Determination of factors affecting post-partum depression in primary healthcare during the COVID-19 pandemic

Abstract

Postpartum depression is a phenomenon that occurs in the first postpartum days. Symptoms of postpartum depression peak on days 3 to 5 postpartum with a duration ranging from a few hours to several days. Of course, this will be different during the Covid-19 pandemic. The aim of this study was to analyze the determinants that influence the incidence of post-partum depression in primary health during the pandemic. The method in this research is descriptive analysis with cross sectional approach with a total sample of 100 respondents. The research instrument used a standard instrument, namely the EPDS (Edinburgh Postnatal Depression Scale) instrument. The results of the study were the determinant factors of parity in primigravida and attitudes. From the results of this study, it can be concluded that the dominant factors that greatly influence the risk of post-partum depression in women in primary health during the pandemic are parity (primigravida) and the attitude of women who take it for granted when they know that they are at risk of post-partum depression.

Introduction

Postpartum depression is a mild postpartum stress syndrome experienced by mothers. Postpartum stress in postpartum mothers usually begins with postpartum depression. The incidence of postpartum depression in mothers who have just given birth is currently very worrying. The results showed that in DKI Jakarta by dr. Irawati Sp. Kj showed that 25% of the 580 mothers who became respondents experienced postpartum depression,¹ besides that in the hospital study. Dr. Sutomo, Surabaya, found the number of postpartum depression incidence of 61.4% of mothers who just gave birth. Mothers giving birth during a pandemic experience many different challenges than before a pandemic.² This is what causes the mother to experience excessive stress.

Many factors are thought to influence the occurrence of postpartum depression, including: social support from husband and family, the state and quality of the baby, psychological and environmental stressors, a history of previous emotional problems, hormonal and cultural factors, fatigue after pregnancy and childbirth, overwhelmed by responsibility.³ new responsibilities as a mother and a feeling of not being worthy of being a mother. The risk factors for baby depression syndrome are age, parity, difficult labor and difficulty breastfeeding, difficult or worrying pregnancy, any kind of childhood trauma (history of depression) that can lead to depression, more specifically the relationship full of problems with mothers in childhood and support from the husband who can background postpartum depression syndrome.⁴ The risk of postpartum depression sufferers at the age <20 years or> 35 years is 3.5 times greater than patients aged 20-35 year. The risk of primiparous postpartum depression sufferers is 3.6 times greater than patients who are multiparous. It is said that those who have experienced postpartum baby depression are considered very vulnerable to experience it again.⁵

Several studies have shown the role of certain prenatal factors and factors related to the personality of women in the puerperal period. The emotional health of a pregnant woman has been identified as a precursor to mental health during the postnatal period: poor mental health during the prenatal period is associated with an increased risk of psychopathic theology during the postnatal period. Beck found that prenatal depression, prenatal anxiety, and self-esteem had a significant influence on the development of postpartum depression. In addition, the emergence of Post-Traumatic Stress Disorder (PTSD) in the postpartum period appears to be associated with a certain psychopathological history, such as depression, anxiety.⁶

Difficulties encountered during pregnancy have been identified as factors that cause the onset of symptoms of post-traumatic stress disorder. In addition, symptoms of depression and anxiety during pregnancy, as well as unsafe attachment styles in women, are believed to be susceptibility factors in the onset of postpartum PTSD pregnancy. In another study, anxiety correlates with anxiety and depression in the postpartum period.⁷

Perceptions of negative aspects of labor, such as pain felt by mothers in labor, correlate with depressive symptoms in the postpartum period.⁸ Postpartum anxiety during delivery days has been associated with reduced duration of breastfeeding. Changes in the milk ejection reflex are thought to be due to the decreased oxytocin release that occurs when women experience physical or mental stress. Taking into account the longterm consequences of a woman’s emotional and psychological state immediately after delivery, it seems important to identify and identify in these women the determinants of Braid’s symptoms, stress or anxiety.⁹ in the early period to prevent the risk of mental health problems later in life.

