Journal of Affective Disorders 274 (2020) 848–856

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Prevalence and Associated Factors of Postpartum Anxiety and Depression T

Symptoms Among Women in Shanghai, China
Ying Liu, Nafei Guo, Tengteng Li, Wei Zhuang, Hui Jiang
⁎

Nursing Department, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area, Shanghai, China,
201204

ARTICLE INFO ABSTRACT

Keywords: Background: Postpartum anxiety (PPA) and postpartum depression (PPD) are associated with immediate and
Mental health long-term health risks for both mothers and babies. The purpose of this paper was to evaluate relationships
Postpartum anxiety between sociodemographic, perinatal variables, and PPA and PPD symptoms of parturients 6 weeks postpartum.
Postpartum depression Methods: A cross-sectional survey with 1204 women who had a healthy and term birth in a baby-friendly
Risk factors
hospital, Shanghai, China. PPA and PPD symptoms were measured by using the Self-Rating Anxiety Scale (SAS)
Chinese parturients
and the Edinburgh Postnatal Depression Scale (EPDS).
Results: The mean score of SAS and EPDS was 40.79 ± 8.48 and 8.18 ± 5.80, respectively. The estimated
prevalence of PPA and PPD symptoms was 15.2% and 23.2%, respectively. Multivariable logistic regression
analysis showed that the presence of fatigue and PPD symptoms were risk factors for PPA symptoms, whereas
having support from family and being satisfied with labor experience were protective factors. In terms of PPD
symptoms, its risk factors included smoking before pregnancy, maternal separation from baby, fatigue, en-
countering difficulties in breastfeeding, and the presence of PPA symptoms. In contrast, the protective factors for
PPD symptoms were having support from family and having support from colleagues or friends.
Limitations: Convenience sampling and voluntary participation may have led to a selection bias.
Conclusion: PPA and PPD symptoms occur commonly among parturients in Shanghai, China. The findings from
this research provide a better understanding of factors associated with PPA and PPD symptoms and will help
guide personalized approaches to the management of postpartum anxiety and depression.

1. Introduction
Being a new mother, parturients experience both biological and
psychological changes, and also role transitions in family and society.
These changes put parturients at high risk for development of mental
disorders. It is estimated that over 20% women will develop a mental
disorder during pregnancy and/or up to 1 year postpartum
(Vazquez and Miguez, 2019), among which anxiety and depression are
the most common co-morbidities (Pampaka et al., 2018; Tang et al.,
2019).
Although there is no consensus on the definition of postpartum
depression (PPD) (Langan and Goodbred, 2016), PPD has adverse ef-
fects on maternal-infant bonding, parturient health and well-being,
infant development, and healthy family dynamics have all been re-
ported in clinical practice and research (Ding et al., 2019; Tang et al.,
2019; Wikman et al., 2019). Epidemiologic studies report variable rates
of PPD worldwide. The commonly reported global incidence for PPD is
10%-20%, and may be even higher in developing countries
(Halbreich and Karkun, 2006; Husain et al., 2006; Pampaka et al.,
2019).
A high prevalence of anxiety was also detected in parturients, which
is a distinct clinical problem despite the high co-morbidity with de-
pression (Clout and Brown, 2015). Globally, postpartum anxiety (PPA)
is reported to affect 15%-40% of new mothers (Field, 2018). A sys-
tematic review and meta-analysis of 102 studies incorporating 221,974
women from 34 countries found that the prevalence for self-reported
anxiety symptoms was 24.6% in the third trimester, which was much
higher than the first and second trimesters (Dennis et al., 2017). During
the transition to parenthood, PPA also had negative consequences for a
variety of important outcomes for both mother and child, including the
spousal relationship, child adjustment, and parent-child interactions
(Clout and Brown, 2015; Don et al., 2014; Field, 2018).

⁎
Corresponding author: Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, No.2699, West Gaoke Road, Pudong New Area,
Shanghai, China, 201204.
E-mail address: jianghuitest@163.com (H. Jiang).

