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69
Prevalence and Risk Factors of
Postpartum Depression

* Pooja S. Baby, M.Sc (N)

** Diana David, M.Sc (N)
*** Ruby Jose, M.D., DGO

Abstract

Undetected post partum depression affects the mother, her infant, her family and further affects the
society through illness, social dysfunction, death, and the cost of medical services. It is estimated
that only 20 % of mothers with post partum depression are diagnosed and treated, leaving
thousands of new mothers to suffer in silence. A descriptive study was done to identify hospital
based prevalence and risk factors related to postpartum depression among postnatal mothers in
Well Baby Clinic and Obstetrics and Gynaecological Out Patient Departments of a tertiary level
hospital. 250 postnatal mothers who were willing to participate in the study were recruited for the
study. The Edinburgh Postnatal Depression Scale was used to identify mothers who were at risk
for depression. The scale to assess the risk factors associated to the risk levels of postpartum
depression was developed by the investigator. The content validity of the tool was 0.87. The
prevalence of higher likelihood of having postpartum depression among mothers from six to ten
weeks postnatally was found to be 52.4%. Need for migration during pregnancy, heavy house hold
work, financial difficulties, thoughts of abortion in the antenatal period, expectation on specific
gender of the child, perception of high stress during delivery, low birth weight babies, and
presence of constant worry about the child were some of the factors that were significantly
associated with a higher risk for depression. Mothers whose family were dependent on relatives
for daily needs, who had an unhappy married life, and unplanned pregnancy were also found be at
a high risk of developing postpartum depression. The study identifies the importance of early
screening by nurses for postpartum depression and educating the family on the importance of early
identification of symptoms and treatment of postpartum depression.

