|Ahead of print publication
Postpartum depression and its risk factors: A cross-sectional exploratory study
Vinit Rahaney, Abhijeet Faye, Rahul Tadke, Sushil Gawande, Sudhir H Bhave, Vivek Chintaman Kirpekar
Department of Psychiatry, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
|Date of Submission||08-Jan-2021|
|Date of Decision||19-Jan-2021|
|Date of Acceptance||19-Jan-2021|
|Date of Web Publication||15-Mar-2021|
Assistant Professor, Department of Psychiatry (OPD-10), 2nd Floor, OPD Building, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Digdoh Hills, Hingna Road, Nagpur - 440 019, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Postpartum depression (PPD) is a serious mental health condition affecting the psychological/physical health of a mother and the infant significantly. Aims: This study aims at assessing the prevalence, the pattern of symptoms, and the risk factors associated with PPD. The study also aims at finding the correlation between PPD and stressful life events. Subjects and Methods: A cross-sectional study was conducted in a tertiary care hospital on sixty participants after ethics committee approval. Consecutively selected patients in a postpartum state fulfilling the study criteria were selected from obstetric ward and interviewed using semi-structured pro forma, Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM 5), Edinburgh Postnatal Depression Scale, Hamilton Depression Rating Scale (HAM-D), and Presumptive Stressful Life Events Scale (PSLES). Data collected were statistically analyzed with SPSS software using mean, standard deviation, and Chi-square test. Results: Mean age of the participants was 25.53 (standard deviation - 3.2). Prevalence of PPD was 6.7% which was a major depressive disorder as per the DSM 5 criteria. Sadness of mood (Depressed mood), impaired concentration, change in weight, and insomnia were the commonly reported symptoms. Seventy five percent of the participants had PSLES score of >100, indicating higher stress. Furthermore, 75% of the participants with a history of abortion showed a PSLES score above 100. Significant positive correlation was found between PSLES score and HAM-D score, with 63% of the participants with PSLES score >200 had a HAM-D score of >8 (suggestive of depression). Younger (<20 years) or older (>30 years) age at pregnancy, history of abortion, and higher level of stress were found to be the risk factors for developing PPD. Conclusion: Although the prevalence is less, PPD is an important mental health issue. It is worth screening all the patients in postpartum state so as to intervene early if needed. This may help in better care of physical and psychological health of a mother and the newborn.
Keywords: Postpartum depression, prevalence, stressful life events
|How to cite this URL:|
Rahaney V, Faye A, Tadke R, Gawande S, Bhave SH, Kirpekar VC. Postpartum depression and its risk factors: A cross-sectional exploratory study. Ann Indian Psychiatry [Epub ahead of print] [cited 2021 Apr 20]. Available from: https://www.anip.co.in/preprintarticle.asp?id=311205
| Introduction|| |
Pregnancy is an important event in a woman's life. She goes through various physical, hormonal, and psychological changes during pregnancy and postpartum. While physical and endocrine symptoms are treated actively, psychological changes induced by or as a result of the pregnancy are usually given less attention. One of the possible consequences of psychological or emotional changes is “postpartum depression” (PPD). It is usually described under the broad term “Postpartum psychiatric disorders.” Other important psychiatric illnesses that are included under this category are postpartum psychosis and postpartum blues. PPD is a serious mental health condition affecting up to 13% of mothers during their first pregnancy. Onset of symptoms occurs generally within a week after the delivery, may peak by the end of the 4th week, and may occur up to 1 year after delivery., The global prevalence of PPD is estimated at 100–150 cases/1000 births. The prevalence in developing countries varies from 1.9% to 82.1% and from 5.2% to 74.0% in developed countries. In India, the prevalence of PPD was found as 22%. Usual symptoms of PPD are depressed mood, loss of interest in daily activities, appetite and sleep disturbances, psychomotor agitation or retardation, fatigue, feelings of worthlessness or inappropriate guilt, poor concentration, and suicidal ideation. Other important symptoms include decreased confidence in taking care of the baby, emotional lability, irritability, emptiness, difficulty in forming an emotional attachment with the baby, doubting one's ability to care for the baby, and thoughts of harming the baby. Depressed mothers may not breastfeed their babies, seek appropriate health care or follow the desirable infant sleep practices.
