When a New Mother Becomes Mentally Unhealthy, It Is Everyone’s Problem: Shanghai Women’s Perceptions of Perinatal Mental Health Problems

Abstract

Sixteen women in Shanghai participated in semistructured interviews, and thematic analysis was used to interpret their responses. An overarching theme, three main themes, and 13 subthemes were identified. The overarching theme (the old ways and the new—transition into motherhood) in new China, had these main themes: (1) urban Chinese women’s transition into motherhood; (2) family’s support and struggle with tradition; and (3) modern society in the shade of the past. The transition from tradition and modernity can be a source of conflict between the generations and can negatively impact new mothers’ mental health. Loneliness, feeling misunderstood, illiteracy, parental generation’s beliefs, and health-care providers’ attitudes are all barriers to access to care.

Keywords:

• Perinatal mental health
• urban China
• depression
• anxiety
• child policy
• health-care practices

China is undergoing rapid economic and social changes, but the mental health field lags behind (Liu et al., 2011). The main focus of mental health policy reform in China has been on severe mental illness. Even in contemporary China, services for common mental health disorders (CMD) are very limited. The focus must shift away from distributing resources primarily to inpatient care for severe mental health disorders to providing outpatient care for CMDs, which are more prevalent than in middle-income countries (Fisher et al., 2012). In most middle-income countries, treatment gaps are 75%; in China the gap is 91.8% (Liu et al., 2011). The estimated total disability adjusted life years (DALYs) of CMDs translates into a loss of gross domestic product (GDP; Charlson et al., 2016).

The prevalence of mental disorders in the most recent Chinese Mental Health Survey initiated in 2012 was higher than in previous large surveys conducted in 1982 and 1993 (Huang et al., 2019). The substantial gaps in the accessibility of care remained in the most recent survey (Huang et al., 2019; Liu et al., 2011). The prevalence of perinatal depression in China is estimated to be 10%–15% (Zhao et al., 2016), and it is reported to be higher in women of the Chinese one-child generation than in previous generations, and especially high among those women who gave birth to a daughter (Xiong et al., 2018). The one-child policy has led to a stronger preference for boys, and disappointment over the infant’s gender is a significant risk factor for perinatal depression in China (Xie et al., 2011). Furthermore, women without siblings are more likely to be affected by negative mood states (Tseng et al., 1988). Perinatal depression appears to be common in rural areas where no treatment is available and the stigma is high (Wong & Fisher, 2009). Rural areas have a stronger preference for sons, and they exhibit more traditional gender roles in the family than is the case in urban areas, which can also influence rural women’s perinatal mental health. At the same time, epidemiological research shows that women in fast-growing metropolitan areas are at increased risk for developing common mental health disorders (Galea et al., 2011; Virupaksha et al., 2014). Concerns about the burden of mental disorders and their association with urbanicity have grown worldwide. Little is known about the extent of these issues in rapidly expanding megacities such as Shanghai (Chen et al., 2012), but the prevalence of postpartum depression there is 10.9% (Qian & Yan, 2013; Wong & Fisher, 2009). The Chinese government is trying to encourage women to have a second child to counteract concerns regarding the aging society and to secure the labor force. They have not been successful to date. Women are hesitant to have a second child, due to negative consequences on their career, particularly in urban areas such as Shanghai (Schwank et al., 2018).

The situation in urban China is comparable to the studies on labor market participation in the West. Women’s labor market transitions are influenced by their partner’s gender ideology and labor market resources and by the presence of young children in the household (Khoudja & Fleischmann, 2018). Women’s labor market transitions are also influenced by economic pressure and institutional restrictions, which act against women with several children in China (Schwank et al., 2018). The consequences of having children for women’s labor market activity are related to both organizational and national arrangements, such as maternal leave and child‐care supply (Charles, 2011; Schwank et al., 2018).