https://doi.org/10.1016/j.jad.2020.05.028
Received 5 September 2019; Received in revised form 2 April 2020; Accepted 10 May 2020
Available online 23 May 2020
0165-0327/ © 2020 Elsevier B.V. All rights reserved.
Y. Liu, et al.
Understanding the factors that influence PPA and PPD is crucial for
developing effective interventions. Previous studies have reported that
predictors for perinatal depressive symptoms included cigarette
smoking prior to pregnancy (Wikman et al., 2019), social economic
adversity (Alqahtani et al., 2018; Pampaka et al., 2018), unplanned or
unwanted pregnancy (Alqahtani et al., 2018; Biaggi et al., 2016), in-
timate partner violence (Boekhorst et al., 2019; Wikman et al., 2019),
low social support (Biaggi et al., 2016; Boekhorst et al., 2019), and
negative life events (Biaggi et al., 2016; Garman et al., 2019;
Wikman et al., 2019). A longitudinal study showed that those risk
factors were associated with depression for up to 27 years after delivery
(Kingsbury et al., 2018).
Fewer studies have evaluated risk factors for PPA than PPD. A
number of risk factors reported to be associated with PPD have been
reported to have a limited correlation with PPA, including income,
education, and breastfeeding difficulties (Clout and Brown, 2015).
Currently, the risk factors for PPA that have been best established are
poor physical health, unplanned pregnancy, low partner support, lack
of control during labor, pain, and PPD (ElGonzález-Mesa et al., 2019;
Field, 2018; Floris et al., 2017).
Despite the increasing interest in perinatal mental health, research
on the prevalence and risk factors for PPA and PPD symptoms in China
are limited. Although prevalence of PPD symptoms was reported in
some areas of China [Hong Kong, Chengdu, Guangzhou] (Lee et al.,
1998; Lau et al., 2010; Deng et al., 2014), however no recent estimates
are available. One of those studies in Shanghai investigated women
who were in good health and had low-risk pregnancies and were re-
ported with a relatively lower prevalence (Ding et al., 2019). And there
is certainly little attention and less available data on anxiety
(Kang et al., 2016). Furthermore, many researchers have found that
anxiety and depression symptoms co-existed (Clout and Brown, 2015),
but as far as we know, no study has investigated PPA and PPD symp-
toms together in China.
Finally, a Chinese population might differ in terms of risk factors
compared to the general literature. Different health care and welfare
systems, special postpartum practice and family caregivers for the
parturient and newborn, such as mother-in-law, may have special in-
fluence on PPA and PPD symptoms among women in China (Liu et al.,
2015; Yang et al.,2019). Since Chinese women have a “Zuo Yue Zi” or
“sitting the month” traditional practice. In the first few months post-
partum the new mothers and babies usually live with and are taken care
of by the mother or mother-in-law, and new mothers often defer to the
wishes of their elders, as Chinese culture values family harmony and
group mentality, rather than individuality (Liu et al., 2015). So the
relationship with those family caregivers plays an important role in
parturients’ mental health (Kang et al., 2016; Liu et al., 2015).
Thus, the current study determined the prevalence and influencing
factors (sociodemographic and perinatal characteristics) among
Chinese parturients.
2. Materials and Methods
2.1. Research Methods
This was a cross-sectional, descriptive survey conducted among
parturients who had a healthy term delivery in Shanghai, China. The
study was conducted in Shanghai First Maternity and Infant Hospital.
This is a baby-friendly hospital that provides comprehensive obstetric
services. The hospital is one of China's largest providers of maternity
care with approximately 30,000 deliveries per year and also a tertiary
referral center for high-risk pregnancies.
The study population included all women who met the inclusion
criteria. Only women who declined to participate in the study were
excluded. The inclusion criteria were as follows: (1) age 18 and over;
(2) a healthy term birth; (3) no complications 6 weeks postpartum; (4)
competency in Mandarin; and (5) able to access to a mobile phone and
849
Journal of Affective Disorders 274 (2020) 848–856
able to complete an electronic questionnaire.
The study was conducted in accordance with the Declaration of
Helsinki, and ethical approval was obtained from the hospital
Institutional Review Board. Furthermore, informed consent was ob-
tained from every participant. Participants were assured that the in-
formation collected in this study was confidential and anonymous, and
participation was totally voluntary.
2.2. Measurements
Data were collected using a self-administered questionnaire that had
three sections (sociodemographic and perinatal characteristics, PPA
symptoms, and PPD symptoms).
2.2.1. Sociodemographic and Perinatal Characteristics
The first section determined participant sociodemographic and
perinatal factors. The sociodemographic factors (eight items) included
the followings: ethnicity (Han or non-Han); religious believer (yes/no);
cigarette smoking before pregnancy (yes/no); education level (primary,
secondary, and bachelor or master's degree); monthly income (<5000
RMB, 5000-10000 RMB, 10000-15000 RMB, and >15000 RMB); ma-
ternity leave time (<4 months, 4-6 months, 6-12 months, and >12
months); perceived support from family (low, medium, and high); and
perceived support from colleagues or friends (low, medium, and high).
The perinatal factors (nine items) included the followings: un-
planned pregnancy (yes/no); satisfaction with labor experience (un-
satisfied, general, and satisfied); maternal separation (yes/no); number
of caregivers for the parturient and newborn (1, or ≥ 2); primary
caregiver for the parturient and newborn (mother, mother-in-law,
husband, and others); severity of fatigue (4-point scale, no fatigue-to-
severe fatigue); breastfeeding difficulties (yes/no); feeding patterns
(exclusive breastfeeding, mixed feeding, and artificial feeding); and
frequency of baby feeding per day (< 4 times, 4-8 times, and >8
times).
2.2.2. The Self-rating Anxiety Scale (SAS)
PPA symptoms were measured by using the Self-rating Anxiety
Scale (SAS). The SAS was first designed by Zung (1971), and included
20 items using 4-point response options ranging from 1 (never) to 4
(very often) to capture symptoms of anxiety. This 20-item scale asks
participants to rate the intensity of their anxiety symptoms on a 4-point
scale, ranging from 1 (never) to 4 (most of the time). The total score is
calculated by summing all of the responses, which can range from 20-
80. The raw score should be standardized, and the standard score
equals to the raw score multiplied by 1.25. A standard score ≥ 50 (raw
score = 40) is suggested to indicate anxiety symptoms (Kang et al.,
2016). SAS has been well-validated and is commonly used in preg-
nancy, including Chinese gravidas (Hou et al., 2018; Liu et al., 2017). In
this study, the Cronbach's alpha for SAS was 0.768.
2.2.3. The Edinburgh Postnatal Depression Scale (EPDS)
PPD symptoms were measured by using the Edinburgh Postnatal
Depression Scale (EPDS). The EPDS, the most internationally used
screening tool for PPD symptoms, was first designed by
Cox et al. (1987), and has been translated into over 50 languages
(Bergink et al., 2011). The EPDS includes 10 items using 4-point re-
sponse options ranging from 0 (no, not at all) to 3 (yes, most of the
time) to capture symptoms of depression in the past 7 days. The total
score ranges from 0-30, with higher scores indicating greater severity of
symptoms. The most commonly used and recommended cut-offs are ≥
10 to indicate minor or possible depression and ≥ 13 to indicate major
or probable depression in a general postpartum population
(Gibson et al., 2009; Huang and Mathers, 2001; Teng et al., 2005). We
used the Chinese version of the EPDS, the reliability and validity of
which have been established in Taiwan (Heh, 2001), Hong Kong
(Lee et al., 1998), and mainland China (Lau et al., 2010); the Cronbach's
Y. Liu, et al. Journal of Affective Disorders 274 (2020) 848–856

Table 1
Characteristics of the participants (N=1204).
Characteristic n (%)

Ethnicity
Han 1170 (97.2)
Non-Han 34 (2.8)
Religious believer
Yes 72 (6.0%)
No 1132 (94.0%)
Cigarette smoking before pregnancy
Yes 10 (0.8%)
No 1194 (99.2%)
Education level
Primary education 102 (8.5%)
Secondary education 608 (50.5%)
Bachelor or master's degree 494 (41.0%)
Monthly income (RMB)
<5000 211 (17.5%)
5000-10000 470 (39.0%)
10000-15000 232 (19.3%)
>15000 291 (24.2%)
Maternity leave time
<4 months 281 (23.3%)
4-6 months 698 (58.0%)
6-12 months 59 (4.9%)
>12 monthsa 166 (13.8%)
Perceived support from family
Low 119 (9.9%)
Medium 200 (16.6%)
High 885 (73.5%)
Figure 1. Flowchart of participants. Perceived support from colleagues or friends
Low 111 (9.2%)
Medium 209 (17.4%)
alpha for EPDS in this study was 0.862. A cut-off score ≥ 13 was used High 884 (73.4%)
in this study. Unplanned pregnancy
Yes 179 (14.9%)
No 1025 (85.1%)
2.3. Procedure Satisfaction of labor experience
Unsatisfied 67 (5.6%)
The study was conducted over 6 months (January-June 2019). A General 126 (10.5%)
Satisfied 1011 (84%)
total of about 12600 (70/day) women in 6 weeks postpartum were Maternal separation
scheduled for a routine appointment at an outpatient clinic in the re- Yes 181 (15.0%)
search period. A convenience sample was obtained from 1890 eligible No 1023 (85.0%)
women who were invited to participate in the study, and of which 1500 Number of caregivers for the parturient and newborn
1 202 (16.8%)
(79.4%) agreed to participate (see figure 1). After a brief introduction
≥2 1002 (83.2%)
about the objectives and procedures of the research, the trained re- Primary caregiver for the parturient and newborn
search assistants instructed the consented participants to fill out the Mother 461 (38.3%)
questionnaire on their own telephone through an electronic ques- Mother-in-law 322 (26.7%)
tionnaire linked to the WeChat app. All participants were assured that Husband 189 (15.7%)
Othersb 232 (19.3%)
all data would be kept confidential and were used only by the re- Severity of fatigue
searchers. Finally, after a careful examination of all the submitted data Severe fatigue 56 (4.7%)
and deleted the duplicates, completed questionnaires were received Moderate fatigue 292 (24.3%)
from 1204 parturients (80.3%). Mild fatigue 752 (62.5%)
No fatigue 104 (8.6%)
Breastfeeding difficulties
2.4. Data Analyses Yes 617 (51.2%)
No 587 (48.8%)
Feeding patterns
Data were analyzed by using the Statistical Package for Social Exclusive breastfeeding 638 (53.0%)
Sciences (SPSS; version 22.0 for Windows). Sociodemographic and Mixed feeding 416 (34.6%)
perinatal characteristics of the participants were summarized using Artificial feeding 150 (12.5%)
frequencies and percentages for categorical variables. A χ² test and Frequency of baby feeding (per day)
< 4 times 81 (6.7%)
logistic regression analysis were performed to evaluate the association
4-8 times 565 (46.9%)
of factors related to PPA and PPD symptoms. The crude odds ratio (OR) >8 times 558 (46.3%)
and adjusted OR (aOR) were estimated with respective 95% confidence PPA symptoms
intervals (CIs). Variables were included into the multivariate logistic Yes (SAS score ≥ 50) 183 (15.2%)
regression model if the variables had a significant association (p ≤ No (SAS score < 50) 1021 (84.8%)
PPD symptoms
0.20) with the χ² test or were deemed important enough clinically,
despite no statistical significance. All statistics were performed using (continued on next page)
two-sided tests, and the alpha level of significance was set at 0.05.

