|Year : 2014 | Volume
| Issue : 3 | Page : 309-316
Incidence and evaluation of factors contributing towards postpartum depression
Daniel Saldanha1, Neelam Rathi2, Himadri Bal3, Bhushan Chaudhari1
1 Departments of Psychiatry, Padmashree Dr D. Y. Patil Medical College, Hospital and Research Center, Dr D Y Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
2 Departments of Obstetrics and Gynecology, 155 Base Hospital, Tejpore, India
3 Departments of Obstetrics and Gynecology, Padmashree Dr D. Y. Patil Medical College, Hospital and Research Center, Dr D Y Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||18-Mar-2014|
Flat No 1102, N Block, Grevillea Magarpattacity, Pune - 411 013, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Pregnancy and childbirth produce a variety of physiological, psychological and social consequences. Attitudes toward pregnancy and childbirth vary from culture to culture. There is evidence to suggest mothers with young infants experience depressive symptoms and 10-15% major depression. Aim: To study the incidence and factors contributing toward postpartum depression Materials and Methods: Married women 18-35 years of age attending the antenatal and postnatal out-patient clinic were studied during 2007 and January 2008. 200 women who had delivered between 1 June 2007 and 1 January 2008 were included in the postpartum phase to calculate the incidence of postpartum depression. The prospective mothers were approached in their 3 rd trimester of pregnancy. Critically ill, past history of depression, co morbid medical or psychiatric illnesses were excluded. The diagnosis of postpartum depression (PPD) was made as per international classification of diseases (ICD 10). They were administered the beck depression inventory (BDI), Presumptive stressful life event scale, Edinburgh Postnatal Depression Scale (EPDS) and General Health Questionnaire (GHQ-12) scale. The women were subsequently reviewed in their postpartum phase in the postnatal out-patient/child immunization clinic at 2, 4 and 6 weeks after delivery. The non-depressed mothers acted as the controls. Results: A Total of 186 women out of 200 registered for the study 40 had scores above 13 on EPDS and grouped as depressive met ICD 10 diagnostic criteria. The remaining 146 were non depressive. 14 women dropped out of the study. Incidence of PPD was 21.51%. The study found 14/27 (51.8%) of the risk factors associated with PPDs were statistically significant. Significant number of mothers had high antenatal GHQ and both antenatal and postnatal BDI scores. BDI and EPDS scores remained high during the postnatal follow-up in the depressed group, which showed the presence of PPD in mothers with young infants. Conclusions: There is a need for sensitizing primary health-care givers regarding PPD and is an important health issue that should not be ignored.
Keywords: Beck depression inventory, Edinburgh postnatal depression scale, general health questionnaire, postpartum depression, pregnancy
|How to cite this article:|
Saldanha D, Rathi N, Bal H, Chaudhari B. Incidence and evaluation of factors contributing towards postpartum depression. Med J DY Patil Univ 2014;7:309-16
|How to cite this URL:|
Saldanha D, Rathi N, Bal H, Chaudhari B. Incidence and evaluation of factors contributing towards postpartum depression. Med J DY Patil Univ [serial online] 2014 [cited 2021 Dec 3];7:309-16. Available from: https://www.mjdrdypu.org/text.asp?2014/7/3/309/128972
| Introduction|| |
Pregnancy and childbirth are important events in the life of a woman recognized since Esquirol's (1845) description of postpartum psychosis.  Attitudes toward pregnancy and childbirth vary widely from culture to culture and within the same culture. Pregnancy is regarded as a positive and necessary event for woman's personal fulfillment and social acceptance. 50% of mothers experience some depressive symptoms in the 1 st year of child birth.  Postpartum disorders are distinguished by their onset within the first 4 weeks postpartum.  Postpartum depression (PPD) is a prolonged and serious condition generally occurs in at least 13% of women within 4-6 weeks after delivery with low mood, anhedonia, forgetfulness, irritability, anxiety, sleep disturbance and postpartum psychosis though rare, is seen in 1-2/1000 deliveries. , There is evidence to suggest high risk of depression in developing countries.  Robertson et al. found the strongest risk factors being prenatal depression, prenatal anxiety, stressful life events, lack of social support and a history of depression before the pregnancy.  Obstetric factors and low socio-economic status were described as small risk factors. Since the majority of patients with PPD report within 6-8 weeks following delivery, primary care givers need to be sensitized to the problem for early diagnosis. A simple self-reporting Edinburgh postnatal depression scale (EPDS) is useful.  The present study was aimed to examine the incidence and the factors recognized to be relevant in the onset of PPD in Indian women.
