“When Their Joy Turns into Pain”: A Qualitative Phenomenological Study of Postpartum Depression among Southern Pakistani Mothers

“When Their Joy Turns into Pain”: A Qualitative Phenomenological Study of Postpartum Depression among Southern Pakistani Mothers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “When Their Joy Turns into Pain”: A Qualitative Phenomenological Study of Postpartum Depression among Southern Pakistani Mothers Sidra Zia, Najma Iqbal Malik, Shamshad Bashir, Areej Nasir, Rubina Bhatti, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7899187/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background The majority of women across the world suffer from postpartum depression (PPD), a mental health condition that affects women’s lives after delivery. In middle-income countries like Pakistan, PPD is not considered a serious condition and is deliberately stigmatized. In this qualitative study, we explored sociocultural, emotional, and structural determinants of PPD among Pakistani women. Methods We employed a qualitative research design and conducted interviews with 21 postpartum women in two hospitals in the marginalized Southern Punjab region of Pakistan. A thematic analysis was then used to generate themes. Results: Five major themes were identified causing PPD in the Southern Punjab mothers: 1) healthcare providers' attitude and support, 2) limited spousal and family support and postpartum depression, 3) anxiety as a result of sudden alterations in body and appearance, 4) postpartum breastfeeding depression, and 5) lack of sleep and postpartum depression. Multiple sub-themes contributing to these major themes were: healthcare providers' insulting attitude before and after birthing, masculinity standards and emotional concealment, emotional neglect and internalized shame, limited family support and lack of time for self-care, body shaming and stigmatization by in-Laws, loss of appetite and disappointment with infant's appearance, physical load and suicidal Ideation induced by breastfeeding burden, emotional strain of breastfeeding twins, body image and weight loss, decline in sexual desire, and guilt of feeling emotionally distant as a mother. Conclusion PPD among Southern Pakistani women is strongly connected with social, cultural, interpersonal, and structural factors. Therefore, it cannot be treated without socio-culturally tailored maternal mental health interventions that cover not just biological but also emotional support, respectful maternity care, and social protection. Incorporation of postpartum mental health screening and counseling into primary healthcare is the most essential intervention to ensure maternal health and early childhood development outcomes. Postpartum Depression Mothers Qualitative Study Pakistan Sociocultural Factors Figures Figure 1 Introduction Postpartum depression (PPD) is a psychiatric disorder that occurs in women all over the world, and symptoms usually manifest within the initial four weeks following childbirth ( 1 ). Postnatal depression and anxiety are prevalent illnesses that beset women disproportionately more than men, with significant consequences for maternal and child health ( 2 , 3 ). The American Psychological Association (2007) states that symptoms of PPD might include emotional detachment from the infant, preoccupation with worrying about the baby, loss of interest in activities, worthlessness, self-destructive or destructive behaviors towards the baby, excessive crying without an identifiable cause, and intense despair ( 4 ). These symptoms contribute to significant distress for mothers and their families and thus increased concern globally ( 5 ). PPD is more common in low- and middle-income settings (LMICs) than high-income countries, with suicide during pregnancy becoming a significant public health concern among women of reproductive age in these environments ( 6 ). Prevalence estimates in Asian nations vary significantly, ranging from 7% to 33% ( 7 ), and numerous researchers believe that PPD can occur at any time during the first year after delivery ( 8 ). The condition has severe health ramifications, impacting mothers' physical and emotional well-being, as well as that of their infants ( 9 ). Postpartum realities tend to differ from societal standards concerning body image, leading to feelings of dissatisfaction and emotional distress ( 10 ). In the Middle East, women faced PPD because of low economic status, pregnancy-related problems, illiteracy, unwanted pregnancy, being a housewife, insufficient societal care from household members, and formula milk dependency ( 11 ). Depression is the reason for poor health and early demise internationally, as well as in the United Arab Emirates ( 12 ). In the UAE and Abu Dhabi, women have little interest in breastfeeding. Women can fight with PPD when they breastfeed their infant ( 13 ). PPD is associated with a variety of adverse outcomes, such as maternal suicide, disrupted bonding with the baby, premature discontinuation of breastfeeding, and developmental delays in children ( 14 ). In extreme circumstances, hospitalization can be considered because self-inflicted injury is risky ( 15 ). Though it is widespread, there is limited understanding about the connection between postpartum depression and social support ( 16 ). Long-term effects of PPD are chronic depressive symptoms, marital discord, poor mother-child attachment, and a harmful impact on a child's emotional and cognitive growth ( 17 ). Postpartum women are especially vulnerable to physical discomforts like pain in muscles, pain from cuts, headaches, nipple soreness, difficulty in breastfeeding, and disturbances in sleep, adding to the psychological burden ( 18 , 19 ). Socioeconomic issues such as poverty and unemployment are major causes of PPD ( 20 ). Research in LMICs, such as Nigeria and Pakistan, identifies predictors such as a history of depression, young maternal age (15–29 years), low autonomy of household decision-making, domestic violence, unwanted pregnancy, and early breastfeeding difficulties as key predictors of postpartum anxiety and depression ( 21 , 22 ). Such challenges highlight the multifaceted relationship between economic deprivation and mental health in maternal care ( 23 , 24 ). Some studies show that economic stress intensifies PPD ( 25 , 26 ). Although healthy eating with high intakes of anti-inflammatory and antioxidant foods, such as vegetables, fruits, cereals, nuts, and olive oil, can provide protection ( 27 ), these foods may be beyond the reach of poor women. The gap of the study is economic and cultural factors; a lack of social support from family, loss of postpartum intimacy, expectations by in-laws, and disrespect from healthcare professionals might cause other sources of stress among mothers. Poverty, economic uncertainty, and social and financial inequalities are frequently neglected; however, these realities are considered seriously in mental health after delivery. Our study tries to explain all these factors. Even though the respondents lived in a joint family system, they suffered from PPD because the in-laws told them that it was their parents’ duty, and the parents said it was their in-laws' duty to take care of that woman. Therefore, the objective of the current research is to investigate how multiple social, cultural, and economic factors in Southern Pakistan exacerbate postpartum depression in mothers. Methods Study Design and Participant Selection A phenomenological study design was used to elucidate participants lived experiences, systematically analyze their verbatim narratives, and derive emergent themes through a structured interpretive process. Thirty women were initially recruited from two hospitals for this study. Due to thematic saturation in their stories, 21 participants were finally included in the study. Data collection took place between June to December 2024. Participants were from both literate and illiterate backgrounds, but all of them lived in joint family systems. None of the participants were familiar with postpartum depression (PPD); they had mostly sought advice from gynecologists to know why they went through the psychological and emotional difficulties after delivery. Each interview took around 30 to 60 minutes and was audio-recorded with the permission of the participants. Interviews were conducted in Seraiki or Urdu, according to the language preference of the participant, and subsequently transcribed and translated into English for analysis. Table 1 Sociodemographic Characteristics of Mothers (n = 21) Sociodemographic characteristics show that the majority of mothers were illiterate with low-income status (Table 1 ). Respondent Age in Years No. of Children Education Level Income of Household Employment Status M1 23 2 Primary 18K Unemployed M2 29 3 Middle 25K Home-based worker M3 28 1 No formal education 15K Unemployed M4 23 2 Matric 20K Part-time teacher M5 34 4 Intermediate 32K Unemployed M6 30 3 Primary 22K Home tailor M7 27 1 Middle 19K Unemployed M8 29 5 No formal education 17K Unemployed M9 22 4 Matric 28K Midwife (informal) M10 23 2 Intermediate 30K Private sector job M11 25 2 Primary 23K Daily wage worker M12 23 3 Middle 26K Home-based stitching M13 22 1 No formal education 14K Unemployed M14 33 4 Matric 27K Shop helper M15 29 2 Intermediate 31K Government clerk M16 35 6 No formal education 16K Unemployed M17 24 1 Middle 20K Beauty parlor assistant M18 28 3 Primary 24K Unemployed M19 27 2 Matric 22K Housemaid M20 26 3 Intermediate 35K Schoolteacher (private) M21 23 5 Primary 21K Seasonal laborer Inclusion and Exclusion Criteria Participants were recruited if they had given birth in the previous year and had reported experiencing postpartum depression symptoms, or were willing to undergo a semi-structured interview (face-to-face or over the telephone). Those women who had a previous clinical diagnosis of psychiatric illness not related to childbirth, or those who refused to be involved, were excluded from the research. Ethical Considerations Ethical clearance for this research was granted by the Institutional Review Board (IRB) of the Department of Anthropology, Islamia University of Bahawalpur (Approval No. IUB/ANTH/99; approved on 5 June 2024). Informed verbal consent was obtained from all participants before their inclusion in the study. Participant confidentiality was rigorously upheld, with pseudonyms assigned in all transcripts to safeguard personal identities. The study was conducted in accordance with internationally recognized ethical standards, emphasizing voluntarism, anonymity, and respect for human dignity. Data Collection Data were gathered from two private hospitals located in an underdeveloped area of Pakistan, through semi-structured interviews, either face-to-face or by phone, as convenient for the participants. The sample size was 21 women who shared the experience of PPD. Interviews were structured to capture the women's subjective experiences of postpartum distress based on a pre-tested interview questionnaire. The interview guide included several open-ended questions. For example, why is emotional attachment to the infant difficult for some women and easy for others? What causes upsetting thoughts of harming or rejecting the baby, and how do mothers with twins respond differently to PPD under increased demands? Sleep deprivation is thought to be a contributing factor, but does it necessarily cause PPD, and how does the ensuing fatigue compound feelings of guilt in mothers who inadvertently neglect their babies? Difficulty breastfeeding—especially with two children—tends to produce emotional distress, but how does this hurdle cross over into diminished sexual desire and self-concept? And do unanticipated physical or emotional trauma at birth make a woman more susceptible to PPD? The external support role is also critical: How do hospital staff, family, and even spousal behaviors influence maternal mental health after childbirth? PPD in young women is the result of a complex combination of biological, psychological, and social factors, and critical questions arise regarding its etiology. It is important to know these complex effects to solve the silent battles of new mothers. Data Analysis The data were analyzed via Interpretative Phenomenological Analysis (IPA), which is a suitable method for examining how people give meaning to lived experiences. Analysis occurred across several stages. Two researchers (SZ, FA) thoroughly familiarized themselves with the raw qualitative data. They read the textual data multiple times to ensure accurate coding. Text and narratives with analogous meanings were identified, and codes were recognized for these statements. Next, emergent themes were constructed from single transcripts to maintain an idiographic emphasis. These were compared across participants to establish common patterns, while still taking into account each person's distinctive individual account. This methodology permitted a deep, rich exploration of the psychosocial and cultural aspects of PPD within the study group (Fig. 1 ). We developed a grounded theory based on our data. Our analysis might suggest that when mothers enter motherhood with expectations of care and emotional support, but receive neglect, criticism, and physical burden, they experience a self-loss which manifests as postpartum depression. Economic constraints, gender norms, family dynamics, and unmet emotional needs mold this. Results Theme 1: Healthcare Providers' Attitude and Support Some of the participants indicated that nurses' and doctors' attitudes were not pleasant and even heart-wrenching at times. Most women believed the medical professionals made their condition sound more serious than it was during labor, instilling unwarranted panic. Healthcare Providers' Insulting Attitude before Birthing A mother described her experience at her first child's delivery: " It was my initial delivery. My waterbag had broken, but I wasn't in labor. I got to the hospital, and a nurse entered and right away performed a vaginal examination. I said to her, 'Why did you stick your fingers in when it's obvious my waterbag has already broken?' She flew into a rage and said to me, 'Your cervix isn't dilated—now you'll have to have a cesarean section ." (M3) " I arrived