850
Y. Liu, et al.
Table 1 (continued)
Characteristic n (%)
Yes (EPDS score ≥ 13) 279 (23.2%)
No (EPDS score < 13) 925 (76.8%)
PPA refers to Postpartum Anxiety.
SAS refers to the Self-rating Anxiety Scale.
PPD refers to Postpartum Depression.
EPDS refers to the Edinburgh Postnatal Depression Scale.
a
Unemployed housewives or self-employed women were included in this
group.
b
Others caregivers included nannies, maternity matrons, and maternity
service workers.
3. Results
3.1. Characteristics of Study Participants
Table 1 shows the sociodemographic and perinatal characteristics of
the participants. Of the 1204 participants in the study, 91.5% had de-
grees in secondary education or above, 14.9% had unplanned preg-
nancies, 84% felt satisfied with the labor experience, 38.3% received
support from their mother, and 26.7% received support from their
mother-in-law. The mean standard SAS score was 40.79 (SD, 8.478) and
PPA symptoms was identified in 15.2% of the study population when a
cut-off point of 50 was used. The mean EPDS score was 8.18 (SD, 5.803)
and the prevalence of PPD symptoms, as defined by an EPDS score ≥
13, was 23.2%.
3.2. Factors Influencing PPA Symptoms
Table 2 shows the factors associated with the odds for reporting
symptoms of PPA. We examined the relationships between socio-
demographic and perinatal characteristics and PPA symptoms. A sig-
nificant difference was noted between the anxiety and non-anxiety
groups by chi-square tests with respect to cigarette smoking before
pregnancy (p = 0.03), education level (p = 0.04), monthly income
(p = 0.02), perceived support from family (p < 0.01), perceived sup-
port from colleagues or friends (p < 0.01), unplanned pregnancy (p <
0.01), satisfaction with labor experience (p < 0.01), number of care-
givers for the parturient and newborn (p = 0.05), primary caregiver for
the parturient and newborn (p = 0.03), severity of fatigue (p < 0.01),
breastfeeding difficulties (p = 0.01), and PPD symptoms (p < 0.01).
Multivariable logistic regression analysis showed that compared
with parturients who received high support from family, parturients
who had low or medium support were more likely to report symptoms
of PPA. Compared with parturients who were satisfied with labor ex-
perience, parturients who were neutral or unsatisfied with labor ex-
perience were more likely to report symptoms of PPA. Parturients who
had severe fatigue were more likely to report symptoms of anxiety than
parturients who had no fatigue. The presence of PPD symptoms also
increased the risk for PPA symptoms.
3.3. Factors Influencing PPD Symptoms
Table 3 shows the factors associated with the odds for reporting
symptoms of PPD. We examined relationships between socio-
demographic and perinatal characteristics and PPD symptoms. Sig-
nificant differences between the depression and non-depression groups
were observed by chi-square tests with respect to cigarette smoking
before pregnancy (p < 0.01), education level (p < 0.01), perceived
support from family (p < 0.01), perceived support from colleagues or
friends (p < 0.01), unplanned pregnancy (p = 0.02), satisfaction with
labor experience (p < 0.01), maternal separation (p < 0.01), number of
caregivers for the parturient and newborn (p = 0.02), primary
851
Journal of Affective Disorders 274 (2020) 848–856
caregiver for the parturient and newborn (p = 0.05), severity of fatigue
(p < 0.01), breastfeeding difficulties (p < 0.01), and PPA symptoms (p
< 0.01).
Multivariable logistic regression analysis showed that compared
with parturients who received high support from the family, parturients
who received low) or medium support were more likely to report
symptoms of PPD. Parturients who received low support from collea-
gues or friends were more likely to have PPD symptoms than parturi-
ents who received high support. Although the number of parturients
who smoked cigarettes before pregnancy was extremely low, cigarette
smoking before pregnancy increased the odds of PPD, as did maternal
separation, and breastfeeding difficulties. With respect to the severity of
fatigue, parturients with low or severe fatigue were more likely to re-
port symptoms of depression than parturients with no fatigue. PPA
symptoms also increased the risk for PPD symptoms.
4. Discussion
4.1. Prevalence of PPA and PPD Symptoms
The present study investigated the prevalence of PPA and PPD
symptoms among Chinese parturients 6 weeks postpartum. This study
showed that PPA symptoms affected 15.2% of the study population,
which was consistent with the prevalence reported internationally [13-
40%] (Field, 2018; Dennis, 2016), but there are no data from China that
can be used for comparison.
The prevalence of PPD symptoms was 23.2% in the current study,
which was much higher than reported in other Chinese populations
years ago [Hong Kong, 5.5% (Lee et al., 1998); Chengdu, 4.7%
(Lau et al., 2010); Shanghai, 11.8% (Ding et al., 2019)], but consistent
with results reported in Guangzhou [27.4%] (Deng et al., 2014). With
the development of the social economy, several factors including in-
creasing public awareness of maternal mental health, expert sugges-
tions of routine screening perinatal mental health, and more validated
screening tools were used may explain the increased detection of PPD
symptoms (Avalos et al., 2016). The participants in the
Ding et al. study (2019) conducted in Shanghai were generally in good
health and did not have high-risk pregnancies or complications that
may contribute to a lower prevalence. Moreover, the estimated pre-
valence of PPD symptoms varies significantly across different studies
due to different sampling methodologies, varying instruments, and cut-
off points. Studies emphasized that PPD symptoms was a common and
significant problem, particularly in developing countries
(Halbreich and Karkun, 2006; Husain et al., 2006). Given the high rate
of PPD in Chinese women, increasing awareness of this problem among
health care providers and the general public is important for early de-
tection and intervention.
Although maternal intervention for physical care of pregnant
women has improved dramatically in China over recent decades, little
attention had been paid to maternal mental health, especially in the
clinical aspects. In July 2019, an expert consensus on mental health
management of pregnant women was released in July 2019, which
suggested that maternal mental health screening should be part of
routine maternal health care and recommended that at least four times
maternal mental health screening should be performed: early stages of
pregnancy (13 + 6 weeks), mid-pregnancy(14-27 + 6 weeks), late
pregnancy (28 weeks and after), and 6 weeks postpartum. But due to
the huge medical need and the relatively inadequate supply of medical
resources, the medical personnel were overworked to fully im-
plemented the consensus clinically, and only assessment for PPD
symptoms had been performed in some hospitals by the obstetricians.
Besides, in most Obstetrics and Gynecology hospitals in China, there is
no psychiatry department. If the women screened positive for the risk of
anxiety or depression, they were offered psychological support and
humanistic care by clinicians, and with their permission, referrals
would be made to an allied mental health care facility if necessary
Y. Liu, et al. Journal of Affective Disorders 274 (2020) 848–856