Studies also show that stressful life events during pregnancy may increase the risk for PPD. Various contributors to PPD are family history of psychiatric illness, history of domestic abuse, poor marital relationship, negative attitude toward pregnancy, and lack of social support. Some studies have found high level of relational stress as a main contributory factor for PPD. The risk of PPD is also high in those with the past history of depression or history of PPD in previous pregnancies. Literature evidence has shown that both stressful life events and PPD can have a negative impact on maternal and infant health (physical and mental)., PPD also has adverse effects on maternal interaction with infant and mother baby bonding which is important for the infant's social, behavioral, and cognitive development. Mothers having PPD are less reciprocative to their infants, show less attachment, and may result in poor infant health outcomes., Research conducted in a low- and middle-income country mentioned that maternal PPD may result in adverse psychological consequences in children up to 10 years later. Thus, despite being a considerable health issue for many women, PPD often remains undiagnosed or untreated. With this background, this study was conducted to assess the prevalence, pattern of depressive symptoms, and risk factors associated with PPD.
| Subjects and Methods|| |
A cross-sectional single interview study was conducted in a tertiary care hospital and research center. Considering the logistic feasibility, the sample size was calculated as 60. The power of the study is 93.2% (alpha 0.05) assuming the prevalence of PPD in general population. The duration of the study was 6 months (September 2019 to February 2020). After the approval from Institutional Ethics Committee and permission from the Head of the Department of Obstetrics and Gynecology, patients admitted in the Obstetrics and Gynecology ward, in postpartum state were considered for inclusion in the study. Participants were given detailed information about the study and informed consent was taken for the participation. Patients included were those in postpartum period of <1 month of delivery and above 18 years of age. Those not willing to participate or give informed consent and are seriously ill or unable to answer the questions were excluded. The aims of the study were to assess the prevalence and pattern of symptoms of PPD, to assess the presence of stressors, and to find the correlation between PPD and stressors. Participants were interviewed with following tools.
Semi-structured pro forma
It included questions related to the sociodemographic profile, details about pregnancy and child birth (present and past), family and relationship history, and information about the stressors.
Diagnostic and Statistical Manual of Mental Disorders criteria
This is used for the diagnosis of PPD.
Edinburgh Postnatal Depression Scale
This questionnaire was developed to identify PPD in women. It has ten questions, and each question has four options. The scoring for each option ranges from 0 to 3. The maximum score is 30. A total score of more than 10 suggests that minor or major depression may be present. The scale is found to have satisfactory sensitivity and specificity as a screening tool. It is also sensitive to the change in the severity of depression over the time.
Hamilton Depression Rating Scale
Hamilton Depression Rating Scale (HAM-D) has proven to be useful for determining a patient's level of depression before, during, and after the treatment. It is administered by a clinician experienced in working with psychiatric patients. Although HAM-D has 21 items, the scoring is based on the first 17. It generally takes 15–20 min to complete the interview and score the results. Eight items are scored on a 5-point scale, ranging from 0 = not present to 4 = severe. Nine are scored from 0 to 2. Total score ranges from 0 to 63 with a score <7 considered normal, 8–13, a mild depression, 14–18, a moderate depression, 19–22 as a severe depression, and >23 as a very severe depression. Its sensitivity is 86.4% and specificity 92.2%.
Presumptive Stressful Life Events Scale (PSLES) was developed specifically for the Indian population in 1984 by Singh et al. This scale is based on the Social Readjustment Rating Questionnaire of Holmes and Rahe (1967). There are 51 life events that are relevant to the Indian setting, and the score is based on the mean score of general population standardized for two time frames, past 1 year and lifetime. The total score is used as stressful life event score and higher the score, more stressful the life event.
All the data were tabulated, and statistical analysis was done with IBM SPSS Statistics for Windows, Version 26.0. (Armonk, NY: IBM Corp.) using Mean, standard deviation, and Chi-square test. A P = 0.05 or less was considered significant.
| Results|| |
The demographic characteristics of sixty participants are as mentioned on [Table 1].
Mean age of the participants was 25.53 (standard deviation – 3.2). Majority of the participants were in the age group of 21–30 (88.33%), lived in a rural area (86.67%), educated up to graduation or above (48.33%), married for 5 years or less (81.67%), and 46.67% were in their first postpartum period. There were no participants with family history of psychiatric illness or history of psychiatric illness in previous pregnancies. One participant had a history of depression in past as per the documents patient had, which was treated by a psychiatrist.