with my mother for delivery. The nurse began reprimanding me publicly : 'Did you think giving birth was a joke ? Look at you now, crying like a child!' I was embarrassed and demeaned. I was already frightened, and in place of reassurance, I received insults." (M7) These kinds of interactions increased anxiety at already vulnerable moments. All participants emphasized the importance of healthcare professionals creating a peaceful, supportive, and empathetic atmosphere to ensure mothers feel psychologically safe. Healthcare Providers' Attitude after Birthing One woman recounted how an insensitive comment by a doctor soon after the birth precipitated her depressive symptoms: " Immediately after my cesarean, the physician pulled out my baby and said, 'Who does your baby look like? He's not as pretty as you.' That really stuck with me—I kept thinking I had given birth to a not-so-attractive child. My depression started in the delivery room." (M12) Several mothers complained about the way practitioners treated mother-infant bonding immediately after delivery. A woman recalled being kept apart from her newborn: “ I understood how valuable colostrum is for the newborn, but the doctors immediately shifted my baby away from me after giving birth. I was not able to feed my child during those first few hours. Now, my child has weakened immunity, frequent allergic reactions, and asthma. I feel guilty—and that guilt became the cradle of my postpartum depression.” (M9) Theme 2: limited Spousal and family Support and Postpartum Depression Masculinity Standards and Emotional Concealment Most of the women said that emotional and physical spousal lack of support was a leading cause of postpartum depression. They had anticipated more love and affection after giving birth, expecting it to place them in an elevated position in the home. Their husbands emotionally and physically withdrew, perceiving caregiving as threatening their masculinity. One participant said: “My husband wouldn’t support me after giving birth. He thought that helping a woman makes one a weak man, like he is her slave. He felt it was humiliating.” (M1) Loneliness and disillusionment with marriage were widespread. One woman eloquently described her quest for emotional connection: “I begged my husband to be kind to me, but he remained silent. Then I went to ChatGPT and typed, ‘I’m tired of life—be kind.’ That chatbot was kinder than my own husband.” (M10) Emotional Neglect and Internalized Shame Participants highlighted the significant healing benefits of a husband’s love and emotional support during and after delivery, as opposed to all other forms of medical care. To many, childbearing was a most naked experience in life when emotional support meant everything. “My depression started the moment I left the labor room. My husband spotted our newborn—cesarean-born—and complained, ‘Why did you deliver such a thin baby? Why are his legs twisted?’ I was embarrassed and brokenhearted.” (M6) Some women also reported that postpartum physical changes—e.g., coloration of skin, puffiness under eyes, graying of hair—added to emotional upset when their husbands faulted or rejected them. “ After I gave birth, my husband deserted me at my mother's place. My skin turned dark, my eyes puffed up, and my hair greyed. The doctor explained it was due to an insufficient multivitamin. But for the care that I needed, I was deserted.” (M8) The emotional detachment usually resulted in poor mother-child attachment. Where the fathers were indifferent towards their children, some of the women confessed being indifferent too, not in terms of neglect but as a result of emotional exhaustion. “My anxiety began due to the attitude of my husband—he totally transformed after giving birth. Now, whenever my baby begins crying, I simply browse through my phone, trying to make my husband understand that if he doesn’t care about our child, then I don’t care either. I even said to my baby: ‘If your father is a good father, I’ll be a good mother.” (M5) Limited Family Support A newly delivered mother has some expectations from her in-laws as well as from her parents. One woman explains: “I delivered twin babies. After the delivery, my mother makes desi chicken soup. After some days, my mother asked me, ‘Your in-laws should bring the chicken, otherwise we cannot arrange’, my in-laws said, ‘It is your mother's duty to take care of you and your twins for forty days’. I feel very worried and depressed; I thought I was a burden upon them.” (M2) Theme 3: Anxiety as a Result of Sudden Alterations in Body and Appearance First-time motherhood was reported as an emotionally charged and physically demanding experience. Women stated that the sudden change in their bodies after giving birth—particularly through cesarean section—was hard to bear and caused them anxiety and depression. “It was so abnormal to just wake up and become a mother via C-section. I began to feel postpartum depression when I saw myself—my body skinny, my face colorless, and my breasts hanging low. Losing my beauty so fast was sorrowful. People told me to consume fruits, nuts, and dry fruits, but we cannot buy these things." (M16) Lack of Time for Self-Care Women with more than one child tended to say that they were overwhelmed by caregiving duties and had no time or less time for their own needs. Such a lack of personal care exacerbated psychological distress. “I have three children, one of whom is a newborn. I just think about showering, washing my hair, or getting dressed up—but I can't do any of them. My depression has gotten to the point where I don't care about my children. Sometimes I want to throw them or splash them out of frustration.” (M18) The emotional stress at times prompted mothers to respond negatively toward their crying babies. Some imitated the faces of their babies or labeled them negatively, reflecting disconnection and distress. Body Shaming and Stigmatization by In-Laws Several women stated that postpartum frailty and weight loss resulted in gossiping and mockery from the in-laws. Such social stigmatization caused feelings of shame, inadequacy, and furthered postpartum depression. One participant said: “I often hear my relatives say, ‘You’ve aged after just one delivery.’ They compare me to a lizard and call my baby a baby lizard. My depression began right after hearing these things. If a woman only eats potato curry, how is she supposed to gain weight?” (M21) Another participant added: "Everyone in my in-laws treated me well before giving birth since I was healthy and fat. However, after delivery, my baby appeared malnourished, and I became skinny. Their attitude changed totally. I feel that everyone in my in-laws' home has turned against me." (M4) Loss of Appetite and Disappointment with Infant's Appearance For most of the participants, their dreams of having a healthy and beautiful baby were dashed, and they withdrew emotionally, and sometimes even physically, e.g., loss of appetite. "I lost my appetite upon seeing my underweight and weak baby. I loved food a lot before marriage, but felt nothing after giving birth. I was heartbroken and began to despise my infant because he was not as beautiful as I had envisioned." (M11) Theme 4: Postpartum Breastfeeding Depression Physical Load and Suicidal Ideas Induced by Breastfeeding Breastfeeding was portrayed for most women as one of the most physically and emotionally taxing parts of the early motherhood experience. Some of the participants indicated that lengthy breastfeeding sessions drained them physically and emotionally, with a lack of support from their spouses, particularly when their efforts were not valued or appreciated. "Upon giving birth to my baby girl, my husband insisted on exclusive breastfeeding," I told him that it was so hard—my nipples were puffy, and I ached. I would rather give formula milk, but he insulted me as ignorant, useless, and accused me of imitating others. He even set fire to the feeding bottle. I was totally desperate. I hurled my baby on the floor and went upstairs. I cut my wrist with a knife—I just wanted to die. Instead of supporting me, my husband phoned his mother, and she said, 'Take the baby back to her parents. My son is not able to look after her or the baby." (M13) This account illustrates how a lack of empathy and support during breastfeeding challenges can propel mothers to psychological crises, such as suicidal thoughts. Emotional Strain of Breastfeeding Twins Twin mothers tend to experience increased stress as a result of the concurrent demands of two babies. One of the participants narrated her overwhelming experience: "Breastfeeding my twins has made my nipples large and sore. I weep throughout nearly every feed. My frustration increases when I glance at them. I am perpetually fatigued. I do not enjoy my twins, and nor do I enjoy myself either." (M19) This statement shows how the physical cost of lactation, in association with sleep deprivation and emotional exhaustion, can contribute to resentment and self-hatred among mothers. Body Image and Weight Loss Routine breastfeeding, particularly if not accompanied by proper nutrition, caused some mothers to lose considerable amounts of weight, leading to perceptions of ugliness and rejection within their marital lives. " My depression started when I saw that breastfeeding was causing my breasts to shrink and my body to become thin. I lost weight rapidly, and my husband was no longer attracted to me." (M14) These experiences illustrate how postpartum physical changes, when not positively appreciated, can harm a woman's self-esteem and body image. Decline in Sexual Desire Most of the lactating women reported a significant reduction in sexual desire, which in a few instances generated tension within the marital relationship. The emotional and endocrine consequences of breastfeeding, along with physical fatigue, rendered women unable to engage in sexual intimacy. "I have no sexual desire. I'm breastfeeding and simply don't feel like it. When my husband pressures me, I sometimes say, 'If it's your desire, then go ahead and enjoy—I'm not involved." (M20) This separation highlights the detachment that many women experience from their partners in the postpartum period, and which is often compounded by a failure to comprehend their physical and emotional status. Theme 5: Lack of Sleep and Postpartum Depression Sleep deprivation was a foremost cause of postpartum depression in a lot of women. Mothers explained endless, unbroken nights of care that had them physically drained and emotionally unstable. " Whenever my baby cried, I felt he was crying just to ruin my life. I stayed up all night to breastfeed and watch him. My depression awakened the moment he did." (M17) Twin mothers described even more distress from the coordinated and insistent needs of two babies. "My twins are very fussy. I have no love for them. My body hurts everywhere—my muscles, my belly. I just wish they would sleep for hours at a time, but they just keep waking up. I become so angry just seeing them." (M15) Most women wanted to rest but could not even get minimal sleep with constant caregiving commitments. In families with more than one child, the load became heavier. “I work 24 hours continuously, not resting at all, taking care of my infant and my other children. My eyes are hollow, with dark circles under them. I hardly get four hours of sleep every night, which is not sufficient for my body and brain. At times, I feel like sleeping without anyone disturbing me.” (M8) Cultural expectations contributed to the pressure as well. Mothers had even been judged severely for attempting to rest in the day. "Whenever I nap with my baby, my in-laws become upset. They say it is bad luck to sleep at sunset. They ask me why I want to sleep just because the baby is sleeping." (M3) These narratives indicate how sleep deprivation, in addition to cultural expectations and caregiving burden, can awfully exacerbate a mother's mental health during the postpartum period. Guilt of Feeling Emotionally Distant as a Mother A number of working mothers described feeling intensely guilty for being unable to emotionally connect with their infants. Managing work life and childcare consumed them, making them feel drained and emotionally flat. "I pray all the time to God to fill my heart with love for my children. But nothing is there. I was deeply depressed for three months following childbirth. I am ashamed of myself—I don't believe I'm a good mother." (M9) This emotional distance—often driven by fatigue, unfulfilled dreams, and insufficient support—helped create a painful inner struggle for mothers who wanted to be caring but felt unable. Discussion This research sought to investigate the experiences of mothers with postpartum depression (PPD) after giving birth. Multiple overarching categories emerged from our findings: social, personal, and psychological distress. Social categories involved unfulfilled expectations of in-laws, inadequate emotional or practical help from husbands, and unsympathetic attitudes from medical staff. Psychological symptoms involved worthlessness, depression, comparison with other mothers, and even rejection or resentment of the baby. Personal actions involved ignoring a hungry or crying baby and expecting the spouse to assume the caregiver's role. The theme, loss of interest in life and child, is an expression of the emotional detachment and intense psychological suffering of some new mothers. A South East England study pointed out the relationship between PPD and the overall mental health issues of women, with stress laid on the importance of emotional support and recovery time ( 27 ). Feelings of emptiness, intention to harm the infant, shame related to perceived maternal incompetence, and avoidance of caregiving responsibilities were the identified subthemes under psychological distress. It has been found that women with PPD feel incompetent, underqualified, or unsuccessful as mothers ( 28 ). In other instances, the severe dislike of the newborn or the wish to harm the baby stems from unfulfilled emotional needs during pregnancy. A Dutch study found that denial of maternal emotional needs may severely hurt the self-esteem of a woman and trigger undesirable psychological reactions ( 29 ). Likewise, Iranian and