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Prevalence and risk factors of postpartum depression at a tertiary care institute

Pregnancy and postnatal period are considered as most fragile periods for women in her life. Postpartum period is a time of tremendous emotional and physical change for women as they adapt to new roles and alteration in their physiology. Biological, psychological and social factors operate in a combined way, resulting in various mental health problems occurring at this stage. In addition to physical stress, significant psycho social stress is experienced by the mother. Hence women are vulnerable to mood disorders in this period. Up to 85% of the women experience some type of mood disturbance in postnatal period. Postpartum psychiatric disorders can be divided in to three categories depending on the severity: Postpartum blues, Postpartum depression and Postpartum psychosis. Postpartum blues is usually mild and transient, resolves in few days to a week. ABSTRACT


INTRODUCTION
Pregnancy and postnatal period are considered as most fragile periods for women in her life. Postpartum period is a time of tremendous emotional and physical change for women as they adapt to new roles and alteration in their physiology. Biological, psychological and social factors operate in a combined way, resulting in various mental health problems occurring at this stage. In addition to physical stress, significant psycho social stress is experienced by the mother. Hence women are vulnerable to mood disorders in this period. Up to 85% of the women experience some type of mood disturbance in postnatal period. 1 Postpartum psychiatric disorders can be divided in to three categories depending on the severity: Postpartum blues, Postpartum depression and Postpartum psychosis. Postpartum blues is usually mild and transient, resolves in few days to a week.
Postpartum depression (PPD) is a depressive disorder, which affects women after childbirth. Despite its serious consequences and amenability to treatment, PPD often remains unrecognized. Depression during this time of life affects bonding with infant which may lead to malnutrition and other various complications in the infant. Infant might be neglected in its early growing phase in life, which may lead to psychiatric illness later. Women affected with PPD are also at high risk for recurrent depression. Many mothers are not aware that they are depressed; others have social stigma which prevents them from seeking medical help. If the depression is undetected or detected but not taking treatment due to lack of awareness of the disease, it has serious consequences for mother, child and the whole family. The prevalence of PPD is 10%-15% in developed countries while most of the Indian and South Asian studies show prevalence of 15%. 2 The first and most important step to manage postpartum depression is accurate assessment of the symptoms and early diagnosis. Screening helps in identifying mothers at risk and assists in prevention of PPD. This study focuses on the prevalence of probable depression among postnatal women attending a tertiary care institute in south India and to identify the risk factors that affect postpartum depression. This study intends to add to the existing knowledge about the prevalence of postpartum depression and associated risk factors.

METHODS
This study was a cross sectional study, performed over a period of three months from January 2019 to march 2019 at ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, a teaching hospital in southern India. 200 postnatal mothers were recruited for the study, who were in postpartum period from 1 to 6 weeks after delivery. They were recruited from in patients and postnatal clinic after applying inclusion and exclusion criteria. After explaining the nature and purpose of the study, written informed consent was taken from the participants.
Specially designed proforma was used to record various determinants to assess the risk factors which could contribute to postpartum depression. Then pre-designed and pretested questionnaire (EDPS-Edinburgh Postnatal Depression Scale) was used to detect the depressive symptoms in postnatal mothers. EDPS was created specifically for postpartum women for screening depression. It has been well validated and found to have high sensitivity, specificity and accuracy. EDPS scale has ten components in it. Each item is rated from 0 to 3, yielding a total score of 0-30. Seven of its items are reverse scored. EDPS score cut off 13 or more was used to calculate the prevalence of postnatal depression in the study group.
The scale was administered by the investigator in the language known to the patient for ease of understanding, which was Tamil.

Inclusion criteria
• All postnatal mothers from day 8 to 6 weeks postpartum irrespective of age, parity, socio economic status, mode of delivery and gestational age at delivery.

Exclusion criteria
• Previously diagnosed to have depression • Women on treatment for any psychiatric disorder.

The various determinants that were evaluated to assess the risk factors
• Social and demographic factors: age, educational qualification, socio economic status, whether working or not. • Medical and obstetric history: presence of any comorbid illness, gravida (primi/ multi), history of treatment for infertility, history of miscarriage, history of intra uterine fetal demise (IUFD), number of living children, gender of living children, whether pregnancy was planned pregnancy/ unplanned pregnancy, presence of complication during pregnancy. • Perinatal events: mode of delivery, gestational age at delivery, complication during delivery, fear regarding gender of the child, gender of the baby, NICU admission, Lactation failure. • Family and relationship factors: whether single parent, family structure (nuclear/joint), housing (spacious/overcrowding), financial difficulty, support from partner, support from parent, support from in laws.