[Table 2] shows the distribution of participants as per the results of Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM 5), Edinburgh Postnatal Depression Scale (EPDS), HAM-D, and PSLES.
|Table 2: Distribution of participants based on Diagnostic and Statistical Manual of Mental Disorders version 5, Edinburgh Postnatal Depression Scale, Hamilton Depression Rating Scale and Presumptive Stressful Life Events Scale scores|
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As per DSM 5 criteria, 6.7% of the participants fulfilled the criteria for major depressive disorder. EPDS score also suggested that possible depression was present in 6.7% of the participants. The common symptoms reported in patients with PPD were sadness of mood (depressed mood), change in weight (loss), insomnia, and impaired concentration. HAM-D Score of >8 was seen in 27 participants (45%). A PSLES score showed more number of participants (75%) having higher stress (score >100). Common symptoms of depression were depressed mood, change in weight, impaired concentration, insomnia, loss of energy/interest, guilt feelings, and psychomotor retardation which were similar to those present in depression not related to child birth [Table 2].
There was no statistically significant difference when EPDS score was compared with the number of pregnancies. Nearly 7.1% of the participants after their 1st pregnancy and 8% after their 2nd pregnancy had an EPDS Score of 10 or above which was suggestive of possible depression. 46.4% of the participants after their 1st pregnancy, 28% after their second pregnancy, and 57.1% of participants with multiple pregnancies had a PSLES score above 200.
Although statistically not significant, 39.3% of the participants after their 1st pregnancy, 44% after their 2nd pregnancy, and 71.4% of the participants with multiple pregnancies had a HAM-D score of >8 suggestive of depression [Table 3].
|Table 3: Obstetric history and Edinburgh Postnatal Depression Scale, Presumptive Stressful Life Events Scale and Hamilton Depression Rating Scale|
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Twenty percent of the participants in the age group <20 and 11.5% in the age group 26–30 had an EPDS score in the range of possible depression. PSLES score was higher in the age group of more than 25 years compared to those <25 years of age. More number of participants in the age group of 21–30 years were found to have a HAM-D score <7 whereas, in the age groups of <20 years and 31–35 years, majority of the participants had HAM-D score of >8 suggestive of higher prevalence of depression among younger and older mothers [Table 4].
|Table 4: Distribution of age across the scores of Edinburgh Postnatal Depression Scale, Presumptive Stressful Life Events Scale and Hamilton Depression Rating Scale|
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On comparing history of abortion with EPDS score, it was observed that 7.7% of participants with no history of abortion had an EPDS score in the range of possible depression (>10). Nesarly 75% of the participants with a history of abortion showed a PSLES score above 100, though the finding was not statistically significant. HAM-D score was significantly higher in the participants with a positive history of abortion compared to those with no history of abortion (P = 0.043). HAM-D score of >8 was found in 75% of the participants with a history of abortion (6 out of 8) suggestive of depression[Table 5].
|Table 5: History of abortion and scores on Edinburgh Postnatal Depression Scale, Presumptive Stressful Life Events Scale and Hamilton Depression Rating Scale|
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On comparing PSLES score with HAM-D score, it was found that 63% of the participants whose PSLES score was above 200 had a HAM-D score in the range of 8 or more suggestive of depression which was significantly higher compared to those with PSLES score <200 (P < 0.01)[Table 6].
|Table 6: Correlation between Presumptive Stressful Life Events Scale and Hamilton Depression Rating Scale|
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| Discussion|| |
There is a scarcity of research in the field of epidemiology of PPD in India. This study is one of the efforts to contribute in this regard.
As per the DSM 5 criteria, prevalence of PPD in this study was found to be 6.7%. This finding was similar to that of a study conducted by Dubey et al. which showed a prevalence of 6%. Another study with similar findings was conducted by Liu S that estimated a prevalence of 6.7%. Findings of EPDS have corroborated with the DSM 5 findings in this context.
Various studies have quoted different values for the prevalence of PPD. The variation in prevalence ranges from 3% to 38% as per a meta-analysis. Other studies have noted the prevalence of PPD as 5.2% to 74.0% in developed countries and 1.9%–82.1% in developing countries. The prevalence of depression as per HAM-D scale in this study was 45% which is in line with the findings of abovementioned studies. Symptoms of depression were similar to those in depression not associated with child birth which is similar to findings of other studies.
HAM-D score was lesser (nondepressive range) in more number of participants in the age group of 21–30 years, whereas in the age groups of <20 years and 31–35 years, majority of the participants had a HAM-D score of >8, indicative of depression. Similarly, PSLES score was lesser in age group of 21–30 years compared to those in the age group of <20 years and 31–35 years. These findings were similar to that of the study conducted in rural South India, which suggested that patients under the age of 20 or over 30 are at a higher risk for PPD. This finding may be due to higher levels of stress associated with an early or late pregnancy which may manifest as depression.
