as perhaps being a paradigm for women’s
position in society, at the moment. That they’re
struggling to do the things men do, to do the things
women have always done, to make a success of all the
things they do. (4: 19–22)
In a world where women are expected to take on a
number of roles there are social and personal pressures
to have children. There is a tension between motherhood
(the private sphere) and achievement (the public sphere)
Yet there is still pressure from outside to do this
[have children], and from inside to think that maybe
this is going to make your life complete when nothing
much else has. And that maybe if you don’t you’ll
regret it, and for people who are adamant about
collecting achievements its yet another thing they feel
that they have to do and make a success of, whether
or not they’ve made a success of other things. And
it’s a very, very different project, for want of a better
word, to embark upon. (4: 28–33).
Implicit in the problem’s source lies a judgement
about women and their roles. The emphasis is less on
resolving the conflict and more on recognising the
consequences of not making a choice between one role
(worker, achiever) and the other (mother).
They come from families who have perhaps, um if
they didn’t come directly in contact with a lot of
parenting, if indeed their mother stayed at home, and
its quite likely she didn’tyThey could see that she
enjoyed being somewhere else, [and thus they have]
some difficulties knowing what the motherhood role
is all about. (4: 22–27).
A variety of solutions are possible. One concerns
either acceptance or rejection of the maternal role to
avoid the long-term consequences of unresolved conflict.
And there are an awful lot of people who need to be
helped to see that motherhood may not be the right
direction for them, but it always has to be their
choice, but its nice to let them see what their choices
might be. (4: 324–327)
Another solution concerns educating women to have
a realistic view of parenting, as the following quote
illustrates.
ypeople just think oh I can do my Ph.D. while I
have my baby and they realise that it’s very hard to
get enough done while you’re having a baby and I
think we’re not realistically giving people an idea of
what it’s like to have a baby. (11: 676–678)
Postnatal depression is an overstated reaction to the
transition to motherhood
In this frame, the transition to motherhood, i.e., the
experience of ‘becoming’ a mother is the dominant
feature, and part of this transition is a tendency to
exaggerate the negative aspects of the experience.
ysometimes I think women pathologise themselves
where the natural transition now to motherhood is
‘Oh no I have postnatal depression’ where
they’re actually feeling something normal which is
the chaos of ‘I have to adjust to my life. I can’t go to
a restaurant any more, or go to the movies, I have
the baby to think about’. Which is all pretty
depressing. I mean, your life, it’s such a transition
to a different life, when you have the kids. And
often they, the normal transition I think can get
pathologised. ‘I had that postnatal depression.’
(11: 54–61)
Some participants consider that one of the causes of
the problem is women’s inability to accept the changes
that accompany the experience of parenting a young
infant. Women who do not accept the transition to
motherhood may come to believe that they are
postnatally depressed, one participant remarking:
Well I think that we now talk about it as if ‘‘Oh look
I had a bit of postnatal depression.’’ You don’t have
a bit of a serious mental health problem. (6: 71–71)
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Thus postnatal depression is used as a way of
identifying a cause of feeling less, rather than more,
competent.
I guess having a baby is discovering the mother
within, and that’s a process that takes time where one
feels more or less competent on various days. (11:
341–342)
Remedies in this frame are about assisting women to
negotiate the transition, and include strategies to engage
the mother in the transition and possibly distract her
from a focusing too intently on herself:
And if we can help people in life transitions, be it
retirement or whatever, any transition hopefully
shakes up a person be it because of the transition,
and we grow and learn. You know, we could more
positively frame it. (11: 213–215)
So I would often do mother–infant work. Say where I
feel the mum isn’t in tune with the baby to help notice
how the baby is responding to her when she actually
isn’t aware. (11: 297–299)
Postnatal depression may be the inevitable result of a
society that under-values motherhood
This frame concerns society undervaluing of the
maternal role, and is discussed by participants whose
experiences have brought them into contact with women
and their children on a day-to-day basis, in maternal and
child health services for example. While cause in the
fourth frame parenting in a hostile world concerns the
social and financial context in which families rear young
children, issues of financial security for example, this
frame concerns the isolation of women and young
children from the rest of society.
It is a public health issue, but it’s also very much a
community issue, and I think that the people who’ve
said that parenting isn’t valued are right. Nothing
that doesn’t earn a high salary and have a long
training period is valued. (4: 56–58)
The problem is tied up with women being ‘shut out’
of, isolated from, broader society.
I think our culture very much devalues and isolates
women having children and I think that is a
profoundly dysfunctional aspect of our culture.
And it’s not just women, it’s men. I think new
families are unsustainably isolated and ill-supported
by contemporary western culture. (3: 12–16)
For women then, depression is an understandable
response to this.
