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Risk factors of postpartum depression

Background: Postpartum depression (PPD) is one of the most common puerperal psychiatric illnesses impairing quality of life and mental health of the mother and also the child. Aim: The aim is to study the prevalence and risk factors of PPD. Materials and Methods: This cross‐sectional observational study was done on a sample of 295 mothers who delivered and were followed up at a tertiary care hospital. The mothers were administered Edinburgh Postnatal Depression Scale, and demographic, psychosocial, and clinical data were collected. Results: The age of the participant mothers ranged from 18 to 35 years and age at marriage ranged from 21 to 24 years. In most of the mothers, the parity was 2 and they had institutional vaginal delivery. The prevalence of PPD in this population of mothers was 30.84%. The factors that had a statistically significant association with PPD included: lower educational status of mother, lower family income, rural place of residence, higher parity, preterm delivery, and adverse events in newborn. Conclusion: PPD is a common mental health problem in the postpartum period. Sociodemographic factors such as low educational status of mothers, rural population, and low monthly family income were found to be associated with PPD. Primipara status, preterm delivery, and adverse events in newborn were also significantly associated.

Mental health stigma and social norms in India often prevent mothers from reaching out for professional help. [2] Many of the cases go unreported because the focus shifts from the mother to the baby after delivery. Hence, even when mothers face physical exhaustion, weakness, and an overall lack of physical and mental well-being, it tends to go unnoticed not only by the family members but even by the mothers themselves. [3] Mental disorders are said to be of postpartum onset if the onset is within 6 weeks of delivery, according to the International Classification of Disease-10, Classification of Mental and Behavioral Disorders-Research and Diagnostic Criteria. [4] Diagnostic P ostpartum depression (PPD) is a complex mix of physical, emotional, and behavioral changes that happen in some women after delivery. Hippocrates hypothesized that postpartum symptoms were due to suppressed puerperal discharge or a direction of milk from breast to the brain or influx of the blood to the breast. Subsequent literature divided psychiatric disorders of mothers in the reproductive age group into "insanity of pregnancy," "puerperal insanity," and "insanity of lactation." The increased risk of mental illness in newly delivered mothers has been recognized since Esquirol description of postpartum psychosis in 1845. [1] In India, social and cultural beliefs about the postpartum period are often based on Ayurveda and other age-old traditions. and Statistical Manual of Mental Disorders-5 th Edition states that the onset must occur within 4 weeks of delivery and symptoms must last at least 2 weeks to qualify as a depressive episode. [5] A systematic review of 47 studies from 18 countries reported a prevalence of 19.8% and suggested that the burden of perinatal mental health disorders, including PPD, is high in low-and lower-middle-income countries. [6] A meta-analysis of 38 studies involving 20,043 Indian mothers revealed overall prevalence of PPD to be 22%. [7] Another meta-analysis of 84 studies revealed that the important significant predictors of PPD are the presence of depression before or during pregnancy, life events, marital relationship, and socioeconomic status. [8] PPD has been conceptualized in a biopsychosocial framework with hypothalamic-pituitary-adrenal axis dysregulation, inflammatory process, and genetic vulnerabilities as biological factors, as well as stressful life events, quality of relationship, and social support among significant psychosocial factors. [9] Despite the growing number of empirical studies in regional communities on PPD in India, there is a lack of hospital-based study of heterogeneous population, using a valid screening tool that looks not only at the overall burden of PPD but also at its associated risk factors. [7] The aim of this study is to estimate the prevalence and to describe the risk factors of PPD.

MATERIALS AND METHODS
This was a hospital-based, cross-sectional, observational study conducted in a tertiary care hospital on mothers in the age group of 18-35 years who had delivered either at labor room or operation theater, had reported to obstetrics and gynecology or pediatric outpatient departments (OPDs), and were willing to participate in the study. The study obtained permission from the institutional ethical committee. All subjects gave informed consent.

Exclusion criteria
1. Patients with a diagnosis of intellectual disability, substance use disorders, central nervous system disorders, psychosis, bipolar disorders, preexisting depression 2. Critically ill patients.
A total of 295 women who had delivered between December 1, 2018, and September 30, 2020, were included. The biographical, sociodemographic, medical, and obstetric data of the consenting mothers were recorded on a specially designed pro forma. Any uneducated subjects were helped by researcher in filling the pro forma and questionnaires. Psychosocial stressors, addiction in husband, and domestic violence during the past 1 year were assessed by means of a brief interview.
The women were reviewed in their postpartum phase in the postnatal ward/child immunization clinic after delivery. Those who fulfilled the inclusion criteria were taken up for study. They were screened by using Edinburgh Postnatal Depression Scale (EPDS). EPDS is a self-reporting questionnaire which was designed to detect depression among women in the postpartum period. [10] The EPDS focuses on psychological rather than somatic symptoms of depression and demonstrates high sensitivity and reliability for the detection of PPD. It consists of ten items. Each item has four responses, which are scored from 0 to 3 based on severity. The cutoff score indicative of depression was taken as 12. The EPDS has 86% sensitivity, 78% specificity, and 73% positive predictive value (proportion of respondents scoring positive in the test who had a mental disorder diagnosed by clinical interview). Cronbach's alpha (internal consistency) of EPDS has been found to be 0.83. [11] This scale was administered at obstetrics and gynecology or pediatric OPDs during follow-up.
A diagnosis of depression was made only if the criteria for a depressive episode as per the ICD-10 Diagnostic Criteria for Research were met. [4] All diagnosed cases were provided appropriate intervention. Clearance was obtained from the institutional ethics committee before commencing interaction with patients. Data analysis was done by using Statistical Package for the Social Sciences) Version 25.0. (IBM, Chicago, USA) using appropriate statistical tests.

