Original article
Risk factors of postpartum depression in Ramhormoz city, Iran

Introduction

Postpartum depression (PPD) affects women in developed as well as developing countries. The overall prevalence of clinically significant postpartum depressive symptoms is estimated to be 7-19%. Around a third of “postnatal depression” cases begin in pregnancy and around a quarter begin before pregnancy (Gaynes et al. 2005; Ahmed et al. 2011; Al Dallal et al. 2012; Vliegen et al. 2014). The prevalence of PPD in Iran was 25.3% (95% CI: 22.7-27.9%). Amongst subgroups of unwanted delivery, illiterate, housewives, and having a history of depression the prevalence was 43.4%, 31.6%, 30.7%, and 45.2% respectively. Postpartum depression presents with the same symptoms as for a major depressive episode occurring outside of the prenatal period, including core symptoms of depressed mood and/or loss of pleasure, together with additional symptoms, including changes in weight or sleep, fatigue or loss of energy, feelings of worthlessness or guilt, concentration difficulties, and suicidal ideation (American Psychiatric Association 1994). The Edinburgh Postnatal Depression Scale (EPDS) is a brief and widely used instrument for measuring postnatal depression. Although this approach has been criticized, the EPDS has showed good sensitivity and specificity, particularly when used to detect both major and minor depression (Montazeri et al. 2007). The Edinburgh Postnatal Depression included biological, psychological, and sociological aspects interacting with a woman’s risk individually (Klainin et al. 2009). Sociological factors such as unwanted delivery, occupation, literacy, and history of depression have been more frequently reported throughout original research and a meta-analysis (Bahadoran et al. 2008).
According to the potential adverse effects of postpartum depression in mothers and their families, prevention is the key issue. Since studies have demonstrated the multifactorial nature of postpartum depression, identifying and eliminating any of the factors can reduce the risk of postpartum depression. Right now, the current care during pregnancy and after it is limited to physical care. Therefore, introducing effective factors on postpartum depression to those involved in the care of mothers will help to reduce it. The aim of this study was to determine factors associated with PPD in women.

Material and methods

It was a cross-sectional study on 143 pregnant women who were referred to health centers in Ramhormoz city located in Khuzestan province, Iran during March 20 to September 21 in 2013; they gave informed consent to participate in the study.
Inclusion criteria:
• pregnant women 15-45 years old,
• pregnant women with primipara to tripara,
• pregnant women were willing and had informed consent to participate in this study. Exclusion criteria:
• individuals with psychiatric disease,
• use of psychiatric drugs,
• history of psychiatric disease in the family,
• chronic disease,
• history of nulliparity,
• pregnancy complications such as high blood pressure, convulsion, fetal malformations, preterm birth,
• hospitalization for other reasons,
• obtaining scores higher than 12 in the Edinburgh questionnaire by women in the third trimester of pregnancy.
After subjects entered the study, Edinburgh standard criteria were completed for PPD. This questionnaire has a sensitivity of 75% and specificity 95%, based on another study (Uwakwe et al. 2003). In several studies performed in Iran, content validity of the questionnaire has been confirmed for Persian language (Khorramirad et al. 2010). In the present study, reliability was confirmed by Cronbach’s alpha coefficient of more than 7%. This questionnaire contains 10 questions. Each question receives a score of 0 to 3 based on the nature of the response. The cut-off score on the questionnaire was 12. Individuals who gained scores equal to or greater than 12 were considered as depressed persons and women with scores lower than 12 were normal. Also, the questionnaire was completed in the third trimester of pregnancy and in the last visit before delivery. Women who obtained scores higher than 12 were excluded from the study. Finally, 120 cases remained and six weeks after delivery, or the next visit, the questionnaire was completed again. The demographic data included age of mother, parity, maternal education, satisfaction with baby gender of newborn, method of delivery, history of violence, husband’s feeling in recent pregnancy, family support, good experience of childbirth, unwanted pregnancy, method of delivery, satisfaction with baby gender of newborn, Newborn’s disease during birth, ready to accept responsibility for pregnancy, husband’s support. Health service status was collected.

