Postpartum Depression: The Forgotten Mother Experience

: Background: Postpartum blues refers to the temporary mood depression experienced by new mothers due to hormonal changes, having new responsibilities due to having a baby, and parenting duties. This condition is a mood disorder that occurs after childbirth, reflecting psychological dysregulation. Purpose: This literature study aims to identify factors that influence the occurrence of postpartum blues, signs and symptoms, and the prevention and management of postpartum blues. Method: The method used in this literature study is a literature search from various sources, such as academic journals and online articles. A literature search was performed using keywords related to postpartum blues. Results: There are six studies on postpartum blues; factors that influence postpartum blues are primigravida mothers, age, salary, education, employment, breastfeeding process, health education after delivery, type of delivery, induction of labour and complications of labour, parity, pregnancy status, mother's readiness, readiness for childbirth, marital satisfaction, husband's support, and social support, as well as having economic tensions. While the signs and symptoms are sadness, crying easily, easily defeated, easily anxious, sensitive, unstable, feeling unable to care for the baby, feeling guilty, disturbed sleep, and eating disorders. Management and prevention of postpartum blues include massage, physical activity, use of vitamins and hormones, acupressure, and massage therapy. Conclusion: Health workers need to carry out screening and early detection so that appropriate treatment can be given and does not lead to postpartum depression.


Introduction
Childbirth is a major event in life, not only because birth implies a new birth, but also because of the process of birth itself (Hoffmann & Banse, 2021). In this period a woman will get and begin to take on a new role as a mother, through the puerperium. The postpartum period is a critical psychological transition period for mothers (Inekwe & Lee, 2022). During this period there was intense physical and emotional vulnerability (Tosto et al., 2023). This is caused by physical and psychological changes, as well as family structures that require an adaptation process (Al-Zahrani et al., 2021). Postpartum blues is related to a temporary condition of depressed mood in the mother as a result of hormonal changes, the responsibility of having a new baby, and having the task of caring for children. Post partum blues is a mood disorder that occurs after childbirth and reflects psychological dysregulation (Okunola et al., 2021).
Altered mental and emotional states occur from the early postpartum blues and place the mother at risk starting with the early stages of postpartum blues and progressing over time to postpartum depression and psychosis. Postpartum blues is a risk factor for more severe mood disorders in the postpartum period, so early diagnosis is needed in order to provide appropriate and fast support to the mother and avoid more severe mood disorders (Tosto et al., 2023).
In several studies it was stated that the prevalence of postpartum blues was 39%, with an average of 13.7% to 76%, which has been reported (Rezaie-Keikhaie et al., 2020). In addition, Ghosh & Bhat (2022) stated that the prevalence of postpartum blues was 28.8% with 14.2% developing postpartum depression (Ghosh & Bhat, 2022). The incidence of postpartum blues in Indonesia is relatively high, namely 37% to 67%. As many as 80% of primigravida mothers experience postpartum blues, and 10% -15% of these cases develop postpartum depression (Purnamaningrum et al., 2018). Meanwhile, the development of postpartum blues into major depression must be prevented because of the risk that the mother may be compelled to self-harm, commit suicide, or abandon her baby.
Postpartum blues is characterized by feelings of sadness and anxiety that can occur every day after giving birth. In addition, postpartum blues will cause the mother to not be interested in caring for her baby, to be unable to recognize the baby's needs, to cry often, even to death, and to lack self-confidence. In addition, the impact of postpartum blues that is not handled will result in the baby not getting exclusive breastfeeding so that growth and development is disrupted, then behavioral problems and emotional problems occur (Handayani et al., 2021). These symptoms usually occur on the third or fourth day, and the attacks usually peak on the fifth and fourteenth day after delivery (postpartum). If postpartum blues symptoms persist for more than two weeks, the woman may develop more significant symptoms of postpartum depression and postpartum depression. So it needs proper prevention and treatment of mothers who are detected postpartum blues.

Method
This study uses a literature review. Research data were obtained through literature review and empirical studies in previous research journals that focused on postpartum blues, postnatal blues, or baby blues. The intended data is a topic related to postpartum depression. From several sources, it is then narrated as reading material, meaning a systematic, explicit and reproducible method for identifying, evaluating and synthesizing research works and ideas that have been produced by researchers and practitioners.
According to (Okoli & Schabram, 2010), namely providing a theoretical background/base for the research to be carried out, studying the depth or breadth of existing research related to the topic to be studied and answering practical questions with an understanding of what has been produced by previous research. Data collection uses Google Scholar, Scopus, and Research gate data-based search engines. The research flow is presented in Figure 1.

