The Relational and Cultural Dimensions of Postnatal Depression: A

Comprehensive Literature Review

Xiuqi Liu

College of Liberal Arts and Sciences, University of Iowa, Iowa City, 52240, U.S.A.

Keywords: Postnatal Depression, Cultural Differences, Stress.

Abstract: There are multiple theories about the causes of postpartum depression (PDD). Genetics, hormones, social

environment, and other physical and psychological factors can change parents' condition. As a result, the

global rate of postpartum depression in mothers went from single digits percent to over 50 percent. One of

the main consequences of PDD is a high risk of suicide. However, there is only a vague idea of how

postpartum depression manifests itself in different ways for both sexes. What causes these differences? What

causes postpartum depression in partner and maternal, apart from biological factors? This review describes

the development of Postnatal Depression in recent years, from being ignored to being gradually classified into

maternal and paternal postpartum depression, and explains the relationship between them. The article also

describes the factors that associated with PPD: marital satisfaction and cultural differences. For the last, the

review describes the common problems in the current research on PPD: insufficient diversity of samples in

Western studies and the limitations of the same treatment and intervention methods in different regions. The

article's significance is to invoke other researchers to consider discrepancies in PDD caused by gender, and

the differences in the effectiveness of interventions for PDD in different cultural contexts.

1 INTRODUCTION

In the early edition of the DSM, postpartum issues

were first mentioned as postpartum psychosis and did

not have a category. In the DSM-4, postpartum

depression (PPD) was included in the mood disorder.

Within the revision process, researchers once

considered there was no need to extend the definition

or other symptoms of postpartum depression, which

could be seen as the diagnosis and importance of PPD

developed lately (Segre and Davis, 2013). Currently,

PDD is defined as a major depressive episode that

occurs during pregnancy or within 4 weeks after

delivery (Serati et al., 2016). As the academic

research deepens, PDD is subdivided into maternal

postpartum depression and paternal postpartum

depression. Even during the whole trimester of the

pregnancy, the partner could have the chance to have

the symptoms of PDD (Rao et al., 2020). Therefore,

the diagnostic criteria and assessments of PPD also

evolve, from observation to detection of dopamine,

endorphin, or serotonin, etc. The inducement factors

of PPD also vary with deepened understanding from

psychology, and sociology, which will be discussed

in this literature review. This paper will focus on the

interaction of maternal and paternal postpartum

depression, marital relationships, and different

influencing factors in cultural differences.

2 MATERNAL AND PATERNAL

PDD: IMPLICATIONS AND

INFLUENCES

2.1 Maternal and Paternal Postpartum

Depression

PPD is not a single gender or single situation disorder,

it affects the status of the whole family. Both sides of

the partner could suffer from PPD, and even families

who adopt new members could experience PPD

(Adler et al., 2023). Many factors come together to

influence these family members, including family

mental illness history, social-economic status,

education level, and marital status (Alshikh Ahmad et

al., 2021; Ansari et al., 2021; Khadijeh et al., 2023 &

Wang et al., 2021). To be more specific, studies

consider that the PPD of one partner could predict the

psychological state of the other partner, which is

strongly correlated (Barooj-Kiakalaee et al., 2022 &

Zheng et al., 2022). As a result, PPD also produces

Liu, X.

The Relational and Cultural Dimensions of Postnatal Depression: A Comprehensive Literature Review.

DOI: 10.5220/0014053100004942

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 2nd International Conference on Applied Psychology and Mar keting Management (APMM 2025), pages 34-38

ISBN: 978-989-758-791-7

interactions and contagion effects among family

members in the same environment.

Although there is positive strong correlation

between couples’ psychological states, symptoms are

different between maternal PPD and paternal PPD.

For maternal PPD, patients showed internal

tendencies, such as crying, depression, loss of

interest, and guilt (Johansson et al., 2020). For

paternal PPD status, they display external tendencies

like anger, stress, and risky behaviors. The

differences on both sides commonly stem from

different expectations given by social roles. In many

developing countries, fathers could suffer from PPD

because of income, quantity of family, and financial

issues (Wedajo et al., 2023). In contrast, maternal

PPD would be more easily affected by physical

influences: family history of psychiatric and

pregnancy complications, especially gestational

diabetes (Agrawal et al., 2022). This difference in

introversion and extroversion reflects societal

expectations of different gender roles and highlights

the important role of marriage context in PPD.

2.2 PPD and Marital Satisfaction

PPD impacts on the long-term from individual health

to relationship stability of couples. Many studies

clearly show a correlation between PPD and marital

satisfaction. A good marital relationship can not only

provide emotional support but also relieve the mental

burden of postpartum partners and improve the

family’s sense of atmosphere.

