Although postnatal depression is a common condition, with adverse effects on the child, mother and partner, there has been no research to date linking analyses of its origins and consequences with studies of service provision in different national health and social systems.

The Transcultural Study of Postnatal Depression (TCS–ND)was setup to develop a set of instruments to facilitate such research.

Seven research instruments were piloted in studies carried out in ten centres in eight countries. A qualitative study looked at the cross-cultural equivalence of the concept of postnatal depression.

The results are reported in the individual papers in this supplement.

Reliable and culturally valid measures are now available for future comparative research into postnatal depression within different health systems and countries.

Postnatal depression seems to be a universal condition with similar rates in different countries. However, anthropologists question the cross-cultural equivalence of depression, particularly at a life stage so influenced by cultural factors.

To develop a qualitative method to explore whether postnatal depression is universally recognised, attributed and described and to enquire into people's perceptions of remedies and services for morbid states of unhappiness within the context of local services.

The study took place in 15 centres in 11 countries and drew on three groups of informants: focus groups with new mothers, interview swith fathers and grandmothers, and interviews with health professionals. Textual analysis of these three groups was conducted separately in each centre and emergent themes compared across centres.

All centres described morbid unhappiness after childbirth comparable to postnatal depression but not all saw this as an illness remediable by health interventions.

Although the findings of this study support the universality of a morbid state of unhappiness following childbirth, they also support concerns about the cross-cultural equivalence of postnatal depression as an illness requiring the intervention of health professionals; this has implications for future research.

To date, no study has used standardised diagnostic assessment procedures to determine whether rates of perinatal depression vary across cultures.

To adapt the Structured Clinical Interview for DSM–IV Disorders (SCID) for assessing depression and other non-psychotic psychiatric illness perinatally and to pilot the instrument in different centres and cultures.

Assessments using the adapted SCID and the Edinburgh Postnatal Depression Scale were conducted during the third trimester of pregnancy and at 6 months postpartum with 296 women from ten sites in eight countries. Point prevalence rates during pregnancy and the postnatal period and adjusted 6-month period prevalence rates were computed for caseness, depression and major depression.

The third trimester and 6-month point prevalence rates for perinatal depression were 6.9% and 8.0%, respectively. Postnatal 6-month period prevalence rates for perinatal depression ranged from 2.1% to 31.6% across centres and there were significant differences in these rates between centres.

Study findings suggest that the SCID was successfully adapted for this context. Further research on determinants of differences inprevalence of depression across cultures isneeded.

There is evidence that stressors may trigger the onset of a depressive episode in vulnerable women. A new UK interview measure, the Contextual Assessment of the Maternity Experience (CAME), was designed to assess major risk factors for emotional disturbances, especially depression, during pregnancy and post-partum.

Within the context of a cros-scultural study, to establish the use fulness of the CAME, and to test expected associations of the measure with characteristics of the social context and with major or minor depression.

The CAME was administered antenatally and postnatally in ten study sites, respectively to 296 and 249 women. Affective disorder throughout pregnancy and upto 6 month spostnatally was assessed by means of the Structured Clinical Interview for DSM–IV Axis I Disorders.

Adversity, poor relationship with either a partner or a confidant, and negative feelings about the pregnancy all predicted onset of depression during the perinatal period.

The CAME was able to assess major domains relevant to the psychosocial context of the maternity experience in different cultures. Overall, the instrument showed acceptable psychometric properties in its first use in different cultural settings.

Insecure attachment style relates to major depression in women, but its relationship to depression associated with childbirth is largely unknown. A new UK-designed measure, the Attachment Style Interview (ASI), has potential for cross-cultural use as a risk marker for maternal disorder.

To establish the reliability of the ASI across centres, its stability over a 9-month period, and its associations with social context and majoror minor depression.

The ASI was used by nine centres antenatally on 204 women, with 174 followed up 6 months postnatally. Interrater reliability was tested and the ASI was repeated on a subset of 96 women. Affective disorder was assessed by means of the Structured Clinical Interview for DSM–IV.

Satisfactory interrater reliability was achieved with relatively high stability rates at follow-up. Insecure attachment related to lower social class position and more negative social context. Specific associations of avoidant attachment style (angry–dismissive or withdrawn) with antenatal disorder, and anxious style (enmeshed or fearful) with postnatal disorder were found.

The ASI can be used reliably in European and US centres as a measure for risk associated with childbirth. Its use will contribute to theoretically underpinned preventive action for disorders associated with childbirth.

Infant development is adversely affected in the context of postnatal depression. This relationship may be mediated by both the nature of early mother-infant interactions and the quality of the home environment.

To establish the usefulness of the Global Ratings Scales of Mother–Infant Interaction and the Infant–Toddler version of the Home Observation for the Measurement of the Environment (IT–HOME), and to test expected associations of the measures with characteristics of the social context and with major or minor depression.

Both assessments were administered postnatally in four European centres; 144 mothers were assessed with the Global Ratings Scales and 114 with the IT–HOME. Affective disorder was assessed by means of the Structured Clinical Interview for DSM–IV Disorders.

Analyses of mother–infant interaction indicated no main effect for depression but maternal sensitivity to infant behaviour was associated with better infant communication, especially for women who were not depressed. Poor overall emotional support also reduced sensitivity scores. Poor support was also related to poorer IT–HOME scores, but there was no effect of depression.

The Global Ratings Scales were effectively applied but there was less evidence of the usefulness of the IT–HOME.

Little is known about the availability and uptake of health and welfare services by women with postnatal depression in different countries.

Within the context of a cross cultural research study, to develop and test methods for undertaking quantitative health services research in postnatal depression.

Interviews with service planners and the collation of key health indicators were used to obtain a profile of service avail ability and provision. A service use questionnaire was developed and administered to a pilot sample in a number of European study centres.

Marked differences in service access and use were observed between the centres, including postnatal nursing care and contacts with primary care services. Rates of use of specialist services were generally low. Common barriers to access to care included perceived service quality and responsiveness. On the basis of the pilot work, a postnatal depression version of the Service Receipt Inventory was revised and finalised.

This preliminary study demonstrated the methodological feasibility of describing and quantifying service use, highlighted the varied and often limited use of care in this population, and indicated the need for an improved understanding of the resource needs and implications of postnatal depression.