RESULTS
The prevalence of PPD is presented in Table 1. The age of the participant mothers ranged from 18 to 35 years. Other demographic characteristics are summarized in Table 2. Clinical characteristics of the subjects are shown in Table 3. Correlation of PPD with sociodemographic factors and clinical factors is given in Tables 3-5, respectively.

DISCUSSION
The study revealed a 30.84% prevalence of PPD among the participant mothers. Similar finding of 27.2% was also reported among 14,447 Turkish postpartum mothers and of 35.5% was reported among 895 Indian postpartum mothers. [12,13]

Risk factors related to postpartum depression Place of residence
In this study, 95 (32%) were from rural background of whom 40 (42%) were depressed (P ≤ 0.05). Meit et al. reported that mothers from rural areas were at greater risk for the development of PPD. [14] An integrative review of 11 articles also reported higher prevalence of PPD in rural areas. [15] On the other hand, a study of 6126 postpartum mothers of Canada found the prevalence of PPD to be higher among women living in urban areas than among those living in rural, semirural, or semiurban areas. [16] Community-based studies of PPD in India, in agreement with our findings, revealed that the prevalence of PPD was higher among the rural population. [17,18] This association may be consequence of many factors such as differences in socioeconomic status, education, lower awareness, and stigma of mental illness.

Adverse events in newborn
It has been reported that depression during postpartum period was significantly associated with adverse events in newborn. [19,20] A meta-analysis among 12,810 postpartum mothers revealed sickness or death of newborn associated with increased prevalence of PPD. [21] Similarly, the present study also observed a significant association between maternal PPD and live birth with complications. Complications in the child or death are associated with stress response, triggering depressive symptoms.

Preterm delivery
In this study, 18.3% of mothers had preterm deliveries out of which 59% developed PPD. A systematic review and meta-analysis revealed preterm birth to be a risk factor for PPD. [22] A prospective cohort study also found a significant association between duration of pregnancy and PPD. [23] This may be related to biological vulnerability of the mother to unexpected hormonal and homeostatic changes during preterm deliveries.

Educational status of mother
Our study found a statistically significant association between lower level of education and PPD, which is in  agreement with the findings of earlier studies. [24,25] It is hypothesized that low education is related to reduced awareness about postpartum care and good child-rearing practices.

Family income
Our study further found that the prevalence of PPD falls with rise in monthly family income. Our results are in consonance with the results of an earlier study. [26] Financial constraints possibly lower the spending on health and well-being of the mother.

Parity
Primiparous mothers had significantly higher prevalence of PPD in the present study. Similarly, in a study of 1503 primiparous and 1487 multiparous mothers, parity was significantly associated with PPD. Primipara mothers have more discomfort and problems in the puerperium, compared to multipara mothers. The multiparous mothers have more satisfaction and experience acquired with previous children. These were possibly the reason for lower reports of PPD. [27] Age of mother and age at marriage This study did not reveal any significant association between maternal age and PPD. Similar findings were also reported by other studies where no significant association was found between maternal age and PPD. [28,29] Further, no statistically significant association was found between age at marriage and PPD which is in agreement with earlier studies. [28,29] Strengths A structured, reliable, and widely accepted instrument, the EPDS was used in this study. Participant mothers were from a heterogeneous geographical origin of the armed forces population, representing the diversity of the Indian population. It improved the external validity of the study. A large number of variables (maternal age, age at marriage, parity, family income, duration of pregnancy, medical complications during pregnancy, etc.,) were evaluated for detailed analysis of risk factors of PPD.

Limitations
This was a cross-sectional study design without a control group. The study was carried out among both inpatients and outpatients. Hence, the possibility of recall bias among outpatients exists. The study was conducted in a tertiary care hospital in a metropolitan city. The sample was not truly representative of the population as more complicated cases are referred there. Therefore, the results may not be generalized to the community.

CONCLUSION
PPD is a common mental health problem in the puerperal period. Sociodemographic factors such as lower  educational status of mothers, rural population, and lower family income were associated with PPD. Primipara status, preterm delivery, and adverse events in newborn were also significantly associated.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.