Abstract
H istorically, postnatal depression (PND) was thought to be uncommon in non-Western societies, with the traditional support of non-industrialized communities considered to be protective.[1], [2] An increasing number of studies of PND in Asian communities suggest that this disorder does exist,3–5 although different factors may be involved. Leung et al. report domestic violence (mainly verbal) was a significant factor in their Chinese (Hong Kong) cohort.[6] In a similar group, Lee et al. reported that conflict with the mother-in-law is a predictor of PND and that the cultural practice of mandated family support did slightly decrease the incidence.[3] This was also found in a study on Taiwanese women.[5] This purpose of the present article is to review the cultural issues related to motherhood and PND in Korean women. It is worth noting there are a number of Korean communities in Australia.
MOTHERHOOD IN KOREA
Koreans have lived under the influences of Shamanism, Buddhism, Taoism and Confucianism; among these, the Confucian principle has dominated the Korean view of family. Thus, children incur a debt to their parents and their duty includes treating parents respectfully at all times, taking care of them in their old age, mourning them well at proper funerals, and performing annual memorial ceremonies for them after their deaths. In addition, they should have children (sons) and maintain the continuity of the bloodline. The typical family in previous generations was large, with three or four generations usually living together. Sons remained home after they married, while daughters went to live with their husband's family. The family should be run as a benevolent monarchy, the eldest man as household head, with patriarchal regulation of women and children.
Within this traditional family, being a daughter-in-law meant enduring the hardships of life, which used to be described as ‘hotter than hot pepper’. The daughter-in-law should obey her mother-in-law who had the power to send her back home; this would mean that she had to spend the rest of her life in disgrace and poverty. Her husband, who was supposed to respect and obey his mother, could not be of much help. A humorous Korean proverb says that a new bride must be ‘three years deaf, three years dumb and three years blind’. She should not be upset by scolding, rather she should not hear at all. She should not lose her temper and say things she might regret later, so it is better not to talk at all. She should also not criticize her new family, rather she should see nothing. Although the industrialization of the country has meant that many young married couples live in their own homes, separated from their extended families, the couple-orientated families are still positioned within the wider network of extended family relations.
Being pregnant and a mother brings with it an increase in status, as well as many traditional taboos (Table 1). After childbirth, a straw rope was hung across the gate to announce the arrival of a new baby. The rope was maintained usually for 3 weeks, during which outsiders could not enter the house and outings of the new mother and her family were also restricted.[7] This practice helped the family to relax and focus on themselves and to protect the newborn and the mother from possible infections.
Traditional pregnancy taboos in Korean society[12]
The mother is traditionally provided with special food for 21 days after childbirth. For the first 7 days, rice and seaweed soup were offered to aid her recovery. Meat soup and rice were prepared for the mother on the 14th and 21st days after birth.[7] Even during times of food shortage, rice and meat were procured for the mother. Eating hard, hot, cold, salt and spicy food was thought to cause dental problems and therefore prohibited. Exposure to cold water or cold wind during the first 3 weeks after childbirth was also discouraged because people believed it would cause chronic joint pains. Hard work during that period was also considered to cause a lifetime of health problems. Any strain on the wrist or waist was avoided because it was harmful to the joints. The taboos and rules of the puerperal period are still prevalent in contemporary Korea while the ones during pregnancy are now not as strict as before. Many mothers are very cautious to keep their body warm and to avoid any strain to the joints after childbirth. Some mothers decline showering, taking a bath and brushing their teeth for the first 21 days.
SINGLE MOTHERHOOD IN KOREA
What has been described so far relates to the traditional culture and beliefs surrounding childbirth in a family setting. The reaction of family and society is completely different when a pregnancy or childbirth takes place outside a family unit.