So I think thatybecause our systems are so poor,
that, you only really need a low susceptibilityyto get
depressed as a result of the lack of support and the
physical exhaustion and the social isolation that you
might be experiencing for the first time. (3: 55–59)
The cause is partially identifiable through a perceived
attitude to mothers that tells them that they must take
responsibility for their choices. An evaluation of our
culture is apparent here.
And I think there’s a sense, which we’re pretty close
to in contemporary culture that, well ‘you decided
that, you chose to have a child, it’s your fault. You
cope with it, you manage it’. (3: 342–344)
One remedy concerns changing attitudes.
I think there is an environment where one can feel
valued for one’s role as a parent and have a sense that
the community actually values what you’re doing,
through parenting. (3: 339–342)
So we need to, there’s still a lot of attitudinal work
that can be done about, you know, women getting
the support that they need, that their lives are safer
and more secure. I think you can change some of
those things. That you can also have a great deal of
impacty(9: 322–326)
How such interventions would be undertaken, how-
ever, remains unspecified. Along with this call for
changes in community attitudes and values is a
summons to rename postnatal depression as postnatal
distress, to make the difficulties associated with mother-
hood more visible and society more responsive.
And I think we should be talking about distress, and
I think we have to, we’ve been trying hard, and think
it has been happening that there’s an increased
awareness of the stress and difficulty new parents
face. And an increasing emphasis on local govern-
ment, child care, families, neighbourhoods, political
systems, state and federal governments in doing
things to make parenting a little easier. (3: 237–242)
Table 2 summarises each frame identified with respect
to the four functions of framing following Entman
(1993).
Discussion
The underlying issue we were seeking to address was
whether particular solutions or policies have a tendency
to be adopted because there has been insufficient
reflection on problem setting and alternative problem
framing. A simple thematic analysis of our data would
have supplied a description of problem, solutions and
issues. A framing analysis, on the other hand, allowed us
to delve deeper into meaning behind words and
ARTICLE IN PRESSB. Lloyd, P. Hawe / Social Science & Medicine 57 (2003) 1783–17951790
ARTIC
LEIN
PRES
S
Table 2
Postnatal depression frames identified in interviews with 10 health decision-makers
Frame Define the problem Diagnose the source Make evaluative judgement Suggest remedy
Innate vulnerability A psychiatric category Vulnerability to depressive
illness; psychological and social
risk factors
Correct diagnosis of women with
‘true’ postnatal depression
Improved services for women
diagnosed with depression
Crises in coping Inability to cope with the task of
parenting
Source is not specified Outcomes more important than
correct diagnosis
Focus on needs of individual—
therapeutic or community
approaches
Chain of negative consequences Consequences for women and
families, particularly the children
of women who have experienced
depression
The source is largely
unrepresented in the frame
Women as effective parents Individual therapy to solve the
potential problems of infants,
partners and children across
generations
Parenting in a hostile world Socio-economic circumstances in
which parenting takes place
Social and economic conditions Societal responsibility, not just
health system
Cognitive behaviour therapy;
change social structures;
improved communities;
changing community attitudes
Role conflict Depression results from women
taking multiple roles
Juggling roles; conflict Acceptance of the motherhood
role over others to reduce the
conflict
Therapeutic approaches to assist
the woman to resolve her conflict
The transition to motherhood Incomplete transition to
motherhood/failure to uncover
‘the mother within’
‘Pathologising’ the feelings
associated with a normal
transition to motherhood
Women must allow themselves
to accept the transition
Therapeutic approaches to assist
women to negotiate the
transition
Undervalued motherhood Parenting, mothering, not a
valued occupation
Social and psychological
isolation of women with young
children
Evaluation of culture that
encourages women to have
children, and then leaves them to
cope with difficulties
Changing community attitudes;
make difficulties associated with
parenting more visible
B.
Llo
yd
,P
.H
aw
e/
So
cial
Scien
ce&
Med
icine
57
(2
00
3)
17
83
–1
79
51791
language that may even be invisible or unquestioned by
the speaker. The creation of a more open-handed
professional discourse can be threatening in exposing
inconsistencies in logic and making any dissonance of
ideas apparent. We witnessed frustration from partici-
pants when they felt only able to offer simple solutions
to what they fear are complex problems. Had we looked
only at formal discourses in national and state-level
policy documents, this would have given just a partial
view compared to the rich discussion of postnatal
depression we captured here.
The postnatal depression frames identified in this
study reveal discourses about a range of issues including
maternal subjectivity, the role of society, of health
professionals, the institution of ‘health care’, and the
philosophical and professional tensions among the
different players trying all ostensibly trying to ‘help’.
The framing approach served its purpose, which was to
expand understandings of professional views of post-
natal depression, and to provide a framework for
examining the theories, values and ideologies which
inform the way helping professionals think about the
problem.