Around 57% of the participants after their 1st pregnancy, 36% after their second pregnancy, and more than 70% with multiple pregnancies had a higher PSLES score. It is a known fact that pregnancy can act as a significantly stressful life event in a woman's life, but the experience and confidence gained to cope up with it during the first pregnancy may help a woman during her second pregnancy leading to reduced stress to some extent. On the other hand, multiple pregnancies may lead to exhaustion of coping resources which can further lead to an increase in the distress level of a woman. This may also be affected by various social and cultural factors.
More than 7% of the participants after their 1st pregnancy and 8% after their 2nd pregnancy had an EPDS Score of 10 or above suggesting possible depression. None of the participants with multiple pregnancies had an EPDS score in the range of possible depression. On the contrary, more than 2/3rd of the participants with multiple pregnancies had a HAM-D score in the range of >8. This finding of multi-parity being associated with an increased prevalence of depressive symptoms can be explained as going through the physiological changes in the body during every pregnancy and addition of responsibilities of rearing the children along with usual other roles woman has to play in Indian culture resulting in reduced attention toward self-health. This in turn may affect the psychological health of the woman and increase the risk for depression. There is mixed literature about this aspect of PPD. Some studies have mentioned that multiparous women had lower levels of social support and marital satisfaction which may lead to manifestation of depressive symptoms. Another study found that having two or more children, due to higher psychological burden, is a risk factor for the occurrence of depression. Some other studies in the literature have suggested that high parity is a risk factor for PPD among many others like financial difficulties, marital conflict, birth of a girl child, poor family support, past history of psychiatric illness, presence of pregnancy related complications, and low education level. On the contrary, Redshaw and Henderson concluded in their study that multiparity plays a protective role in PPD. Another study by Kheirabadi et al. has also stated that initial pregnancies have a higher risk of PPD compared to later pregnancies.
Although statistically nonsignificant, more number of participants with a history of abortion had a higher score on PSLES. This indicates that a history of abortion can act as a stressor and it may worsen the ability to cope with the current stressful situation. Vukelić et al. mentioned in their study that psychosocial factors contribute to the development of stress after abortion. Stigma and misconceptions related to abortion may contribute to the same.
Majority of the participants with a history of abortion showed a HAM-D score in the range suggestive of depression, whereas majority of participants without a history of abortion had a HAM-D score in the range not suggestive of depression. This finding was statistically significant. Thus, the prevalence of depression among the patients with history of abortion was significantly higher as compared to those without history of abortion. This is self-explanatory as abortion, whether spontaneous or missed, can be stressful for a woman. Even the process of going through an induced abortion or medical termination of pregnancy can be exhausting and emotionally painful for “to be” mother which may result in depression. Similar findings were seen in a study conducted by Nomura et al. mentioning that the diagnosis of depression is high among women undergoing an abortion. Another study also found high rates of anxiety (61.7%) and depression (85%) in women undergoing abortions.
PSLES and HAM-D scores showed statistically significant positive correlation. More the level of stress, higher was the score on HAM-D. This was justifiable as increased levels of stress can manifest or eventually turn into depressive symptoms. Studies have found a positive correlation of postpartum depressive symptoms with increasing numbers of cumulative stressful life events., Some authors have also stated that the presence of more than one stressor was associated with a higher prevalence of postpartum depressive symptoms and the strongest association was observed for partner stress.
No correlation was found between PPD and factors such as education level, residential background, family support, and family/personal/past history of psychiatric illness.
| Conclusion|| |
In this study, the prevalence of PPD was 6.7%. Younger or older age at the time of delivery and history of abortion were significant risk factors for developing PPD. The presence of stressors was directly proportional to the prevalence of depression. We recommend routine screening for depression and the risk factors of PPD in all postpartum women so as to identify the condition and intervene as early as possible. This will help to prevent the negative consequences of stressful life events and postpartum depression on maternal and infant health.
This was a cross-sectional single interview study with a small sample size; longitudinal or follow-up studies would yield better results. In this study, cumulative approach was considered, irrespective of types of stressors and the effects of accumulation of reported life stressors was considered to assess the risk of PPD. Because of which, the unique effect of each stressor on PPD could not be studied. Other risk factors such as domestic violence, marital conflicts, gender of a newborn, support of a “to be” father, and financial issues were not studied.
We acknowledge head of the department of obstetrics for allowing and helping us in enrolling the participants in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]