During the days of Confucius, young boys were separated from young girls from the age of 7, and boys and girls were not allowed to be together on their own. Affection or love played no part in the choice of a spouse because the parents, with the aid of a matchmaker, usually arranged the marriage. The couple generally did not meet until the day of the wedding and thus sex education was not necessary until a few days before the wedding. Korean society has changed a great deal since those days and the expression of affection is becoming a common sight on a campus or on the street. But the majority of Korean people still have a conservative view on sex; this is reflected in sex education in high schools, which emphasizes the importance of maintaining virginity rather than the provision of practical information. Mass-media, books, magazines and friends are the major source of teenagers' knowledge of sex.[8] The lack of advice and guidance results in increased unwanted pregnancy and abortion. Most teenage mothers have given little or no thought to pregnancy and contraception at the time of conception,[9] and only 8.9% of unmarried mothers use contraceptives.[10] With the growing need for practical guides for teenagers and their parents, sex is still such a private issue in Korea that a sex educator's lecture on television caused a national sensation in 1999. The educator became a celebrity after her late-night television lecture, ‘Beautiful sex for our children’, had drawn a record-breaking audience. She talked to the teenagers about pornography, rape and abortion and to the mothers as to how to talk to their sons and daughters about sex. However, she did not discuss contraception because she thought that South Korean society was not ready for that.
Most pregnancies occurring outside marriage in Korea end in termination; only 10% of teenage pregnancies proceed to full-term and delivery.[11] The reasons that unmarried mothers maintained the pregnancy were that they had not been able to arrange termination in time, that they were lacking money for termination and that they wanted a baby.[10] Fostering is common in babies born outside marriage.[12] This high rate of termination and fostering is due to the social stigma and the emotional and economical difficulty the mother and the baby have to face.
In one study, only approximately 30% of unmarried mothers, who were determined to raise their baby, told their family about the pregnancy; of these mothers, 41.3% were confronted with indifference, rejection and abandonment.[13] If the family does not support the mother, she has to find a place to stay for delivery and post-partum care. In many cases, institutions for the unmarried mother, public or private, become her temporary shelter.
Thus, for the family, having a daughter who becomes pregnant before marriage is a great source of shame. Even if her family accepts her, she witnesses the pain her family experience through being shunned by villagers and friends. Her sister or brother could also be rejected by future parents-in-law due to the pregnancy.
Social prejudice is harsh. An unmarried pregnant woman, if she was working, would not take maternity leave because she would not want her pregnancy known. She must give up her job and find another home after childbirth and keep her baby a secret. When the baby grows and goes to school, he/she also could be stigmatized in the class.
KOREAN IMMIGRANT MOTHERS
Like all immigrants, settling into a new country may present significant cultural challenges and stresses, isolation being particularly common. For women in this situation, to then become mothers means that they are faced with a medical system potentially at odds with their own beliefs and customs. A number of researchers have highlighted the importance of health professionals being trained in different cultural values and customs and for this to become integrated into normal obstetric care.[14] Choi and Yoo highlighted the importance of integrating traditional postnatal care in Korean-American women.[15], [16] Although this group has not been studied in Australia, Vietnamese, Filipino and Turkish women immigrants in Victoria, like their Australian counterparts, were more likely to be depressed if they were isolated and lacking support.[17]
POSTNATAL DEPRESSION IN KOREA
There are no large-scale epidemiological data on PND in Korea; it might be thought that the prevalence is low if the estimates are made on the basis of the number of patients who visited psychiatric clinics. A few articles written from the 1960s to 1980s by psychiatrists show that the average number of cases of PND referred to or visiting the psychiatry clinics in a university hospital was 5-6 per year maximum.18–20 Considering that approximately 900 000 babies were born yearly during the 1980s, cases of PND seen in clinical practice would appear to be extremely rare. More recent studies on PND in Korea have assessed obstetric patients. Some of these small-scale studies reported that 15-28% of mothers scored high on the Edinburgh Postnatal Depression Scale or Beck Depression Inventory during the postnatal period.21–23 Even with the methodological limitations of those studies, it may be said that the majority of the women with postnatal depression are not recognized by mental health professionals as they are seeking help elsewhere or not at all.
Causes of low recognition
There appear to be a number of possible causes for the low recognition of PND.
