Running head: Research Proposal Assignment 1

Anxiety and depression in postpartum period among multiparous women in Maternity

and Children Hospital

NDR 3101350

Scholarly Inquiry

King Faisal University

College of Applied Medical Sciences

Department of Nursing

Students' name:

Jumanah Al-Abduwahed 218020699

Rahaf Aldossery 218016621
Fatimah Al-Smail 218034813
Nissren Al-Hassan 218016908
Razan Al-Humily 218008398
Maha Hakami 218026737
Sarah Al-Othman 218015149

Supervising by: Dr. Abeer Othman

Submitted on: 15 / 4 / 2021

Running head: Research Proposal Assignment 2

Research problem

Postpartum women are more vulnerable to experience anxiety and depression.

Until this day, there is many evidences that shows the factors contributed to having
anxiety and depression in postpartum women, such as Professional workers does not
have enough skills to deal with postpartum women that lead to have suicidal ideas
(Elliott et al. 2020). Also, it is associated with many problem to the infant such as
interrupted sleep cycle for newborn , and be associated with anomalies of brain
structure, so that will lead to difficult infant and childhood temperament (Mikšie et
al., 2020) . In addition, postpartum depression relate with diminished functioning for
mother and causes physical ,psychological ,sexual harm and high  risk for long-term
mental problems(Pilkington et al. 2016; Mandal et al. 2018). According to Kroll-
Desrosiers, maternal depression can be a cause of death and there is up to 20%
terminated their lives (Kroll-Desrosiers et al. 2017). However, this study determined
factors that affects multiparous women to having anxiety and depression, such as lack
social support and ineffective coping mechanism.(Cacciola & Psouni, 2020; Elliott et
al., 2020; Pilkington et al., 2016)

Introduction

Postpartum distress’ in first months after birth new mothers experience many
sudden changes, that increasing their chance of affected to depression, anxiety and
stress in postpartum period. (Elliott et al., 2020). Postpartum depression is mood
disorder beginning from birth until six weeks involves felling of sadness , solitude,
loss of assurance, loss engaging in  daily functions. (Mikšie et al., 2020). Also, it is
related with loss interest of daily activities and have bad affect cognitive, emotional,
psychological, and physical development and it impact on mothers and infant health.
(Pilkington et al., 2016) Depression limitations in physical and psychological
functioning even following recovery from depressive episodes (Okun et al., 2018). In
addition, it is a major common disease among suicide victims in the perinatal period,
and shows a variation in risk and protective factors.(Matsumura et al. 2019). Anxiety
is a feeling of fear and it will decrease in the first  trimester to 3 months and increase
from 3 to 30 months postpartum(Canário & Figueiredo, 2019). Multiparous women
increase in postpartum period that having experienced one or more previous
parturitions (Canário & Figueiredo, 2019). Depressed Mothers, who don’t have ‘time
Running head: Research Proposal Assignment 3

for self’ and support from family and friends.  (Pourmehr et al., 2018). Furthermore,
they are scored in the ‘moderate’ to ‘extremely severe’ ranges Analysis is based on
this dichotomy (i.e. ‘normal–mild range’ versus ‘moderate to extremely severe’
symptoms). (Pourmehr et al., 2018) Moreover, they had significantly higher OASIS
(Overall Anxiety Severity and Impairment Scale), PHQ9  (Patient Health
Questionnaire -9-item) and EPDS (Edinburgh Postnatal Depression Scale)(Okun et
al., 2018). Crying : is adaptive emotion regulation strategy used to promote pro-social
behavior from others.(Pilkington et al., 2016).

Literature Review

As said by Elliott and Cook (2020), having three objectives that included
depression level likened to  stress and anxiety levels in non-clinical population that
divides to general and postpartum mothers sample, postpartum depression mothers
correlation to anxiety and stress prevalence, and analyzing outcomes by comparing
negative social exchange to  awareness of social support.  There was 242 postpartum
women entered in the research. To conclude, general population have lower levels of
depression, anxiety and stress compared to postnatal women. There is no different in
negative social exchange significantly to  awareness of social support for postpartum
women.

According to Cacciola and Psouni study that conducted on 2020 that had one
objective to evaluate the postnatal depressed women who had insecure attachment in
their adulthood stage that have effect on not asking for assistance from others. There
is thirty seven depressed women entered their study. In sum up, women who had
avoidant attachment styles belief that healthcare professionals are untrustworthy
people and think they have the ability to handle their situation by own selves.

Mandal, Hooker, Vally, and Taft conducted in 2018. Their study planned to
explore the connection between intimate partner violence (IPV), depression, and
anxiety among postnatal women. The population was 2621 women. To sum up, the
result of their study showed up depression, anxiety, and IPV are widespread among
women exhibited to IPV are significantly more possibly to summary depression and
anxiety than are non-abused women.
Running head: Research Proposal Assignment 4

A study of Pilkington, Whelan, and Milne that conducted on 2016 that had
aim to examination maternal crying related to distress and they need for support after
delivery. The total woman was participants was 137 primiparous mother. In the end of
examination, the woman after delivery was need support from her husbend that keep
it from problem mood.

