Social and Cultural Influences on Women’s Health 527experience, which often involves inpatient psychiatric treat-
ment, can be devastating for women and their families.
For all the postpartum reactions discussed previously,
health psychologists and other care providers can play a vital
role in helping women and their families adjust and focus on
their strengths and resources to facilitate coping at a time
when childbirth results in unanticipated stressors. Additional
work is needed to add to the growing body of literature
reporting increased onset and/or exacerbation of anxiety
disorders, such as panic disorder and obsessive compulsive
disorder, during pregnancy and postpartum (e.g., L. Cohen
et al., 1996; Shear & Mammen, 1995; Williams & Koran,
1997). Postpartum psychiatric disorders and resulting mother-
infant bonding problems in the postpartum period have con-
sequences not only for the woman, but also for the developing
child in terms of cognitive de“cits, and emotional and behav-
ioral disturbances, for example (e.g., Martins & Gaffan, 2000;
L. Murray & Cooper, 1997; Sinclair & Murray, 1998). Re-
search and clinical attention to screen for, and address, these
issues is growing (e.g., Brockington et al., 2001). Prevention
efforts are needed not only to educate those women with a his-
tory of depression and anxiety about postpartum reactions
and possible consequences so that coping strategies can be
enhanced and activated ideally prior to birth, but also to en-
courage women to adopt more realistic expectations about
pregnancy, motherhood, and infant-mother attachment.
Peripartum Cardiomyopathy
Pertipartum cardiomyopathy (PPCM) is a rare, life-threatening
congestive heart failure of unknown cause that occurs most
often in the last trimester of pregnancy or the “rst six months
postpartum. It has been estimated that PPCM occurs in one of
every 3,000 to 4,000 pregnancies with approximately 1,000 to
1,300 women in the United States affected each year (Ventura,
Peters, Martin, & Maurer, 1997). While the criteria for diag-
nosing PPCM varies slightly because of the rarity of the disor-
der, the criteria most commonly referred to was established by
Demakis and Rahimtoola (1971). These criteria require the de-
velopment of cardiac failure during pregnancy or after delivery
as speci“ed previously in the absence of prior demonstrable
heart disease and determinable etiology for the cardiac failure.
In recent years, modern diagnostic echocardiography has pro-
vided evidence of left ventricular systolic dysfunction, which
has helped differentiate PPCM from shared pregnancy-related
symptoms that can mimic heart failure. Some of the common
symptoms shared between PPCM and pregnancy include pedal
edema, dyspnea, fatigue, weight gain, chest and abdominal
discomfort, and cough.
The identi“ed risk factors for PPCM include multiparity,
advanced maternal age, multifetal pregnancy, preeclampsia,
gestational hypertension, and African American race (Pearson
et al., 2000). It is unclear if racial status is an independent
risk factor or a result of an interaction of race and hyperten-
sion. While the etiology of PPCM remains unknown, current
evidence suggests PPCM is a type of myocarditis (in”amma-
tion of the muscular tissue of the heart) with proposed causes
such as abnormal immune responses to pregnancy, maladap-
tive responses to the hemodynamic stresses of pregnancy,
stress-activated cytokines, and prolonged tocolysis (Pearson,
et al., 2000). In some women, PPCM resolves completely
after delivery; however, there is a high mortality rate for
women who do not experience a resolution of symptoms
within six months following delivery (C. Brown & Bertolet,
1998), with mortality rates in the United States ranging from
25% to 50% (Lampert & Lang, 1995). Women with PPCM
appear to be at high risk for pregnancy complications or
mortality should they become pregnant again (C. Brown &
Bertolet, 1998; Lampert & Lang, 1995).
Because of the limited understanding of the medical etiol-
ogy of PPCM, the majority of research has focused on the
medical aspects, failing to address psychosocial factors re-
lated to PPCM and its impact. The sudden and unexpected
nature of PPCM compounds the stress for women and their
families, who are also adjusting to the physical and emotional
demands normally imposed by pregnancy and the birth of a
child. In one of few studies examining psychosocial factors
relating to PPCM, Geller, Striepe, Lewis, and Petrucci (1996)
studied a sample of women with PPCM admitted to a
heart transplant unit for evaluation. Factors such as stressful
life events (e.g., history of abuse or unstable relationships;
history of miscarriage or cesarean section), health-related
behaviors (e.g., substance use; nutritional/dietary concerns),
social support, and coping style were assessed (Geller,
Striepe, & Petrucci, 1994). In addition to the stressors of
pregnancy and the diagnosis of PPCM, these psychosocial
factors could potentially exacerbate the physical symptoms
or contribute to treatment-related issues, such as noncompli-
ance, comorbid psychological or substance abuse disorders,
and adjustment to lifestyle changes imposed by the illness.
Studies employing appropriate comparison cohorts are
needed to further evaluate these psychosocial factors.SOCIALAND CULTURAL INFLUENCES
ON WOMEN’S HEALTHEarlier in this chapter, we discussed the advances and short-
comings in the research and health care of women. It is im-
portant that strides continue to be made to better understand
how women•s expression of disease symptoms, potential
warning signs, and risk factors for both psychological and