| Materials and Methods|| |
The study was under taken between 1 June 2007 and January 2008 in a large military hospital. Institutional ethical clearance was obtained. Married women in the age group of 18-35 years attending the antenatal and postnatal out-patient department (OPD) of obstetrics were taken. 200 women who had delivered between 1 June 2007 and 1 January 2008 were included in the postpartum phase. The prospective mothers were approached in their 3 rd trimester of pregnancy during their visit to the antenatal OPD. Informed consent was obtained. All Critically ill antenatal cases who could not give written consent, past history of depression, co-morbid medical or psychiatric illnesses were excluded from the study.
Data was recorded on a specially designed proforma. The life events, psychosocial stressors, relationships including support from husband/family, availability of spouse, domestic violence were assessed by means of a brief interview, which covered major life events during the past 1-year. Physical examination of the subjects was carried out by obstetrician. The prospective mothers were administered the beck depression inventory (BDI) and other instruments by the residents in Psychiatry. BDI is a 21 item scale that was developed for adults to screen the symptoms of depression (Beck, 1973). Each item has four responses scored from 0 to 3. Total obtainable score is 62. Researchers have recommended a higher optimal cut-off 11/12 for BDI during pregnancy and Postpartum period as the symptoms of depression. , A score of 11 was taken as a cut off for depression in this study. EPDS  is a 10 item self-rating scale designed to detect depression among women in the early postpartum period. Total score is 30. A threshold score of 12/13 suggests depression. A cut off score of 13 as advised by the researchers  was taken. The scale was administered during postnatal follow-up at 2, 4, 6 weeks. Presumptive stressful life event scale is a scale of 51 life events based on social readjustments rating questionnaire by Holmes and Rahe to find stress levels (specially prepared for the adult Indian population by Singh and Kaur in1984 assessed a number of life events in the past 1 year). General health questionnaire (GHQ) is a well-known rating scale applicable for the detection of postnatal psychiatric morbidity. GHQ-12 is a 12 item self-administered sensitive screening instrument. Maximum score is 12, which is scored in a bimodal fashion (0-0-1) and cut off was taken as 3. A score of more than 3 identifies the disorder in question. Women were reviewed in the postnatal OPD/Child immunization clinic at 2, 4 and 6 weeks after delivery.14 women who were lost to follow-up were excluded. EPDS and BDI scales were administered by the residents in Psychiatry at all the follow-up visits. A diagnosis of depression based on international classification of diseases (ICD 10) diagnostic criteria for PPD was made by the consultants in Psychiatry who were blind to the study. Non-depressed mothers acted as the controls for correlating various risk factors.
| Results|| |
The study was planned to determine the incidence of PPD and to examine a number of demographic, psychosocial, menstrual and obstetric factors that may be associated with the onset of depression in the postpartum period in women attending a tertiary care military hospital. Two hundred pregnant females who reported for their regular antenatal checkup were followed-up. Out of the selected number only 186 turned up for their regular postnatal checks and immunization clinic. Of the 186, 40 had scores above 13 on EPDS and were found to be depressive as per ICD 10 criteria. The incidence of PPD in the study group was found to be 21.51%. Remaining 146 (78.49%) were designated as a non-depressive group and they served as controls. Age wise both groups were similar, the mean age being 23.95 years among the depressed and 25.92 years among the non-depressed mothers. There was no correlation of maternal age with PPD [Table 1].