Result and Discussion
The results of the study found that from the five articles analyzed, it was found what factors influenced that level. insecurities in adolescents and strategies that can help them overcome these insecurities. The five articles used have relevance and pay attention to research objectives. The following Table 1 reviews the results of the analysis in this article.
Postpartum "blues" are defined as low mood and mild depressive symptoms that are transient and selflimited. Postpartum blues is a normal postpartum event experienced by women after giving birth. This condition generally occurs on the third or fourth day, and peaks on the fifth and fourteenth day postpartum (K. Moyo et al., 2022).
Postpartum blues or baby blues is sadness that occurs 14 days after giving birth which can cause more severe mental disorders, namely postpartum depression, if not handled properly. Mood lability in the first 14 days postpartum is associated with psychiatric symptoms and is the strongest predictor of subsequent psychopathology.

Causes of Postpartum Blues
Postpartum blues is caused by husband's support (Renata & Agus, 2021;Utami & Nurfita, 2022), high levels of stress, parity (Handayani et al., 2021), abuse, depression during pregnancy, and marital dissatisfaction (Ghosh & Bhat, 2022), premature birth (Okunola et al., 2021) are also causes of postpartum blues (Hutchens & Kearney, 2020). According to Purwati & Noviyana (2020), concern for babies, tired mothers, comments from people around them about mothers, support and presence of husbands (Handayani et al., 2021), adaptation to the presence of babies are factors that can cause postpartum blues (Purwati & Noviyana, 2020). Data reported by Vaezi et al. (2019) who found no relationship between postpartum depression and education. This is inversely proportional to the research of Nurhayati & Sophia (2022), during the Covid-19 period the causes of postpartum blues were education, age, and economy (Utami & Nurfita, 2022 The results of this study were that the highest EPDS score on the first day was 12.33, and after the 9th day the EPDS score decreased to 6.86. The decrease occurred every day until the 9th day. score ≥ 3. All participants were randomly assigned to an intervention group (Self-EAR program) and a control group (standard postpartum care program). Data were analyzed using descriptive statistics, chi-square test, t-test, and repeated measure analysis of variance program's Self-EAR score of (p-value=0.002) and serum allopregnanolone concentration (pvalue=0.001). In the intervention group, the postpartum blues score was lower than the control group; in addition, allopregnanolone serum levels were much higher when compared to the control group.

Signs and symptoms
Postpartum blues is a psychological disorder of postpartum mothers with symptoms of sadness, crying easily, irritability and anxiety, sensitive, unstable, feeling unable to care for the baby, feeling guilty, disturbed sleep, and reduced mother's appetite (Purnamaningrum et al., 2018). If postpartum blues symptoms persist for more than two weeks, the woman may experience more significant symptoms of postpartum depression and postpartum psychosis (Thomas et al., 2018). In a study by Adeyemo et al. (2020) which was conducted in Nigeria, it was found that postpartum blues is one of the predictors that causes postpartum depression (Adeyemo et al., 2020). In Pius and Djoda's study, postpartum blues was not only a risk factor but an independent predictor of postpartum depression (Moyo & Djoda, 2020). So it is necessary to do early detection as a prevention of continuing postpartum blues (Okunola et al., 2021).

Postpartum Blues Screening
Screening or early detection as a prevention so as not to progress to postpartum depression (Okunola et al., 2021). There are 2 types of screening that can be used and their sensitivity and specificity have been tested, namely the Edinburgh Postnatal Depression Scale (EPDS) questionnaire and the Patient Health Questionnaire-9 (PHQ-9). The presentation results of sensitivity testing were 46.7% and 66.7% respectively; the test results for the PHQ-9 method were 46.7% and 73.3%, respectively (Sarli & Ifayanti, 2018).