Dutch studies identified that insufficient social support impacts negatively on maternal emotional health, even in women with no history of depression ( 30 , 31 ). Mothers of twins especially experienced greater stress and anxiety, wishing that their babies could sleep during the day. The mere diagnosis of twin pregnancy was seen as a risk to the health of the mother ( 32 ). These mothers also had other challenges in coping with pregnancy complications, feeding the two infants, lack of sleep, economic strain, and social isolation—all of which put them at risk for PPD ( 33 ). In Palestine, studies indicated that the absence of emotional and practical support from spouses and families was a key risk factor for PPD ( 34 ). Emotional loads like body dissatisfaction and guilt were also frequently reported. Mothers felt ashamed of being unable to love their babies as they should. Sadness, anxiety, loneliness, guilt, and inadequacy were pervasive ( 35 ). In the UK, guilt and shame were found to be significant predictors of emotional distress, such as anxiety and depression ( 36 ). Some of our study's mothers even reported suicidal ideation, which was usually precipitated by failure to breastfeed. This is consistent with evidence that self-injury and suicidal ideation towards the infant are more common in women with PPD ( 37 ). In Middle Eastern and Islamic contexts, people cannot realize the need but live with mental health disorders; they think it is a stigma to diagnose PPD ( 38 ). One study found relevant from the Northern West Bank of Palestine, which explains PPD danger aspects include absence of public support, the spouse’s small education, and traumatic trials throughout pregnancy ( 39 ). In Saudi women, the stigma of mental illness has led to ignoring postpartum mental well-being, as primary signs of a continued postpartum depression can harmfully disturb mother–baby attachment, and may disturb lactation and caregiving performance ( 40 ). PPD further affects interpersonal relationships, leading to conflict and dissatisfaction in marriage. Chinese studies corroborated our results, with a report of attempted suicide during the period of lactation. Another study in Huzhou, China, concluded that extended breastfeeding, low infant health, and lack of partner support exacerbated maternal depression, while partner care, affection, and emotional intimacy reduced depressive symptomatology ( 41 ). Our results are confirmed by a study in Northern California that attributed low socioeconomic standing—i.e., lack of employment and economic hardship—to greater severity of PPD ( 42 ). Parallel evidence in Dhaka, Uttar Pradesh, and Kenya has highlighted that poor healthcare accessibility, economic poverty, domestic violence, and social isolation are among the main causes of PPD ( 43 , 44 ). Beauty and health standards were also at issue. Women are made to feel ugly following childbirth, and this promotes rejection by their husbands and additional trauma. In a Pakistani study, 85% of respondents reported being aware of vitamins used for skin beauty, although fewer than half utilized them ( 45 ). This speaks to how socio-cultural beauty standards can conflict with mental health. Additionally, breastfeeding affects physical appearance, which can lower self-esteem. Supportive social relationships during lactation—particularly husbands—can serve to buffer these issues ( 41 ). Structural barriers were also identified as a key concern. According to an Iranian study, there were major barriers to obtaining mental health care, such as the absence of trained personnel, inadequate funding, and ineffective implementation of programs. The same was observed in Pakistan, where public health policies mostly do not allow for inclusive, sustainable, and effective maternal healthcare ( 46 ). In addition, cultural pressures for the "beauty" of baby delivery can intensify maternal body dissatisfaction. This has been associated with risk behavior and psychological distress in contemporary societies ( 47 ). A few mothers in our sample were not able to deliver colostrum—an important initial type of milk—because of systemic barriers such as being physically separated from their infants after cesarean section. Colostrum, which is high in immunoglobulin A (IgA), is critical for the infant's immune defense and gut microbiota establishment ( 48 ). Study Limitations and Strengths The study has some limitations. The sample was small, and participants were not involved in clinical trials. Most women lacked the confidence to openly discuss their mental health problems, and there continues to be a general lack of awareness and value placed on maternal psychological health. Future studies need to examine the advice presented by gynecologists and medical practitioners regarding maternal mental health. A high level of priority is needed for research examining whether financial limitations or psychological reasons play a more significant role in inducing PPD. Policymakers and clinicians need to make evaluations on a broader scale for psychological screening across pregnancy and postpartum to achieve early detection and intervention for vulnerable mothers. This research brings to the fore the intricate, intensely personal, and sometimes painful postpartum depression experiences of women in Southern Pakistan. Strength is a cultural factor, not mental or medical aspects, which show the family and community's hopes. Its strengths are mothers’ voices in the form of verbatim and private thoughts about PPD. The results identify that postpartum depression is more than a medical condition, but a sociocultural construct based on gender roles, emotional neglect, no husband and in-law support, physical burnout, financial strains, and unrealistic expectations of motherhood. Women reported deep emotional distress associated with a change in body image, difficulty with breastfeeding, lack of sleep, and feeling like a failure as mothers. Of greatest concern were accounts of suicidal ideation, emotional distance from infants, and overwhelming guilt and resentment. Lack of empathy and emotional support, particularly from husbands, was always related to the occurrence and exacerbation of depressive symptoms. Beyond this, cultural stereotypes surrounding mental illness and romanticized conceptions of mothering make women experience isolation and shame. These findings highlight the imperative for culturally targeted maternal mental health treatment, counseling of the spouse, and public policy that acknowledges and promotes women's psychosocial health during and following childbirth. Conclusion Tackling postpartum depression needs something greater than medical remedies—it demands a complete change in the way society views women's emotional needs, gender equality in caregiving, and the demystification of maternal mental health talk in homes and healthcare systems. There are severe implications for PPD, like Tenacious grief, burden, bleakness, or comparing herself with others. In extreme circumstances, suicidal feelings. There are also severe implications for infants. Babies might display late linguistic growth, bigger bad-temperedness, and delayed complications with education and laws. When they grow in a tense atmosphere, they accept very little expressive reaction and attachment. The key policy for the government is to provide resources to women, especially for housewives, so that they do not feel an inferiority complex and depression. The government should provide Reasonable, available protection for mothers, especially marginalized women. There should be Community awareness movements to decrease humiliation about PPD. Declarations Conflict of Interest The authors declare no conflict of interest. Author Contributions SZ and FA designed the study and conceived the manuscript. SZ and FA drafted the manuscript. SZ, NIM, SB, AN, RB, MS, FA, SZ, and HA were involved in revising the manuscript. All authors were involved in writing the manuscript and approved its final version. Funding This research received no external funding. Acknowledgments We acknowledge the support of local healthcare providers and local mothers in the data collection process of this study. Data Availability The original data presented in this study are included in the article. Further inquiries can be directed to the corresponding author(s). Declarations Ethical approval and consent to participate The study adhered to the guidelines of the Declaration of Helsinki. Ethical approval for the study was obtained from the Research Ethics Committee of the Islamia University of Bahawalpur, Pakistan (Number: IUB-IBC-99; Date of Approval: 6 June 2024). All participants were fully informed about the nature of the study beforehand, and then they provided informed consent. Informed consent was obtained from all subjects and/or their legal guardian(s). Consent for publication Not applicable Author Details Sidra Zia is Research Associate, Department of Anthropology, The Islamia University of Bahawalpur, Bahawalpur Pakistan. Prof. Najma Iqbal Malik is Chair of Department of Psychology at University of Sargodha, Sargodha, Punjab, Pakistan. Shamshad Bashir is Assistant Professor at Department of Psychology, Lahore Garrison University, Lahore Pakistan. Areej Nasir is Researcher at Department of Psychology at University of Sargodha, Sargodha, Punjab, Pakistan. Rubina Bhatti is the Dean of the Faculty of Social Sciences and a Professor in the Department of Information Management at The Islamia University of Bahawalpur, Pakistan. Prof. Muhammad Saleem is Chairman of Department of Applied Psychology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. Farooq Ahmed is Associate Professor and Chairman of Department of Anthropology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. Haleema Al-Sabbah is Professor at Department of Public Health, College of Health Sciences, Abu Dhabi University, Dubai, United Arab Emirates. Competing interests The authors declare that they have no competing interests. Clinical trial number Not applicable. References Wisner KL, Moses-Kolko EL, Sit DK. Postpartum depression: a disorder in search of a definition. Arch Womens Ment Health . 2010;13(1):37–40. Albert PR. Why is depression more prevalent in women? J Psychiatry Neurosci . 2015;40:219–21. doi:10.1503/jpn.150205 Saeed Q, Shafique K, Chaudhry N. Lived experiences of mothers with postnatal anxiety: a qualitative phenomenology study from Pakistan. BMJ Open . 2024;14(5):e078203. Maxwell D, Robinson SR, Rogers K. “I keep it to myself”: A qualitative meta-interpretive synthesis of experiences of postpartum depression among marginalised women. Health Soc Care Community . 2019;27(3):e23–36. Eastwood JG, Jalaludin BB, Kemp LA, Phung HN, Barnett BE. Relationship of postnatal depressive symptoms to infant temperament, maternal expectations, social support and other potential risk factors: findings from a large Australian cross-sectional study. BMC Pregnancy Childbirth . 2012;12:148. Kumari P, Basu S. Postpartum Depression and Its Determinants: A Cross-Sectional Study. Cureus . 2024;16(11):e74044. doi:10.7759/cureus.74044 Hahn-Holbrook J, Cornwell-Hinrichs T, Anaya I. Economic and health predictors of national postpartum depression prevalence: a systematic review, meta-analysis, and meta-regression of 291 studies from 56 countries. Front Psychiatry . 2018;8:248. Yu Y, Liang HF, Chen J, Li ZB, Han YS, Chen JX, Li JC. Postpartum depression: Current status and possible identification using biomarkers. Front Psychiatry . 2021;12:620371. Sadat Z, Abedzadeh-Kalahroudi M, Atrian MK, Karimian Z, Sooki Z. The impact of postpartum depression on quality of life in women after child's birth. Iran Red Crescent Med J . 2014;16(2):e14995. Kochan M, Kabukcuoglu K. ‘I wish I had my pre-pregnancy body after birth… but I have to be supported’: a theoretical study based on body image perception in working mothers during the postpartum period. J Obstet Gynaecol . 2022;42(5):1103–11. Alshikh Ahmad H, Alkhatib A, Luo J. Prevalence and risk factors of postpartum depression in the Middle East: a systematic review and meta-analysis. BMC Pregnancy Childbirth . 2021;21(1):542. World Health Organization. Comprehensive Mental Health Action Plan 2013–2030. Geneva: World Health Organization; 2021. Al Rajabi A, Alkatheeri H, Hijazi R, Kennedy L. Breastfeeding is associated with reduction in postpartum depression in the United Arab Emirates: a retrospective cross-sectional study. Sci Rep . 2025;15(1):10528. Morikawa M, Okada T, Ando M, Aleksic B, Kunimoto S, Nakamura Y, Kubota C, Uno Y, Tamaji A, Hayakawa N, Furumura K. Relationship between social support during pregnancy and postpartum depressive state: a prospective cohort study. Sci Rep . 2015;5:10520. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016. Cho H, Lee K, Choi E, Cho HN, Park B, Suh M, Rhee Y, Choi KS. Association between social support and postpartum depression. Sci Rep . 2022;12(1):3128. Jannati N, Farokhzadian J, Ahmadian L. The experience of healthcare professionals providing mental health services to mothers with postpartum depression: a qualitative study. Sultan Qaboos Univ Med J . 2021;21(4):554. Borrero L, Dietsch A, Santurri LE, Ewen HH. New mothers with postpartum depression: a qualitative exploration of healthcare decision-making. Qual Health Res . 2024;34(3):217–26. Jiaming W, Xin G, Jiajia D, Junjie P, Xue H, Yunchuan L, Yuanfang W. Psychological experience of patients with postpartum depression: a qualitative meta-synthesis. PLoS One . 2024;19(11):e0312996. Finlayson K, Crossland N, Bonet M, Downe S. What matters to women in the postnatal period: a meta-synthesis of qualitative studies. PLoS One . 2020;15(4):e0231415. Agbaje OS, Anyanwu JI, Umoke PI, Iwuagwu TE, Iweama CN, Ozoemena EL, Nnaji IR. Depressive and anxiety symptoms and associated factors among postnatal women in Enugu-North Senatorial District, South-East Nigeria: a cross-sectional study. Arch Public Health . 2019;77(1):1. Ali NS, Ali BS, Azam IS. Post partum anxiety and depression in peri-urban communities of Karachi, Pakistan: a quasi-experimental study. BMC Public Health . 2009;9(1):384. Das J, Do QT, Friedman J, McKenzie D, Scott K. Mental health and poverty in developing countries: Revisiting the relationship. Soc Sci Med . 