Marital satisfaction is usually used to assess

happiness and relationship stability between couples

(Tavakol et al., 2017). Multiple researchers pointed

out that the rise of PPD has a strong negative

correlation with marital satisfaction (Odinka et al.,

2018 & Khalajinia et al., 2020). Besides, higher

marital satisfaction also predicts lower paternal

postpartum depression, which indicates that partner

relationships affect depression levels (Barooj-

Kiakalaee et al., 2022). In other words, the degree of

PPD fluctuates as the marital relationship dynamic.

The Stress-Buffering Model has proved that

supporting could reduce the negative effects of stress,

particularly when dealing with major life events

(Wheaton, 1985). Thus, emotional support is also an

important factor in PPD. Studies show that higher

emotional and social support is correlated with a

lower risk of PPD (Khadijeh et al., 2023; Khalajinia

et al., 2020; Cho et al., 2022 & Leonard et al., 2020).

Emotional support is not only shown as

understanding and company for partners but also

practical help and encouragement during postpartum.

Thus, partners would receive psychological comfort

during mood swings and practical help in the

parenting process. In general, the positive family

atmosphere and social support brought about by high

marital satisfaction can effectively alleviate the

symptoms of postpartum depression.

2.3 Cultural Factors

Due to differences in cross-cultural variables such as

national development level, people’s cultural level,

economic status, and understanding of research scale,

some PPD measurement methods cannot be fully

used in extraction in different countries, resulting in

different results (Halbreich and Karkun, 2006 &

Wang et al., 2021). For instance, the relationship

between daughter-in-law and mother-in-law has

become an important predictor of PPD for some

cultures. In China, it is normal for women to live with

their husband’s family during marriage. Different

from the influence between husband and wife, a

disharmonious relationship with the mother-in-law

significantly increases the risk of PPD (Zheng et al.,

2022). Because of the value differences between the

old generation and the new generation with

expectations, conflicts between mother-in-law and

daughter-in-law became the effect factor for PPD. For

cultural reasons, whether or not one gets along well

with one's partner's parents is a factor that is rarely

considered in many Western PDD studies.

Apart from the impact caused by the forced

integration of two families, mothers in Asian

households often hold a culturally specific role. They

are expected to devote themselves to raising their

children after giving birth. As societal role

expectations evolve and life responsibilities increase,

mothers’ contributions to the family become more

significant yet often invisible, frequently perceived as

routine or taken for granted. Consequently, the lack

of additional support or care from other family

members during this period can result in feelings of

isolation and helplessness, potentially contributing to

PPD. Furthermore, cultural norms and expectations

imposed by elders place additional stress on mothers,

exacerbating their vulnerability to PPD. family

members rarely offer additional support or care in

response.

Under other cultural backgrounds, the risk factors

of PPD are also different. Due to political instability

and social conflict, the prevalence rate of PPD in

some Arab countries remains high, and Palestine

refugee women in Amman refugees are more likely

to suffer from PPD than other women in Irbid in

Jordan (Yoneda et al., 2021). The rise in PPD due to

The Relational and Cultural Dimensions of Postnatal Depression: A Comprehensive Literature Review

particular political factors is associated with post-

traumatic stress disorder (PTSD). It has been shown

that postpartum is associated with PTSD. PP-PTSD is

the strongest risk factor for PPD (Liu et al., 2021).

Overall, cultural, political, and social factors in

different regions have led to complex regional

differences in the risk of PPD. The existence of these

cross-cultural factors means that prevention and

intervention for PPD are needed on a global standard,

and these differences need to be taken into account.

3 DISCUSSION

3.1 Discussion and Suggestion

PPD is a global disease that faces significant

challenges in research since high-risk factors and

prevalence could change across cultures. It creates a

common challenge researchers face—the diversity of

sample populations. With limited diversity, the

research findings could be less valid. Differences in

cultural backgrounds and geographic locations may

be solved by self-report measures or questionnaires.

Researchers could choose to translate the language

into the local language and then translate the results

back. It could solve most issues but also expose

another problem: these scales were not initially

designed for different background countries and

language restrictions. Questions on the assessment

tools may not be entirely suitable for local people.

Besides, due to the diversity of cultural backgrounds,

impact factors for PDD in one region may not be

considered in another district; for instance, the

relationship between mother-in-law and daughter-in-

law resulting from cohabitation in a collectivist

society is rarely considered in a relationship between

couples living alone in an individualistic society. This

evidence proved that assessment tools could not be

sustained for various backgrounds.