Okun, Mancuso, Hobel, Schetter, and Coussons conducted on 2018. Their

study purpose was to assess the quality of sleep  and the connection to anxiety and
depression symptoms. The population was 116 pregnant  women. In the end, the
result of their study showed that there is an unfovrable influenced from sleep quality
on postpartum-women so doctors have to ask for quality of sleep during period of
perinatal in order to be beside mothers and mothers’ baby for postpartum period.

Referring to Matsumura, Hamazaki, Tsuchida, Kasamatsu, and Inadera

(2019),  they involved 90,194 mothers in their study. There is a link between
increasing postpartum depression  symptoms and prevalence to low education level.

A study of Mikšie, Uglešie, Jakab, Holik, Srb, and Degmečie that conducted
on 2020 that had the purpose of investigation impacts breastfeeding on a young baby
development and postnatal depression. The number of participants was 209 pregnant
women. In conclusion, breastfeeding mothers was less vulnerable  to depressed and
anxious contrast to non-breastfeeding mothers.

A research of Aimee, Benjamin, Jessica, Yurima, Tiffany, Kristina that

conducted on 2016. Their research aim was to investigate connection between
peripartum synthetic for give oxytocin and improvement of depression with anxiety
disease after one year of delivery. The total population was 46,732 who divided to
exposed group (n = 9,684) compared to unexposed group (n = 37,048) deliveries. At
the end, their research indicates that female had peripartum take to synthetic oxytocin
had risk more than female don’t take synthetic oxytocin.

As part of Canário and Figueiredo (2019) research that examines symptoms

of  anxiety and depression that changes based on gender and parity from the
beginning of pregnancy to thirty months postnatal period. The numbers of participants
is 258 that equal 129 couples. In short,  multiparous women in jeopardy of developing
Running head: Research Proposal Assignment 5

symptoms of anxiety and depression during postnatal period than primiparous

women.

As explained by Pourmehr, Niroomand, Shakouri, Asgarlou, and Khalili

(2018) in their study to explore the relation of retention of the women’s weight after a 
year of delivery to anxiety and depression  in three trimesters of pregnancy and the
beginning of postnatal period. The number of participants was 245 women, who have
normal BMI and  62 women, who have higher than 35 BMI during. pregnancy. Thus,
postnatal depression and retention of the women’s weight after a  year of delivery
associated with first trimester.

Elliott and Cook (2020) and Pilkington, Whelan, and Milne (2016), their study
have connection that post-partum women need to their significant people to support
them and let them stay away from being depressed and feeling anxious. (Elliott &
Cook, 2020; Pilkington et al., 2016)

Matsumura, Hamazaki, Tsuchida, Kasamatsu, and Inadera (2019) and Mikšie,

Uglešie, Jakab, Holik, Srb, and Degmečie (2020), there is similarly resulting in their
studies that if the women have low education about what to lead to have postpartum
depression, such as avoiding breast feeding, they will have increased incidence of
depression symptoms. (Matsumura et al. 2019; Mikšie et al., 2020)

Study significance

In our research we will emphasize on factors that makes multiparous women

at high risk of developing postpartum period that includes insufficient social support
and unsuccessful coping skills. (Cacciola & Psouni, 2020; Canário & Figueiredo,
2019; Elliott et al., 2020; Pilkington et al., 2016) For a woman, you must prepare
yourself psychologically, because as a mother you have a more important role and
responsibilities. Try as much as possible not to exhaust yourself but instead try to
relax. Also, seek and accept help from others. For the spouse, if he notices his partner
any sign of distress such as crying and he supports her emotionally and helps to
provides care for child, so her anxiety and stress symptoms will decrease. Also, This
will improve her psyche, and she will take care more of her baby. (Pilkington et al.,
2016) For health services, they will know how crucial to do special training about
how to communicate and support women in the postnatal period. (Elliott et al., 2020)
Running head: Research Proposal Assignment 6

As researchers, we recognize this problem by use our result that will help pregnant
women to avoid postpartum depression. So, we can give them support during
pregnancy in order to prevent postpartum depression. There is a conflict between
symptoms of mothers during pregnancy and postpartum period. Some studies showed
that mothers after delivery have a lot of changes that happened to her which makes
her at high risk of postpartum depression. In other hand, other research identified that
women have low symptoms of depression during pregnancy until a few months after
delivery.(Canário & Figueiredo, 2019; Elliott et al., 2020)

Research purpose

To determine anxiety and depression in postpartum period among multiparous

women in Maternity and Children Hospital.

Research question

Among multiparous women in Maternity and Children Hospital, what are

anxiety and depression during postpartum period level?

Research hypotheses

Multiparous women have high level of anxiety and depression during

postpartum period.

Method

Research design

The study used quantitative-survey.

Accessible population

Multiparous women during postpartum period.

Sampling method

This study used convenience strategy to select sample.

Setting

Maternity and Children Hospital, Al-Ahsa.