2007;65(3):467–80. Mariam KA, Srinivasan K. Antenatal psychological distress and postnatal depression: A prospective study from an urban clinic. Asian J Psychiatry . 2009;2(2):71–3. Yaqoob H, Ju XD, Bibi M, Anwar S, Naz S. A systematic review of risk factors of postpartum depression. Evidence from Asian culture. Acta Psychol . 2024;249:104436. Papadopoulou SK, Pavlidou E, Dakanalis A, Antasouras G, Vorvolakos T, Mentzelou M, Serdari A, Pandi AL, Spanoudaki M, Alexatou O, et al. Postpartum depression is associated with maternal sociodemographic and anthropometric characteristics, perinatal outcomes, breastfeeding practices, and Mediterranean diet adherence. Nutrients . 2023;15:3853. doi:10.3390/nu15173853 Coates R, de Visser R, Ayers S. Not identifying with postnatal depression: a qualitative study of women's postnatal symptoms of distress and need for support. J Psychosom Obstet Gynaecol . 2015;36(3):114–21. doi:10.3109/0167482X.2015.1059418 Coates R, Ayers S, De Visser R. Women’s experiences of postnatal distress: a qualitative study. BMC Pregnancy Childbirth . 2014;14:4. Blom EA, Jansen PW, Verhulst FC, Hofman A, Raat H, Jaddoe VW, Coolman M, Steegers EA, Tiemeier H. Perinatal complications increase the risk of postpartum depression: The Generation R Study. BJOG . 2010;117(11):1390–8. Kazemi A, Ghaedrahmati M, Kheirabadi GR, Ebrahimi A, Bahrami M. The experiences of pregnancy and childbirth in women with postpartum depression: a qualitative study. Iran J Psychiatry Behav Sci . 2018;12(4):7. Raisanen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland. BMJ Open . 2013;3(11):e004047. doi:10.1136/bmjopen-2013-004047 Bonanni G, Longo VL, Airoldi C, Meli F, Familiari A, Romanzi F, Pellegrino M, Visconti D, Serio A, Lanzone A, Bevilacqua E. Is the mental health of couples with twins more at risk? Results from an Italian cohort study. Front Psychiatry . 2024;15:1284090. Wenze SJ, Battle CL, Tezanos KM. Raising multiples: mental health of mothers and fathers in early parenthood. Arch Womens Ment Health . 2015;18(2):163–76. doi:10.1007/s00737-014-0484-x Mattar B, Wahdan Y, Nemer M, Abu-Rmeileh NM. Postpartum depression: perception, management, and help-seeking barriers in a Palestinian context: a qualitative study. BMC Pregnancy Childbirth . 2025;25(1):411. Ayub S, Fatima M, Sikander A, Nawaz K, Zahra SD. Exploring the lived experiences of mothers with postpartum depression: a qualitative study on emotional challenges and coping strategies. 2025. Jackson L, O’Donoghue E, Helm J, Gentilcore R, Hussain A. ‘Some days are not a good day to be a mum’: exploring lived experiences of guilt and shame in the early postpartum period. Eur J Investig Health Psychol Educ . 2024;14(12):3019–38. Pope CJ, Mazmanian D. Breastfeeding and postpartum depression: an overview and methodological recommendations for future research. Depress Res Treat . 2016;2016:4765310. Sharif L, Babhair R, Alzahrani D, Abuladel A, Kabli A, Alzahrani R, Alghamdi L, Mahsoon A, Sharif K, Alharazi R, Wright R. Unraveling the stigma: a qualitative descriptive exploration of the relationship between culture, religion, and mental disorders in Saudi Arabia. BMC Psychol . 2025;13(1):425. Wildali D, Nazzal S, Hamshari S, Belkebir S. Prevalence and risk factors of postpartum depression among women attending primary healthcare centers in northern of West Bank/Palestine: a cross-sectional study. BMC Womens Health . 2024;24(1):43. Zarroug M, Altaf MF, Shaikh S, Tidjani A, Bashir O, Ayash MI, Abdalla HK, Zarroug SH. The prevalence and risk factors of postpartum depression among Saudi Arabian women: a systematic review and meta-analysis. InHealthcare . 2025;13(16):2040. Ruan JM, Wu LJ. Postpartum depression and partner support during the period of lactation: correlation research and its influencing factors. World J Psychiatry . 2024;14(1):119. Goyal D, Gay C, Lee KA. How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers? Women’s Health Issues . 2010;20(2):96–104. Kapoor B, Malik N, Gupta G, Khan IA. A cross-sectional study exploring postpartum depression at a tertiary care center in eastern Uttar Pradesh, India. Cureus . 2024;16(4). Gribbin C, Achieng F, K’Oloo A, Barsosio HC, Kwobah E, Kariuki S, Nabwera HM. Exploring the influence of postnatal depression on neonatal care practices among mothers in Western Kenya: a qualitative study. Women’s Health . 2023;19:17455057231189547. Khalil SB, Ali I. Negotiating beauty in Pakistan: a qualitative exploration of body image, nutrition, and cultural ideals among young women in Azad Jammu & Kashmir. Dialogues Health . 2025;100225. Ahmed F, Malik NI, Malik N, Qureshi MG, Shahzad M, Shahid M, Zia S, Tang K. Key challenges to optimal therapeutic coverage and maternal utilization of CMAM Program in rural southern Pakistan: a qualitative exploratory study. Nutrients . 2022;14(13):2612. doi:10.3390/nu14132612 León MP, González-Martí I, Contreras-Jordán OR. What do children think of their perceived and ideal bodies? Understandings of body image at early ages: a mixed study. Int J Environ Res Public Health . 2021;18(9):4871. Jozsa F, Thistle J. Anatomy, Colostrum. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Feb 5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 17 Nov, 2025 Editor invited by journal 25 Oct, 2025 Editor assigned by journal 22 Oct, 2025 Submission checks completed at journal 22 Oct, 2025 First submitted to journal 19 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7899187","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":550004570,"identity":"5c1ce556-bd1e-441a-90dd-2ffe458a9e38","order_by":0,"name":"Sidra Zia","email":"","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":false,"prefix":"","firstName":"Sidra","middleName":"","lastName":"Zia","suffix":""},{"id":550004571,"identity":"8628e059-1f85-4d70-82b3-1e9a9515dd38","order_by":1,"name":"Najma Iqbal Malik","email":"","orcid":"","institution":"University of Sargodha","correspondingAuthor":false,"prefix":"","firstName":"Najma","middleName":"Iqbal","lastName":"Malik","suffix":""},{"id":550004572,"identity":"f15c88f9-c3b3-443a-908e-e490bb4c199a","order_by":2,"name":"Shamshad Bashir","email":"","orcid":"","institution":"Lahore Garrison University","correspondingAuthor":false,"prefix":"","firstName":"Shamshad","middleName":"","lastName":"Bashir","suffix":""},{"id":550004573,"identity":"0c4af507-f617-463d-bf9f-59b964bf3c97","order_by":3,"name":"Areej Nasir","email":"","orcid":"","institution":"University of Sargodha","correspondingAuthor":false,"prefix":"","firstName":"Areej","middleName":"","lastName":"Nasir","suffix":""},{"id":550004575,"identity":"baabcadf-0b5a-4020-921a-aa7bd7dd68cb","order_by":4,"name":"Rubina Bhatti","email":"","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":false,"prefix":"","firstName":"Rubina","middleName":"","lastName":"Bhatti","suffix":""},{"id":550004578,"identity":"5297fcf0-6734-48e5-b576-c1872056968a","order_by":5,"name":"Muhammad Saleem","email":"","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Saleem","suffix":""},{"id":550004579,"identity":"f625ae96-e6b5-475a-98b7-1400f3c85b96","order_by":6,"name":"Farooq Ahmed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYBAC9gYowwCIJT4YMCRA2Qk4tfAcQNIiOYNkLdI8DMRoYT/78MGHMgZ5c7HDB2/bFBzOY2Bv3ibBuCMNtxaedGPDGecYDHfOTku2zjE4XMzAc6xMgvFMDk4t9gxpbNK8bQyMG27nmEkDtSQ2SOSYSTC2VeC2hf8ZWIv9htv536QtQFrk3xDQIgGxJRFoC5s0A9gWHpAW3A7jkXjGDPSLRPKG22nGlj0G6cVsPGnFFoln8HifP40RGGI2thtuJz+88eOPdR4/++GNNz7uSMapBQLYJJDYICKxgYAOiDJkwEhQyygYBaNgFIwgAACLKE1wIo3OegAAAABJRU5ErkJggg==","orcid":"","institution":"Islamia University of Bahawalpur","correspondingAuthor":true,"prefix":"","firstName":"Farooq","middleName":"","lastName":"Ahmed","suffix":""},{"id":550004580,"identity":"bda51e0f-0bc7-45d0-abef-0349264ab682","order_by":7,"name":"Haleema Al Sabbah","email":"","orcid":"","institution":"Department of Public Health, College of Health Sciences, Abu Dhabi University,","correspondingAuthor":false,"prefix":"","firstName":"Haleema","middleName":"Al","lastName":"Sabbah","suffix":""}],"badges":[],"createdAt":"2025-10-19 14:23:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7899187/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7899187/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96847678,"identity":"1ea58104-332b-4441-8ba9-fb00a1a7a9f3","added_by":"auto","created_at":"2025-11-26 16:51:44","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":468570,"visible":true,"origin":"","legend":"","description":"","filename":"BMCPSYCHOLOGYPPD2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/738d18d2db7c758f3d4bc88b.docx"},{"id":96919078,"identity":"0fa3f4f7-2a99-47bd-99f7-d38e55cc7ea2","added_by":"auto","created_at":"2025-11-27 14:13:06","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9498,"visible":true,"origin":"","legend":"","description":"","filename":"67665da858214e2685b4f5225bb2dc2a.json","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/fa98806bdb6b369f83350113.json"},{"id":96918250,"identity":"7a0a2e77-6630-4cd6-b17b-6d306f74cf46","added_by":"auto","created_at":"2025-11-27 14:11:31","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":134736,"visible":true,"origin":"","legend":"","description":"","filename":"67665da858214e2685b4f5225bb2dc2a1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/3e066be5aa1d64dbd03c8ca8.xml"},{"id":96847672,"identity":"3a80b2ec-1a82-48c0-ad2f-ef2cd43da01e","added_by":"auto","created_at":"2025-11-26 16:51:44","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82620,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/2f8539b5f8766ec38a957fec.jpeg"},{"id":96847679,"identity":"dd35bbec-cf0c-43f5-8436-7bd234746c26","added_by":"auto","created_at":"2025-11-26 16:51:44","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":392286,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/f3a11e22430e2bb1d656e528.jpeg"},{"id":96917386,"identity":"573c80b9-e49f-4851-94ba-4d86997ca6bd","added_by":"auto","created_at":"2025-11-27 14:09:39","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":16689,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/4bdaacef7fd738d4192018ab.png"},{"id":96919137,"identity":"1e392c0f-4afa-4c1c-98e4-e5d9740b1a38","added_by":"auto","created_at":"2025-11-27 14:13:13","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":41779,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/7e3c006d097ad715b5f725c2.png"},{"id":96847680,"identity":"ffd369c2-b049-49b9-a69e-371c850daa97","added_by":"auto","created_at":"2025-11-26 16:51:44","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":131721,"visible":true,"origin":"","legend":"","description":"","filename":"67665da858214e2685b4f5225bb2dc2a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/3bca0537323d1ca8ae1e7779.xml"},{"id":96917797,"identity":"5ea457a1-7ea6-4e68-958e-92b71c70dc95","added_by":"auto","created_at":"2025-11-27 14:10:35","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":143831,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/b8b9d8e079c11f0b9933520e.html"},{"id":96847670,"identity":"3e953166-5d6e-4274-846d-81ae77eb9698","added_by":"auto","created_at":"2025-11-26 16:51:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":366100,"visible":true,"origin":"","legend":"\u003cp\u003eSociocultural Factors Responsible for PPD in Pakistani Mothers\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/598c75c2f0c62c8fcba74ecc.png"},{"id":96923118,"identity":"d89f6b33-c523-4ddb-b109-a3b24ced2999","added_by":"auto","created_at":"2025-11-27 14:20:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1457598,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7899187/v1/66fd62e2-1ebe-424e-b26a-093fd3087fb4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“When Their Joy Turns into Pain”: A Qualitative Phenomenological Study of Postpartum Depression among Southern Pakistani Mothers","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePostpartum depression (PPD) is a psychiatric disorder that occurs in women all over the world, and symptoms usually manifest within the initial four weeks following childbirth (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Postnatal depression and anxiety are prevalent illnesses that beset women disproportionately more than men, with significant consequences for maternal and child health (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The American Psychological Association (2007) states that symptoms of PPD might include emotional detachment from the infant, preoccupation with worrying about the baby, loss of interest in activities, worthlessness, self-destructive or destructive behaviors towards the baby, excessive crying without an identifiable cause, and intense despair (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These symptoms contribute to significant distress for mothers and their families and thus increased concern globally (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePPD is more common in low- and middle-income settings (LMICs) than high-income countries, with suicide during pregnancy becoming a significant public health concern among women of reproductive age in these environments (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Prevalence estimates in Asian nations vary significantly, ranging from 7% to 33% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), and numerous researchers believe that PPD can occur at any time during the first year after delivery (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The condition has severe health ramifications, impacting mothers' physical and emotional well-being, as well as that of their infants (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Postpartum realities tend to differ from societal standards concerning body image, leading to feelings of dissatisfaction and emotional distress (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the Middle East, women faced PPD because of low economic status, pregnancy-related problems, illiteracy, unwanted pregnancy, being a housewife, insufficient societal care from household members, and formula milk dependency (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Depression is the reason for poor health and early demise internationally, as well as in the United Arab Emirates (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In the UAE and Abu Dhabi, women