(Li et al., 2019).
4.2. Factors Influencing PPA and PPD Symptoms
We used data obtained from a variety of measures to compare the
sociodemographic and perinatal profiles of parturients with and
without PPA symptoms, and parturients with and without PPD symp-
toms.
First, despite the symptomatic distinctions between anxiety and
depression, anxiety symptoms primarily include worry, fear, and

Table 2
Factors associated with PPA symptoms based on bivariate and multivariate analyses.
Characteristic PPA Symptoms OR (95%CI) aOR (95%CI)
No (n= 1021) n (%) Yes (n= 183) n (%)

Ethnicity
Han 992 (97.2%) 178 (97.3%) 1.04 (0.40, 2.7)
Non-Han 29 (2.8%) 5 (2.7%) 1 (ref.)
Religious believer
Yes 63 (6.2%) 9 (4.9%) 0.79 (0.39, 1.61)
No 958 (93.8%) 174 (95.1%) 1 (ref.)
Cigarette smoking before pregnancy
Yes 6 (0.6%) 4 (2.2%) 3.78 (1.06, 13.53)
No 1015 (99.4%) 179 (97.8%) 1 (ref.)
Education level
Primary education 81 (7.9%) 21 (11.5%) 1.84 (1.06, 3.19)
Secondary education 507 (49.7%) 101 (55.2%) 1.14 (1.00, 1.99)
Bachelor or master's degree 433 (42.4%) 61 (33.3%) 1 (ref.)
Monthly income (RMB)
<5000 172 (16.8%) 39 (21.3%) 2.13 (1.26, 3.59)
5000-10000 393 (38.5%) 77 (42.1%) 1.84 (1.16, 2.92)
10000-15000 193 (18.9%) 39 (21.3%) 1.80 (1.13, 3.19)
>15000 263 (25.8%) 28 (15.3%) 1 (ref.)
Maternity leave time
<4 months 233 (22.8%) 48 (26.2%) 1.02 (0.61, 1.69)
4-6 months 598 (58.6%) 100 (54.6%) 0.82 (0.52, 1.30)
6-12 months 52 (5.1%) 7 (3.8%) 0.66 (0.27, 1.61)
>12 months 138 (13.5%) 28 (15.3%) 1 (ref.)
Perceived support from family
Low 78 (7.6%) 41 (22.4%) 4.76 (3.07, 7.37) 1.994 (1.18, 3.38)
Medium 146 (14.3%) 54 (29.5%) 3.35 (2.29, 4.91) 1.972 (1.25, 3.11)
High 797 (78.1%) 88 (48.1%) 1 (ref.) 1 (ref.)
Perceived support from colleagues or friends
Low 72 (7.1%) 39 (21.3%) 4.72 (3.02, 7.37)
Medium 156 (15.3%) 53 (29.0%) 2.96 (2.03, 4.33)
High 793 (77.7%) 91 (49.7%) 1 (ref.)
Unplanned pregnancy
Yes 136 (13.3%) 43 (23.5%) 2.00 (1.36, 2.94) 1.52(0.94, 2.44)
No 885 (86.7%) 140 (76.5%) 1 (ref.) 1 (ref.)
Satisfaction of labor experience
Unsatisfied 37 (3.6%) 30 (16.4%) 6.26 (3.72, 10.51) 5.55 (2.95, 10.47)
General 89 (8.7%) 37 (20.2%) 3.21 (2.09, 4.93) 2.91 (1.74, 4.86)
Satisfied 895 (87.7%) 116 (63.4%) 1 (ref.) 1 (ref.)
Maternal separation
Yes 151 (14.8%) 30 (16.4%) 1.13 (0.74, 1.73)
No 870 (85.2%) 153 (83.6%) 1 (ref.)
Number of caregivers for the parturient and newborn
1 162 (15.9%) 40 (21.9%) 1.48 (1.01, 2.19)
≥2 859 (84.1%) 143 (78.1%) 1 (ref.)
Primary caregiver for the parturient and newborn
Mother 406 (39.8%) 55 (30.1%) 1 (ref.)
Mother-in-law 265 (26.0%) 57 (31.1%) 1.59 (1.06, 2.37)
Husband 151 (14.8%) 38 (20.8%) 1.86 (1.18, 2.92)
Others 199 (19.5%) 33 (18.0%) 1.22 (0.77, 1.95)
Severity of fatigue
Severe fatigue 27 (2.6%) 29 (15.8%) 26.85 (8.69, 83.00) 6.47 (1.88, 22.19)
Moderate fatigue 224 (21.9%) 68 (37.2%) 7.59 (2.69, 21.38) 2.41 (0.79, 7.35)
Mild fatigue 670 (65.6%) 82 (44.8%) 3.06 (1.10, 8.53) 1.64 (0.55, 4.86)
No fatigue 100 (9.8%) 4 (2.2%) 1 (ref.) 1 (ref.)
Breastfeeding difficulties
Yes 507 (49.7%) 110 (60.1%) 1.53 (1.11, 2.10)
No 514 (50.3%) 73 (39.9%) 1 (ref.)
Feeding patterns
Exclusive breastfeeding 551 (54.0%) 87 (47.5%) 0.69 (0.43, 1.10)
Mixed feeding 348 (34.1%) 68 (37.2%) 0.85 (0.52, 1.38)
Artificial feeding 122 (11.9%) 28 (15.3%) 1 (ref.)
Frequency of baby feeding (per day)
< 4 times 68 (6.7%) 13 (7.1%) 0.92 (0.49, 1.73)
4-8 times 491 (48.1%) 74 (40.4%) 0.73 (0.52, 1.01)
>8 times 462 (45.2%) 96 (52.5%) 1 (ref.)
PPD symptoms
(continued on next page)