In a large survey conducted to assess perinatal mental health in urban Chinese women, most were well educated—over 80% had a college degree (Schwank, Andersson, et al., 2019). Similar results were found in the Shanghai birth cohort study, where 60%–80% of the women had a college degree (Zhang et al., 2019). Men tended to have a slightly lower educational level than women and were more often from second-tier cities or more rural areas. Most couples described their situation as financially very comfortable. Educational differences and urban versus more rural background can create tension within couples, which the previous surveys have shown. A less supportive husband was more common in the group of women with lower mental well-being (Schwank, Andersson, et al., 2019). Urban women accustomed to egalitarian roles in their relationship struggled with the transition to motherhood and the traditional role expectations following the birth of a child, such as the relationship with their mother-in-law. The women considered their mother-in-law the person they would trust the least to talk about their mental health problems and would not turn to her for support (Schwank, Andersson, et al., 2019).

Social stigma is one of the biggest barriers to seeking mental health care in China. In a recent study (Chen, 2018a), 34.6% of primary care physicians (PCPs) reported that patients with depression, or their families, were reluctant to accept a diagnosis; nearly 80% of patients were hesitant to consult a mental health specialist. The limited availability of specialists and lack of trust in health-care professionals leads to very low numbers of women seeking help for perinatal mental health problems, even if they are aware of their problems (Schwank et al., 2018). Perinatal care professionals refer to the lack of education and limited resources of professionals as a core problem in the accessibility of mental health care services (Schwank, Wickberg, et al., 2019). The social stigma hinders women from seeking care for perinatal mental health problems, as it is embedded in their family structure. In Chinese societies, postpartum care is influenced by both traditional beliefs and contemporary health-care practices (Posmontier & Horowitz, 2004). For example, “doing the month” is a 30-day Chinese postpartum ritual that involves physical and social prescriptions and taboos. According to Chinese folk and classical medicine, postpartum women are in a state of extreme yin and yang imbalance, which results in weakness and vulnerability (Chen, 2001). The ritual practice of doing the month involves a series of practices related to the maternal role, physical activity, maintenance of body warmth, and consumption of foods believed to restore maternal postpartum health (Liu et al., 2014). “Doing the month” has been considered to have both positive and negative impacts on maternal well-being. For example, the protective role of doing the month in the tradition of familial support and rest after confinement is positive. However, confinement could contribute to or fail to protect against PPD, due to diminished social support in modern Chinese society, as well as pressure and conflicts with the mother-in-law. Thus urban Chinese women are forced to balance their work in the labor force and traditional values (Wong & Fisher, 2009).

The rapid cultural and economic changes, and greater access to higher education, have led some urban women to question traditional practices such as doing the month and to modify traditional postpartum care (Liu et al., 2014). Traditional rituals that contribute to social order are being challenged and transformed in response to contemporary social changes in family structures, women’s status, and health-care systems (Yeh et al., 2014). Yet the ancient Confucian philosophy is still present in contemporary China, reflected in filial piety and the central role of education to be a good Confucian scholar and member of society (Hwang, 2011). Parents and parents-in-law encourage new mothers to follow traditional practices (Liu et al., 2014). Traditionally, mothers-in-law have significant authority in Chinese homes and have had a great influence on the postpartum care of their daughters-in-law (Wong & Fisher, 2009). These traditions and expectations, such as doing the month or dedicating significant time to educating children, play a central role in the family dynamics, and thus relate to the well-being of new mothers and fathers.

High-quality evidence about mental health problems in the perinatal period must be generated, especially at the local level, to make pregnancy and motherhood safer for women in urban China. This is relevant to the current discourse about the reduction of the fertility rate in China, despite the introduction of the two-child policy. Insight into women’s perceptions of being pregnant and taking care of their newborn child is essential to provide mental health care that is relevant and acceptable to women and their families. Therefore, the present study was designed to explore the perceptions of and attributions about mental health among pregnant women and new mothers in Shanghai, China. The interview approach facilitates a discourse on common mental health disorders in a society with an intricate somatization of mental health disorders (Chang & Kleinman, 2002; Kleinman, 2013).