have little interest in breastfeeding. Women can fight with PPD when they breastfeed their infant (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePPD is associated with a variety of adverse outcomes, such as maternal suicide, disrupted bonding with the baby, premature discontinuation of breastfeeding, and developmental delays in children (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In extreme circumstances, hospitalization can be considered because self-inflicted injury is risky (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Though it is widespread, there is limited understanding about the connection between postpartum depression and social support (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLong-term effects of PPD are chronic depressive symptoms, marital discord, poor mother-child attachment, and a harmful impact on a child's emotional and cognitive growth (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Postpartum women are especially vulnerable to physical discomforts like pain in muscles, pain from cuts, headaches, nipple soreness, difficulty in breastfeeding, and disturbances in sleep, adding to the psychological burden (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSocioeconomic issues such as poverty and unemployment are major causes of PPD (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Research in LMICs, such as Nigeria and Pakistan, identifies predictors such as a history of depression, young maternal age (15\u0026ndash;29 years), low autonomy of household decision-making, domestic violence, unwanted pregnancy, and early breastfeeding difficulties as key predictors of postpartum anxiety and depression (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Such challenges highlight the multifaceted relationship between economic deprivation and mental health in maternal care (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSome studies show that economic stress intensifies PPD (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Although healthy eating with high intakes of anti-inflammatory and antioxidant foods, such as vegetables, fruits, cereals, nuts, and olive oil, can provide protection (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), these foods may be beyond the reach of poor women. The gap of the study is economic and cultural factors; a lack of social support from family, loss of postpartum intimacy, expectations by in-laws, and disrespect from healthcare professionals might cause other sources of stress among mothers.\u003c/p\u003e\u003cp\u003ePoverty, economic uncertainty, and social and financial inequalities are frequently neglected; however, these realities are considered seriously in mental health after delivery. Our study tries to explain all these factors. Even though the respondents lived in a joint family system, they suffered from PPD because the in-laws told them that it was their parents\u0026rsquo; duty, and the parents said it was their in-laws' duty to take care of that woman. Therefore, the objective of the current research is to investigate how multiple social, cultural, and economic factors in Southern Pakistan exacerbate postpartum depression in mothers.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Participant Selection\u003c/strong\u003e\u003cp\u003eA phenomenological study design was used to elucidate participants lived experiences, systematically analyze their verbatim narratives, and derive emergent themes through a structured interpretive process. Thirty women were initially recruited from two hospitals for this study. Due to thematic saturation in their stories, 21 participants were finally included in the study. Data collection took place between June to December 2024. Participants were from both literate and illiterate backgrounds, but all of them lived in joint family systems. None of the participants were familiar with postpartum depression (PPD); they had mostly sought advice from gynecologists to know why they went through the psychological and emotional difficulties after delivery. Each interview took around 30 to 60 minutes and was audio-recorded with the permission of the participants. Interviews were conducted in Seraiki or Urdu, according to the language preference of the participant, and subsequently transcribed and translated into English for analysis.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eSociodemographic Characteristics of Mothers (n\u0026thinsp;=\u0026thinsp;21)\u003c/b\u003e Sociodemographic characteristics show that the majority of mothers were illiterate with low-income status (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRespondent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge in Years\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. of Children\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducation Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIncome of Household\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEmployment Status\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHome-based worker\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMatric\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePart-time teacher\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHome tailor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMatric\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMidwife (informal)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePrivate sector job\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDaily wage worker\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHome-based stitching\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMatric\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eShop helper\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGovernment clerk\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBeauty parlor assistant\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMatric\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHousemaid\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntermediate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSchoolteacher (private)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eM21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21K\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSeasonal laborer\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eParticipants were recruited if they had given birth in the previous year and had reported experiencing postpartum depression symptoms, or were willing to undergo a semi-structured interview (face-to-face or over the telephone). Those women who had a previous clinical diagnosis of psychiatric illness not related to childbirth, or those who refused to be involved, were excluded from the research.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e Ethical clearance for this research was granted by the Institutional Review Board (IRB) of the Department of Anthropology, Islamia University of Bahawalpur (Approval No. IUB/ANTH/99; approved on 5 June 2024). Informed verbal consent was obtained from all participants before their inclusion in the study. Participant confidentiality was rigorously upheld, with pseudonyms assigned in all transcripts to safeguard personal identities. The study was conducted in accordance with internationally recognized ethical standards, emphasizing voluntarism, anonymity, and respect for human dignity.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eData were gathered from two private hospitals located in an underdeveloped area of Pakistan, through semi-structured interviews, either face-to-face or by phone, as convenient for the participants. The sample size was 21 women who shared the experience of PPD. Interviews were structured to capture the women's subjective experiences of postpartum distress based on a pre-tested interview questionnaire. The interview guide included several open-ended questions. For example, why is emotional attachment to the infant difficult for some women and easy for others? What causes upsetting thoughts of harming or rejecting the baby, and how do mothers with twins respond differently to PPD under increased demands? Sleep deprivation is thought to be a contributing factor, but does it necessarily cause PPD, and how does the ensuing fatigue compound feelings of guilt in mothers who inadvertently neglect their babies? Difficulty breastfeeding\u0026mdash;especially with two children\u0026mdash;tends to produce emotional distress, but how does this hurdle cross over into diminished sexual desire and self-concept? And do unanticipated physical or emotional trauma at birth make a woman more susceptible to PPD? The external support role is also critical: How do hospital staff, family, and even spousal behaviors influence maternal mental health after childbirth? PPD in young women is the result of a complex combination of biological, psychological, and social factors, and critical questions arise regarding its etiology. It is important to know these complex effects to solve the silent battles of new mothers.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe data were analyzed via Interpretative Phenomenological Analysis (IPA), which is a suitable method for examining how people give meaning to lived experiences. Analysis occurred across several stages. Two researchers (SZ, FA) thoroughly familiarized themselves with the raw qualitative data. They read the textual data multiple times to ensure accurate coding. Text and narratives with analogous meanings were identified, and codes were recognized for these statements. Next, emergent themes were constructed from single transcripts to maintain an idiographic emphasis. These were compared across participants to establish common patterns, while still taking into account each person's distinctive individual account. This methodology permitted a deep, rich exploration of the psychosocial and cultural aspects of PPD within the study group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We developed a grounded theory based on our data. Our analysis might suggest that when mothers enter motherhood with expectations of care and emotional support, but receive neglect, criticism, and physical burden, they experience a self-loss which manifests as postpartum depression. Economic constraints, gender norms, family dynamics, and unmet emotional needs mold this.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eTheme 1: Healthcare Providers' Attitude and Support\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSome of the participants indicated that nurses' and doctors' attitudes were not pleasant and even heart-wrenching at times. Most women believed the medical professionals made their condition sound more serious than it was during labor, instilling unwarranted panic.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eHealthcare Providers' Insulting Attitude before Birthing\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA mother described her experience at her first child's delivery:\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eIt was my initial delivery. My waterbag had broken, but I wasn't in labor. I got to the hospital, and a nurse entered and right away performed a vaginal examination. I said to her, 'Why did you stick your fingers in when it's obvious my waterbag has already broken?' She flew into a rage and said to me, 'Your cervix isn't dilated\u0026mdash;now you'll have to have a cesarean section\u003c/em\u003e.\" (M3)\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eI arrived with my mother for delivery. The nurse began reprimanding me publicly\u003c/em\u003e: \u003cem\u003e'Did you think giving birth was a joke\u003c/em\u003e? \u003cem\u003eLook at you now, crying like a child!' I was embarrassed and demeaned. I was already frightened, and in place of reassurance, I received insults.\"\u003c/em\u003e (M7)\u003c/p\u003e\u003cp\u003eThese kinds of interactions increased anxiety at already vulnerable moments. All participants emphasized the importance of healthcare professionals creating a peaceful, supportive, and empathetic atmosphere to ensure mothers feel psychologically safe.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eHealthcare Providers' Attitude after Birthing\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOne woman recounted how an insensitive comment by a doctor soon after the birth precipitated her depressive symptoms:\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eImmediately after my cesarean, the physician pulled out my baby and said, 'Who does your baby look like? He's not as pretty as you.' That really stuck with me\u0026mdash;I kept thinking I had given birth to a not-so-attractive child. My depression started in the delivery room.\"\u003c/em\u003e (M12)\u003c/p\u003e\u003cp\u003eSeveral mothers complained about the way practitioners treated mother-infant bonding immediately after delivery. A woman recalled being kept apart from her newborn:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI understood how valuable colostrum is for the newborn, but the doctors immediately shifted my baby away from me after giving birth. I was not able to feed my child during those first few hours. Now, my child has weakened immunity, frequent allergic reactions, and asthma. I feel guilty\u0026mdash;and that guilt became the cradle of my postpartum depression.\u0026rdquo;\u003c/em\u003e (M9)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: limited Spousal and family Support and Postpartum Depression\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eMasculinity Standards and Emotional Concealment\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMost of the women said that emotional and physical spousal lack of support was a leading cause of postpartum depression. They had anticipated more love and affection after giving birth, expecting it to place them in an elevated position in the home.\u003c/p\u003e\u003cp\u003eTheir husbands emotionally and physically withdrew, perceiving caregiving as threatening their masculinity. One participant said:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My husband wouldn\u0026rsquo;t support me after giving birth. He thought that helping a woman makes one a weak man, like he is her slave. He felt it was humiliating.