852
Y. Liu, et al.
Table 2 (continued)
Characteristic PPA Symptoms
No (n= 1021) n (%)
Yes (EPDS score ≥ 13) 151 (14.8%)
No (EPDS score < 13) 870 (85.2%)
Ref: reference category
Bold values indicate statistical significance.
aOR: adjusted for cigarette smoking before pregnancy, education level, monthly income, unplanned pregnancy, number of caregivers for the parturient and newborn,
primary caregiver for the parturient and newborn, severity of fatigue, satisfaction of labor experience, perceived support from family, perceived support from
colleagues or friends, breastfeeding difficulties, frequency of baby feeding, and depression. p values in bold font indicate statistical significance.
PPA refers to Postpartum Anxiety.
PPD refers to Postpartum Depression.
EPDS refers to the Edinburgh Postnatal Depression Scale.
avoidance, whereas depression symptoms mainly include sadness,
hopelessness, and worthlessness (Liu et al., 2017). A significant asso-
ciation existed between PPA and PPD, as suggested by others
(Pampaka et al., 2018; Roman et al., 2019). Anxiety was one of the
most significant psychological factors associated with depression in the
current study and vice versa.
Not surprisingly, and consistent with the findings of previous stu-
dies (Boekhorst et al., 2019; Field, 2018; Milgrom et al., 2019), the level
of social support and severity of postpartum fatigue were two key
factors that predicted PPA and PPD symptoms. Parturients with low
support from the family were at much higher risk for PPA and PPD
symptoms than parturients who received high support. In addition, low
support from friends or colleagues was also significantly associated
with PPD symptoms after controlling for other factors. Parturients who
had severe fatigue were more likely to report symptoms of PPA and PPD
than parturients who had no fatigue.
An interesting finding in this study was that the number of care-
givers and primary caregivers for parturients and newborns was cor-
related with PPA and PPD symptoms, although not significantly sig-
nificant based on multivariable analysis. Compared with parturients
who had 2 or more caregivers, parturients who had only one caregiver
were at increased risk for PPA and PPD symptoms. Compared with
parturients who were supported by their mothers, parturients who were
primarily attended by their mother-in-laws were at increased risk for
PPA and PPD symptoms. This finding could be explained by the fact
that the number of caregivers and primary caregivers also serves as a
support resource, which strengthens the self-esteem for new mothers,
provides emotional support, and enables the parturient to better adapt
to the role of motherhood (Ding et al., 2018). In China, postpartum care
for the new mother and newborn is often provided by a female family
member (usually the mother or mother-in-law) or maternity service
workers [nannies and maternity matrons] (Kang et al., 2016; Liu et al.,
2015). Another possible reason is that compared to mother-in-laws,
women generally had deeper affection and a more trusting relationship
with their mothers. The intimacy and enriched emotional support can
help buffer the stress (Fisher et al., 2012; Ding et al., 2018). Thus, we
conclude that parturients who are supported by more caregivers and
their mothers experience less PPA and PPD symptoms across the tran-
sition.
Moreover, unplanned pregnancy was correlated with PPA and PPD
symptoms based on univariate analysis, which was in agreement with
other studies (Alqahtani et al., 2018; Biaggi et al., 2016), although it
failed to reach statistical significance based on multivariable analysis.
The combined effects of excessive stress, discontinuation of treatment,
low social support may contribute to emotional distress among women
with unplanned pregnancies (Bayrampour et al., 2015). Women with
lower level of education were more likely to experience symptoms of
PPA and PPD (Boekhorst et al., 2019). Education may function as a
protective factor, by enhancing feelings of self-efficacy and reducing
feelings of shame, which may contribute to reducing mental disorders
(Biaggi et al., 2016). Maternal separation has also been identified as
853
Journal of Affective Disorders 274 (2020) 848–856
OR (95%CI) aOR (95%CI)
Yes (n= 183) n (%)
128 (69.9%) 13.41 (9.35, 19.22) 9.22 (6.20, 13.72)
55 (30.1%) 1 (ref.) 1 (ref.)
another risk factor for PPD symptoms in this study. The literature
suggests that for mothers who had physical separation from their in-
fants, they may lack the opportunity to develop an attachment to their
infants, and this may trigger intense negative emotions like power-
lessness, despair, and feeling like an outsider (Scime et al., 2019). Our
study also showed that satisfaction of labor experience was associated
with PPA symptoms but not with PPD symptoms, which was in agree-
ment with a larger sample survey [n=4657] (Bell et al., 2016). The null
relationship between satisfaction of labor experience and PPD symp-
toms may be explained by the subjective nature of satisfaction and
limited operational measures of women's satisfaction, and more rig-
orous studies are suggested.
Additionally, cigarette smoking is a critical modifiable factor to
consider with respect to emotional status, including depression and
anxiety symptoms. In the current study, we confirmed that cigarette
smoking before pregnancy increased the odds of PPD symptoms (aOR,
5.136; 95% CI, 1.008-26.171), and was also associated with PPA
symptoms based on univariate analysis. These findings are consistent
with previous cross-sectional and longitudinal studies (Alibekova et al.,
2016; Michal et al., 2013). Although the number of parturients who
smoked cigarettes before pregnancy was extremely low in this study,
secondhand smoke exposure can not be ignored. Previous studies found
that paternal smoking in the women's presence was independently as-
sociated with maternal emotional disturbance, including depression
and anxiety. Restricting women's secondhand smoke exposure during
perinatal period is also suggested (Alibekova et al., 2016; Michal et al.,
2013).
4.3. Clinical implications
The results of the current study have several potential clinical im-
plications. Foremost, the high prevalence of PPD symptoms found in
this study was associated with, in part, by low family support, low
support from friends or colleagues, cigarette smoking before pregnancy,
separation from the newborn, fatigue, and breastfeeding difficulties.
According to the expert consensus on mental health management of
pregnant women (2019) issued by the China Preventive Medicine
Association and China maternal and Child Health Association, maternal
mental health assessments should be performed throughout pregnancy
and followed up to at least 6 weeks postpartum. We also recommend
that for women contemplating pregnancy, gravidas, and parturients
should be routinely assessed for these key risk factors.
The identification of risk factors and screening of high-risk popu-
lation are the initial steps that should be implemented in clinical
practice, and personalized interventions are important next steps.
Although, interventions such as cognitive behavior therapy have been
proved effective in reducing PPA and PPD in some research
(Field, 2018; Green et al., 2015), but larger more well designed studies
are needed. Still, there is a long way to go to implement patient-cen-
tered interventions clinically.
Our findings of risk factors may also offer some insights for targeted
Y. Liu, et al. Journal of Affective Disorders 274 (2020) 848–856

intervention: The findings highlighted contributions of social support to
alleviate PPA and PPD symptoms and promote positive psychological
outcomes. Social support and interpersonal relationships (e.g., family,
friends, and colleagues) are often targeted in intervention for women
experiencing mental disorders and have been recommended in many
studies (Grekin et al., 2017; Nillni et al., 2018). It is suggested that
during the first critical months of motherhood, the quantity and quality
of women's social support networks should be assessed, such as the
social support levels that women perceived. For women who encounter
relationship problems or difficulties in bonding or handling the infants,

Table 3
Factors associated with PPD symptoms based on bivariate and multivariate analyses.
Characteristic PPD Symptoms OR (95%CI) aOR (95%CI)
No (n= 925) n (%) Yes (n= 279) n (%)