Keywords: postpartum depression, risk factors, prevalence, postnatal

Introduction The available evidence indicates similar prevalence rates of

Depression is one of the most common illnesses
complicating the post partum period. Although health care
professionals are aware of this evidence, postnatal depression
goes undetected and untreated in many postnatal women. In
the joyful context of birthing a baby the flipside involving
stress associated with becoming a mother is often forgotten.
* Quality Assurance Nurse, Medical Trust Hospital, Ernakulum
** Professor, College of Nursing, CMC, Vellore
post partum depression (PPD) in both developed and
developing countries. An Australian study revealed a
concerning level of psychological morbidity with 17%
experiencing depression and 13% experiencing anxiety at six
months postpartum (Yelland, Sutherland, and Brown, 2010).
During 2004-2005, the prevalence of self reported depression
in 17 US states ranged from 11.7% to 20.4% (Center for
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Prevalence and Risk Factors of Postpartum Depression
Disease Control and Prevention, 2008). A cohort study was
conducted in the rural areas of Vellore, Tamilnadu to assess
the incidence and risk factors of PPD by Chandran, Tharyan,
Muliyil, and Abraham (2002). In that study the incidence of
PPD was found to be 11%. Savarimuthu et al. (2010)
identified the prevalence of PPD among postpartum mothers
between 2 and 10 weeks postpartum as 26.3% in the selected
villages of Vellore. The risk factors identified were current
age, age at first delivery of the postnatal less than 20 years or
greater than 31 years, schooling less than five years, thoughts
of aborting current pregnancy, unhappy marriage, physical
abuse during current pregnancy and after childbirth,
husband's use of alcohol, girl child delivered in the absence of
living boys and a preference for a boy, low birth weight, and a
family history of depression. Untreated maternal depression
not only increases morbidity in the women, it impairs
mother's ability to take care of their infants and can lead to
adverse child outcomes. Hence early identification of the
symptoms is crucial for the treatment as well as taking
preventive interventions.
Objectives
The objectives of this study were to
§ identify the prevalence of postpartum depression at 6
to 10 weeks of postnatal period
§ associate selected demographic variables with
postpartum depression
§ compare the selected risk factors between mothers
with and without postpartum depression
Methods
Design and sampling
A descriptive design was used. The subjects were
mothers at 6 weeks to 10 weeks of postnatal period who came
to the Obstetrics and Gynecology Out Patient Department
(OG OPD) or Well Baby Clinic. A total of 250 mothers who
gave consent and were willing to participate in the study
during the study period were recruited.
Instruments
The instrument consisted of three parts.
*** Professor, Obstetrics & Gynaecology, C.M.C., Vellore
70
Part 1 - Demographic data: This section consisted of
demographic data like age, number of weeks after delivery,
monthly income, number of pregnancies, number of
deliveries, number of living children, number of abortions or
still births, gender of this child, number of live male children,
number of death of children after birth, and type of delivery.
Part 2 - The Edinburgh Postnatal Depression Scale: The
Edinburgh Postnatal Depression Scale (EPDS) was used to
assess the prevalence of PPD (Cox, Holden, Sagodsky, 1987).
This standardised scale's sensitivity was 86.4, the specificity
was 91.1, and the positive predictive value was 0.78. It was
translated into Tamil. Reliability was checked by performing
back translation. The measures give information about how
many mothers are at different levels of risk for developing
postpartum depression. Further assessment is needed to
establish a diagnosis of depression.
0-9: Scores in this range may indicate the presence of some
symptoms of distress that may be short-lived and are less
likely to interfere with day to day ability to function at home
or at work.
10-12: Scores within this range indicate presence of
symptoms of distress that may be discomforting. The
assessment has to be repeated in 2 weeks time to monitor
progress. If the scores increase to above 12 further
assessment and referral may be needed.
>13: Scores above 12 require further assessment and
appropriate managements as the likelihood of depression is
high. A referral to a psychiatrist / psychologist maybe
necessary.
Any woman who scores 1, 2 or 3 on item 10 requires
further evaluation before leaving the office to ensure her own
safety and that of the baby. The scale's maximum score is 30.
