Postpartum Depression Among Arab Women in Israel : Comparing Traditional and Modernized Women in a Traditional Society

The objective of this study was to understand how Arab women in Israel experience one of the most significant transitions in their lives, pregnancy and childbirth, who have undergone transitions toward modernity in their traditional society. The study included questionnaire to determine whether each woman has more traditional or modernized tendencies within the traditional Arab society. The study included 202 women, After the women expressed their willingness to participate in the study, five sessions were held: Immediately after marriage – modernization questionnaire, During the last two months of pregnancy – EPDS questionnaire, During the final month of pregnancy – EPDS questionnaire, After on one month of the deliveryEPDS questionnaire and After six months of the deliveryEPDS questionnaire It clearly revealed a modernization trend among Arab women in Israel. This study found that 12% to 15% of the sample suffered from PPD. It showed that modern women suffered from more severe depression after delivery than their traditional peers did. Nearly all the women diagnosed with PPD were closer to the modern end of the spectrum. When symptoms were discovered in traditional women, the changes in their behavior appeared to be more of an overall conclusion of this study. This study emphasizes the need for intervention programs to support the changes that women in Arab society in Israel are undergoing. The findings enable the early detection of the population at risk for PPD.


Postpartum Depression
Postpartum depression (PPD) refers to diverse depressive symptoms that occur at any time after childbirth; it can last from a month to a year (Centers for Disease Control and Prevention, 2008).According to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders, PPD is defined as the first four weeks of postpartum during depression or loss of interest in most activities, moreover.For a woman to be diagnosed with PPD, she has to experience at least one of the following symptoms: changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts (American Psychiatric Association, 2013).
The current study aims to understand how Arab women in Israel experience one of the most significant transitions in their lives, pregnancy and childbirth, who have undergone transitions toward modernity in their traditional society.The study focuses on whether leaving the traditional society affects PPD and whether a more individualist personality yields a higher prevalence of PPD.
The following sections will focus on Arab social values, Arab women, and PPD among Arab women.

Cultural Values of Arab Society in Israel and the Importance of Family Structure
In recent years, Arab society in Israel has undergone significant changes in various aspects of life, such as social, economic, and educational changes.These include changes in the status of women, changes in the family structure, and socio-cultural transitions.Understanding these changes and their impact on Arab society in Israel in general and on the individuals that constitute it in particular is a fascinating and important area of theoretical research.
Arabs in Israel live simultaneously in two different worlds.They are exposed to the Western culture of the country in which they live while maintaining their Eastern-style culture.Whereas the Israeli majority generally represents a modern, Western-oriented society, Arab culture in Israel still represents a traditional society.
This clash between two entirely different cultures leads to intercultural conflicts between two extremes (Gith, 2014a).Young, educated members of Arab society are the most inclined to struggles within the family as a result of the multicultural contexts in which they live.Living in both cultures in parallel may result in cultural conflicts between parents and their children, particularly among those who have received higher education.These cultural conflicts may affect the parents' influence on various aspects of their children's lives, such as selecting a spouse and the woman's ability to choose to pursue a career or stay at home (Al-Krenawi & Lev-Wiesel, 1999).
Family struggles develop when the family or the family members do not maintain balance and harmony in their own lives, with their surroundings, and with the outside world.Young Arab adults who attend Israeli or Western universities and develop a Western, post-industrial, social perspective that focuses on the human ability to control nature and that views all problems as solvable may develop conflicts with the values of the Arab family in which they live, on both the personal and interpersonal levels (Haj Yahia, 1994).
Despite the transformations that Arab society is undergoing, powerful tendencies still exist toward a more collective orientation on the social and family levels, as opposed to an individualist orientation (Kulik, 2004).In Arab society, the needs of the family will always be given precedence over social relationships and friendships outside of the family.The Arab individual is raised to serve the family, meaning the collective (Dwairy, 2006); hence, the failure or success of the individual reflects on the family (Iancu et al., 2011).These behavioral patterns serve as a reminder that the self-confidence, importance, excellence, decency, and identity of each family member is determined by their relationships with other family members and how they treat one another (Haj Yahia, 1994).In addition, the mutual dependence within the nuclear family and with members of the extended family is of the highest priority.