Ethnicity
Han 898 (97.1%) 272 (97.5%) 1.17 (0.50, 2.71)
Non-Han 27 (2.9%) 7 (2.5%) 1 (ref.)
Religious believer
Yes 58 (6.3%) 14 (5.0%) 0.79 (0.43, 1.44)
No 867 (93.7%) 265 (95.0%) 1 (ref.)
Cigarette smoking before pregnancy
Yes 4 (0.4%) 6 (2.2%) 5.06 (1.42, 18.06) 5.14 (1.01, 26.17)
No 921 (99.6%) 273 (97.8%) 1 (ref.) 1 (ref.)
Education level
Primary education 80 (8.6%) 22 (7.9%) 1.19 (0.07, 2.00) 0.73 (0.37, 1.45)
Secondary education 444 (48.0%) 164 (58.8%) 1.59 (1.19, 2.12) 1.47 (1.05, 2.08)
Bachelor or master's degree 401 (43.4%) 93 (33.3%) 1 (ref.) 1 (ref.)
Monthly income (RMB)
<5000 163 (17.6%) 48 (17.2%) 1.35 (0.87, 2.10)
5000-10000 354 (38.3%) 116 (41.6%) 1.51 (1.05, 2.17)
10000-15000 169 (18.3%) 63 (22.6%) 1.71 (1.13, 2.60)
>15000 239 (25.8%) 52 (18.6%) 1 (ref.)
Maternity leave time
<4 months 207 (22.4%) 74 (26.5%) 1.02 (0.66, 1.58)
4-6 months 545 (58.9%) 153 (54.8%) 0.80 (0.54, 1.19)
6-12 months 50 (5.4%) 9 (3.2%) 0.52 (0.23, 1.14)
>12 months 123 (13.3%) 43 (15.4%) 1 (ref.)
Perceived support from family
Low 58 (6.3%) 61 (21.9%) 5.46 (3.65, 8.15) 2.15 (1.22, 3.80)
Medium 125 (13.5%) 75 (26.8%) 3.11 (2.22, 4.36) 1.69 (1.10, 2.61)
High 724 (80.2%) 143 (51.3%) 1 (ref.) 1 (ref.)
Perceived support from colleagues or friends
Low 52 (5.6%) 59 (21.1%) 5.64 (3.74, 8.52) 1.90 (1.07, 3.38)
Medium 137 (14.8%) 72 (25.8%) 2.61 (1.87, 3.66) 1.22 (0.79, 1.88)
High 736 (79.6%) 148 (53.0%) 1 (ref.) 1 (ref.)
Unplanned pregnancy
Yes 121 (13.1%) 58 (20.8%) 1.74 (1.23, 2.47) 1.47 (0.95, 2.27)
No 804 (86.9%) 221 (79.2%) 1 (ref.) 1 (ref.)
Satisfaction of labor experience
Unsatisfied 40 (4.3%) 27 (9.7%) 2.54 (1.53, 4.24)
General 86 (9.3%) 40 (14.3%) 1.75 (1.17, 2.63)
Satisfied 799 (86.4%) 212 (76.0%) 1 (ref.)
Maternal separation
Yes 120 (13.0%) 61 (21.9%) 1.88 (1.33, 2.64) 1.80 (1.19, 2.73)
No 805 (87.0%) 218 (78.1%) 1 (ref.) 1 (ref.)
Number of caregivers for the parturient and newborn
1 142 (15.4%) 60 (21.5%) 1.51 (1.08, 2.12)
≥2 783 (84.6%) 219 (78.5%) 1 (ref.)
Primary caregiver for the parturient and nowborn
Mother 371 (40.1%) 90 (32.3%) 1 (ref.)
Mother-in-law 233 (25.2%) 89 (31.9%) 1.58 (1.13, 2.20)
Husband 140 (15.1%) 49 (17.6%) 1.44 (0.97, 2.15)
Others 181 (19.6%) 51 (18.3%) 1.16 (0.79, 1.71)
Severity of fatigue
Severe fatigue 23 (2.5%) 33 (11.8%) 35.87 (11.56, 111.30) 8.84 (2.60, 30.08)
Moderate fatigue 180 (19.5%) 112 (40.1%) 15.56 (5.57, 43.44) 8.47 (2.92, 24.62)
Mild fatigue 622 (67.2%) 130 (46.6%) 5.23 (1.89, 14.45) 3.87 (1.35, 11.07)
No fatigue 100 (10.8%) 4 (1.4%) 1 (ref.) 1 (ref.)
Breastfeeding difficulties
Yes 436 (47.1%) 181 (64.9%) 2.07 (1.57, 2.73) 1.52 (1.08, 2.13)
No 489 (52.9%) 98 (35.1%) 1 (ref.) 1 (ref.)
Feeding patterns
Exclusive breastfeeding 504 (54.5%) 134 (48.0%) 0.91 (0.59, 1.39)
Mixed feeding 305 (33.0%) 111 (39.8%) 1.24 (0.80, 1.93)
Artificial feeding 116 (12.5%) 34 (12.2%) 1 (ref.)
Frequency of baby feeding (per day)
< 4 times 59 (6.4%) 22 (7.9%) 1.22 (0.72, 2.06)
4-8 times 439 (47.5%) 126 (45.2%) 0.94 (0.71, 1.24)
>8 times 427 (46.2%) 131 (47.0%) 1 (ref.)
PPA symptoms
(continued on next page)