Statistical analysis
The results for qualitative data were presented in frequency and percentage. Binary logistic regression was used to predict the contribution of each independent risk factor to arrive at the depression level, which happens to be the dependent risk factor in this study. The statistical analysis was done by using SPSS 21.0. The significant level was used at p < 0.05. The following symbols were used. * just significant at p< 0.05** more significant at p<0.001,*** highly significant at p <0.0001 and NS for Not significant. A total of 200 cases were studied. Prevalence of postnatal depression was found to be 25% using Edinburgh Postnatal Depression Scale. The score ≥13 was considered as presence of depression (Table 1).

RESULTS
Most common age group in the study was 21 years to 30 years (77%) followed by 31 years to 40 years (22%). Out of 200 women 61% of the women were not working, while 39% were working women. A total of 116 women (58%) were graduates, out of which 94 women had undergraduate degree while 22 women had postgraduate degree. Women belonging to upper class were common 48%, followed by middle class 24% (Table 2).  Present pregnancy was planned pregnancy in 88% of the cases and unplanned in 12% of the cases. Either medical or obstetric complication was present in 53% of the cases (Table 3).   Each independent risk factor to postpartum depression was analyzed using Binary logistic regression by using Backward stepwise Likelihood Ratio method. In this method insignificant risk factors had been removed stepwise to give the most significant risk factors. In our study Backward LR method followed 20 steps to give the most significant risk factors.  (Table 6). The final step of logistic regression was shown in the table 7 which describes the most significant risk factors to develop postnatal depression.
Educational qualification was not found as contributing risk factor to postpartum depression. Women with lesser educational qualification (primary education) were at 3 times (OR= 3.029) increased risk of developing depression as compared to women with secondary and degree education, though it was statistically not significant (Table 7).
Primi gravida were at 4 times increased risk of postpartum depression compared to multi gravida (OR=4.028). Women with history of miscarriage were at 3 times increased risk of developing postpartum depression (OR=3.58). Women whose pregnancy was unplanned were at 6 times increased risk of developing postpartum depression (Table 7).
Fear regarding gender of the child (OR= 0.257), failure of lactation (OR= 0.336) were not contributing risk factors to postpartum depression in this study ( Table 7).
Overcrowding of the house and absent partner support were found to have odds ratio of OR=0.115 and OR= 0.031 respectively as compared to spacious house and partner support. Hence spacious house and partner support were found to be protective factors to combat depression in postnatal women in this study (Table 7). A total of 116 women (58%) were graduates, out of which 94 women had undergraduate degree while 22 women had postgraduate degree. Women belonging to upper class were common 48%, followed by middle class 24%.

DISCUSSION
Risk factors were analyzed using Binary logistic regression by using Backward LR Method. Analysis showed unplanned pregnancy, primi gravida and history of miscarriage were statistically significant for postpartum depression, hence they were potential risk factors.
Women whose pregnancy was unplanned were at 6 times increased risk of developing depression. Educational qualification was not found as contributing risk factor to postpartum depression in our study. A study conducted by Suguna A et al also showed that there was no significant association between postnatal depression and age of the woman, educational status, occupation. 8 Fear regarding gender of the child (OR= 0.257), failure of lactation (OR= 0.336) were significantly not contributing risk factors to postpartum depression in this study.
Partner support was found to be a protective factor to combat depression in postnatal women in this study. In a study conducted by Saldanha D et al in north India, the prevalence of postpartum depression was more (60%) when partner support was not there. 4 Study by Nimisha DD et al in north India showed that women who could not confide in their partners were observed to be having odds 10.43 times higher of having postpartum depression than those who could confide in their partners. 9 Lack of partner support was associated with depression among postnatal women, in a study conducted by Swapan G et al in north india. 10 Spacious house was found to have a protective role from developing postpartum depression in our study. Study by Swapan G et al in north India also found similar finding that overcrowding of the house was significantly associated with postpartum depression. 10

CONCLUSION
In our study, the prevalence of postpartum depression was 25%. Prevalence in this hospital based study is consistent with the rates found in other studies. Important risk factors for postpartum depression found in this study were unplanned pregnancy, primi gravida and history of miscarriage. No significant association was noted between postpartum depression and age, educational qualification, socio economic status. Fear regarding gender of the child and failure of lactation were not contributing risk factors to postpartum depression in this study. Spacious house and partner support were found to be protective factors to combat depression in postnatal women in our study.
Early screening of postnatal women for depression will reduce the adverse outcomes among both mother and the child. But scarcity of available mental health resources, inequities in their distribution and inefficiencies in their utilization are the key obstacles to optimal mental health, especially in low resource countries.
Prevalence rate and risk factors in the present study strengthens the findings of previous studies and signifies the importance of identifying postpartum depression. Hence, we recommend screening of all postnatal mothers for depression during postpartum period based on this study. More extensive studies involving larger samples in future might be helpful in identifying additional risk factors for postpartum depression.