Status of Arab Women
Although the tradition of arranged marriages is quickly disappearing, the process of selecting a spouse is still strongly influenced by the family.A bride is selected by the extended family, not by the potential groom.The engagement period is short, and the couple is escorted by family members when they meet.This indicates that parents and extended families have an extremely powerful impact on the process of choosing a spouse (Al-Krenawi & Lev-Wiesel, 1999).
When a young man is interested in marrying, he will ask his parents or their representatives to meet with the woman's parents.Despite the various transformations in Arab society in Israel, the society remains a patriarchal one that places women beneath men in the family hierarchy (Haj Yahia, 1994).Women generally have a lower status than men do in the Arab family; they are usually inferior to their brothers, husbands, and brothers-in-law.An Arab woman is expected to be dependent on her husband, to accommodate his desires and needs, and to be a source of support for her husband and his family (Avitzur, 1987;Ibrahim, 1993).The husband will generally take on the instrumentally dominant roles in the family, provide the primary financial support, and be responsible for protecting his wife (Haboush, 2007).The husband is the protector, while the woman has to carry out her husband's wishes (Mourad, 2010).Women play the more expressive roles as housewives.The changes in the status of Arab women in Israel over the past two decades are more quantitative changes that primarily affect women's education and ability to work outside the home rather than qualitative, fundamental changes that affect their status within the family and their relationship with the spouse (Haj Yahia, 1994).Their roles as women and mothers, and society's expectations of women, remain unchanged (Ibrahim, 1993), which reflects protection and social stability (Crabtree, 2007).
Relationships between men and women are unequal despite the changes that Arab society has undergone; women remain inferior to men in the family hierarchy (Gith, 2013).The Arab family and society place little value on issues of gender equality.Given the lack of gender equality and the control of the spouse over the woman, as discussed above, the current study will examine the correlation between PPD and women's relationships with their spouses in Arab society.
Nevertheless, the partial interaction between Arab and Jewish societies in Israel has contributed to changing the status of Arab women to a certain extent.
Arab society is mostly a collective one.To understand its characteristics, the following section will discuss collectivism vs. individualism in Arab society.

Collectivism vs. Individualism in Arab Society
Western culture tends to emphasize individualism, viewing each person as a separate entity that is distinguished from the overall social identity.In contrast, in traditional Arab society, the collective identity is given priority over the individual (Dwairy & Van Sickle, 1996).
During the normative development process in Western societies, individuals undergo a process of psychosocial separation from their parents.An integral part of this separation is the development of a unique, autonomous identity (Bergman & Pine, 1975;Erikson, 1950Erikson, /1963;;Mahler, 1968).Similar developments are not seen in African, Asian, South American, or Middle Eastern societies (Sue & Sue, 1990).In these societies, particularly in Arab society, the collective identity of the family remains at the center (Hofstede, 1980), and the individual remains an integral part of that identity.Individuals tend to view themselves as an inseparable part of a central, collective identity.Family members who attempt to declare their own individual identity will be considered unusual and will face criticism and even condemnation.Today's Arab society is considered more authoritative and collective than democratic and individualistic (Geraisy, 1984).
Collectivism is still preferred over individualism in the social setting and the family framework (Gith, 2014b).Collectivists emphasize principles of hierarchy, in which the father is in charge and the women in the family are subordinate to the men.Collectivist societies emphasize group fate and group achievements, as well as mutual dependence between members of the group.Collectivist cultures demand obedience, obligation, and sacrifice for the sake of the group and attribute higher value to social norms than to individual ones.Members of societies of this kind generally tend to control their emotions rather than express them.
In the case of Arab society, collectivism still has a major influence (Mourad, 2010).Arab society focuses on the extended family, and relatives are expected to live in close proximity to one another (i.e., in the same neighborhood or place; S. Bin-Rafaah, personal communication, November 7, 2012).