Method

Participants

Shanghai women who were currently pregnant or who had experienced childbirth were invited via WeChat to participate in the study, using the snowball technique described by Polit and Beck (2018). Potential informants were identified via Fudan University’s Redhouse Hospital, Shanghai Women’s and Children’s Health Center, and the Chinese American Psychoanalytic Alliance (CAPA). All (n = 16) participants were well-educated women from urban Shanghai, China. The participants in the present study were young professionals of childbearing age, primarily from the one-child generation, and currently not in treatment for mental health care. Their mean age was 35.75 years. The women were pregnant or had one or more children; 12 of the 16 women had a Shanghai household registration and Shanghai citizenship (hukou), which provides privileged access to health care and education for their children (Table 1).

Table 1. Demographics study participants.

Participants	N = 16
Mean age (years)	35.75 (30–47)
Nationality
Chinese	16
Household registration (Hukou)
Shanghainese	12
Urban migrant	4
Marital status
Married	16
Education
Ph.D.	2
Master’s degree	7
Bachelor’s degree	5
High school	2
Profession
Medical doctor	4
Public health	2
Private sector	10
Hours at work (hr/week)
<40	3
=40	6
>40	7
Monthly individual income (CNY)
<10,000	9
=10,000–20,000	5
>20,000	2
Number of children
Pregnant (first child)	2
One	8
Two	4
Three	2

Note: The official exchange rate was approximately USD = 6.20 to CNY; N: number of participants.

Procedure

We developed an interview guide based on our earlier study’s (Schwank et al., 2018) results and our broad areas of inquiry. The interview guide includes eight open-ended questions about women’s perceptions of and attitudes toward mental health, especially during the perinatal period, their current mental well-being, and a retrospective view on their well-being during pregnancy and after having given birth. We initiated the interviews by inquiring about a global understanding of physical and mental health, and we proceeded with more specific questions on mental health and help-seeking behavior, support, and causes of mental health problems during the perinatal period. Different aspects of societal, family, individual, and health-care perspectives were emphasized. The interviews were conducted in English with a Chinese translator who was trained in psychology, tape-recorded, and transcribed. Written notes were kept to supplement the verbatim transcripts. The interviews took place at Fudan University Redhouse Hospital or at the women’s preferred location. The interview length was 60 minutes, on average, with a range of 45–90 minutes. Informed consent was obtained from all participants. Ethical approval was obtained from the Ethics Committee in Stockholm and from the Obstetrics and Gynecology Hospital, Fudan University. Data collection took place in Shanghai, China in December 2018. Three pilot interviews were conducted by a professional translator and a member of our research team.

Analysis

Thematic analysis, as described by Braun and Clarke (2006), was used. To ensure trustworthiness we selected an optimal data-collection method to answer our research questions. We took an inductive approach and maintained broad description of occurrences. The sample size of 16 interviews was considered sufficient for the study’s purpose (Graneheim & Lundman, 2004; Moretti et al., 2011; Sandelowski, 1995). The richness of the data and the homogeneity of the study participants further supports this decision (Burmeister & Aitken, 2012).

To assure credibility, we (HL, EA, SS) read the interviews independently and used quotations to illustrate the themes and to provide transparency. Verification by the three of us ensured that the emergent themes accurately reflect the data. Communalities and differences were then described. Themes were identified in a bottom-up approach (Frith & Gleeson, 2004). The analysis resulted in themes, subthemes, and one overarching theme. In the first step, the text was read independently by two authors and meaning units were ascertained. In the thematic analysis, we categorized the material in different steps of the analytic process according to similar expressions of thoughts and feelings. Themes and illustrative quotes were identified, discussed, and compared against the original areas of inquiry of urban Chinese women’s perceptions of causes of perinatal mental health, their help-seeking behavior, and the transition into motherhood.

The interview technique showed confirmability, despite the preconception that stigma would be related to disclosure about mental health. The interviews provided new information and genuine insight into the women’s understanding and expression of mental health (Moretti et al., 2011). The data from the interviews accurately represents the information that the participants provided, and the interpretations of those data quotes emphasize the interviewees’ contributions (Polit, 2016). We strived for dependability by verifying the consistency of the findings with the collected raw data (Elo et al., 2014).