854
Y. Liu, et al.
Table 3 (continued)
Characteristic PPD Symptoms
No (n= 925) n (%)
Yes (SAS score ≥ 50) 55 (5.9%)
No (SAS score < 50) 870 (94.1%)
Ref: reference category
Bold values indicate statistical significance.
aOR: adjusted for cigarette smoking before pregnancy, education level, monthly income, maternity leave time, unplanned pregnancy, number of caregivers for the
parturient and newborn, primary caregiver for the parturient and newborn, severity of fatigue, maternal separation, satisfaction with labor experience, perceived
support from family, perceived support from colleagues or friends, breastfeeding difficulties, and anxiety.
PPD refers to Postpartum Depression.
PPA refers to Postpartum Anxiety.
SAS refers to the Self-rating Anxiety Scale.
support should be offered. Prevention and tailored intervention focus
on increasing support from family members (spousal, mother, and
mother-in-law), peers (friends, colleagues) and health care providers
(midwives, obstetricians, and nurses) should be developed and im-
plemented (Li et al., 2019; Li et al., 2017).
Also, women's risk of mental health can be modified by improving
the labor experience, it is important to appreciate the modifying effect
that caregivers can have on women's satisfaction of labor experience,
and then influence their postpartum mental health (Bell et al., 2016).
5. Limitations
Several limitations of this study need to be considered when inter-
preting the findings. First, convenience sampling and the voluntary
nature of participation may have led to a selection bias. The sample of
this study was recruited from a cosmopolitan city of China, and higher
education and income levels were observed in the sample population.
Besides the characteristics of women who declined to participate and
non-responders were not available for analysis due to the online data
collection method. Thus, the generalization of our findings should be
further confirmed in other populations. The second limitation was that
PPA and PPD symptoms were assessed by a self-report screening tool
rather than a clinical diagnosis interview. Although the SAS and EPDS
are widely used tools and have good psychometric properties
(Gibson et al., 2009; Vazquez and Miguez, 2019), the SAS and EPDS are
not diagnostic tools; Also, fatigue and social support were not assessed
by structured questionnaires. The absence of strong measures may limit
conclusions on the accuracy or internal validity of the measures
(Fellmeth et al., 2019). Finally, the cross-sectional study can only
provide a snapshot of PPA and PPD symptoms experienced by par-
turients 6 weeks postpartum, and the causal relationships among study
variables throughout the antepartum, and postpartum course cannot be
analyzed. Therefore, more longitudinal data should be achieved further
to verify our findings.
6. Conclusions
PPA and PPD symptoms commonly occur among parturients in
Shanghai, China. The findings from this research provide a better un-
derstanding of the factors influencing PPA and PPD symptoms, which
would offer possible opportunity for early detection and early inter-
vention. In this study, we found that PPA symptoms were more
common among parturients who received lower support from family,
were dissatisfied with the labor experience, and had more fatigue. Risk
factors for PPD symptoms included low family support, low support
from friends or colleagues, cigarette smoking before pregnancy, se-
paration from the newborn, fatigue, and breastfeeding difficulties. It is
an initial step for researchers and clinicians to develop a more com-
prehensive understanding of women who have higher risks of PPA and
PPD symptoms. We hope that by raising awareness of maternal mental
health in China, women will be routinely screened for perinatal mental
855
Journal of Affective Disorders 274 (2020) 848–856
OR (95%CI) aOR (95%CI)
Yes (n= 279) n (%)
128 (45.9%) 13.41 (9.35, 19.22) 9.44 (6.33, 14.07)
151 (54.1%) 1 (ref.) 1 (ref.)
disorders. And more robust studies included those risk factors in path
analysis or profile analysis models are suggested to determine the re-
lative contributions of those factors. Also, more evidence-based studies
are needed to better inform the screening and intervention.
Author Contribution
H. Jiang was the principle investigator for this project and made
critical revisions to the article. Y. Liu was responsible for analyzing and
interpreting the data, and drafting the manuscript. N. Guo and T. Li
assisted in data collection, analysis. W. Zhuang supervised provided
technical suggestions. All authors have approved the final article.
Funding Sources
This study got the fund supports from the Science and Technology
Commission of Shanghai Municipality grant No.19DZ2306400,
Shanghai Municipal Medical and Health Discipline Construction pro-
jects grant No.2017ZZ02015 and Shanghai First Maternity and Infant
Hospital grant No.2017RC08.
Ethical Approval
Ethical approval was obtained from the hospital Institutional
Review Board. Furthermore informed consent was obtained from every
participant. Participants were assured that the information collected in
this study was confidential and anonymous, and their participation was
totally voluntary.
Declaration of Competing Interest
None Declared.
Acknowledgments
The authors are especially grateful to all who participated in this
study, including the faculty at the Shanghai First Maternity and Infant
Hospital Affiliated with Tongji University and the mothers who shared
their time and information. This study would not have been possible
without their assistance.
Supplementary Materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2020.05.028.
Reference
Alibekova, R., Huang, J.P., Lee, T.S., Au, H.K., Chen, Y.H., 2016. Effects of smoking on
perinatal depression and anxiety in mothers and fathers: A prospective cohort study.
J Affect Disord 193, 18–26.
Y. Liu, et al.
Alqahtani, A.H., Al Khedair, K., Al-Jeheiman, R., Al-Turki, H.A., Al Qahtani, N.H., 2018.
Anxiety and depression during pregnancy in women attending clinics in a University
Hospital in Eastern province of Saudi Arabia: prevalence and associated factors.
International journal of women's health 10, 101–108.
Avalos, L.A., Raine-Bennett, T., Chen, H., Adams, A.S., Flanagan, T., 2016. Improved
Perinatal Depression Screening, Treatment, and Outcomes With a Universal Obstetric
Program. Obstetrics & Gynecology 127, 917–925.
Bayrampour, H, McDonald, S, Tough, S, 2015. Risk factors of transient and persistent
anxiety during pregnancy. Midwifery 31 (6), 582–589.
Bell, A.F., Carter, C.S., Davis, J.M., Golding, J., Adejumo, O., Pyra, M., Connelly, J.J.,
Rubin, L.H., 2016. Childbirth and symptoms of postpartum depression and anxiety: a
prospective birth cohort study. Arch Womens Ment Health 19, 219–227.
Bergink, V., Kooistra, L., Lambregtse-van den Berg, M.P., Wijnen, H., Bunevicius, R., van
Baar, A., Pop, V., 2011. Validation of the Edinburgh Depression Scale during preg-
nancy. Journal of Psychosomatic Research 70, 385–389.
Biaggi, A., Conroy, S., Pawlby, S., Pariante, C.M., 2016. Identifying the women at risk of
antenatal anxiety and depression: A systematic review. J Affect Disord 191, 62–77.
Boekhorst, M., Beerthuizen, A., Endendijk, J.J., van Broekhoven, K.E.M., van Baar, A.,
Bergink, V., Pop, V.J.M., 2019. Different trajectories of depressive symptoms during
pregnancy. J Affect Disord 248, 139–146.
Clout, D., Brown, R., 2015. Sociodemographic, pregnancy, obstetric, and postnatal pre-
dictors of postpartum stress, anxiety and depression in new mothers. J Affect Disord
188, 60–67.
Cox, J.L., Holden, J.M., Sagovsky, R., 1987. Detection of postnatal depression.
Development of the 10-item Edinburgh Postnatal Depression Scale. The British
journal of psychiatry: the journal of mental science 150, 782–786.
Deng, A.W., Xiong, R.B., Jiang, T.T., Luo, Y.P., Chen, W.Z., 2014. Prevalence and risk
factors of postpartum depression in a population-based sample of women in Tangxia
Community. Guangzhou. Asian Pacific journal of tropical medicine 7, 244–249.
Dennis, C.L., Falah-Hassani, K., Shiri, R., 2017. Prevalence of antenatal and postnatal
anxiety: systematic review and meta-analysis. The British journal of psychiatry: the
journal of mental science 210, 315–323.
Ding, G., Niu, L., Vinturache, A., Zhang, J., Lu, M., Gao, Y., Pan, S., Tian, Y., 2019. “Doing