Relationship Between Individualism (or Cultural Conflict) and Depression Rates
The relevance of life events to depressive disturbance is expected to vary as a function of the cultural and educational background.
Educational background is essential in western society.Educational background bears on whether people even seek help in problems, what types of help they seek, what types of coping styles and social supports they have and how much the society attach stigma to the postpartum depression.Educational and social factors contribute to the causation of postpartum depression including exposure to poverty and violence, education level (DHHS, 1999).
Caldwell-Harris and Ayç iç egi (2006) indicated that collectivism was positively correlated with depression.Individualism scores, particularly horizontal individualism scores, were negatively correlated with this scale.This is because humans need interdependence; thus, persons with an extreme collectivist orientation may be at risk for some symptoms of depression.
However, another study indicated that collective societies, unlike Western ones, emphasize interdependence rather than independence and are supported by the extended family (Al-Issa, 2000).Collective societies view humans in relation to their community and social roles; therefore, depression rates in these societies are lower than in individual societies.Individualism emphasizes that behavior is a reflection of personal traits; therefore, an individual in a collective society is not as frequently ostracized or left to deal with the symptoms of depression alone.

Depression Among Women During Pregnancy and After Delivery
Depression is one of the most common emotional disorders in Western countries, affecting 10% to 25% of women and 5% to 12% of men who suffer from symptoms of depression (Rihmer & Angst, 2004).The situation is entirely different in Arab societies, where depression rates are significantly lower: Approximately 1.3% of patients in psychiatric hospitals suffer from depression.The vast majority of Arab patients suffering from depression express their condition through physical symptoms such as chest or head pains or difficulty breathing (Bazzoui, 1970).The tendency to experience distress in a somatic rather than a psychological mode was found among Bedouin-Arab women in Israel (Al Krenawi & Graham, 2004).Another research found that Arab women suffer from somatic complaints (Hamdan, 2009).
The differences in the prevalence and form of depression between Western and Arab societies can be expressed by a single important component: Emotional disorders after childbirth are very common and considered almost normative, as the woman copes with various difficulties and challenges presented by this new stage in her life.During the period after childbirth, depression is more common than at other times in life, ranging from depression that requires hospitalization to symptoms of clinical depression that do not require psychiatric hospitalization (Cox, Murray, & Chapman, 1993;Kendall et al., 1987).Different kinds of disorders may emerge, all of which can be placed on a spectrum ranging from psychotic depression to passing incidents of crying and minor depression known in the literature as -maternity blues.‖Neurotic depression is located between the two ends of the spectrum.

PPD in Arab Society
Although it is clear from research studies that Arab women of different ethnic groups suffer from PPD, information on PPD among Arab women living in Israel is scarce.Okasha (1994) conducted research in Egypt on depression; one of the most important findings of his study was that the ability and tendency to express emotions is a key prognosis factor when studying cultural models and specific families.This means that when defining depression, cultural differences and specific situations must be considered.Glasser et al. (2012) aimed to identify risk factors of depressive symptoms among pregnant and postnatal Arab women in Israel.They found that the rate of postnatal depressive symptoms was significantly higher among women living in Muslim than in Druze communities.The rates of antenatal and postnatal depression among Arab women in northern Israel were higher than those of Jewish Israeli women in the same region and considerably lower than those of Arab Bedouin women in southern Israel.
Several studies have indicated significantly higher rates of PPD symptoms in modernized societies than in traditional ones.However, PPD among Arab women, specifically in Israel, has received inadequate attention in the literature.
Growing evidence suggests that women in industrialized countries may experience higher rates of PPD.Israel is an important example of a country with both traditional and modernized Arab women.Therefore, the purpose of this study is to examine whether modernized Arab women are more likely to develop PPD than traditional women in a traditional society.