Out of 27 factors that were studied as many as 13 factors (48.15%) age, occupation, place of residence, age of menarche, socioeconomic status, menstrual disorder, duration of marriage, parity of mother, sex preference, previous pregnancy complications and abortions, planned and Unplanned pregnancy, pregnancy and delivery complications and mode of delivery were statistically not significant. 14/27 (51.85%) of the risk factors i.e., education, marital disharmony, domestic violence, family history of mental illness, time of delivery (pre-, full- and post-dated), health of the new born, hospitalization of the baby, breastfeeding, gender of the new born, bonding, availability of the husband at the time of delivery, type of help available at delivery time, stressors or life events, antenatal depression were statistically significant and hence were potential risk factors [Table 1], [Table 2], [Table 3].
Mean scores of the depressive mothers at different intervals of study. i.e., antenatal and postpartum at 2 weeks, 4 weeks and 6 weeks on BDI and at 2 weeks, 4 weeks and 6 weeks on EPDS remained high and were statistically significant [Table 4] and [Table 5]. Mean GHQ scores were also significantly higher among depressed group than among the non-depressed group [Table 6].
| Discussion|| |
The first aim of the study was to identify the incidence. The wide range of reports that cite a mean prevalence rates of PPD of 10-15% in developed countries may not reflect a true picture of the actual global prevalence. , The incidence of 21.51% in the study cannot be compared with these prevalence rates. Inandi et al.  too reported incidence of 31.1% for non-psychotic PPD in Turkish mothers in the 1 st year. The high prevalence rate of 23% at 6-8 weeks in a follow-up of 270 women from antenatal to postpartum period by Patel et al. though not comparable is closer to the incidence in our study.  Following a group of 359 and 478 women in the last trimester of pregnancy and 6-12 weeks after delivery Chandran et al.  and Thangappah et al.  reported prevalence of 11.0% and 5.9% in rural south India. The high incidence of PPD in our study may be due to the population studied belonged to spouses of Military persons. Changing social set up, preference for nuclear families, declining social support, not following usual rituals which used to demarcate the 1 st month of puerperium in our culture may also add to the depressive symptoms. The abundant social support made available to the new mother affects the occurrence of postnatal depression. According to traditional beliefs, a recently delivered woman is encouraged to recover her health by taking rest and adequate nutrition. In the first postnatal month, she is spared from all the household chores and is attended by a relative; usually the mother or the mother in law. Apart from assisting in chores she helps and instructs the new mother on childcare matters. 109/146 (74.6%) of the non-depressed mothers reported that they had help either from the mother or the mother in law compared with only 35% (i.e., 14/40) among the depressed mothers. The intimacy and enriched emotional and maternal support, indigenous practices and rituals strengthens young mothers' self-esteem and provides a buffer against the stress and hardship faced in motherhood. This delays the onset of major depression and ameliorates mood disturbance to a sub threshold level. Using EPDS in 300 women serving in Jordanian Armed Forces Yehia et al.  found the presence of mild PPD symptoms in 39%, Moderate in 28% and severe in 16% compared with prevalence of 22% in a study of 353 Civil Jordanian women by Mohammad et al. 
Factors Related to PPD
The second aim of the study was to identify the risk factors for PPD. Since there are not many Indian studies on PPD especially in a group such as the military, we designed and conducted a prospective study of PPD, by examining a set of relevant variables relating to socio-demographic, psychosocial, menstrual and obstetric factors in women while they were pregnant and after they had given birth.
As regards socio-demographic factors, the study group did not show any statistical significance with age, occupation, place of residence and age of menarche.
