As a qualitative researcher interested for some time in the possibilities of meta-analysis of qualitative studies, I relished the opportunity to read one with close attention and understand more about what this approach offers.

This blog also continues the theme of peer support; an emerging topic in woodland conversations.

Jones et al published this meta-ethnography in Midwifery earlier this year (Jones et al, 2014). They aimed to explore the impact of peer support in the context of perinatal mental illness. The authors explain a preference for the term ‘perinatal mental illness’ (PMI) as it aims to encompass the recognition that women may experience mental ill health (and not just depression) before and after the birth of their child and that the postnatal period should be considered to last for at least one year after the birth of the child. They report that estimates of incidence vary widely from 3 to 25% of women.

Peer support is increasingly recognised as having great value in the context of mental health, often playing a key role in recovery and maintenance of wellbeing (see Mental Health Foundation website). While the authors state there is an absence of a consistent definition of peer support, they go on to say that:

broadly defined, peer relationships involve an equal status, similar adverse experiences, founded on the key principles of respect, shared responsibility and mutual agreement of what is helpful.

Others would probably add that the support can come in many forms but the defining feature is being mutually offered and reciprocated.

The authors explain that evidence of the efficacy of peer and social support for women before and after childbirth is mixed and there is a need to understand more about how ‘support’ processes work in practice. To do this they searched for and synthesised the findings of qualitative studies which explored women’s experiences of a peer support intervention.

Methods

Through a search of four relevant databases, the authors identified five studies suitable for inclusion in the meta-ethnography. These studies involved 95 women with postnatal/postpartum (PND or PPD) depression from England, Canada and Finland.

An established process was followed for synthesising the findings (Noblit and Hare, 1988) from the identified studies and made it clear how the authors had approached this task in a systematic way, adopting a stepwise approach starting with an index paper and building on this. The process included checking for disconfirming evidence as they progressed.  As none was found they did not need to use ‘refutational translation’ techniques.

Results

The authors identified four meta-themes across the five papers included in the review:

Isolation: the role of peer support

Women across all the studies spoke of isolation, highlighting the difficulties this posed in terms of being able to benefit from peer support interventions and being instrumental in their journey towards depression. People they were in contact with (family, friends, other mothers) could contribute to their feelings of disengagement and isolation because they did not share the same experiences of mental distress.

Seeking validation through peer support

Women searched for their feelings and experiences to be validated by others with similar experiences. Engaging generally with networks of other mothers didn’t always achieve this, leaving mothers with feelings of depression unable to speak up, leading to continued problems.

The importance of social norms of motherhood

Women experienced intense feelings of motherhood ‘failure’ when their symptoms of depression prevented them from being able to live out the good mother identity. The shame and embarrassment associated with failure was identified as a problem across all studies. Women therefore used a variety of different approaches to conceal how they were really feeling.

Finding affirmation/a way forward: the impact of peer support

Finding other mothers who had experienced similar mental distress in motherhood was considered a valuable part of the journey towards recovery. Feelings of commonality emerged within these new relationships, enabling the mothers to re-evaluate their own experiences and gain benefit from being understood by peers.

Conclusions

The authors state:

Our findings indicate that women want to access peer support but need to have somewhere that is safe for them to be themselves, to talk openly about how they feel; somewhere for them to unsilence their voices. For the women in the studies, the search for a peer environment in which they could be honest about how they felt was an essential part of the search for understanding and validation.

They go on to say:

The importance of the ‘correct’ type of peer support, which acknowledges their PMI and its associated expression – therefore, is central to women achieving their sense of normalcy.

Limitations

The authors acknowledge the small number of studies identified in this review and conclude this is because of a lack of research in this area. It would be helpful to know whether the authors considered also including ‘self-help’ or similar in the search. Much peer support comes about through communities organising themselves which historically has been called self-help. However, as this review was concerned with ‘peer support interventions’ it may be that the authors were more interested in formal conceptualisations of peer support, for example, as something offered/provided by health services.

They seem to somewhat elide the issue of quality with the five relevant studies identified. Apart from noting the time since the studies were reported, they simply tabulate some of the study characteristics. It should be noted that:

• Three had very small sample sizes (less than 10 women) and one had a large sample size for a qualitative study (52 women), leaving questions about the quality of the analysis
• For four of the studies nothing is known about how the women were recruited nor is anything known about the demographics of the women for any studies
• No information is given about the peer support interventions that the women experienced

So it’s difficult to know which women and in what circumstances these findings are most relevant to and hence how generalisable they are.

The authors also conclude that the meta-ethnography has brought together ‘disparate strands of qualitative research’ but I wasn’t clear how they reached this conclusion, as we are presented with information in the paper which suggest the studies were broadly similar, including the findings.

Summary

The key contribution this paper makes to our understanding of peer support, especially in the context of interventions being offered by services (which some have termed the ‘colonisation’ of peer support), is to highlight the need for the right sort of peer to make the relationship beneficial and an aid to recovery. If the people involved don’t share the essential experience, the support may have the opposite effect. In the context of PMI, the key defining characteristic of a peer is mental distress in the context of motherhood – motherhood by itself is not a sufficient condition for useful peer support.

I must admit to being surprised when I read the phrase ‘the internet was used by women in a seemingly desperate attempt for validation’ (my emphasis). The authors seem to contrast information seeking on the internet (credible) with the search for ‘virtual’ peers (non-credible). Peer support by digital means is increasingly common and forms the bedrock of many contemporary support communities. Moreover, it may be even better suited to women experiencing PMI than face to face peer support. The authors found, in all the studies, mothers with PMI experienced physical and social isolation:

• Difficulty getting out of the house
• No local connections
• Finding the right sort of peer (mothers with PMI are less common than mothers)
• Stigma influencing help seeking behaviour

To my mind, these factors might make online, remote and, where needed, anonymous peer support actually more feasible and accessible. So in that sense, not ‘desperate’ at all but entirely practical and understandable. As quoted in the paper, ‘it’s the sharing of experiences with other women that really matters’ (Raymond, 2009), not necessarily the medium.

Links

Jones CCG, Jomeen J, Hayer M (2014). The impact of peer support in the context of perinatal mental illness: a meta-ethnography. Midwifery 30 (2014) 491-498 [Abstract]

Information about Peer Support. Mental Health Foundation website, last accessed 7 January 2015.

Noblit GW, Hare RD (1988) Meta-ethnography: Synthesizing Qualitative Studies, Sage publications, Newbury Park [Sage publications]