526 Women’s Health Psychology
have done everything they can to con“rm that they are
truly infertile. Women such as these report relief when they
“nally stop treatment (Lee, 1998). Furthermore, couples un-
dergoing infertility treatment can be faced with “nancial
hardship because of the high cost of ongoing treatment.
For many women, treatment subsequent to the infertility
procedures ultimately may involve efforts to promote accep-
tance of their infertility and exploration of alternatives to
childbirth (e.g., surrogate motherhood, adoption, remaining
childless). However, these options bring their own unique set
of challenges, stressors, and stigma. It is vital for health
and mental health providers to recognize and appreciate
the enduring and pervasive consequences of infertility for
those who remain childless by chance as opposed to choice
(Cooper-Hilbert, 1998; Lee, 1998). To understand the nature
of these reactions and psychosocial consequences, there is a
great need for further research„especially research employ-
ing appropriate comparison groups.
Postpartum Reactions
Although the frequency of many psychiatric disorders is
increased in the postpartum period, three puerperal conditions„
postpartum dysphoria, depression, and psychosis„have been
described most commonly, with the increased onset most evi-
dent within 30 days following childbirth (e.g., Llewellyn et al.,
1997; O•Hara & Swain, 1996). Postpartum dysphoria, which
has also been referred to as •baby bluesŽ or postpartum blues,
is a mild and transient condition involving tearfulness and de-
pressed mood that peaks at about the “fth day postpartum and, in
large part, has been attributed to normal hormonal ”uctuations
following childbirth (O•Hara, Schlechter, Lewis, & Varner,
1991). Postpartum dysphoria appears to be independent of
speci“c sociocultural or environmental factors and consistent
across cultures (Kumar, 1994). Estimates suggest that 26% to
85% of all mothers experience postpartum blues, the wide range
due to differing assessment techniques across studies (O•Hara
et al., 1991). Postpartum dysphoria, which usually resolves
within ten days without treatment, has yet to be established as an
entity clearly distinct from normal experience.
Postpartum depression is more severe and persistent than
postpartum dysphoria, with symptoms resembling those of
other forms of major depressive disorder. This condition oc-
curs in 10% to 16% of women in the “rst six months after
they have given birth, with onset usually within two weeks of
childbirth (Llewellyn et al., 1997; O•Hara & Swain, 1996).
Community-based surveys„many of which used the
Edinburgh Postnatal Depression Scale„indicate that rates of
postpartum depression seem to be relatively consistent across
countries, although estimates tended to vary when other
assessment tools were employed and depending on how the
time frame of the postpartum period was de“ned (see Lee,
1998). In addition to signi“cant physiological changes fol-
lowing delivery, major adjustment is required because of
changing social and personal circumstances, especially with
the birth of the “rst child. Although psychosocial stressors
and hormonal shifts have been suspected of playing a role in
the development of postpartum depression, prior psychiatric
history is a signi“cant and well-documented risk factor: 20%
to 30% of women with a history of major depression prior
to conception develop postpartum depression, and a prior
episode of postpartum depression or depression during a pre-
vious pregnancy increases a women•s risk following subse-
quent pregnancies (50% to 62%; Llewellyn et al., 1997;
O•Hara & Swain, 1996). During pregnancy, 10% to 16% of
women meet the diagnostic criteria for major depression
(Llewellyn et al., 1997). Psychosocial factors implicated in-
clude life events (e.g., marital discord), limited social support
of an appropriate nature, and personality factors (Kumar,
1994; O•Hara et al., 1991; O•Hara & Swain, 1996). Unrealis-
tic societal stereotypes that bias women to expect that moth-
erhood and maternal-infant bonding come immediately and
easily, and are natural phenomenon that are always positive
and ful“lling, may also have implications for the development
of postpartum depression (Kumar, 1994; Lee, 1998).
The most severe, albeit rare, of the three postpartum con-
ditions is postpartum psychosis, which occurs in one to two of
every 1,000 deliveries and across all societies as far back as
150 years (Kendell, Chalmers, & Platz, 1987; Kumar, 1994).
Symptoms are similar to those of schizophrenia, but the con-
tent of hallucinations and delusions often involves themes as-
sociated with pregnancy, childbirth, or the baby, and suicidal
and infanticidal ideation can be present. Symptoms similar
to an organic brain syndrome (e.g., confusion, attentional
de“cits, clouding of the senses) have also been noted. More
than 50% of women with this disorder also meet criteria for
postpartum depression (Kendell et al., 1987). The primary
risk factors include a family history, but particularly a per-
sonal history, of psychiatric illness (e.g., bipolar disorder),
with women who experience postpartum psychosis at ele-
vated risk for later episodes. It appears that a diathesis
(biological predisposition) stress (childbirth) model may best
explain postpartum psychosis at this point, because research
generally has not con“rmed an association between this dis-
order and purely biological factors or social factors (e.g., prior
life events, social support or marital discord; see Lee, 1998).
Although the onset of postpartum psychosis ordinarily is
rapid, occurring in the “rst 48 to 72 hours to two weeks post-
delivery, risk remains high for several months (Kendell et al.,
1987); therefore, women with a psychiatric history should be
monitored closely. The prognosis for postpartum psychosis is
much more positive than for other psychotic disorders, yet the