Running head: Research Proposal Assignment 7

Inclusion and exclusion criteria

Women from the first day to six months postpartum, their age not exceed fifty,
and having more than one child are inclusion criteria . However, non-saudi women,
having history of mental illnesses or complication during pregnancy (eclampsia,
placenta previa, and pre-eclampsia), chronic disease (hypertension and diabetic
mellitus), or smoking and drug abuse are exclusion criteria.

Ethical consideration

Ethics approval will provided by Institutional Review Boards (IRBs). All

procedures performed will compliance with ethical standers of the institution and
national researcher committee. For confidentiality and privacy, the survey will not
include any personal information that will identify participants. Participants
voluntarily approve to engage in the research with full disclosure of the benefits and
risks and explanation of the aim and procedures of the research after that all
participants sign the informed consent.

Data collection method and instrument

This study use self-report scale and Depression, Anxiety and Stress Scale
(DASS-21; Lovibond and Lovibond 1995) tool to collect data. It will be electronic
survey that distributes by using WhatsApp Messenger. DASS-21 has 21 questions,
which scores on a four-point from (0) never to (3) almost always. It evaluates
depression and anxiety that divides to four scores categories. The first category is
mild which scored 10 to 13 for depression and 8 to 9 for anxiety. The second category
is moderate which scored 14 to 20 for depression and 10 to 14 for anxiety. The third
category is severe that scored 21 to 27 for depression and 15 to 19 for anxiety. The
fourth category is extremely severe that scored 28 for depression and 20 for anxiety.
(Elliott et al., 2020; Mandal et al., 2018; Pilkington et al., 2016)

Implication for nursing practice

The result will help to avoid postnatal depression and anxiety by making it
easier for her spouse to assist her by being beside her, and enabling women and their
families to understand the point behind crying in the postnatal period. (Pilkington et
al., 2016) As healthcare professionals, being more aware of how attachment
Running head: Research Proposal Assignment 8

temperament  impacts on help-seeking attitude that appears important. (Cacciola &

Psouni, 2020) Furthermore, The National Perinatal Depression Initiative furnished
supplying for a national roll-out of universal screening for postpartum depression,
community alertness,  more access to emotional supports, and coaching for the health
care provider. (Elliott et al., 2020) In addition, developing and implementing required
programs for early detection and screening of early gestational depression and anxiety
for provide on time interventions which will aid to minimize postpartum weight
retention (PPWR) and other obesity complications. (Pourmehr et al., 2018)
Running head: Research Proposal Assignment 9

Reference

Cacciola, E., & Psouni, E. (2020). Insecure attachment and other help-seeking barriers

among women depressed postpartum. International Journal of Environmental

Research and Public Health. 17: 3887.

Canário, C., & Figueiredo, B. (2017). Anxiety and depressive symptoms in women

and men from early pregnancy to 30 months postpartum. Journal of

Reproductive and Infant Psychology. 35(5): 431–449.

Elliott, A. E., Elliott, P. C., and Cook, R. (2020). Postpartum maternal distress: A

multidimensional illness requiring a multilevel, multidiscipline response.

Australian Journal of Primary Health. 26(3): 222-226. 

Kroll-Desrosiers , A.R., Nephew, B.C., Babb, J.A., Guilarte-Walker, Y., Moore

Simas, T.A., & Deligiannidis, K.M. (2017). Association of peripartum

synthetic oxytocin administration and depressive and anxiety disorders within

the first postpartum year. Depress Anxiety. 34(2): 137-146.

Mandal, S.K., Hooker, L., Vally, H., & Taft, A. (2018). Partner violence and postnatal

mental health: Cross-sectional analysis of factors associated with depression

and anxiety in new mothers. Australian Journal of Primary Health. 24: 434–

440.

Matsumura, K., Hamazaki, K., Tsuchida, A., Kasamatsu, H., & Inadera, H. (2019).

Education level and risk of postpartum depression: Results from the Japan

environment and children’s study. BMC Psychiatry. 19: 419.

Running head: Research Proposal Assignment 10

Mikšie S., Uglešie B., Jakab J., Holik D., Srb A. M., and Degmečie D. (2020).

Positive effect of breastfeeding on child development, anxiety, and postpartum

depression. Environmental Research and Public Health. 17: 25–27.

Okun, M.L., Mancuso, R.A., Hobel, C.J., Schetter, C.D., & Coussons-Read, M.

(2018). Poor sleep quality increases symptoms of depression and anxiety in

postpartum women. J Behav Med. 41: 703–710.

Pilkington, P. D., Whelan, T. A. & Milne, L. C. (2016). Maternal crying and

postpartum distress: The moderating role of partner support. Journal of

Reproductive and Infant Psychology. 34: 64–76.

Pourmehr, H.S., Niroomand, S., Shakouri, S.K., Asgarlou, Z., & Khalili, A.F. (2018).

Association between antenatal and postpartum depression and anxiety

with weight retention 1 year after childbirth: A longitudinal study. Community

Mental Health Journal. 54: 1284–1294.