the month” and postpartum depression among Chinese women: A Shanghai pro-
spective cohort study. Women and Birth.
Don, B.P., Chong, A., Biehle, S.N., Gordon, A., Mickelson, K.D., 2014. Anxiety across the
transition to parenthood: change trajectories among low-risk parents. Anxiety, Stress,
& Coping 27, 633–649.
ElGonzález-Mesa, E., Kabukcuoglu, K., Körükcü, O., Blasco, M., Ibrahim, N., Cazorla-
Granados, O., Kavas, T., 2019. Correlates for state and trait anxiety in a multicultural
sample of Turkish and Spanish women at first trimester of pregnancy. Journal of
Affective Disorders 249, 1–7.
Fellmeth, G., Opondo, C., Henderson, J., Redshaw, M., McNeill, J., Lynn, F., Alderdice, F.,
2019. Identifying postnatal depression: Comparison of a self-reported depression item
with Edinburgh Postnatal Depression Scale scores at three months postpartum.
Journal of Affective Disorders 251, 8–14.
Field, T., 2018. Postnatal anxiety prevalence, predictors and effects on development: A
narrative review. Infant behavior & development 51, 24–32.
Fisher, J., Cabral de Mello, M., Patel, V., Rahman, A., Tran, T., Holton, S., Holmes, W.,
2012. Prevalence and determinants of common perinatal mental disorders in women
in low- and lower-middle-income countries: a systematic review. Bulletin of the
World Health Organization 90, 139g–149g.
Floris, L., Irion, O., Courvoisier, D., 2017. Influence of obstetrical events on satisfaction
and anxiety during childbirth: a prospective longitudinal study. Psychology, health &
medicine 22, 969–977.
Garman, E.C., Schneider, M., Lund, C., 2019. Perinatal depressive symptoms among low-
income South African women at risk of depression: trajectories and predictors. BMC
Pregnancy Childbirth 19, 202.
Gibson, J., McKenzie-McHarg, K., Shakespeare, J., Price, J., Gray, R., 2009. A systematic
review of studies validating the Edinburgh Postnatal Depression Scale in antepartum
and postpartum women. Acta Psychiatrica Scandinavica 119, 350–364.
Green, S.M., Haber, E., Frey, B.N., McCabe, R.E., 2015. Cognitive-behavioral group
treatment for perinatal anxiety: a pilot study. Arch Womens Ment Health 18,
631–638.
Grekin, R., Brock, R.L., O'Hara, M.W., 2017. The effects of trauma on perinatal depres-
sion: Examining trajectories of depression from pregnancy through 24 months post-
partum in an at-risk population. J Affect Disord 218, 269–276.
Ding, Guodong, Yu, Jing, Vinturache, Angela, Gu, Haoxiang, Lu, Min, 2018. Therapeutic
Effects of the Traditional “Doing the Month” Practices on Postpartum Depression in
China. American Journal of Psychiatry 175, 1071–1072.
Halbreich, U., Karkun, S., 2006. Cross-cultural and social diversity of prevalence of
postpartum depression and depressive symptoms. J Affect Disord 91, 97–111.
Heh, S.S., 2001. Validation of the Chinese version of the Edinburgh Postnatal Depression
Scale: detecting postnatal depression in Taiwanese women. Hu li yan jiu = Nursing
research 9, 105–113.
856
Journal of Affective Disorders 274 (2020) 848–856
Hou, Q., Li, S., Jiang, C., Huang, Y., Huang, L., Ye, J., Pan, Z., Teng, T., Wang, Q., Jiang,
Y., Zhang, H., Liu, C., Li, M., Mo, Z., Yang, X., 2018. The associations between ma-
ternal lifestyles and antenatal stress and anxiety in Chinese pregnant women: A cross-
sectional study. Scientific reports 8, 10771.
Huang, Y.C., Mathers, N., 2001. Postnatal depression – biological or cultural? A com-
parative study of postnatal women in the UK and Taiwan. J Adv Nurs 33, 279–287.
Husain, N., Bevc, I., Husain, M., Chaudhry, I.B., Atif, N., Rahman, A., 2006. Prevalence
and social correlates of postnatal depression in a low income country. Archives of
women's mental health 9, 197–202.
Kang, Y.T., Yao, Y., Dou, J., Guo, X., Li, S.Y., Zhao, C.N., Han, H.Z., Li, B., 2016.
Prevalence and Risk Factors of Maternal Anxiety in Late Pregnancy in China. Int J
Environ Res Public Health 13.
Kingsbury, A.M., Plotnikova, M., Clavarino, A., Mamun, A., Najman, J.M., 2018. Social
adversity in pregnancy and trajectories of women's depressive symptoms: A long-
itudinal study. Women and birth: journal of the Australian College of Midwives 31,
52–58.
Langan, R., Goodbred, A.J., 2016. Identification and Management of Peripartum
Depression. American family physician 93, 852–858.
Lau, Y., Wang, Y., Yin, L., Chan, K.S., Guo, X., 2010. Validation of the Mainland Chinese
version of the Edinburgh Postnatal Depression Scale in Chengdu mothers. Int J Nurs
Stud 47, 1139–1151.
Lee, D.T., Yip, S.K., Chiu, H.F., Leung, T.Y., Chan, K.P., Chau, I.O., Leung, H.C., Chung,
T.K., 1998. Detecting postnatal depression in Chinese women. Validation of the
Chinese version of the Edinburgh Postnatal Depression Scale. The British journal of
psychiatry: the journal of mental science 172, 433–437.
Li, T., Guo, N., Jiang, H., Eldadah, M., Zhuang, W., 2019. Social support and second
trimester depression. Midwifery 69, 158–162.
Li, Y., Long, Z., Cao, D., Cao, F., 2017. Social support and depression across the perinatal
period: A longitudinal study. Journal of Clinical Nursing 26, 2776–2783.
Liu, L., Xu, N., Wang, L., 2017. Moderating role of self-efficacy on the associations of
social support with depressive and anxiety symptoms in Chinese patients with
rheumatoid arthritis. Neuropsychiatric disease and treatment 13, 2141–2150.
Liu, Y.Q., Petrini, M., Maloni, J.A., 2015. “Doing the month”: Postpartum practices in
Chinese women. Nursing & Health Sciences 17, 5–14.
Michal, M., Wiltink, J., Reiner, I., Kirschner, Y., Wild, P.S., Schulz, A., Zwiener, I.,
Blettner, M., Beutel, M.E., 2013. Association of mental distress with smoking status in
the community: Results from the Gutenberg Health Study. Journal of Affective
Disorders 146, 355–360.
Milgrom, J., Hirshler, Y., Reece, J., Holt, C., Gemmill, A.W., 2019. Social Support—A
Protective Factor for Depressed Perinatal Women? International Journal of
Environmental Research and Public Health 16, 1426.
Nillni, Y.I., Mehralizade, A., Mayer, L., Milanovic, S., 2018. Treatment of depression,
anxiety, and trauma-related disorders during the perinatal period: A systematic re-
view. Clinical Psychology Review 66, 136–148.
Pampaka, D., Papatheodorou, S.I., AlSeaidan, M., Al Wotayan, R., Wright, R.J., Buring,
J.E., Dockery, D.W., Christophi, C.A., 2018. Depressive symptoms and comorbid
problems in pregnancy - results from a population based study. J Psychosom Res 112,
53–58.
Pampaka, D., Papatheodorou, S.I., AlSeaidan, M., Al Wotayan, R., Wright, R.J., Buring,
J.E., Dockery, D.W., Christophi, C.A., 2019. Postnatal depressive symptoms in women
with and without antenatal depressive symptoms: results from a prospective cohort
study. Archives of women's mental health 22, 93–103.
Roman, M., Bostan, C.M., Diaconu-Gherasim, L.R., Constantin, T., 2019. Personality
Traits and Postnatal Depression: The Mediated Role of Postnatal Anxiety and
Moderated Role of Type of Birth. Front Psychol 10, 1625.
Scime, N.V., Gavarkovs, A.G., Chaput, K.H., 2019. The effect of skin-to-skin care on
postpartum depression among mothers of preterm or low birthweight infants: A
systematic review and meta-analysis. Journal of Affective Disorders 253, 376–384.
Tang, X., Lu, Z., Hu, D., Zhong, X., 2019. Influencing factors for prenatal Stress, anxiety
and depression in early pregnancy among women in Chongqing, China. Journal of
Affective Disorders 253, 292–302.
Teng, H.W., Hsu, C.S., Shih, S.M., Lu, M.L., Pan, J.J., Shen, W.W., 2005. Screening
postpartum depression with the Taiwanese version of the Edinburgh Postnatal
Depression scale. Comprehensive psychiatry 46, 261–265.
Vazquez, M.B., Miguez, M.C., 2019. Validation of the Edinburgh postnatal depression
scale as a screening tool for depression in Spanish pregnant women. J Affect Disord
246, 515–521.
Wikman, A., Axfors, C., Iliadis, S.I., Cox, J., Fransson, E., Skalkidou, A., 2019.
Characteristics of women with different perinatal depression trajectories. Journal of
neuroscience research.
Yang, X., Ke, S., Gao, L.L., 2019. Social support, parental role competence and satisfaction
among Chinese mothers and fathers in the early postpartum period: A cross-sectional
study [published online ahead of print, 2019 Jun 21]. Women Birth.
Zung, W.W.K., 1971. A Rating Instrument For Anxiety Disorders. Psychosomatics 12,
371–379.