Results

We found an overarching theme, three main themes, and 13 subthemes. The overarching theme, the old ways and the new—transition into motherhood in new China, was divided into these main themes: (1) urban Chinese women’s transition into motherhood; (2) family’s support and struggle with tradition; and (3) modern society in the shade of the past (Table 2).

Table 2. Themes and subthemes.

Overarching theme	Themes	Subthemes
The old ways and the new—transition into motherhood in new China	1. Urban Chinese women’s transition into motherhood	1. Talking cure through friends and family
		4: Women’s strategies and activities to improve status quo
		5: Share experience of mental health
		8: Loneliness and isolation
	2. Family’s support and struggle with tradition	3: (Mediator) role of the husband
		7: Family demands and expectations
		7.1. Demands
		7.2. Expectations
	3. Modern society in the shade of the past	2: Attitudes and perceptions
		6: Forever child
		9: Education and information to prevent mental health problems
		9.1. To the individual
		9.2. To society

The overarching theme captures the Shanghai women’s discourse on aspects that impact their perinatal mental health and their position of being in between generations, between the old and the new China, and between the traditional Chinese role of motherhood and the modern role of women in society. They are both mothers and part of modern society as professional women with access to high-tech medicine and all aspects of a cosmopolitan lifestyle.

Urban Chinese Women’s Transition Into Motherhood

The women described their experience of transitioning into motherhood and discussed strategies and activities to improve their mental well-being. They openly shared challenges in dealing with perinatal mental health problems that they themselves had encountered or that friends whom they supported had experienced. The women described the causes of their problems and to whom they would or would not turn for support. They pronounced their need to take time on their own and to take responsibility and action for themselves, but also discussed loneliness and isolation in their role as mothers. The participants described how they took initiative, such as disobeying the ritual of “doing the month,” which requires that they stay at home, by leaving the house earlier than their parents or in-laws wanted them to do. Many women emphasized the importance of connecting with the outside world by returning to work, after having stayed at home with their baby. Connecting with society, colleagues, or a network of women from the same generation were all considered essential to improve mental health and well-being. The role of the mother-in-law recurred as a major source of conflict during the transition to motherhood. The prominent gap between their generation and the parental generation, and between urban and rural understandings of parenting, was described as a situation that created tension:

The conflict with the mother-in-law is the main source of her feeling mentally unwell. (#W4)

The women shared personal stories and anecdotes about acquaintances’ perinatal mental health problems in urban China. There was a sense of being left alone with the situation and family members’ neglect of mental health and lack of awareness. When they talked about mental health problems, the women often related their problems to family problems, such as having an unsupportive husband. Lack of resources and support within the family resulted in escalations of many situations, and in the worst case resulted in lethal outcomes, such as suicide.

Everything he did, I was not happy and I cried during the night. I even wanted to kill myself several times. I was living on the second floor, so I couldn’t really hurt myself. So, I didn’t have a lot of chances to hurt myself, but I realized it was pretty serious. (#W15)

The women struggled with their role in between generations and with the loneliness and isolation they felt among family members. They described how their own mother’s problems and their desires to have a sibling had affected them. They spoke of forced abortions, penalties for a second child, and the desire for a son during the one-child policy. They expressed fantasies and ideas about family norms.

When I was young, I was soooo lonely and craving more a younger brother, a younger sister. When I heard my mother was pregnant with a second baby, I was soooo excited, but then she had an abortion because of the policy. (#W9)

Some women mentioned a recent childbirth or childbirth “tourism” to the United States and its consequences for their mental health. One woman shared the story of a friend who had moved to the United States to have her baby. She spoke of the loneliness and depression her friend felt without her husband. The women spoke of close friends, who sometimes took the role of a sibling.