A statistically significant association of PPD was found with education [Table 1]. This was also the finding of Yehia et al.  Predominance of less educated (less than 12 th standard) among the depressed mothers was significant. 70% of the mothers did not complete education beyond class 12. Significance of PPD with higher education could not be studied as post-graduates constituted only 12.37%. 10.22%, women reported having no formal education, but none of them was found to be depressed, which contradicts studies conducted in developing countries ,, reporting low education level to be a significant contributor to PPD. The reason could be that these women enjoyed good social support as well as support of the spouse despite being uneducated. Decreased incidence of PPD among graduates and post-graduates noted in the study could be because of their higher self-esteem, financial independence and better interpersonal relationship.
The association of PPD and socioeconomic status was statistically significant in this study, which is consistent with that of Yehia et al.  [Table 1]. We found high income protected against development of depressive symptoms. Higher income group constituted 19.89% out of which 8.1% were depressed while in lower income group 24.83% population was depressed, which is a significant finding. Most other studies have also reported that lack of money was a risk factor for depression and that lower socio-economic status is related with poor mental health. ,
Occupation of Mothers
No specific occupation showed increased incidence of depression. Only 20 (10.75%) out of 168 were employed out of which four developed PPD. In most of the Indian studies, , the study group mostly constituted of house wives as compared with western studies where a significant number were employed.  It is unclear in what way the relationship between maternal unemployment and depression is related. It may reflect low self-esteem of non-working mothers or the substantial role change for women who were previously employed, but who following childbirth has no future employment planned.
Place of Residence and Duration of Marriage
We did not find any correlation with place of residence and PPD nor in the duration of the marriage. Johnstone et al.  have reported that women in rural areas are at risk for development of PPD. This relation may be a consequence of many factors, such as differences in socio-economic status, fertility and family organization in rural and urban areas. 
Mean Age of Menarche and Menstrual Disturbances
The mean age of menarche and menstrual disturbances in the depressive compared with the non-depressives did not show any statistical significance. 35% depressed mothers reported having menstrual irregularities/premenstrual dysphoria as compared with 21.91% of the non-depressed group.
Family History of Mental Illness
Positive Family history of mental illness was found to be a significant risk factor. 25% (10/40) depressed women in the study group gave positive history of depression/psychiatric illness in their family compared with 5.47% (8/186) in non-depressed group. Studies conducted by Josefsson et al.  Johnstone et al.  Pope  and Steiner  have also reported family history of depression to be a consistent risk factor for PPD.
Marital Disharmony and Domestic Violence
A significant association of PPD with marital disharmony and domestic violence was found in the study. Out of the 24 in the study group who disclosed to be having strained relations with spouse 22 were found to be depressed. 22/26 mothers reported ongoing domestic violence in their marriage. Sixteen depressed mothers gave the history of regular alcohol abuse by their husbands and thus strained relationship. Robinsons and Stewart  suggested that the effects of parenthood on all aspects of mother's psychosocial functioning should not be underestimated. A supportive relationship helps to mitigate the stresses while strained relationships can precipitate depression. In many cases, the family system has to be reorganized and couples have to adopt more traditional roles following the birth of a child. The mother usually shares greater parenting tasks. With added burden of childcare there is less time for socializing. Wife beating by the husbands prevalent in rural India  and in west  suggests violence against women is a major public health concern as it significantly impacts their mental health.
Parity of Mother and Desire for a Particular Sex of Baby
There was no statistically significant relationship between parity and sex preference of baby with the onset of PPD. Primipara constituted 45.70% of the total study group. 47.85%, mothers expressed a desire for a male baby while 46.77% refused to divulge their preference. Only 5.38% expressed a desire for a female child. It is true Indian mothers are at a constant pressure to bear a male child and subsequent discrepancy in the sex of the baby predisposes many for PPD. ,[ 14]
Previous pregnancy complications and abortions
Association of previous pregnancy complications or history of abortions with PPD had no association. 12/40 (30%) mothers who developed PPD had a history of abortions whereas 24/146 (16.43%) in non-depressed mothers gave a history of abortions. Correlation between the number and mode of abortions (spontaneous or planned) with PPD could not be established.