Research Questions
1. Do tendency toward modernization have an impact on the emergence of PPD?

A correlation exists between the degree of depression and the tendency toward modernization among
women in traditional societies.The more modern the woman within the traditional society, the greater the risk of PPD.

Questionnaire
A questionnaire was used to determine whether each woman has more traditional or modernized tendencies within the traditional Arab society.The questionnaire was developed specifically for this study based on a broad theoretical background that addressed issues of change and transformation in the Arab society.The questionnaire contained 45 questions.A statistical analysis of the answers yielded the indices: (1) the woman's approach to social criticism (5 items), sample item: I don't considerate social criticism (2) the woman's attitude toward the distribution of roles between herself and her spouse (6 items), sample item: my husband should help me in family roles (3) self-expression and realization (6 items), sample item: I can express my emotions freely (4) the woman's attitude toward the increased rights that society grants to men (6 items), sample item: men receive more rights than they should receive (5) the woman's approach to premarital sexual relations (6 items), sample item: premarital sexual relations should be permitted and The rating method was from 1 (Disagree Strongly), 2(Disagree), 3(Slightly Disagree), 4 (Slightly Agree), 5(Agree).
To compute scores of every category, the mean of the Reponses of each category (of the relevant items) was calculated.
A general demographic questionnaire was developed.The demographic variables included age, gender, marital status, education level, and depression experience.Demographic questions are designed to elicit information from respondents concerning their personal characteristics and social background.
Items with a poor fit were removed using two closely related criteria.To compute the criteria, the score range was divided into four score levels in such a way that each of the score groups had an approximately equal number of respondents.Many of the remaining items had significant values.
Figure 1 illustrates the questionnaire development process.

Edinburgh Postnatal Depression Scale
The Edinburgh Postnatal Depression Scale (EPDS) is a unique assessment tool developed by Cox et al. (1987) to diagnose PPD.This scale has been used on Arab women in Israel (Glaser et al., 2011(Glaser et al., , 2012)).The questionnaire is simple and easy to use and has been proven to be a good predictor of PPD.It has been shown to yield high specificity and sensitivity rates.This questionnaire has been used by Arab societies and in the Persian Gulf principalities (Abou-Saleh & Gubash, 1997), with a high validity rate.
The questionnaire contains a 10-item scale, which focuses on the cognitive and affective features of depression.
It is a self-report scale that has been validated for use during pregnancy and the postnatal period.A score of above 12 is widely used to indicate probable depressive disorder among women, although it cannot confirm a diagnosis of depression.
Responses to the test are scored as 0, 1, 2, or 3 according to the increased severity of the symptom.The total score of the EPDS is determined by calculating the scores for each of the 10 items.The cut-off scores range from 9 to 13 points.Therefore, a woman scoring 9 or more points or indicating any depression-that is she scores 1 or higher on question 10-indicating depression.
The internal consistency of the current EPDS version using Cronbach's alpha coefficient was found 0.804.Ghubash, Abou-Saleh, and Daradkeh (1997) validated the Arabic version of the EPDS.They reported a sensitivity of 91% (specificity of 84%) at a cut-off score of 10 and a sensitivity of 73% (specificity of 90%) at a cut-off score of 13.
The research carried out between the years 2016 until 2017.