Another limitation is the reliability of the self-

reported data. Due to the influence of social

desirability bias or misinterpretation, participants

may hide or underestimate their symptoms. In more

than half of the cases, potential patients refused to

disclose their symptoms (Carlson, 2024). Disparities

in understanding PDD are also evident. Cultural

norms often lead patients to feel ashamed or

dismissed, discouraging them from seeking help.

These cultural influences exacerbates differences in

awareness and prioritization of PDD across regions,

contributing to an uneven recognition of the

condition. Since the research sample size and regional

development are the key predictors of PPD

prevalence, addressing these limitations is essential

(Wang et al., 2021). Improving cross-cultural validity

in PDD research not only enhances the universality of

findings but also guides the creation of more inclusive

and culturally sensitive assessment tools.

3.2 Limitations of Treatment and

Intervention Approaches

Traditional treatments include medications, such as

antidepressants, intravenous injections, and

psychotherapy. This standardized treatment method

requires observation of the treatment effect based on

individual preferences. Different countries and

regions make this tendency more obvious. For

example, in religious countries, patients may prefer to

seek spiritual support from religious leaders or

through religious rituals. Religious counseling and

prayer may be more acceptable to these populations

than standard medication or psychotherapy. In some

other areas, traditional therapies (such as herbal

remedies, acupuncture, etc.) are considered more

natural and safer for the treatment of PPD and may be

preferred. Although community and family support

can partially replace formal therapy in areas where

mental health services are scarce, they often lack

professionalism, may not provide timely

psychological intervention, and may even be

misleading.

Many standardized psychotherapies, such as

cognitive behavioral therapy (CBT), were originally

developed within a specific Western cultural

framework, which may limit their ability to identify

culturally specific depressive symptoms. Applying

these methods directly to patients from various

cultural backgrounds risks reducing their

effectiveness. These cultural mismatches highlight

the need for treatment approaches beyond medication

to be adapted with greater cultural sensitivity.

Without sufficient flexibility, global standards for the

diagnosis and treatment of PPD may fail to address

diverse cultural needs, ultimately resulting in

suboptimal treatment outcomes.

4 CONCLUSION

This review explores the evolving definition of

postpartum depression (PPD) in recent editions of the

DSM. Currently, PPD is categorized into two distinct

forms: maternal postpartum depression and partner

postpartum depression. Within a marital relationship,

the mental health of partners strongly influences each

other, exhibiting a significant positive correlation.

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However, this correlation does not indicate that the

two forms of PPD are identical. Maternal PPD is

more likely to be influenced by internal factors, such

as physical health, pregnancy-related complications,

and a family history of psychiatric disorders. In

contrast, paternal PPD is often shaped by external

social role pressures.

In addition to marital dynamics, cultural factors

significantly impact the manifestation of PPD. Cross-

cultural differences introduce diverse variables, such

as generational communication conflicts in

cohabiting households and the instability caused by

political and social unrest in certain regions. These

cultural variations highlight the necessity for region-

specific prevention and intervention strategies for

PPD. Moreover, the assessment tools used for PPD

diagnosis must account for cultural diversity,

ensuring flexibility and effectiveness to achieve

global standardization in testing.

Future research should focus on developing

culturally sensitive assessment tools that consider the

unique sociocultural factors influencing PPD in

different regions. Longitudinal studies investigating

the interplay between maternal and paternal PPD can

provide deeper insights into their bidirectional

influence. Additionally, research exploring the

effectiveness of culturally tailored interventions and

prevention programs will be essential in addressing

the global diversity of PPD experiences.

REFERENCES

L. S. Segre, W. N. Davis, Postpartum Depression and

Perinatal Mood Disorders in the DSM (2013) Available

online at: https://www.postpartum.net/postpartum-

support-international-the-dsm5/

M. Serati, M. Redaelli, M. Buoli, and A. C. Altamura,

Perinatal major depression biomarkers: A systematic

review. J. Affect. Disord., 193, 391–404 (2016)

W.-W. Rao, X.-M. Zhu, Q.-Q. Zong, Q. Zhang, B. J. Hall,

G. S. Ungvari, Y.-T. Xiang Prevalence of prenatal and

postpartum depression in fathers: A comprehensive

meta-analysis of observational surveys, J. Affect.