Present study did not show any correlation of PPD with pregnancy being planned or unplanned. 28/109 (25.66%) females with an unplanned pregnancy as compared with 12/27 (20.77%) with planned pregnancy were found to be depressed subsequently. A total of 58.60% study sample had unplanned pregnancies. This high percentage could be because almost 45% of the study group was primipara. Early marriage, decreased awareness and a social pressure to have a baby within 1 st year of marriage could be the reason. Beck  states there is lack of consistent evidence to link PPD with planned pregnancy.
Pregnancy and Delivery Complications
There was no association of pregnancy and delivery complications with regard to PPD. Burger et al. in a survey of 1095 mothers reported that women with severe antenatal complications were more likely to develop PPD than are those without.  59 (31.72%) mothers who had obstetric complications 15/59 (25.43%) developed PPD. The overall high incidence of obstetric complications in this study could have been because being a tertiary medical center it caters for high risk pregnancies like antiphospholipid antibodies positive, pregnancy induced hypertension (PIH) and assisted conceptions. We did not find any association between the mean hemoglobin value in the depressed and the non-depressed with PPD.
Time of Delivery
The time of delivery did influence the incidence of PPD. 20/186 (11.83%) had preterm delivery, out of which 63.6% developed PPD subsequently. Similar results about the significance of preterm deliveries have been reported. ,
Type of Delivery
The mode of delivery did not seem to influence the incidence of PPD. Compared with other studies a significant percentage (26.34%) of mothers in our study, underwent lower segment caesarean section as a large number in the study group had complicated pregnancies and precious babies. Emergency caesarian has been reported to be a significant contributor to PPD.  In this study, as mothers were being treated for complications most were prepared for caesarian well in advance.
Health and Hospitalization of the New Born
Infant care in infants with medical problems is a difficult task, which contributes to maternal distress.  18/40 (45%) depressed mothers reported their newborn babies to be low birth weight and were unwell compared to 9.5% babies of the non-depressed mothers. The depressed group also reported difficulty in managing their ill newborn. Hospitalization of newborn too is a significant contributor to PPD. A high percentage of newborn of the depressed population (25%) were hospitalized in the wake of neonatal complications, as compared with newborns of the non-depressed group (2.05%). Baby's hospitalization contributed an additional stress to the new mother.
A total of 178 mothers (95.70%) in the study breast-fed their babies. Women in our communities' breast feed their babies and enjoy a good bonding. This could delay or ameliorate the onset of emotional problems in the new mother. Eight mothers in the present study bottle-fed their babies, out of which six were depressed. Hence, the study could elicit an association between PPDs with feeding as reported by other studies.  Breastfeeding can be influenced by the physical and psychological well-being of the woman and the baby and also influenced by the social and cultural mores of the mother's friends, family, professionals who support breastfeeding and of the wider society and culture in which they live. ,, Breastfeeding may enhance self-esteem and so make depression less likely, alternatively, women who are depressed or discontented with their maternal role may give up breastfeeding readily.
Gender of the Newborn and Bonding
Preference for a male child, which is deeply rooted in the Indians  as well as in some South Asian countries  , makes pregnancy a stressful experience. In the event that the child is a girl, the risk of depression is greater. It has been suggested that the family's collective joy at the arrival of the male infant helps support the mother and negate the risk associated with other stressors. 10/40 (25%) depressed as compared to 2/146 (1.36%) of non-depressed mothers who participated in the study reported difficulty in bonding with their babies. The negative reaction of family members toward birth of a female baby, preference for male baby being communicated to the mother and those delivering females end up receiving less support and inability to bond with the newborn. In addition, deteriorating marital/partner relationship after the birth of a girl baby compounds the problem.