Three general approaches to solving the problem of
postnatal depression are evident in the frames. These are
individual therapeutic approaches, social competence
approaches and societal approaches. Formal biomedical
discourse about postnatal depression is best represented
in the first frame identified here as Innate Vulnerability.
Here postnatal depression is lodged in the positivist
traditions of epidemiology, with its emphasis on causal
relationships between risk factors and mental health,
and psychiatric discourse with its emphasis on diagnos-
tic categories (Brown, 1990; Brown, 1995; Wearing,
1994). With respect to solutions, postnatal depression
requires appropriate diagnosis, followed by treatment
only for those women who meet criteria for depression,
these women being ‘the proper business of psychiatry (2:
322).’ The emphasis on individual risk factors restricts
preventive approaches to postnatal depression to the
early identification and design of specific interventions
for women at risk.
Social competence approaches incorporated frames
that sought to shift women from the mode of ‘not-
coping’ to the mode of coping. This was evident in the
second frame Crisis in Coping and in the sixth frame
Overstated Reaction to the Transition to Motherhood.
Here motherhood is a ‘process that takes time, where
one feels more or less competent on various days’ (11:
341–343) and the skill comes in focusing women more
towards the competent end of this spectrum. In this
approach the mother is discouraged from ‘pathologis-
ing’ a normal experience. Even the professionals
themselves prefer not to dwell too much on the formal
name of the condition being experienced, exemplified by
the comment ‘if you look at caseness you may obscure
effective work’ (10: 289–293). Tactics to assist the
mother lie in helping her to accept ups and downs,
being able to ask for help and in teaching mothers new
skills, like picking up on communication cues from their
babies.
A third set of alternative understandings of postnatal
depression were located by participants in the social
environment in which parenting takes place. For
example, in the frame identified as Parenting in A
Hostile World, postnatal depression is viewed as a
condition related to social adversity. Here, even the most
resilient woman may be at risk of depression. Similar
issues arose in the seventh frame Undervaluing of
Motherhood. Postnatal depression is identified with
respect to struggling with roles and maternal identity
as evidenced in the fifth frame Role Conflict. These
frames reflect concerns with the impact of the social
environment on women’s well-being after childbirth. All
suggest that there may be solutions to the problem of
postnatal depression that do not involve a separation of
women who are experiencing depression from those who
are not. For example, Role Conflict can be conceptua-
lised as a societal rather than a psychological issue,
stemming from competing discourses about women’s
roles, and a social environment that does not always
lend adequate or appropriate support to women’s
choices.
Significantly, part of a solution suggested in the
seventh frame, Undervaluing of Motherhood, was to
discard the use of the term postnatal depression in
favour of the term postnatal distress. This is also evident
in the sixth frame—Overstated Reaction to the Transition
Motherhood. We interpret this as an attempt to
deactivate the dominant biomedical framing of post-
natal depression. Changing the name of the disorder has
considerable symbolic value. It is an example of acute
ontological tensions between the dominant biomedical
paradigm and alternative paradigms that were identified
in this study.
We witnessed immense frustration among participants
as they talked through issues contained within the
societal-level frames (frames 4, 5 and 7). Even among
participants who strongly advocated individual thera-
peutic approaches to postnatal depression, there was an
acknowledgement of the failure of these interventions to
provide sustainable improvements to the mental health
of women with young children. Framing postnatal
depression as a societal-level issue raises feelings of
helplessness in the face of the breadth of the problem.
The dominant training paradigm of health professionals
is one-to-one helping and this may inevitably reduce the
capacity of health professionals to articulate solutions
that move beyond this domain. It may reduce the sense
of efficacy that professionals have in the face of these
broader issues. Significantly, participants did not lack
clarity when describing societal influences on mothering
ARTICLE IN PRESSB. Lloyd, P. Hawe / Social Science & Medicine 57 (2003) 1783–17951792
(the problem end of the spectrum), but they did not offer
solutions to this with any parallel degree of specificity.
For example, ‘a bit of support and some community
style interventions’ (9:17–29) were named as solutions
but were not easily elaborated. Participants could not
elaborate on these approaches in terms of underlying
theories. No participant mentioned the theoretical
underpinning of social interventions, or why they should
be ‘better’ solutions, even though a significant literature
supporting ecological (environment) level interventions
exists (Vincent & Trickett, 1983; McLeroy, Bibeau,
Steckler, & Glanz, 1988). Participants could more
readily invoke Theories of the Problem than Theories
of the Solution. (McLeroy et al., 1993). The solution-
level theories that did emerge (such as building coping
skills), were all at an individual level. The societal-level
suggestions, by being poorly articulated, were in effect
‘damned by faint praise’ (to quote Alexander Pope).