Disord., 263, 491–499 (2020)

L. Adler, I. Yehoshua, & M. Mizrahi Reuveni, Postpartum

depression among fathers with children born through

surrogacy: A cross-sectional study. J. Psychiatr. Pract.,

29(1), 3–10 (2023)

H. Alshikh Ahmad, A. Alkhatib, & J. Luo, Prevalence and

risk factors of postpartum depression in the Middle

East: A systematic review and Meta–analysis. BMC

Pregnancy Childbirth, 21(1) (2021)

N. S. Ansari, J. Shah, C. Dennis, & P. S. Shah, Risk factors

for postpartum depressive symptoms among fathers: A

systematic review and meta ‐ analysis. Acta Obstet

Gynecol Scand, 100(7), 1186–1199 (2021)

H. Khadijeh, K. Maryam, S. Nadereh, & Z. Maryam,

Structural model of postpartum depression based on

social support and marital satisfaction by Mediating

Resilience. J. adv. biomed. sci. (2023)

D. Wang, Y-L. Li, D. Qiu, & S-Y. Xiao, Factors influencing

paternal postpartum depression: A systematic review

and meta-analysis. J. Affect. Disord., 293, 51 – 63

(2021)

O. Barooj-Kiakalaee, S.-H. Hosseini, R-A.

Mohammadpour-Tahmtan,M. Hosseini-Tabaghdehi, S.

Jahanfar, Z. Esmaeili-Douki, & Z. Shahhosseini,

Paternal postpartum depression ’ s relationship to

maternal pre and postpartum depression, and father-

mother dyads marital satisfaction: A structural equation

model analysis of a longitudinal study. J. Affect.

Disord., 297, 375–380 (2022)

J. Zheng, K. Sun, S. Aili, X. Yang, & L. Gao, Predictors of

postpartum depression among Chinese mothers and

fathers in the early postnatal period: A cross-sectional

study. Midwifery, 105, 103233 (2022)

M. Johansson, Y. Benderix, & I. Svensson, Mothers’ and

fathers’ lived experiences of postpartum depression

and parental stress after childbirth: A qualitative study.

Int. J. Qual. Stud. Health Well-being, 15(1), 1722564

(2020)

L. F. Wedajo, S. S. Alemu, M. A. Tola, & S. M. Teferi,

Paternal postnatal depression and associated factors:

Community-based cross-sectional study. SAGE Open

Med., 11 (2023).

I. Agrawal, A. M. Mehendale, & R. Malhotra, Risk factors

of postpartum depression. Cureus. (2022)

Z. Tavakol, Z. Behboodi Moghadam, A. Nikbakht

Nasrabadi, H. Salehiniya, & E. Rezaei, A review of the

factors associated with marital satisfaction. Galen Med.

J., 6(3) (2017)

J. I. Odinka, M. Nwoke, J. C. Chukwuorji, K. Egbuagu, P.

Mefoh, P. C. Odinka, K. U. Amadi, & R. C. Muomah,

Post-partum depression, anxiety and marital

satisfaction: A perspective from southeastern Nigeria.

S. Afr. j. psychiatry, 24 (2018)

Z. Khalajinia, V. Akbari, P. Rahmatinejad, M. Shater, & M.

Vahedian, Investigation of the relationship of perceived

social support and spiritual well-being with postpartum

depression. J. educ. health promot., 9(1), 174 (2020)

B. Wheaton, Models for the Stress-Buffering Functions of

Coping Resources. J. Health Soc. Behav., 26(4), 352–

364 (1985)

H. Cho, et al., Association between social support and

postpartum depression. (2022) Available online at:

https://www.nature.com/articles/s41598-022-07248-7

K. S. Leonard, M. B. Evans, K. H. Kjerulff, & D. Symons

Downs, Postpartum perceived stress explains the

association between perceived social support and

depressive symptoms. Womens Health Issues, 30(4),

231–239 (2020)

U. Halbreich, & S. Karkun, Cross-cultural and social

diversity of prevalence of postpartum depression and

The Relational and Cultural Dimensions of Postnatal Depression: A Comprehensive Literature Review

depressive symptoms. J. Affect. Disord., 91(2 – 3),

97–111 (2006)

Z. Wang, J. Liu, H. Shuai, Z. Cai, X. Fu, Y. Liu, X. Xiao,

W. Zhang, E. Krabbendam, S. Liu, Z. Liu, Z. Li, B. X.

Yang, Mapping global prevalence of depression among

postpartum women. Transl Psychiatry, 11(1) (2021)

K. Yoneda, M. Hababeh, A. Kitamura, A. Seita, & Y.

Kamiya, Prevalence and characteristics of Palestine

refugee mothers at risk of postpartum depression in

Amman, Jordan: A cross-sectional study. Lancet, 398

(2021)

Y. Liu, L. Zhang, N. Guo, & H. Jiang, Postpartum

depression and postpartum post-traumatic stress

disorder: Prevalence and associated factors. BMC

Psychiatry, 21(1) (2021)

K. Carlson, Postpartum depression. StatPearls (2024)

Available online at

https://www.ncbi.nlm.nih.gov/books/NBK519070/

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