Data analysis

Data were entered into the SPSS software (version 19, SPSS, Inc., Chicago, IL, USA), and analyzed using descriptive and analytical statistical tests such as one-sample t-test, independent sample t-test, one-way ANOVA and 2 test. The significance level was considered 0.05.

Results

The average age was 24.67 ±3.26 years. 42% of the participants had diploma-level education, and 19.5% and 10.6% had respectively college education or were illiterate. Almost 69% of subjects were housewives. The average number of deliveries was 1.83 ±0.07. Frequencies of women with primiparity, bipara, and tripara were 42%, 25%, and 31% respectively. Most women had wanted pregnancy. Of 33% subjects who had unwanted pregnancy, 64% were suffering from depression. The prevalence of postpartum depression was 47% in mothers who had low economic conditions, and it was 10% in participants who had good economic conditions. This rate was 14% in those who were satisfied with gender of the infant, and in others it was 76% (Table 1).
Postpartum depression had occurred in more than 50% of mothers who had child birth three or more times. The prevalence rate among people with hypertension, severe vomiting and back pain during pregnancy was 33%, 25% and 35% respectively. Findings showed a significant association between maternal disease during pregnancy, age of mother, parity, maternal education, satisfaction with gender of newborn, and the method of delivery, and postpartum depression (p < 0.05) (Table 2).
The mean prevalence of postpartum depression was different in mothers with unwanted pregnancy, newborn’s disease during birth, ready to accept responsibility for pregnancy, spouse’s satisfaction, number of pregnancy, and husband’s feeling in recent pregnancy (p < 0.05). As can be seen in Table 2, some factors associated with postpartum depression included a history of violence, family support, a good experience of childbirth, satisfaction with gender of newborn, infant’s disease, and health service status.

Discussion

Findings of this research indicated similarity to a study which showed an association between age of mothers and postpartum depression. High maternal age is a factor influencing postpartum depression. It is possible that younger mothers face lower postpartum depression due to using new information, important for prenatal care, and having higher education (Beck et al. 2001). A study showed that as parity increases, depression risk rises (Hung et al. 2011; Hung et al. 2004). In other words, when there are large numbers of children, a mother has less time for rest and recreation. As a result, these factors can lead to fatigue, and can make her susceptible to postpartum depression (Khodadadi et al. 2008). However, Beck and Verdoux did not find an association between parity and postpartum depression (Beck et al. 2001; Verdoux et al. 2002).
Dennis believes that an unwanted pregnancy can lead to lack of acceptance of the child, and depression may develop (Dennis et al. 2004; Sadat et al. 2014). Other studies, like this study, revealed that a much higher stress level causes likelihood of postpartum depression. Therefore, the main issue is the person’s reaction to stress (Dennis et al. 2004; Wang et al. 2003).
In our study, support of mother is defined as communication network mothers with their husbands, families and friends. Result had emphasized that if social support by husbands is reduced, risk of depression increases (Fisch et al. 1997; Hopkins et al. 2000). Brockington stated that lack of an appropriate relationship with the spouse causes increased risk of postpartum depression (Brockington et al. 1996). One of the most important social supports is having health insurance. Women who have insurance coverage are less concerned about costs. As a result, they have less stress, and then low risk of depression (Abdollahi et al. 2014).
The research conducted by Chee showed that not having a good experience of childbirth is associated with postpartum depression (Chee et al. 2005).
Hopkins et al. demonstrated that stress due to newborn’s disease is related to PPD. Infant characteristics can affect maternal attitudes and behaviors. The responsibility of keeping an infant limits the mother’s social communication, and she has less independence than in the past, especially when a newborn is sick (Edwards et al. 1994; Mazaheri et al. 2014).
Verdoux stated that there was an association between the type of disease or problem and depression because long-term treatments and hospitalization can increase the risk of depression. He also indicated that higher education in mothers enhances information about awareness of civil rights and physical and mental health needs. Therefore, compatibility with existing conditions will be easier (Verdoux et al. 2002). In conclusion, the prevalence of postpartum depression is high. Therefore, identification of the risk factors for postpartum depression is essential to reduce the frequency of this disorder.