Does framing postnatal depression either as a
psychiatric disorder or a societal disorder matter? The
consequence lies in where solutions are sought. When
the mind is preoccupied with individual therapeutic
approaches, opportunities to consider alternative solu-
tions to the problem of postnatal depression may be
precluded. That is, the difficulties, isolation and stress
experienced by many women with small children,
irrespective of a diagnosis of depression are not the
focus. The peer-reviewed literature’s almost exclusive
preoccupation with risk factors, their identification, or
more recently their use in screening instruments for
depression, particularly in the antepartum (Brugha et al.,
2000; Webster, Linnane, Dibley, & Pritchard, 2000)
appears to have had little impact on the prevalence of
depression and distress after childbirth. Solutions to the
problem of postnatal depression that result from
individual and remedial ways of thinking have a
tendency to reduce the complexities of the social and
cultural context to explanations of intra-psychic pro-
cesses (Busfield, 2000). For example, one national policy
document on postnatal depression in Australia actually
refers to first-time parenthood as ‘the psychological
transition from individual to parent’ (Pope, 1995, p. 14)
(italics added). In our study, cognitive behaviour
therapy was suggested by some participants, to help
women reinforce themselves against the implications of
socio-economic hardship. It was offered as an individual
solution to provide women with the cognitive and
emotional stamina to help them endure what may be
unfair, untenable or even threatening situations.
The concept of distress or unhappiness after child-
birth, rather than depression, removes the experiences of
women from a psychiatric context into the social and
cultural context in which they mother. This acknowl-
edges the difficulties experienced by women as mothers,
and of women more generally. The research literature
suggests that postnatal depression differs little (in terms
of quality or of prevalence) from depressive episodes
that occur at other times in women’s lives. Some
participants felt that there is little reason for identifying
it as anything other than ‘depression’. This supports the
view that its temporal relation to the event of childbirth
should not endow depression and distress occurring
after childbirth with a distinctive status. Depression
occurring as the result of other events, for example,
divorce or retirement, are not accorded such status, as
one of this study’s participants pointed out. Defining
postnatal depression as a reaction to a discrete event
may not draw us into solutions more satisfactory than
we already have. Debriefing mothers after particular
types of birth events for example, has recently shown no
difference to rates of depression (Small, Lumley,
Donahue, Potter, & Waldenstrom, 2000). Interestingly,
this failure was greeted with a lively discussion of the
methodological design of the study in question (Bland,
2000; Lumley & Small, 2000; Powell & Davies, 2001;
Small & Lumley, 2001; Stallard, 2001). Significantly,
only one set of commentators drew attention to the
larger issue of how the problem was being theorised, by
noting that debriefing is aimed at preventing posttrau-
matic stress disorder, not depression (Boyce & Condon,
2001).
Successful prevention at a population level may
require alternative understandings of mental health
problems that conceptualise conditions like depression
as constructs in dynamic relation to the social, historical,
cultural, economic and political context. It may be
possible to do this without taking away the care and
attention for the small proportion of women whose
pregnancy triggers psychosis or an intractable episode of
major depression. We are reminded that Thomas Szaz’s
seminal work denouncing ‘mental illness as myth’ was
scorned for trivialising the biochemical imbalances
involved in psychosis (Szasz, 1960). But at the same
time his essay and subsequent book made huge strides in
showing how social processes of society itself distribute
responsibility and blame for illness.
Tension between psychiatric/medical discourse and
other discourses in health is a central feature of this
study. To empower social competence and societal level
ways of framing, we will have to overcome the authority
of the medical discourse and its tendency to capture
those not even trained within that profession. Prospects
here are somewhat dim. A number of researchers have
paid particular attention to the social construction of
knowledge and its relationship to the authority of the
medical profession (Atkinson, 1995; Fisher, 1991;
Harper, 1995; Wearing, 1994). Wearing showed that
non-medical health professionals (for example, nurses
and social workers) exhibit a ‘knowledge dependency’
on psychiatric classification of neurotic and psychotic
illnesses, despite the fact that their own training
programs contain increasing content on the social and
ARTICLE IN PRESSB. Lloyd, P. Hawe / Social Science & Medicine 57 (2003) 1783–1795 1793
cultural context of mental illness. (Wearing, 1994). Thus
lower status professionals come to ape the language and
discourse of the higher status professionals while
perpetuating the status quo. To encourage confident
rethinking in this area, we may have to encourage
mastery of new language.
Acknowledgements
The authors wish to acknowledge the study partici-
pants, who unhesitatingly interrupted busy professional
schedules to give thoughtful responses to our questions.
We also thank the two anonymous reviewers whose
comments contributed to the revised version of this
paper.
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