Research Process
A mixed-design analysis was conducted to examine the following: a. Within-subject (dependent) variables: depression levels before and after delivery b.Between-subject (independent) variables: the degree to which the woman is traditional This study involved long-term research.The participants were recruited through wedding halls and colleges.It was important to recruit through wedding halls to give women the questionnaire before they were influenced by the new society and new home that they were about to enter.In a traditional society, the extended family forms a specific behavioral model that affects the woman and may be different from the model that the woman was presented before marriage.Participants were recruited from colleges at the beginning of the school year; they included students who had married during the summer, which means that the colleges provided a suitable sample of women for this research.After the women expressed their willingness to participate in the study, five sessions were held: a. Immediately after marriagemodernization questionnaire b.During the last two months of pregnancy -EPDS questionnaire c.During the final month of pregnancy -EPDS questionnaire d.After on one month of the delivery-EPDS questionnaire e.After six months of the delivery-EPDS questionnaire

Participants
The study included 206 women, four of whom did not complete the study (two because of miscarriages and two for unknown reasons).The average age of the women was 22.20 (SD = 2.58).Among the participants, 1.5% completed elementary school, 7% completed middle school, 18% completed high school, 37% studied in college, and 36.5% studied in universities.In terms of profession, 49% were students, 30% were housewives, 6% were clerks, 14% were teachers, and 1% were social workers.

Results
The findings support the hypothesis that the women begin to display symptoms of depression before childbirth.
To verify this finding, we analyzed whether the women who suffered from depression before delivery were the same ones who suffered from depression after delivery.The correlation between depression before and after delivery was analyzed, and in nearly all cases, the women's condition did not change.

EPDS averages before and after delivery
Difference score was used to Examine change on a variable over two-time points, it is effective in the current study because we Compared scores before and after delivery (Edward, 2001).Change is often analyzed using data from 2 waves of a longitudinal study, using the difference score especially in health or disease topics (Clarke, 2004).
The correlation between the Time 1 EPDS score and Time 2 EPDS score was (r=0.23,p<0.05).While the number of women who showed that their EPDS did not change was 141.
A general univariate effect of EPDS was found in favor after delivery (Multivariate F (2,179) = 36, p < .001) The univariate ANOVA results pointed to differences between depression before and after delivery.The average score before delivery was 10.61 (SD = 5.26), and the average score after delivery was 12.94 (SD = 6.67)

Correlation Between the Severity of Depression and the Degree of Traditionalism
The correlation between the severity of depression as a continuous variable and the indices that rate the degree of traditionalism as a continuous variable were analyzed using Pearson correlations.All correlations were significantly negative.This means that the more modern the woman (less traditional), the higher the severity of depression (see Table 2).

Correlation Between the Number of Women Who Crossed the Clinical Threshold for Depression Before and After Delivery
40 women were identified as crossing the clinical threshold for depression.
A paired t-test was used to compare differences between the number of women who crossed the clinical threshold for depression before and after delivery.
Insignificant differences were found between the number of women who crossed the clinical threshold for depression before and after delivery (t =1.2, n.s).Nevertheless, the severity of depression increased after delivery.
During the first stage of analysis, we calculated the differences between the scores (severity of depression after delivery minus severity of depression before delivery) and studied the Pearson correlations between the differences as well as the scores for each of the traditionalism indices.
The analyses showed that for each of the indices other than self-expression and the woman's approach to increased rights for men (two indices in which the majority of women were quite modern), a significant correlation was found between the tendency toward modernism and the difference in severity of depression before and after delivery (see Table 3).In other words, in addition to the modernized women displaying a stronger tendency toward depression, the severity of their PPD was higher as well.
Table 3. Pearson correlations between the differences in the depressive scores (before and after delivery) and each of the traditionalism indices

Measure
Pearson correlation Relationship with spouse's family -.22** Approach to social criticism -.29** Approach to spouse's control over the woman's life -.29**Attitude toward distribution of roles between men and women -.15* Self-expression and realization n.s.Attitude toward the increased rights that society grants to men n.s.Approach toward sexual relations before marriage -.20** Approach to the woman's relationship with her mother -.14 Note. n.s.= not significant.*p < .05. **p < .01.