Part 3 - Scale to assess risk factors associated with PPD:
This questionnaire was developed by the investigator to
assess the various risk factors of PPD based on the literature
review and opinion of experts in the field. The items in the
scale are classified according to the past history of the mother,
her antenatal period, delivery experience, postnatal period of
mother and baby, family, environmental conditions, and
medical conditions of the mother. Mothers were asked to
mark the presence or absence of risk factors listed in the
questionnaire. The content validity of the tool was 0.87.
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Prevalence and Risk Factors of Postpartum Depression
Data Collection Procedure
The data collection began after getting the approval
from the Research and Ethics Committee. Mothers who were
at 6 to 10 weeks of postnatal period who attended the well
baby clinic or OG OPD were conveniently selected based on
the inclusion criteria. After obtaining consent from the
mother, self administered questionnaires on demographic
data, EPDS scale and scale to assess risk factors of
postpartum depression were given. According to the EPDS
score mothers were advised and referred to have psychiatric
consultation.
Data Analysis
Descriptive statistics were used to analyze the
prevalence and chi-square test was done to find the
association of demographic variables and risk factors with
postpartum depression.
Results and Discussion
The first objective was to identify the prevalence of
postpartum depression in mothers at 6 to 10 weeks of
postnatal period. According to the EPDS, likelihood of
depression is high among women who scored 13 and above.
In this study, 53.2% of mothers at 6 weeks and 51.1% of
mothers at 10 weeks of postnatal period had scores 13 and
above indicating a higher likelihood of having depression.
Overall prevalence of mothers having higher likelihood of
having PPD was 52.4%. All the mothers who had higher score
were suggested to seek help from psychiatrist. In the previous
studies in South India the prevalence of PPD was found to be
11% - 26.3% (Chandran et al., 2002; Savarimuthu, 2010)
which is considerably lower than the present findings.
However in the previous studies ICD-10 which is the
standard diagnostic tool was used to diagnose depression in
comparison to the EPDS which was used in this study which
measures only how likely the mother may be depressed. In
the study conducted by Savarimuthu where EPDS was used
to screen for postnatal depression in mothers after two to ten
weeks of delivery it was found that the prevalence was 26.3%.
These results indicate a steep increase in the prevalence rates
and a higher likelihood of depression in postnatal women (see
Figure 1). In spite of a rise in standard of living, rate of
depression is hiking in every successive generation. This
warns us that the depression rate may go higher in future too.
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Figure 1. Prevalence of postpartum depression
The second objective was to associate selected
demographic variables with the risk of PPD. No association
was found between postpartum depression and the various
demographic variables like age, number of weeks of delivery,
monthly income, number of pregnancies, number of
deliveries, number of living children, number of abortions or
still births the mother had, gender of this child, number of live
male children, number of death of male children after birth
and type of delivery. In contrast to this, a study conducted
among Australian mothers by Yelland et al (2010), revealed
that mothers who had depressive symptoms were mostly
under 25years of age.
The third objective was to compare the perceived
presence or absence of selected risk factors between mothers
with and without risk for postpartum depression (see Table 1).
Past Experience
Majority (84.4%) of mothers who had to migrate or
relocate their home away from family and friends were at
significantly higher risk for depression (p < .001). The study
finding is in harmony with a study done by Danaci, Dinc,
Deveci, Sen, and Icelli (2002) which reports immigrant status
as a risk factor for postpartum depression.
Antenatal Period
During the antenatal period factors such as thoughts
of aborting the present child and unplanned pregnancy were
significantly associated with high risk for depression. The
findings are supported by a population-based cohort study
investigating postnatal depression in Brazilian mothers in
which it was found that attempted abortion was associated
with PPD (Ludermir, Araya, de Araujo, Valongueiro, &
Lewis, 2011).
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Prevalence and Risk Factors of Postpartum Depression 72