Friends say to me you’re like us, we all are the same. So it’s very helpful to see that I’m not the only one experiencing those feelings. (#W15)

Family’s Support and Struggle With Tradition

China is a collectivist society, where individuals must consider their reputation carefully and maintain harmony at the interpersonal level, which is related to personal and family well-being. Family is considered the smallest significant societal unit. An individual is defined by her relationship with family, relatives, community, and the nation at large. In Chinese parenting, several generations care for the newborn infant. As a result of the one-child policy, all the attention of the grandparents and parents are put on the newborn. This collective parenting and involvement of several generations can result in collective anxiety about the one child.

Family is the core in China and that also affects how we raise and take care of the children. It’s a family project and the family is the core structure in the Chinese society. (#W16)

All the participants agreed on the importance of the husband’s support for women’s mental health. His involvement in childrearing and family dynamics was described as very important for their mental health and well-being.

My husband was always there for me. When he was there for me, I felt safe. If he wasn’t I felt hopeless. (#W8)

The husband’s support was considered a mediator between the generations, especially during the perinatal period, in navigating the relationship between the new mothers and their mothers-in-law. The women shared how their husbands were the people to turn to and trust. They considered having a supportive and caring husband to be central to their well-being and having an unsupportive husband as the main cause of their mental health problems and escalating family problems with their mothers-in-law.

My husband is in the middle when I have “bad temper,” which is caused due to frustration with the parents-in-law that don’t understand my point of view. (#W12)

Other family members, especially mothers-in-law who moved in with couples after the birth, have more demanding positions and expectations within the household. Traditionally, the mother-in-law has exercised significant power in Chinese households. Her opinions and ways of childrearing may cause serious stress for these urban women. The high expectations and demands, and the strong opinions of that parental generation, make the younger women question their own authority and increase their anxiety about being a good-enough mother. The experienced pressure, as well as the anxiety of the parental generation, may increase the young women’s anxiety and uncertainty in their new maternal role.

Modern Society in the Shade of the Past

Women felt stuck between generations, not knowing what to do and whom to trust: themselves or the parental generation. In China, the tradition of Confucian ethics is strong. Medical ethics in modern Chinese hospitals and medical schools are based on European and American protocols and procedures, with high standards, yet they lack the necessary guidelines and concern about mental health care. This leads to a lack of available medical staff and ambiguity about to whom to turn and whom to trust.

Because, you know, Chinese women aren’t allowed to go out during the first month. My mother also forbids me to go out, not to wash my hair or take a bath. I struggled and did it anyway. (#W5)

The influence of Confucian philosophy, with its emphasis on education and studying, was evident in conversation about preventing CMDs. Participants thought the essential focus of health-care providers should be on educating the young couple and getting them ready for their new parental roles.

But the parents need to get some education and some support. I think both parents need to be there and if the father isn’t ready and next to the mother’s side. That is a source for a lot of mental health problems in the mother. It is the biggest problem for the mothers. I think there should be some classes, some education for the parents to get prepared. (#W15)

The women were aware of the health-care system’s focus on physical rather than mental health care and education in China. A glimpse of a shift from traditional perceptions of mental health to a modern understanding of its impact on women’s health was evident. Interviewees emphasized the importance of raising societal awareness of mental health problems.

If there would be nice people, a hotline that I could turn to. I would go, but don’t know if there are such services available in Shanghai. Like a hotline, professionals, a website where I could go and ask for help. (#W5)

Although initially focused on the Chinese discourse of mental health, the women shifted to share their own attitudes and perceptions and highlighted the transition of their understanding of mental health in urban China. The participants expressed how important it is that public discourse change, and they stressed that perinatal mental health problems are embedded in cultural and traditional structures. One woman said: “When a new mother becomes mentally unhealthy, it’s not the fault of another person, it’s everyone’s problem” (#W15).

Grandparents who were allowed only one child now enact their desire for a second child through their grandchild, which creates blurred generation boundaries and interferes with the new generation of parents’ ability to take on their parenting roles. The one-child policy established a Chinese family structure of 4-2-1: four grandparents, two parents, and all attention on the newborn infant. “The newborn child is too close to these two grandparents and the actual parents are still like children” (#W5).