\u0026rdquo;\u003c/em\u003e (M1)\u003c/p\u003e\u003cp\u003eLoneliness and disillusionment with marriage were widespread. One woman eloquently described her quest for emotional connection:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I begged my husband to be kind to me, but he remained silent. Then I went to ChatGPT and typed, \u0026lsquo;I\u0026rsquo;m tired of life\u0026mdash;be kind.\u0026rsquo; That chatbot was kinder than my own husband.\u0026rdquo;\u003c/em\u003e (M10)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eEmotional Neglect and Internalized Shame\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eParticipants highlighted the significant healing benefits of a husband\u0026rsquo;s love and emotional support during and after delivery, as opposed to all other forms of medical care. To many, childbearing was a most naked experience in life when emotional support meant everything.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My depression started the moment I left the labor room. My husband spotted our newborn\u0026mdash;cesarean-born\u0026mdash;and complained, \u0026lsquo;Why did you deliver such a thin baby? Why are his legs twisted?\u0026rsquo; I was embarrassed and brokenhearted.\u0026rdquo;\u003c/em\u003e (M6)\u003c/p\u003e\u003cp\u003eSome women also reported that postpartum physical changes\u0026mdash;e.g., coloration of skin, puffiness under eyes, graying of hair\u0026mdash;added to emotional upset when their husbands faulted or rejected them.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eAfter I gave birth, my husband deserted me at my mother's place. My skin turned dark, my eyes puffed up, and my hair greyed. The doctor explained it was due to an insufficient multivitamin. But for the care that I needed, I was deserted.\u0026rdquo;\u003c/em\u003e (M8)\u003c/p\u003e\u003cp\u003eThe emotional detachment usually resulted in poor mother-child attachment. Where the fathers were indifferent towards their children, some of the women confessed being indifferent too, not in terms of neglect but as a result of emotional exhaustion.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My anxiety began due to the attitude of my husband\u0026mdash;he totally transformed after giving birth. Now, whenever my baby begins crying, I simply browse through my phone, trying to make my husband understand that if he doesn\u0026rsquo;t care about our child, then I don\u0026rsquo;t care either. I even said to my baby: \u0026lsquo;If your father is a good father, I\u0026rsquo;ll be a good mother.\u0026rdquo;\u003c/em\u003e (M5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimited Family Support\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA newly delivered mother has some expectations from her in-laws as well as from her parents. One woman explains:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I delivered twin babies. After the delivery, my mother makes desi chicken soup. After some days, my mother asked me, \u0026lsquo;Your in-laws should bring the chicken, otherwise we cannot arrange\u0026rsquo;, my in-laws said, \u0026lsquo;It is your mother's duty to take care of you and your twins for forty days\u0026rsquo;. I feel very worried and depressed; I thought I was a burden upon them.\u0026rdquo;\u003c/em\u003e (M2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Anxiety as a Result of Sudden Alterations in Body and Appearance\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFirst-time motherhood was reported as an emotionally charged and physically demanding experience. Women stated that the sudden change in their bodies after giving birth\u0026mdash;particularly through cesarean section\u0026mdash;was hard to bear and caused them anxiety and depression.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It was so abnormal to just wake up and become a mother via C-section. I began to feel postpartum depression when I saw myself\u0026mdash;my body skinny, my face colorless, and my breasts hanging low. Losing my beauty so fast was sorrowful. People told me to consume fruits, nuts, and dry fruits, but we cannot buy these things.\"\u003c/em\u003e (M16)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLack of Time for Self-Care\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWomen with more than one child tended to say that they were overwhelmed by caregiving duties and had no time or less time for their own needs. Such a lack of personal care exacerbated psychological distress.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have three children, one of whom is a newborn. I just think about showering, washing my hair, or getting dressed up\u0026mdash;but I can't do any of them. My depression has gotten to the point where I don't care about my children. Sometimes I want to throw them or splash them out of frustration.\u0026rdquo;\u003c/em\u003e (M18)\u003c/p\u003e\u003cp\u003eThe emotional stress at times prompted mothers to respond negatively toward their crying babies. Some imitated the faces of their babies or labeled them negatively, reflecting disconnection and distress.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eBody Shaming and Stigmatization by In-Laws\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSeveral women stated that postpartum frailty and weight loss resulted in gossiping and mockery from the in-laws. Such social stigmatization caused feelings of shame, inadequacy, and furthered postpartum depression.\u003c/p\u003e\u003cp\u003eOne participant said:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I often hear my relatives say, \u0026lsquo;You\u0026rsquo;ve aged after just one delivery.\u0026rsquo; They compare me to a lizard and call my baby a baby lizard. My depression began right after hearing these things. If a woman only eats potato curry, how is she supposed to gain weight?\u0026rdquo;\u003c/em\u003e (M21)\u003c/p\u003e\u003cp\u003eAnother participant added:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Everyone in my in-laws treated me well before giving birth since I was healthy and fat. However, after delivery, my baby appeared malnourished, and I became skinny. Their attitude changed totally. I feel that everyone in my in-laws' home has turned against me.\"\u003c/em\u003e (M4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eLoss of Appetite and Disappointment with Infant's Appearance\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor most of the participants, their dreams of having a healthy and beautiful baby were dashed, and they withdrew emotionally, and sometimes even physically, e.g., loss of appetite.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I lost my appetite upon seeing my underweight and weak baby. I loved food a lot before marriage, but felt nothing after giving birth. I was heartbroken and began to despise my infant because he was not as beautiful as I had envisioned.\"\u003c/em\u003e (M11)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eTheme 4: Postpartum Breastfeeding Depression\u003c/h2\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003ePhysical Load and Suicidal Ideas Induced by Breastfeeding\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBreastfeeding was portrayed for most women as one of the most physically and emotionally taxing parts of the early motherhood experience. Some of the participants indicated that lengthy breastfeeding sessions drained them physically and emotionally, with a lack of support from their spouses, particularly when their efforts were not valued or appreciated.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Upon giving birth to my baby girl, my husband insisted on exclusive breastfeeding,\" I told him that it was so hard\u0026mdash;my nipples were puffy, and I ached. I would rather give formula milk, but he insulted me as ignorant, useless, and accused me of imitating others. He even set fire to the feeding bottle. I was totally desperate. I hurled my baby on the floor and went upstairs. I cut my wrist with a knife\u0026mdash;I just wanted to die. Instead of supporting me, my husband phoned his mother, and she said, 'Take the baby back to her parents. My son is not able to look after her or the baby.\"\u003c/em\u003e (M13)\u003c/p\u003e\u003cp\u003eThis account illustrates how a lack of empathy and support during breastfeeding challenges can propel mothers to psychological crises, such as suicidal thoughts.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eEmotional Strain of Breastfeeding Twins\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTwin mothers tend to experience increased stress as a result of the concurrent demands of two babies. One of the participants narrated her overwhelming experience:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Breastfeeding my twins has made my nipples large and sore. I weep throughout nearly every feed. My frustration increases when I glance at them. I am perpetually fatigued. I do not enjoy my twins, and nor do I enjoy myself either.\"\u003c/em\u003e (M19)\u003c/p\u003e\u003cp\u003eThis statement shows how the physical cost of lactation, in association with sleep deprivation and emotional exhaustion, can contribute to resentment and self-hatred among mothers.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eBody Image and Weight Loss\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eRoutine breastfeeding, particularly if not accompanied by proper nutrition, caused some mothers to lose considerable amounts of weight, leading to perceptions of ugliness and rejection within their marital lives.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eMy depression started when I saw that breastfeeding was causing my breasts to shrink and my body to become thin. I lost weight rapidly, and my husband was no longer attracted to me.\"\u003c/em\u003e (M14)\u003c/p\u003e\u003cp\u003eThese experiences illustrate how postpartum physical changes, when not positively appreciated, can harm a woman's self-esteem and body image.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eDecline in Sexual Desire\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMost of the lactating women reported a significant reduction in sexual desire, which in a few instances generated tension within the marital relationship. The emotional and endocrine consequences of breastfeeding, along with physical fatigue, rendered women unable to engage in sexual intimacy.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I have no sexual desire. I'm breastfeeding and simply don't feel like it. When my husband pressures me, I sometimes say, 'If it's your desire, then go ahead and enjoy\u0026mdash;I'm not involved.\"\u003c/em\u003e (M20)\u003c/p\u003e\u003cp\u003eThis separation highlights the detachment that many women experience from their partners in the postpartum period, and which is often compounded by a failure to comprehend their physical and emotional status.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eTheme 5: Lack of Sleep and Postpartum Depression\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSleep deprivation was a foremost cause of postpartum depression in a lot of women. Mothers explained endless, unbroken nights of care that had them physically drained and emotionally unstable.\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eWhenever my baby cried, I felt he was crying just to ruin my life. I stayed up all night to breastfeed and watch him. My depression awakened the moment he did.\"\u003c/em\u003e (M17)\u003c/p\u003e\u003cp\u003eTwin mothers described even more distress from the coordinated and insistent needs of two babies.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"My twins are very fussy. I have no love for them. My body hurts everywhere\u0026mdash;my muscles, my belly. I just wish they would sleep for hours at a time, but they just keep waking up. I become so angry just seeing them.\"\u003c/em\u003e (M15)\u003c/p\u003e\u003cp\u003eMost women wanted to rest but could not even get minimal sleep with constant caregiving commitments. In families with more than one child, the load became heavier.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I work 24 hours continuously, not resting at all, taking care of my infant and my other children. My eyes are hollow, with dark circles under them. I hardly get four hours of sleep every night, which is not sufficient for my body and brain. At times, I feel like sleeping without anyone disturbing me.\u0026rdquo;\u003c/em\u003e (M8)\u003c/p\u003e\u003cp\u003eCultural expectations contributed to the pressure as well. Mothers had even been judged severely for attempting to rest in the day.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Whenever I nap with my baby, my in-laws become upset. They say it is bad luck to sleep at sunset. They ask me why I want to sleep just because the baby is sleeping.\"\u003c/em\u003e (M3)\u003c/p\u003e\u003cp\u003eThese narratives indicate how sleep deprivation, in addition to cultural expectations and caregiving burden, can awfully exacerbate a mother's mental health during the postpartum period.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eGuilt of Feeling Emotionally Distant as a Mother\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA number of working mothers described feeling intensely guilty for being unable to emotionally connect with their infants. Managing work life and childcare consumed them, making them feel drained and emotionally flat.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I pray all the time to God to fill my heart with love for my children. But nothing is there. I was deeply depressed for three months following childbirth. I am ashamed of myself\u0026mdash;I don't believe I'm a good mother.\"\u003c/em\u003e (M9)\u003c/p\u003e\u003cp\u003eThis emotional distance\u0026mdash;often driven by fatigue, unfulfilled dreams, and insufficient support\u0026mdash;helped create a painful inner struggle for mothers who wanted to be caring but felt unable.