Depression as a normal part of mothering
The Confucian ideal of strict separation of male and female led to the division of labour into inside and outside work: caring for a baby was seen as the woman's role, which should not be shared with her husband. In those days, adjustment to the new role of being a daughter-in-law and a mother was regarded as a test for every woman of their ability to endure. Thus, negative emotions such as sadness, frustration, anger and anxiety experienced by a young wife were viewed as nothing unusual but accepted as a matter of course. The distinction of roles in household chores is still the norm in many families in Korea and the conservative majority believes that a husband who takes an active part in domestic work is radical. Without the husband's help, the workload for a wife after childbirth is huge. To Korean women, being a mother means the end of ‘easy free days’ and the beginning of responsibility and hard work. Therefore, from yesteryear until today, the hardship of child rearing and the accompanying distress has been considered de rigueur. If depressive symptoms develop, it is regarded as a necessary part of being a mother rather than an abnormal condition such as PND.
Family protection
Another reason why women with PND do not present may be related to the familial support and care given to the mother during pregnancy and puerperium. This is common to a number of Asian cultures.[3], [4] Because a big family was regarded as a blessing and the number of male offspring in a family coincided with prosperity, having many children was desired and childbirth has been the ‘business’ of the whole family. When pregnancy occurred, the future mother was treated better because she would give birth to a child of the bloodline. There were many rules and taboos that had to be observed to ensure a healthy child and safe delivery. All family members cooperated for the sake of the health of the child and mother.
Usually 3-4 weeks after childbirth, the routine of the family would return to normal. However, if a mother or baby develops serious problems, the whole family works together to resolve the crisis. Having and raising children is a key function of the family; accordingly, any concern about the mother or child rapidly mobilizes family resources. If the condition of the mother is deemed not good enough for her to be able to care for her baby, family members usually lessen her workload and take an active role in baby care. This might be therapeutic for mild to moderate depressive disorders and may decrease the need for professional help.
Alternative presentations
Another reason that patients may not visit psychiatric clinics could relate to an atypical, especially somatic, symptom presentation of Korean mothers with PND. For example, Sanhupung(post-partum disorder) is a postpartum pain syndrome, which is thought to be caused by inadequate post-partum care.[24] Although the most common complaint is polyarthralgia,[21] its symptoms include joint pain, a sense of coldness in joints, chill, chest tightness, headache, numbness, sleep disturbance, tiredness, dizziness and anxiety.
The oriental definition of health is the harmonious state between man and nature. Mind and body is seen as one holistic system, within which Chiljung(seven emotions) can cause functional disorders in internal organs. Koreans express their emotional problems in somatic symptoms even though they could point to psychological stress as the cause of the symptoms. An example is Hwa-byung(anger disorder), which is found predominantly among middle aged women and manifests in somatic symptoms such as headache, blurred vision, palpitations, a sense of having a lump in the throat and ‘pushing-up’ of the chest, stomach ‘rumbles’ and chest tightness.[25] Hwa-byung is a syndrome in which symptoms are understood by sufferers to be due to suppression of feelings of anger and resentment that form a mass in the chest. Patients can usually identify interpersonal and social problems that give rise to the anger, suppression of which then leads to physical illness. In Confucian society, the ability to repress one's emotions was regarded as a sign of a good upbringing and education. Somatization could have been an acceptable channel of expressing distress, which emanated from interpersonal relations.
Although modern Korean people are becoming more comfortable with the direct expression of feelings, and people with depressive disorders tend to seek psychiatric intervention rather than go to an internist, traditional customs and beliefs concerning childbirth and postnatal care are still popular among mothers and their caretakers. If sanhupung develops, it is interpreted that the mother needs better rest and nutrition and that she receive familial support and care. If conservative care fails, many mothers will opt for oriental medicine or see a obstetrician to help relieve symptoms.[26]
CONCLUSIONS
More work is needed to quantify the incidence of PND in Korea. From studies in other Asian countries, there seems no doubt that PND does exist, but it may present differently. Traditional social support may be protective, but it is worth noting that this is eroding and potentially absent among Australian Korean immigrants. Clinicians need to be aware of the possibility of PND among Korean women and some of the cultural factors impinging on its presentation and treatment.