Discussion

We found that urban Shanghai women struggled with their transition into motherhood, experienced tension within the family, and had difficulty balancing tradition with contemporary values and expectations. Women reported trusting in friends and taking an active role to improve their status as the most helpful responses, similar to results reported by Wu and colleagues (Chen et al., 2019). The women described a clear sense of loneliness and isolation. They were surrounded by family members, yet felt alone due to their unique position between generations and a sudden motherhood role (Schwank et al., 2018; Sun & Li, 2004). The women reported feeling isolated due to postpartum traditions, including “doing the month.” Our findings are in line with previous research on the Chinese tradition of postpartum confinement (Liu et al., 2014). Social isolation and loneliness are both factors associated with depression (Matthews et al., 2016). Therefore, it seems that the practice of doing the month enhances isolation and increases the risk for depression among new mothers (Zhou et al., 2019).

Tension among generations has been described as a primary source of mental health problems in the perinatal period (Xiong et al., 2018). The cross-generational conflicts could be a contributing factor to the high rates of “unstable mood,” which are reported by 50%–75% of first-time mothers in China between the first trimester of pregnancy and 6 months postpartum (Zhou et al., 2018). These results are similar to data from other Asian countries, such as South Korea (Kim et al., 2012).

The transition of Chinese society becomes evident in the discourse as women reported their understanding of the source of conflicts and causes of mental health problems in the perinatal period. Thus the large generation gap and influence of parents-in-law contribute to postpartum depression in China (Guo et al., 2013; Liu et al., 2014). Disharmony between a woman and her mother-in-law is one of the most common conflicts in China, where women traditionally live with their parents-in-law after marriage (Xiong et al., 2018). Researchers have identified a poor mother-in-law relationship as a strong predictor of PPD (Deng et al., 2014).

The implementation of the two-child policy further challenges societal and family changes (Schwank et al., 2018). According to Jiang et al. (2018), differences in beliefs and perception of mental health care and help-seeking behavior are associated with age and educational level; individuals with higher education levels were less likely to be depressed. The women in our study frequently emphasized the distinctions between urban and rural China.

Women from the one-child generation struggled more with transitioning into motherhood (Cheng, 2013; Cheng & Duan, 2016), which could be due to mourning a lost position in the family, as the center of parental attention, which, after the birth of a grandchild, is shifted to the newborn infant (Stern et al., 1988). Negative attitudes toward pregnancy and the role of mother may influence a woman’s ability to care for her child and to be sensitive to the child’s needs, which can result in an aggravation of depressive symptoms (Xiong et al., 2018). The generation of only-children are their family’s only hope for a bright future, and the exclusive devoted love and attention often comes with high expectations and daily pressure to succeed (Xiong et al., 2018). Families’ high hopes and expectations for their only child to be successful may be reflected in the collective anxiety and obsessive parenting of their only child’s grandchild (Schwank et al., 2018).

The women in our study saw their spouses as a primary source of support; in a way, they serve as a “placeholder” for a sibling that the women from the one-child generation missed. In the women’s eyes, their spouse’s support is essential for their mental health and well-being. In our findings, women attributed their mental health problems primarily to their conflicted relationship with their mother-in-law and the confinement, which resulted in isolation and lack of social support. These results are in line with Qian et al.’s (Qian & Qian, 2015) study on well-being and living situation with young children and with Short and colleagues’ (Short et al., 2001) investigation of the impact of the one-child policy and parental involvement in child care.

The husbands of the women in our study were portrayed as mediators between the generations, as long as they acted in a supportive manner. Traditionally in China, the parents-in-law move into the home of the young couple, and they bring with them a very different upbringing and a fundamentally different life history, which causes tension among family members (Wang et al., 2017). The living situation of young urban Chinese couples with a child is different from their age peers in other urban societies. Living with the parents-in-law is a remnant of the past and, depending on the quality of the relationship, can be a potential risk factor for postpartum depression (Wang et al., 2017).