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis research sought to investigate the experiences of mothers with postpartum depression (PPD) after giving birth. Multiple overarching categories emerged from our findings: social, personal, and psychological distress. Social categories involved unfulfilled expectations of in-laws, inadequate emotional or practical help from husbands, and unsympathetic attitudes from medical staff. Psychological symptoms involved worthlessness, depression, comparison with other mothers, and even rejection or resentment of the baby. Personal actions involved ignoring a hungry or crying baby and expecting the spouse to assume the caregiver's role.\u003c/p\u003e\u003cp\u003eThe theme, loss of interest in life and child, is an expression of the emotional detachment and intense psychological suffering of some new mothers. A South East England study pointed out the relationship between PPD and the overall mental health issues of women, with stress laid on the importance of emotional support and recovery time (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Feelings of emptiness, intention to harm the infant, shame related to perceived maternal incompetence, and avoidance of caregiving responsibilities were the identified subthemes under psychological distress.\u003c/p\u003e\u003cp\u003eIt has been found that women with PPD feel incompetent, underqualified, or unsuccessful as mothers (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In other instances, the severe dislike of the newborn or the wish to harm the baby stems from unfulfilled emotional needs during pregnancy. A Dutch study found that denial of maternal emotional needs may severely hurt the self-esteem of a woman and trigger undesirable psychological reactions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Likewise, Iranian and Dutch studies identified that insufficient social support impacts negatively on maternal emotional health, even in women with no history of depression (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMothers of twins especially experienced greater stress and anxiety, wishing that their babies could sleep during the day. The mere diagnosis of twin pregnancy was seen as a risk to the health of the mother (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). These mothers also had other challenges in coping with pregnancy complications, feeding the two infants, lack of sleep, economic strain, and social isolation\u0026mdash;all of which put them at risk for PPD (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In Palestine, studies indicated that the absence of emotional and practical support from spouses and families was a key risk factor for PPD (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEmotional loads like body dissatisfaction and guilt were also frequently reported. Mothers felt ashamed of being unable to love their babies as they should. Sadness, anxiety, loneliness, guilt, and inadequacy were pervasive (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In the UK, guilt and shame were found to be significant predictors of emotional distress, such as anxiety and depression (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Some of our study's mothers even reported suicidal ideation, which was usually precipitated by failure to breastfeed. This is consistent with evidence that self-injury and suicidal ideation towards the infant are more common in women with PPD (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Middle Eastern and Islamic contexts, people cannot realize the need but live with mental health disorders; they think it is a stigma to diagnose PPD (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). One study found relevant from the Northern West Bank of Palestine, which explains PPD danger aspects include absence of public support, the spouse\u0026rsquo;s small education, and traumatic trials throughout pregnancy (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In Saudi women, the stigma of mental illness has led to ignoring postpartum mental well-being, as primary signs of a continued postpartum depression can harmfully disturb mother\u0026ndash;baby attachment, and may disturb lactation and caregiving performance (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePPD further affects interpersonal relationships, leading to conflict and dissatisfaction in marriage. Chinese studies corroborated our results, with a report of attempted suicide during the period of lactation. Another study in Huzhou, China, concluded that extended breastfeeding, low infant health, and lack of partner support exacerbated maternal depression, while partner care, affection, and emotional intimacy reduced depressive symptomatology (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur results are confirmed by a study in Northern California that attributed low socioeconomic standing\u0026mdash;i.e., lack of employment and economic hardship\u0026mdash;to greater severity of PPD (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Parallel evidence in Dhaka, Uttar Pradesh, and Kenya has highlighted that poor healthcare accessibility, economic poverty, domestic violence, and social isolation are among the main causes of PPD (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBeauty and health standards were also at issue. Women are made to feel ugly following childbirth, and this promotes rejection by their husbands and additional trauma. In a Pakistani study, 85% of respondents reported being aware of vitamins used for skin beauty, although fewer than half utilized them (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). This speaks to how socio-cultural beauty standards can conflict with mental health. Additionally, breastfeeding affects physical appearance, which can lower self-esteem. Supportive social relationships during lactation\u0026mdash;particularly husbands\u0026mdash;can serve to buffer these issues (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStructural barriers were also identified as a key concern. According to an Iranian study, there were major barriers to obtaining mental health care, such as the absence of trained personnel, inadequate funding, and ineffective implementation of programs. The same was observed in Pakistan, where public health policies mostly do not allow for inclusive, sustainable, and effective maternal healthcare (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, cultural pressures for the \"beauty\" of baby delivery can intensify maternal body dissatisfaction. This has been associated with risk behavior and psychological distress in contemporary societies (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). A few mothers in our sample were not able to deliver colostrum\u0026mdash;an important initial type of milk\u0026mdash;because of systemic barriers such as being physically separated from their infants after cesarean section. Colostrum, which is high in immunoglobulin A (IgA), is critical for the infant's immune defense and gut microbiota establishment (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003eStudy Limitations and Strengths\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe study has some limitations. The sample was small, and participants were not involved in clinical trials. Most women lacked the confidence to openly discuss their mental health problems, and there continues to be a general lack of awareness and value placed on maternal psychological health. Future studies need to examine the advice presented by gynecologists and medical practitioners regarding maternal mental health. A high level of priority is needed for research examining whether financial limitations or psychological reasons play a more significant role in inducing PPD. Policymakers and clinicians need to make evaluations on a broader scale for psychological screening across pregnancy and postpartum to achieve early detection and intervention for vulnerable mothers.\u003c/p\u003e\u003cp\u003eThis research brings to the fore the intricate, intensely personal, and sometimes painful postpartum depression experiences of women in Southern Pakistan. Strength is a cultural factor, not mental or medical aspects, which show the family and community's hopes. Its strengths are mothers\u0026rsquo; voices in the form of verbatim and private thoughts about PPD. The results identify that postpartum depression is more than a medical condition, but a sociocultural construct based on gender roles, emotional neglect, no husband and in-law support, physical burnout, financial strains, and unrealistic expectations of motherhood. Women reported deep emotional distress associated with a change in body image, difficulty with breastfeeding, lack of sleep, and feeling like a failure as mothers. Of greatest concern were accounts of suicidal ideation, emotional distance from infants, and overwhelming guilt and resentment.\u003c/p\u003e\u003cp\u003eLack of empathy and emotional support, particularly from husbands, was always related to the occurrence and exacerbation of depressive symptoms. Beyond this, cultural stereotypes surrounding mental illness and romanticized conceptions of mothering make women experience isolation and shame. These findings highlight the imperative for culturally targeted maternal mental health treatment, counseling of the spouse, and public policy that acknowledges and promotes women's psychosocial health during and following childbirth.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTackling postpartum depression needs something greater than medical remedies\u0026mdash;it demands a complete change in the way society views women's emotional needs, gender equality in caregiving, and the demystification of maternal mental health talk in homes and healthcare systems. There are severe implications for PPD, like Tenacious grief, burden, bleakness, or comparing herself with others. In extreme circumstances, suicidal feelings. There are also severe implications for infants. Babies might display late linguistic growth, bigger bad-temperedness, and delayed complications with education and laws. When they grow in a tense atmosphere, they accept very little expressive reaction and attachment. The key policy for the government is to provide resources to women, especially for housewives, so that they do not feel an inferiority complex and depression. The government should provide Reasonable, available protection for mothers, especially marginalized women. There should be Community awareness movements to decrease humiliation about PPD.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSZ and FA designed the study and conceived the manuscript. SZ and FA drafted the manuscript. SZ, NIM, SB, AN, RB, MS, FA, SZ, and HA were involved in revising the manuscript. All authors were involved in writing the manuscript and approved its final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the support of local healthcare providers and local mothers in the data collection process of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original data presented in this study are included in the article. Further inquiries can be directed to the corresponding author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study adhered to the guidelines of the Declaration of Helsinki. Ethical approval for the study was obtained from the Research Ethics Committee of the Islamia University of Bahawalpur, Pakistan (Number: IUB-IBC-99; Date of Approval: 6 June 2024). All participants were fully informed about the nature of the study beforehand, and then they provided informed consent. Informed consent was obtained from all subjects and/or their legal guardian(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSidra Zia is Research Associate, Department of Anthropology, The Islamia University of Bahawalpur, Bahawalpur Pakistan. Prof. Najma Iqbal Malik is Chair of Department of Psychology at University of Sargodha, Sargodha, Punjab, Pakistan. Shamshad Bashir is Assistant Professor at Department of Psychology, Lahore Garrison University, Lahore Pakistan. Areej Nasir is Researcher at Department of Psychology at University of Sargodha, Sargodha, Punjab, Pakistan. Rubina Bhatti is the Dean of the Faculty of Social Sciences and a Professor in the Department of Information Management at The Islamia University of Bahawalpur, Pakistan. Prof. Muhammad Saleem is Chairman of Department of Applied Psychology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. \u0026nbsp;Farooq Ahmed is Associate Professor and Chairman of Department of Anthropology at The Islamia University of Bahawalpur, Bahawalpur Pakistan. Haleema Al-Sabbah is Professor at Department of Public Health, College of Health Sciences, Abu Dhabi University, Dubai, United Arab Emirates.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWisner KL, Moses-Kolko EL, Sit DK. Postpartum depression: a disorder in search of a definition. \u003cem\u003eArch Womens Ment Health\u003c/em\u003e. 2010;13(1):37\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eAlbert PR. Why is depression more prevalent in women? \u003cem\u003eJ Psychiatry Neurosci\u003c/em\u003e. 2015;40:219\u0026ndash;21. doi:10.1503/jpn.150205\u003c/li\u003e\n\u003cli\u003eSaeed Q, Shafique K, Chaudhry N. Lived experiences of mothers with postnatal anxiety: a qualitative phenomenology study from Pakistan. \u003cem\u003eBMJ Open\u003c/em\u003e. 2024;14(5):e078203.\u003c/li\u003e\n\u003cli\u003eMaxwell D, Robinson SR, Rogers K. \u0026ldquo;I keep it to myself\u0026rdquo;: A qualitative meta-interpretive synthesis of experiences of postpartum depression among marginalised women. \u003cem\u003eHealth Soc Care Community\u003c/em\u003e. 2019;27(3):e23\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003eEastwood JG, Jalaludin BB, Kemp LA, Phung HN, Barnett BE. Relationship of postnatal depressive symptoms to infant temperament, maternal expectations, social support and other potential risk factors: findings from a large Australian cross-sectional study. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2012;12:148.\u003c/li\u003e\n\u003cli\u003eKumari P, Basu S. Postpartum Depression and Its Determinants: A Cross-Sectional Study. \u003cem\u003eCureus\u003c/em\u003e. 2024;16(11):e74044. doi:10.7759/cureus.74044 \u003c/li\u003e\n\u003cli\u003eHahn-Holbrook J, Cornwell-Hinrichs T, Anaya I. Economic and health predictors of national postpartum depression prevalence: a systematic review, meta-analysis, and meta-regression of 291 studies from 56 countries. \u003cem\u003eFront Psychiatry\u003c/em\u003e. 2018;8:248.