Correlation Between the Relationship With the Spouse and the Degree of Modernism
Another analysis considered the correlation between the woman's relationship with her spouse and the degree of modernism.This was done because of the hypothesis that traditional women would not express a lack of satisfaction with conduct that is considered normative for men in a traditional society, whereas such conduct would be problematic in a modern society (e.g., the husband frequently staying out late at night with friends).
The analysis showed that the more traditional the woman, the fewer problems she reported with her relationship with her spouse.It was therefore necessary to study whether positive correlations between depression and difficulties in the woman's relationship with her spouse are expressed differently in each of the two groups (traditional and modernized; see Table 4).
It was shown that the more modern the women, less relationship with spouse family was indicated (r=-0.72**).
Table 4. Correlation between the woman's relationship with her spouse and the degree of modernism

Measure Pearson correlation
Relationship with spouse's family -.72** Approach to spouse's control over the woman's life -.21**Attitude toward distribution of roles between men and women n.s Note.n.s.= not significant.**p < .01.

Discussion
The objective of this study was to understand how Arab women in Israel experience one of the most significant transitions in their lives, pregnancy and childbirth, and to examine the differences in the prevalence of PPD between traditional women and women who have undergone transitions toward modernity in their traditional society.
The hypothesis was supported, With regard to the correlation between the variable of the women's degree of traditionalism and the severity of their PPD, a negative correlation was revealed between depression and the level of commitment to tradition in all indices.In other words, there is a correlation between PPD and the tendency toward modernization.Correlations were revealed in most indices between the degree of traditionalism and the severity of depression after delivery compared with before delivery (i.e., during the third trimester of the pregnancy).The following figure describes this correlation.A correlation was found between the increased severity of depression and the woman's tendency toward tradition, as expressed by her approach to the increased rights that society grants to men and her own self-expression and personal realization.Most women described themselves as modern under these two parameters; therefore, the tendency toward modernism in these areas is not exceptional and not a contributing factor to increases in the severity in depression after delivery.This finding is important but inconsistent with previous research, which found an association between modern aspects and PPD among women (Alfayumi-Zeadna et al., 2015).Moreover, it can be claimed that the absence of association in his sample may be as a result of the mediation of this relationship by other variables (such as social support).
In Arab society, collectivism still has a major influence (Mourad, 2010).Arab society focuses on the extended family, and relatives are expected to live in close proximity to one another (i.e., in the same neighborhood or place; S. Bin-Rafaah, personal communication, November 7, 2012).These factors are important in traditional society, which reduces PPD.In contrast, in modernized countries, the lack of support has been found to be one of the largest predictors of PPD (Chandran, Tharyan, Muliyil, & Abraham, 2002;Nakku, Nakasi, & Mirembe, 2006).
When considering depression, the study showed that the more modern women suffered from more severe depression both before and after delivery.These findings were especially pronounced when women were classified according to their relationship with the spouse's family, their attitude toward social criticism, and their attitude toward the spouse's control over their lives.These indices are highly connected to pregnancy and childbirth.It seems that women who consider themselves more modern in these respects experience stronger conflict than traditional women do, both before and after delivery.As noted earlier, the very fact of their pregnancy involves greater intervention by the spouse's family and society in general in the woman's personal life.Women with higher tendencies toward modernity in these indices experience a greater deal of conflict under these circumstances.These findings support the hypothesis that the modern woman is at conflict with the traditional society in which she lives (Nakku, Nakasi, & Mirembe, 2006).When considering the woman's approach to the distribution of roles between the man and the woman (a parameter that is less related to society and more related to the home), no differences were found in the severity of depression between modern women and traditional women.
The findings also revealed that both groups demonstrated significant increases in the severity of depression after delivery.The severity levels differed more in women with modern tendencies.Assuming that identical biological components are active in both groups of women, the fact that the severity of depression rose in women with modern tendencies after delivery can be attributed to psychological components that affect this group.Research literature on this subject indicates that biological elements have a smaller impact before delivery.It is therefore likely that it was the psychological elements that affected the women's overall condition, causing depression, while the biological components only enhanced the severity of that depression (Hagen, 1999).