Acknowledgments

We thank all of those who helped us in conducting this study, especially personnel of health centers in Ramhormoz, Khuzestan. We appreciate all subjects who participated in this study. References 1. Ahmed HM, Alalaf SK, Al-Tawil NG. Screening for postpartum depression using Kurdish version of Edinburgh postnatal depression scale. Arch Gynecol Obstet 2011; 285: 1249-1255.
2. Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18: 439-445.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Press, Washington, DC 1994.
4. Abdollahi F, Sazlina SG, Zain AM, et al. Postpartum depression and psycho-socio-demographic predictors. Asia Pac Psychiatry 2014; 6: 425-434.
5. Bahadoran P, Foroushani SS, Ehsanpour S, Abedi A. A meta-analysis on studies about obstetric risk factors of postpartum depression in Iran within 1995–2005. Iran J Nurs Midwifery Res 2008; 13: 129-133.
6. Beck CT. Predictors of postpartum depression: an update. Nurs Res 2001; 50: 275-285.
7. Hung CH, Lin CJ, Stocker J, Yu CY. Predictors of postpartum stress. J Clin Nurs 2011; 20: 666-674.
8. Brockington I. Pregnancy and mental health. W: Motherhood and Mental Health. Oxford University Press, Oxford 1996; 61-134.
9. Chee CY, Lee DT, Chong YS, et al. Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore. J Affect Disord 2005; 89: 157-166.
10. Dennis CL, Janssen PA, Singer J. Identifying women at‐risk for postpartum depression in the immediate postpartum period. Acta Psychiatr Scand 2004; 110: 338-346.
11. Edwards DR, Porter SA, Stein GS. A pilot study of postnatal depression following caesarean section using two retrospective self-rating instruments. J Psychosom Res 1994; 38: 111-117.
12. Fisch RZ, Tadmor OP, Dankner R, Diamant YZ. Postnatal depression: a prospective study of its prevalence, incidence and psychosocial determinants in an Israeli sample. J Obstet Gynaecol Res 1997; 23: 547-554.
13. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess 2005; 119: 1-8.
14. Hopkins J, Campbell SB, Marcus M. Role of infant-related stressors in postpartum depression. J Abnorm Psychol 1987; 96: 237-241.
15. Hung CH. Predictors of postpartum women’s health status. J Nurs Scholarsh 2004; 36: 345-351.
16. Khodadadi N, Mahmoudi H, Mir HS. Postpartum depression relationship with some psychosocial effects in mothers. Journal of Ardabil University of Medical Sciences (JAUMS) 2008.
17. Khorramirad A, Lotfi MM, Bidgoli AS. Prevalence of postpartum depression and related factors in Qom. Pajoohandeh J 2010; 15: 62-66.
18. Klainin P, Arthur DG. Postpartum depression in Asian cultures: a literature review. Int J Nurs Stud 2009; 46: 1355-1373.
19. Mazaheri MA, Rabiei L, Masoudi R, et al. Understanding the factors affecting the postpartum depression in the mothers of Isfahan city. J Educ Health Promot 2014; 3: 65.
20. Montazeri A, Torkan B, Omidvari S. The Edinburgh Postnatal Depression Scale (EPDS): translation and validation study of the Iranian version. BMC Psychiatry 2007; 7: 11.
21. Sadat Z, Kafaei Atrian M, Masoudi Alavi N, et al. Effect of mode of delivery on postpartum depression in Iranian women. J Obstet Gynaecol Res 2014; 40: 172-177.
22. Uwakwe R, Okonkwo JE. Affective (depressive) morbidity in puerperal Nigerian women: validation of the Edinburgh Postnatal Depression Scale. Acta Psychiatr Scand 2003; 107: 251-259.
23. Vliegen N, Casalin S, Luyten P. The course of postpartum depression: a review of longitudinal studies. Harv Rev Psychiatry 2014; 22: 1-22.
24. Verdoux H, Sutter AL, Glatigny-Dallay E, Minisini A. Obstetrical complications and the development of postpartum depressive symptoms: a prospective survey of the MATQUID cohort. Acta Psychiatr Scand 2002; 106: 212-219.
25. Wang SY, Jiang XY, Jan WC, Chen CH. A comparative study of postnatal depression and its predictors in Taiwan and mainland China. Am J Obstet Gynecol 2003; 189: 1407-1412.