Table 1
Association of Risk Factors Related to Postpartum Depression (n= 250)

Risk Factors Risk for depression

Low Moderate High c2 p

value value
(n) % (n) % (n) %

Past Experience

Had to migrate / relocate home 4 12.1 1 3 28 84.8 16.185 <.001

away from family and friends

Antenatal

Thought of aborting this child 0 0 2 11.8 15 88.2 10.479 .005

Did not plan for this pregnancy 11 22 5 10 34 68 6.112 .047

Had expectation on particular 18 22.5 7 8.8 55 68.8 12.859 .002

gender of the child

Labour and Delivery

High level of anxiety and 26 20.6 22 17.5 78 61.9 15.197 .001

stress during labour

Had preterm delivery 3 8.3 6 16.7 27 75 11.481 .003

Postnatal

Had physical abuse after 4 13.8 2 6.9 23 79.3 9.387 .009

child birth

Constantly worried about 19 19 16 16 65 65 13.869 .001

childs health

Have a low birth weight baby 5 14.3 3 8.6 27 77.1 10.035 .007

Family

Have an unhappy married life 2 10.5 1 5.3 16 84.2 8.342 .015

Have too much of household 19 19.8 10 10.4 67 69.8 18.938 <.001

work to handle

Environment

Often experience financial 11 15.9 8 11.6 50 72.5 15.982 <.001

difficulties at home

Family is dependent on 11 18.3 6 10 43 71.7 11.788 .003

relatives for daily needs

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Prevalence and Risk Factors of Postpartum Depression
Mothers who had expectation on a particular gender
of the child had increased risk of developing postpartum
depression when compared with mothers who did not have
any expectations. This finding is supported by findings from
another study in which unmet mother's preference in
pregnancy was found to be a major contributing factor for
PPD in the male dominant societies of Asia.
During Labour
Mothers who had increased anxiety and stress during
labour had increased risk of developing postpartum
depression. Majority (61.9%) of mothers who had high level
of anxiety and stress during labour had high risk for
depression with p value .001 which is statistically
significant. Also there was a high association between
mothers who had preterm delivery and PPD. Among the 36
mothers who had preterm delivery, 75% of mothers had high
risk for depression. A study done by Vigod, Villegas, Dennis,
and Ross (2010) found the rates of postpartum depression
were as high as 40% in the early postpartum period among
mothers with premature infants.
Postnatal Period
Mothers who were physically abused were found to
have increased risk of developing PPD. In a prospective
cohort study done by Woolhouse, Gartland, Hegarty, Donath,
and Brown (2012) 40% of mothers who reported to have
depressive symptoms at 12 months after delivery had a
history of intimate partner violence. PPD was also found
more likely in mothers who constantly worried about child's
health.
Family
In this study, among mothers with unhappy married
life, 84.2% of mothers were found to have high risk for
depression. Also the association of increased household work
and postpartum depression was found to be statistically
significant with p value < .001. This finding is supported by
Hashemi, Azar and Forghani's study (2006) on PPD and its
correlates among mothers living in Zabol (Iran) in which a
significant association was found between PPD and poor
relationship with spouse.
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Environment
Mothers who reported financial difficulties and
whose family was dependent on relatives for daily needs were
also found to have increased risk of PPD.
Limitations
In this study EPD Scale which was used to screen
postnatal mothers for depression measures only the mothers'
risk for depression. As shown in other studies (Savarimuthe et
al., 2010) further assessment is needed to confirm diagnosis
of depression. It is possible that mothers who were willing to
participate in the study were women who were predominantly
distressed and found this as an opportunity to express their
issues and may be the reason for the higher prevalence of at
risk group. A complete community survey may have to be
repeated to understand the true prevalence.
Conclusion
Needs of a postnatal mother is often neglected and
the whole family concentrates on the care of the new baby.
The postnatal women's needs are not addressed adequately.
Even health care professionals are not aware of the increased
prevalence of PPD and the need for a routine screening for all
postnatal mothers. This ignorance and negligence can result
in severe consequence for the mother, her baby, partner,
family and the society. The knowledge gained by this study
directs the health professionals' focus on the need to identify
and treat mothers suffering from PPD early thus improving
their quality of life.
Conflicts of Interest: The authors have declared no conflicts
of interest.
References
Centers for Disease Control and Prevention (2008).
Prevalence of self-reported postpartum depressive
symptoms--17 states, 2004-2005. MMWR. Morbidity
and Mortality Weekly Report, 57(14), 361.
Hashemi, Z., Azar, I. A. S., & Forghani, F. (2006). Postpartum
depression and its correlates among women living in
Zabol (Iran). Iranian Journal of Psychiatry, 1(4), 140-
147.
Indian Journal of Continuing Nursing Education
Vol. 17, No. (1), Jan - June 2016
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Prevalence and Risk Factors of Postpartum Depression 74

Chandran, M., Tharyan, P., Muliyil, J., & Abraham, S. (2002).
Post-partum depression in a cohort of women from a
rural area of Tamil Nadu, India. The British Journal of
Psychiatry, 181(6), 499-504.
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, 150(6), 782-786.
Danaci, A. E., Dinç, G., Deveci, A., ªen, F. S., & Içelli, I.
(2002). Postnatal depression in Turkey: epidemiological
and cultural aspects. Social Psychiatry and Psychiatric
Epidemiology, 37(3), 125-129.
Ludermir, A. B., Araya, R., de Araújo, T. V. B., Valongueiro,
S. A., & Lewis, G. (2011). Postnatal depression in women
after unsuccessful attempted abortion. The British
Journal of Psychiatry, 198(3), 237-238.
Savarimuthu, R. J. S., Ezhilarasu, P., Charles, H.,
Antonisamy, B., Kurian, S., & Jacob, K. S. (2010). Post-
partum depression in the community: A qualitative study
from rural South India. International Journal of Social
Psychiatry, 56I(1), 94-102.
Vigod, S. N., Villegas, L., Dennis, C. L., & Ross, L. E. (2010).
Prevalence and risk factors for postpartum depression
among women with preterm and low-birth-weight
infants: A systematic review. BJOG: An International
Journal of Obstetrics and Gynaecology, 117(5), 540-550.
Woolhouse, H., Gartland, D., Hegarty, K., Donath, S., &
Brown, S. J. (2012). Depressive symptoms and intimate
partner violence in the 12 months after childbirth: A
prospective pregnancy cohort study. BJOG: An
International Journal of Obstetrics and Gynaecology,
119(3), 315-323.
Yelland, J., Sutherland, G., & Brown, S. J. (2010). Postpartum
anxiety, depression and social health: findings from a
population-based survey of Australian women. BioMed
Central Public Health, 10(1), 1.

Answers for CNE Test No. 29

1. D 11. D
2. A 12. A
3. A 13. A
4. D 14. B
5. B 15. A
6. B 16. C
7. C 17. B
8. A 18. A
9. C 19. A
10. D 20. A

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