When considering the correlation between PPD and the tendency toward tradition, a difference was found between the group of women suffering from depression and the group without depression for all indices of tradition.The dichotomous distinction between traditional and modern women emphasizes the differences between them so that modern women are more depressed than traditional women after delivery.This finding reinforces the existence of a correlation between PPD and the level of modernity of Arab women in Israel ( Chandran, Tharyan, Muliyil, & Abraham, 2002).
The current study attributes this difference to psychological and emotional factors derived from individualism and collectivism.While emotional support can often be obtained over the phone or from friends, it is the practical support that many families miss and that puts undue strain on new parents, leading to higher rates of PPD (Hagen, 1999).
The results show that the scores of the tradition indices for women suffering from depression were lower than the scores of those without depression, which means that the depressed women were less traditional overall.This further reinforces the finding of this research that the more modern the women are, the greater their chances of experiencing PPD.Bazzoui (1970) indicated that the difference in the prevalence and form of depression between Western and Arab societies can be expressed by a single important component: The individual in traditional society is surrounded by family (regardless of the family's living arrangements), which prevents the person from feeling alone.Loneliness is a contributor to depression among modern societies and occasionally even leads to suicide attempts and depression.On the other hand, a person who is embraced by the family may have a limited ability to express emotions; therefore, inner struggles are expressed by body language and physical symptoms (Bazzoui, 1970).
This research studied the correlation between the severity of depression before and after delivery and the women's degree of traditional vs. modern tendencies.The findings indicate that in addition to the correlation between PPD and traditional tendencies, the difference in the severity of depression before and after delivery is greater among the more modern women.This interesting finding raises the following question: What do modernize Arab women experience during pregnancy and childbirth that increases their negative emotions after childbirth as compared to before it, compared with traditional women whose negative emotions are not increased to the same extent?
This study tested whether the correlation shown between relationships and depression exists among traditional and modernized women.PPD appears to be significantly more prevalent among modern women.In addition, a reverse correlation was found for traditional women (i.e., the more negative the woman's relationship with her spouse, the lower the likelihood of depression).This interesting finding supports the hypothesis that women in ungratifying relationships find comfort in motherhood and are thus less likely to suffer from depression.This finding is consistent with previous studies indicating higher rates of PPD symptoms in modernized societies than in traditional ones.Growing evidence in industrialized countries suggests that women may experience higher rates of PPD (Bazzoui, 1970).
This study is unique in that it is the first of its kind to be conducted among Arab women in Israel.This research is of dual importance:, it enhances understanding of whether these women suffer from PPD and the correlation between PPD and the changes that these women are experiencing.This study is the first of its kind to compare women with modern tendencies in a traditional society with traditional women in the same setting.
Although the prevalence of PPD was shown to be similar to the prevalence reported in Western societies, the process is different in this population.In a traditional society, the psychological elements are highly active before delivery.This impact becomes even more pronounced when there is a negative interaction between the traditional society and the woman with a tendency toward modernity.This occurs because the very fact of childbirth requires identification with the traditional society and enhances the distress that women with modern tendencies experience within that society (Hagen, 1999).
This study has both clinical and research implications.Clinically, the findings of this study may form the basis for screening women for the risk of psychiatric disorder in the postpartum period to prevent disabling morbidity, especially among modern women.
This study was not without limitations.The cross-sectional design of this study also makes it impossible to prove the causal relationship between major depression and the factors found to be correlated with it.A larger number of respondents would have improved the statistical significance of the results.
A prospective study is needed to establish the actual prevalence of PPD in the general population of Arab women in Israel.Future studies could also further analyze the relationship between PPD and the various factors of individualism-collectivism.

Figure 1 .
Figure 1.Severity of PPD (both time 1 and time 2) as Y-axis and modernized versus traditional category as X-axis

Table 1 .
Statistical description of variables

Table 2 .
Correlations between the severity of depression and the measures of the degree of traditionalism