\u003c/li\u003e\n\u003cli\u003eYu Y, Liang HF, Chen J, Li ZB, Han YS, Chen JX, Li JC. Postpartum depression: Current status and possible identification using biomarkers. \u003cem\u003eFront Psychiatry\u003c/em\u003e. 2021;12:620371.\u003c/li\u003e\n\u003cli\u003eSadat Z, Abedzadeh-Kalahroudi M, Atrian MK, Karimian Z, Sooki Z. The impact of postpartum depression on quality of life in women after child\u0026apos;s birth. \u003cem\u003eIran Red Crescent Med J\u003c/em\u003e. 2014;16(2):e14995.\u003c/li\u003e\n\u003cli\u003eKochan M, Kabukcuoglu K. \u0026lsquo;I wish I had my pre-pregnancy body after birth\u0026hellip; but I have to be supported\u0026rsquo;: a theoretical study based on body image perception in working mothers during the postpartum period. \u003cem\u003eJ Obstet Gynaecol\u003c/em\u003e. 2022;42(5):1103\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eAlshikh Ahmad H, Alkhatib A, Luo J. Prevalence and risk factors of postpartum depression in the Middle East: a systematic review and meta-analysis. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2021;21(1):542.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Comprehensive Mental Health Action Plan 2013\u0026ndash;2030. Geneva: World Health Organization; 2021.\u003c/li\u003e\n\u003cli\u003eAl Rajabi A, Alkatheeri H, Hijazi R, Kennedy L. Breastfeeding is associated with reduction in postpartum depression in the United Arab Emirates: a retrospective cross-sectional study. \u003cem\u003eSci Rep\u003c/em\u003e. 2025;15(1):10528.\u003c/li\u003e\n\u003cli\u003eMorikawa M, Okada T, Ando M, Aleksic B, Kunimoto S, Nakamura Y, Kubota C, Uno Y, Tamaji A, Hayakawa N, Furumura K. Relationship between social support during pregnancy and postpartum depressive state: a prospective cohort study. \u003cem\u003eSci Rep\u003c/em\u003e. 2015;5:10520.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016.\u003c/li\u003e\n\u003cli\u003eCho H, Lee K, Choi E, Cho HN, Park B, Suh M, Rhee Y, Choi KS. Association between social support and postpartum depression. \u003cem\u003eSci Rep\u003c/em\u003e. 2022;12(1):3128.\u003c/li\u003e\n\u003cli\u003eJannati N, Farokhzadian J, Ahmadian L. The experience of healthcare professionals providing mental health services to mothers with postpartum depression: a qualitative study. \u003cem\u003eSultan Qaboos Univ Med J\u003c/em\u003e. 2021;21(4):554.\u003c/li\u003e\n\u003cli\u003eBorrero L, Dietsch A, Santurri LE, Ewen HH. New mothers with postpartum depression: a qualitative exploration of healthcare decision-making. \u003cem\u003eQual Health Res\u003c/em\u003e. 2024;34(3):217\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eJiaming W, Xin G, Jiajia D, Junjie P, Xue H, Yunchuan L, Yuanfang W. Psychological experience of patients with postpartum depression: a qualitative meta-synthesis. \u003cem\u003ePLoS One\u003c/em\u003e. 2024;19(11):e0312996.\u003c/li\u003e\n\u003cli\u003eFinlayson K, Crossland N, Bonet M, Downe S. What matters to women in the postnatal period: a meta-synthesis of qualitative studies. \u003cem\u003ePLoS One\u003c/em\u003e. 2020;15(4):e0231415.\u003c/li\u003e\n\u003cli\u003eAgbaje OS, Anyanwu JI, Umoke PI, Iwuagwu TE, Iweama CN, Ozoemena EL, Nnaji IR. Depressive and anxiety symptoms and associated factors among postnatal women in Enugu-North Senatorial District, South-East Nigeria: a cross-sectional study. \u003cem\u003eArch Public Health\u003c/em\u003e. 2019;77(1):1.\u003c/li\u003e\n\u003cli\u003eAli NS, Ali BS, Azam IS. Post partum anxiety and depression in peri-urban communities of Karachi, Pakistan: a quasi-experimental study. \u003cem\u003eBMC Public Health\u003c/em\u003e. 2009;9(1):384.\u003c/li\u003e\n\u003cli\u003eDas J, Do QT, Friedman J, McKenzie D, Scott K. Mental health and poverty in developing countries: Revisiting the relationship. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2007;65(3):467\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eMariam KA, Srinivasan K. Antenatal psychological distress and postnatal depression: A prospective study from an urban clinic. \u003cem\u003eAsian J Psychiatry\u003c/em\u003e. 2009;2(2):71\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eYaqoob H, Ju XD, Bibi M, Anwar S, Naz S. A systematic review of risk factors of postpartum depression. Evidence from Asian culture. \u003cem\u003eActa Psychol\u003c/em\u003e. 2024;249:104436.\u003c/li\u003e\n\u003cli\u003ePapadopoulou SK, Pavlidou E, Dakanalis A, Antasouras G, Vorvolakos T, Mentzelou M, Serdari A, Pandi AL, Spanoudaki M, Alexatou O, et al. Postpartum depression is associated with maternal sociodemographic and anthropometric characteristics, perinatal outcomes, breastfeeding practices, and Mediterranean diet adherence. \u003cem\u003eNutrients\u003c/em\u003e. 2023;15:3853. doi:10.3390/nu15173853\u003c/li\u003e\n\u003cli\u003eCoates R, de Visser R, Ayers S. Not identifying with postnatal depression: a qualitative study of women\u0026apos;s postnatal symptoms of distress and need for support. \u003cem\u003eJ Psychosom Obstet Gynaecol\u003c/em\u003e. 2015;36(3):114\u0026ndash;21. doi:10.3109/0167482X.2015.1059418\u003c/li\u003e\n\u003cli\u003eCoates R, Ayers S, De Visser R. Women\u0026rsquo;s experiences of postnatal distress: a qualitative study. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2014;14:4.\u003c/li\u003e\n\u003cli\u003eBlom EA, Jansen PW, Verhulst FC, Hofman A, Raat H, Jaddoe VW, Coolman M, Steegers EA, Tiemeier H. Perinatal complications increase the risk of postpartum depression: The Generation R Study. \u003cem\u003eBJOG\u003c/em\u003e. 2010;117(11):1390\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKazemi A, Ghaedrahmati M, Kheirabadi GR, Ebrahimi A, Bahrami M. The experiences of pregnancy and childbirth in women with postpartum depression: a qualitative study. \u003cem\u003eIran J Psychiatry Behav Sci\u003c/em\u003e. 2018;12(4):7.\u003c/li\u003e\n\u003cli\u003eRaisanen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Fear of childbirth predicts postpartum depression: a population-based analysis of 511\u0026thinsp;422 singleton births in Finland. \u003cem\u003eBMJ Open\u003c/em\u003e. 2013;3(11):e004047. doi:10.1136/bmjopen-2013-004047\u003c/li\u003e\n\u003cli\u003eBonanni G, Longo VL, Airoldi C, Meli F, Familiari A, Romanzi F, Pellegrino M, Visconti D, Serio A, Lanzone A, Bevilacqua E. Is the mental health of couples with twins more at risk? Results from an Italian cohort study. \u003cem\u003eFront Psychiatry\u003c/em\u003e. 2024;15:1284090.\u003c/li\u003e\n\u003cli\u003eWenze SJ, Battle CL, Tezanos KM. Raising multiples: mental health of mothers and fathers in early parenthood. \u003cem\u003eArch Womens Ment Health\u003c/em\u003e. 2015;18(2):163\u0026ndash;76. doi:10.1007/s00737-014-0484-x\u003c/li\u003e\n\u003cli\u003eMattar B, Wahdan Y, Nemer M, Abu-Rmeileh NM. Postpartum depression: perception, management, and help-seeking barriers in a Palestinian context: a qualitative study. \u003cem\u003eBMC Pregnancy Childbirth\u003c/em\u003e. 2025;25(1):411.\u003c/li\u003e\n\u003cli\u003eAyub S, Fatima M, Sikander A, Nawaz K, Zahra SD. Exploring the lived experiences of mothers with postpartum depression: a qualitative study on emotional challenges and coping strategies. 2025.\u003c/li\u003e\n\u003cli\u003eJackson L, O\u0026rsquo;Donoghue E, Helm J, Gentilcore R, Hussain A. \u0026lsquo;Some days are not a good day to be a mum\u0026rsquo;: exploring lived experiences of guilt and shame in the early postpartum period. \u003cem\u003eEur J Investig Health Psychol Educ\u003c/em\u003e. 2024;14(12):3019\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003ePope CJ, Mazmanian D. Breastfeeding and postpartum depression: an overview and methodological recommendations for future research. \u003cem\u003eDepress Res Treat\u003c/em\u003e. 2016;2016:4765310.\u003c/li\u003e\n\u003cli\u003eSharif L, Babhair R, Alzahrani D, Abuladel A, Kabli A, Alzahrani R, Alghamdi L, Mahsoon A, Sharif K, Alharazi R, Wright R. Unraveling the stigma: a qualitative descriptive exploration of the relationship between culture, religion, and mental disorders in Saudi Arabia. \u003cem\u003eBMC Psychol\u003c/em\u003e. 2025;13(1):425.\u003c/li\u003e\n\u003cli\u003eWildali D, Nazzal S, Hamshari S, Belkebir S. Prevalence and risk factors of postpartum depression among women attending primary healthcare centers in northern of West Bank/Palestine: a cross-sectional study. \u003cem\u003eBMC Womens Health\u003c/em\u003e. 2024;24(1):43.\u003c/li\u003e\n\u003cli\u003eZarroug M, Altaf MF, Shaikh S, Tidjani A, Bashir O, Ayash MI, Abdalla HK, Zarroug SH. The prevalence and risk factors of postpartum depression among Saudi Arabian women: a systematic review and meta-analysis. \u003cem\u003eInHealthcare\u003c/em\u003e. 2025;13(16):2040.\u003c/li\u003e\n\u003cli\u003eRuan JM, Wu LJ. Postpartum depression and partner support during the period of lactation: correlation research and its influencing factors. \u003cem\u003eWorld J Psychiatry\u003c/em\u003e. 2024;14(1):119.\u003c/li\u003e\n\u003cli\u003eGoyal D, Gay C, Lee KA. How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers? \u003cem\u003eWomen\u0026rsquo;s Health Issues\u003c/em\u003e. 2010;20(2):96\u0026ndash;104.\u003c/li\u003e\n\u003cli\u003eKapoor B, Malik N, Gupta G, Khan IA. A cross-sectional study exploring postpartum depression at a tertiary care center in eastern Uttar Pradesh, India. \u003cem\u003eCureus\u003c/em\u003e. 2024;16(4).\u003c/li\u003e\n\u003cli\u003eGribbin C, Achieng F, K\u0026rsquo;Oloo A, Barsosio HC, Kwobah E, Kariuki S, Nabwera HM. Exploring the influence of postnatal depression on neonatal care practices among mothers in Western Kenya: a qualitative study. \u003cem\u003eWomen\u0026rsquo;s Health\u003c/em\u003e. 2023;19:17455057231189547.\u003c/li\u003e\n\u003cli\u003eKhalil SB, Ali I. Negotiating beauty in Pakistan: a qualitative exploration of body image, nutrition, and cultural ideals among young women in Azad Jammu \u0026amp; Kashmir. \u003cem\u003eDialogues Health\u003c/em\u003e. 2025;100225.\u003c/li\u003e\n\u003cli\u003eAhmed F, Malik NI, Malik N, Qureshi MG, Shahzad M, Shahid M, Zia S, Tang K. Key challenges to optimal therapeutic coverage and maternal utilization of CMAM Program in rural southern Pakistan: a qualitative exploratory study. \u003cem\u003eNutrients\u003c/em\u003e. 2022;14(13):2612. doi:10.3390/nu14132612\u003c/li\u003e\n\u003cli\u003eLe\u0026oacute;n MP, Gonz\u0026aacute;lez-Mart\u0026iacute; I, Contreras-Jord\u0026aacute;n OR. What do children think of their perceived and ideal bodies? Understandings of body image at early ages: a mixed study. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e. 2021;18(9):4871.\u003c/li\u003e\n\u003cli\u003eJozsa F, Thistle J. Anatomy, Colostrum. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Feb 5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postpartum Depression, Mothers, Qualitative Study, Pakistan, Sociocultural Factors","lastPublishedDoi":"10.21203/rs.3.rs-7899187/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7899187/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe majority of women across the world suffer from postpartum depression (PPD), a mental health condition that affects women\u0026rsquo;s lives after delivery. In middle-income countries like Pakistan, PPD is not considered a serious condition and is deliberately stigmatized. In this qualitative study, we explored sociocultural, emotional, and structural determinants of PPD among Pakistani women.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe employed a qualitative research design and conducted interviews with 21 postpartum women in two hospitals in the marginalized Southern Punjab region of Pakistan. A thematic analysis was then used to generate themes.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eFive major themes were identified causing PPD in the Southern Punjab mothers: 1) healthcare providers' attitude and support, 2) limited spousal and family support and postpartum depression, 3) anxiety as a result of sudden alterations in body and appearance, 4) postpartum breastfeeding depression, and 5) lack of sleep and postpartum depression. Multiple sub-themes contributing to these major themes were: healthcare providers' insulting attitude before and after birthing, masculinity standards and emotional concealment, emotional neglect and internalized shame, limited family support and lack of time for self-care, body shaming and stigmatization by in-Laws, loss of appetite and disappointment with infant's appearance, physical load and suicidal Ideation induced by breastfeeding burden, emotional strain of breastfeeding twins, body image and weight loss, decline in sexual desire, and guilt of feeling emotionally distant as a mother.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePPD among Southern Pakistani women is strongly connected with social, cultural, interpersonal, and structural factors. Therefore, it cannot be treated without socio-culturally tailored maternal mental health interventions that cover not just biological but also emotional support, respectful maternity care, and social protection. Incorporation of postpartum mental health screening and counseling into primary healthcare is the most essential intervention to ensure maternal health and early childhood development outcomes.\u003c/p\u003e","manuscriptTitle":"“When Their Joy Turns into Pain”: A Qualitative Phenomenological Study of Postpartum Depression among Southern Pakistani Mothers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 16:51:39","doi":"10.21203/rs.3.rs-7899187/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-11-17T05:46:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-25T09:43:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-23T02:47:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-23T02:46:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-10-19T14:16:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5ed3510-0a5e-4137-98b5-d599feccfd98","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-26T16:51:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-26 16:51:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7899187","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7899187","identity":"rs-7899187","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}