Availability of husbands
Husbands of 24/40 (60%) depressed mothers were not available at the time of delivery as compared with 4/146 (2.73%) of the non-depressed. On-availability of spouse significantly affected the psychological well-being of mothers and was associated with PPD. The high percentage of absence of spouse at the time of delivery is because of military deployment. In 26/40 PPD was significantly higher who lacked social and emotional support at home. It implies that social support does have a significant impact on stress - illness equation. , Perceived social isolation or lack of social support during pregnancy is a strong contributor to depressive symptoms during postpartum period  Researchers dealing with spouses of defense persons all over the globe have reported that women with spouses on military deployment during their pregnancies face a higher risk for PPD.  Carissa Picard a journalist from USA says that when a soldier is away, the spouse has few resources to compensate for the long-term absence and postpartum depression increases by almost three folds.
There was a statistically significant association of PPD in mothers with history of significant life events in past 1 year and psychosocial stressors (P < 0. 001). The occurrences of stressful life events during pregnancy and the postpartum period were reported by 36/40 mothers. Death of loved one, ailing parents, moving home, husband moving to field areas, financial constraints, domestic violence, interpersonal differences with in-laws, abortions were few of the significant events being reported in this study. Pregnancy and birth are often regarded as stressful life events in their own right, and the stressfulness of these events may lead to depression. ,
Ante Partum Depression
Depression during pregnancy was found to be a significant risk factor. Sixty six (35.48%) mothers had depression during the pregnancy; out of these twenty nine (43.9%) had PPD. These results were consistent with the findings reported by Austin  They reported 40% women with PPD display depressive symptomatology during the pregnancy. Studies in both Western and Non-Western societies have documented the presence of ante partum depression , and likely predisposes to postpartum depression.  Ante partum depression predicted continuing depression following delivery in over two-thirds (29/40) of women in the present study.
It was found that before delivery there was a significant difference between the depressive and non-depressive mothers in the BDI score (P < 0.0001) [Table 4]. The mean BDI scores in depressed mothers during the antenatal period were 15.3 ± 4.91 as compared with 7.90 ± 4.77 in non-depressed mothers. During postpartum follow-up the mean scores in the depressed group were 17.65 ± 4.12, 16.88 ± 3.16, 16.48 ± 3.80 at 2, 4 and 6 weeks respectively as compared to 7.27 ± 4.71, 6.02 ± 3.76, 5.82 ± 3.45 in non-depressed group. Sixty six mothers (35.48%) had high BDI values during the antenatal period out of which twenty nine continued to have higher BDI scores even in postpartum follow-up visits shows the point prevalence rate of 15.59%. In depressed mothers the BDI, score did not significantly increase after the delivery, where as in case of non-depressed mothers there was a decline in the BDI scores.
The mean EPDS scores [Table 5] of the depressive population were 16.6 ± 2.81, 16.83 ± 3.23 and 15.3 ± 1.87 at 2, 4 and 6 weeks postpartum respectively and that of the non-depressive mothers 7.35 ± 4.21, 6.36 ± 4.09 and 4.99 ± 3.62. Which were statistically significant at P < 0.0001. This compares well with studies of Najman et al.,  Beeghly et al.  and Rubertsson et al. 
Stress and PPD
Postpartum depressed women scored higher (4.23 ± 2.61) on the GHQ-12 than the non-depressed (1.73 ± 2.45) [Table 6] and this reflects the usual high levels of stress and disorganization associated with the transition to parenthood. In a sample of 1447 Budgayci et al.  in Turkey reported prevalence of PPD lower during the first 2 months of postpartum, which increases to 36% between 7 and 12 months and reaches 42.7% after 13 months. They attribute this to inevitable separation (weaning and care by the nanny) and mothers return to work.
| Conclusion|| |
Antenatal screening and early intervention for perinatal distress, depression and anxiety will go a long way in addressing PPD in young mothers.
Limitations of the Study
The study has not taken into account the role of biological factors along with other factors that were the focus of attention in this study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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