In several studies, social support was negatively correlated with depression among Chinese primiparae (Huang et al., 2019; Kim et al., 2013; Zhou et al., 2018). Perceived social support and conflicts among social support providers were major contributors to stress associated with postpartum depression in previous studies in China (Tang et al., 2016; Xiong et al., 2018).

Going out and talking to female friends was seen as a lifeline for the women in the present study, whereas they attributed their mental health problems to the postpartum ritual of confinement, which led to feeling isolated, trapped, and not able to move about and get out of their homes. The urban women in the present study valued their work and career aspirations, as well as their social network of co-workers and friends. Female friends and co-workers are especially significant for the generation of the one-child policy, who grow up without siblings. The professional role is an important part of urban women’s identity and social ties. This role is particularly challenged by the expectations of having a second child (in light of the two-child policy) and their husband’s attitude toward their work life. Similar concerns about the number of children, career aspirations, and remaining in the labor force have been discussed in international studies (Carmen et al., 2014; Chen, 2018b; Chuang & Lee, 2003). The husband’s negative attitude toward the wife’s career and her desire to remain in the workforce greatly discourages women from continuing their career, even more than the number of young children in the family (Chuang & Lee, 2003).

The importance of education is rooted in ancient Chinese traditions and the Confucian philosophy of learning to gain social status (Hwang, 2011). Particular emphasis and importance is put on family and social harmony (Fung, 2008), which may explain why this was frequently mentioned by the women in the present study. The challenge of whom to trust and to whom to turn (e.g., parental generation, medical professionals) can also be exemplified by the conflict between rich Confusion ethics and medical ethics imported from Europe and the United States, as well as NIH-based procedures and protocols, which lack concern about follow-through (Kleinman, 2010).

Conclusion

Our study generated novel insights into Chinese women’s perceptions of perinatal mental health problems in Shanghai and their care-seeking behavior. The women perceived a sense of loneliness and lack of support in their early motherhood, despite the involvement of family members. Conflicting feelings about transitioning from traditional to modern motherhood and parenting, which affected the women’s mental health, were explored. The majority of the women expressed openness to a talking cure through friends and emphasized the role of a supportive husband for mental well-being. Their friends and husbands were the primary contacts from whom to seek support regarding perinatal mental health problems.

The results provide an important basis for larger survey studies and epidemiological research in urban China, as well as a basis to initiate a discourse on women’s mental health and patient-centered care for CMDs. This is particularly important considering the large treatment gap and the dropping fertility rate in a rapidly aging society that simultaneously wants to maintain its economic growth. Having someone to talk to is essential for women in this state of being “in-between” the old traditions and the requirements of a modern urban Chinese society. Access to nurses and community health-care professionals educated in psychosocial support could be a cost-effective way to improve perinatal mental health. Online, web-based health care services could be a useful alternative, if provided by trustworthy professionals and government agencies. Our interviewees described the contemporary discourse of Shanghai women’s perception of perinatal mental health situation in urban China. These findings are essential for effective resource allocation to mental health care services, in order to close the treatment gap for common mental health disorders, as outpatient clinics for CMDs are limited even in highly developed places such as Shanghai.

Limitations

The sole focus on urban Shanghai women may be considered a limitation. Shanghai is a first-tier city, and the findings may need to be reassessed in other first-tier cities and second-tier cities to extend knowledge. The selected homogeneous sample is another limitation, as it is dominated by a particular section of the society with high educational levels: professionals from the urban Chinese middle class. Further studies in different urban and rural environments are necessary to gain a more general understanding of the perinatal needs of Chinese women and their families.

Acknowledgments

We would like to thank the women for their participation in the present study and all the research staff and clinicians for their hard work, which made this study possible. Thank you to the Shanghai Women’s and Children’s Health Center and Chinese Psychoanalytic Alliance (CAPA) for their support. Thank you to Mandy Hsu, Nicole Pang, and Caroline Reynolds for the language revisions.

Disclosure statement

No potential conflict of interest was reported by the author(s).