Prevention and Management
Prevention of postpartum blues can be done early in pregnancy, including by conducting counseling and affirmative or mindfulness meditation and education during pregnancy so that it can reduce stress levels and can prepare oneself for a new role as a mother (Pan et al., 2019). Although the symptoms of mild postpartum blues are transient, and self-limiting, patients should still be screened carefully for fears of suicide, paranoia, or infanticidal ideas. In addition, sufficient rest is needed to help the patient through adequate sleep. For postpartum mothers who have mild symptoms, psychosocial management that can be done includes increasing support, such as peer support, bonding attachments (Ristanti & Masita, 2020), and counseling from health workers. This intervention is a first-line treatment for postpartum blues (Kallem et al., 2019). In addition, the use of Omega 3 and vitamin D (Dowlati & Meyer, 2021) can be given to postpartum mothers to prevent postpartum blues. Based on research by Abedi et al. (2018) that mothers who experience postpartum depression have an average Vitamin D lower than 25-OH-D (examination of 25-OH vitamin D levels) and moderate insufficiency and severe deficiency are higher in mothers with postpartum depression than normal women.
Postpartum blues is a mild emotional disorder that can be prevented by physical activity (Deniati et al., 2022;Kołomańska-Bogucka & Mazur-Bialy (2019) Kołomańska-Bogucka & Mazur-Bialy, 2019). Physical activity such as exercise is useful for restoring health conditions, accelerating the healing process, recovering and repairing post pregnancy muscle tension, especially in the back, pelvic floor and abdominal muscles and preventing complications. In addition, regular physical activity helps reduce depressive disorders. The mechanism of physical activity can increase the concentration of neurotransmitters such as 5HT (5hydroxytryptamine), dopamine, noradrenaline, and increase the secretion of BDNF (Brain-derived neurotrophic factors produced in the brain) because their content decreases when someone is experiencing depression (Kołomańska-Bogucka & Mazur-Bialy, 2019). Based on a meta-analysis, light or moderate physical activity can reduce symptoms of postpartum depression (Netochi Georgiana, 2021).
Giving massage can also relieve postpartum blues. One of the massages that can be applied is effleurage massage (Sarli & Sari, 2018). Effleurage massage on the mother's perineum which is carried out for 2 weeks can provide comfort and relaxation which will reduce levels of the hormone cortisol and increase the endogenous hormone morphine so that it can reduce postpartum blues (Kusumastuti et al., 2019;Sarli & Sari, 2018). Besides that, using self-empowerment-affirmationrelaxation (Self-EAR) therapy programs can be used as prevention of postpartum blues (Thitipitchayanant et al., 2018). Self-EAR is a program that integrates three techniques for mothers who experience grief after giving birth.
Based on case reports on postpartum blues patients, the use of classical music therapy, providing support and breastfeeding can control the patient's emotions, improve sleep quality, and mothers can breastfeed their babies. Symptoms that appear in mothers who experience postpartum blues are mothers who will be sad, cry easily, angry, worried, sensitive, unstable, feel unable to care for babies, feel guilty, sleep disturbances, and mothers experience appetite disorders. Prevention that can be given is by counseling or providing education to prospective mothers during pregnancy. One of the treatments that can be given is by giving vitamin D or omega 3.
Physical activity, music therapy, providing support, acupressure can relieve postpartum blues. Health workers need to carry out screening and early detection so that appropriate treatment can be given and it does not lead to postpartum depression. This is evidenced by the decreased score of the EPDS (Edinburgh post-natal depression scale) as an instrument for screening symptoms of post-partum depression, the scale decreased from 13 to 8 after being given intervention (Putri & Putri, 2022). In addition, complementary acupressure therapy can reduce EPDS scores (Bohari et al., 2020). Acupressure therapy is beneficial for reducing stress, fatigue, and postpartum depression (Luo et al., 2022). Emphasis on acupressure points involves a reaction between the hypothalamus, and the hypothalamus will convey a message to the pituitary gland/anterior pituitary to produce adrenocorticotropic hormone (ACTH). ACTH hormone will be produced when stress, depression, fear. With ACTH production causing overproduction of cortisol, endorphins and serotonin, all of which are stress relievers, natural pain relievers, provide comfort and pleasure, the body will naturally relax or feel happy (Pirnia et al., 2019).

Conclusion
Postpartum blues is a mental imbalance after giving birth which generally occurs in the first week of the puerperium. Postpartum blues is caused by internal (mother's fatigue, mother's role) and external (lack of husband's support) factors. Symptoms that appear in mothers who experience postpartum blues are mothers who will be sad, cry, angry, worried, sensitive, unstable and feel unable to care for the baby, feel guilty, sleep disturbances, and reduced maternal nutritional intake. Prevention efforts can be done by counseling or educating prospective mothers during pregnancy. Massage, physical activity, music therapy, providing support, acupressure can also relieve postpartum blues. Health workers need to carry out screening and early detection so that appropriate treatment can be given and it does not lead to postpartum depression.