The experience of childbirth, prenatal factors and factors related to women’s personality are likely to influence the emotional and psychological condition of postpartum women.¹⁰ However, no studies have identified the determinants of post-partum depression during a pandemic in primary healthcare. The interesting and innovative nature of this study will help fill gaps in the Indonesian and international literature. In addition, most studies have shown results in postpartum depression in pre-pandemic conditions. The new perspective offered by this study is the determinant factor that causes women in primary healthcare to experience post-partum depression during a pandemic. Because not all areas in the world are covered by adequate facilities to deal with this problem, so this research is useful for better treatment Postpartum mothers in primary healthcare in the future. Therefore, this study aims to identify the determinants of post-partum depression in women in primary healthcare during the Covid-19 pandemic.

Materials and Methods

We conducted a cross-sectional and descriptive study between March 2020 and January 2021.

Participants

One hundred and seventy women were of full age and had given birth between 37 and 41 weeks at the puskesmas in rural areas of Malang district, between the 1st and 6th days postpartum. The criteria for inclusion in this study were: being an adult (over 18 years); after delivery at term (between 37 and 41 weeks) of infants not admitted to neonatology; follow-up deliveries in the maternity ward; has given a free and clear written consent. The criteria for non-inclusion were as follows: women who cannot speak or read Indonesian, women who are illiterate or have intellectual disabilities, women who are underage and who have given birth to twins. All women who met the inclusion criteria and were present on the day of recruitment were fulfilled. Thirty-four women refused to participate in the study and 46 were not available to answer the questionnaire (breastfeeding, infant care, pediatric or gynecology appointments in the room). So that 100 women were finally accepted as respondents.

Data collection procedures

Conducted by the principal investigator of the study at puskesmas and hospital type 3 in rural Malang district. The aims and methods of the study were explained to women during their postnatal stay. After obtaining information about the procedure via a bulletin and given time for reflection, the receiving participant gave clear written consent before filling out the questionnaire. These are then placed by the participant in the box provided for this purpose, placed in the service. The non-mandatory and anonymous nature of participation and study objectives are described, as well as the possibility to withdraw from the study at any time and without justification. It was also proposed, for all women in the workspace, to meet the nurses / midwives in the maternity ward if they wished. This study respects the ethical principles of the Declaration of Helsinki (2013). The research protocol was proposed and then validated by the research ethics committee of Poltekkes Kemenkes Malang.

Statistical analysis of SPSS Software

Version 25 was used to perform all analyzes. First, we move on to imputation of lost data by scale. Then, the normality of the data distribution was analyzed using the Kolmogorov-Smirnov test. Descriptive analysis was first performed, followed by a comparison of the mean test, Pearson’s Chi2s and Fisher test, to identify group differences, according to the cut-off values of the variables of our interest, depending on several determinants. Finally, linear regression analysis was performed to identify predictors of women’s mental health immediately after delivery (stress symptoms). Anxiety and peri-traumatic relationships). The potential predictors used in different models are variables whose results have been shown to be significant in previous univariate statistical analyzes. For each regression model, verification of several conditions was carried out: verification of the presence of colors and arity of the colors was made to go through the observation of the variance inflation factor (VIF). The validity of the model is then verified by residual analysis, ensuring that each model meets the requirements for independence, elasticity homosexuality. and normal residues, as well as a lack of influential data. Bonferroni’s adjustments are made to correct for inflation risk from alpha risk associated with multiple tests. The materiality threshold has been set at 5%.

Measurement instruments

In order to collect socio-demographic and obstetric data from each participant, anamnestic questionnaire was completed at the maternity hospital. This questionnaire was used to gather information about the woman’s psychological history (depression, traumatic events), but also the course of pregnancy (perception of complications for the baby or woman, medically assisted pathways of procreation, etc.) and, finally, parameters related to labor (obstetric data, intensity of pain that is felt, the presence of a partner or complications that are felt by the woman). In order to pay attention to the subjectivity of pregnancy and childbirth, questions that refer to complications in women or babies, or questions about the suffering of the baby during childbirth, awaiting definite responses from the mother in relation to these perceptions. complications. Women are able to explain this complication and provide examples.

The Edinburgh Postpartum Depression Scale (EPDS) was used to assess distress symptoms immediately after delivery. This scale has been translated and validated in Indonesian language and shows good internal consistency in our sample (a = 83). It includes 10 items with an overall score ranging from 0 to 30. It was originally validated for use at from 4 weeks postpartum, but today has been shown to be applicable longer in the early postpartum and antenatal periods. The cut-off score recommended by studies using EPDS immediately after delivery is 11. Beyond this threshold, the risk of developing postpartum stress increases.

Ethical Considerations

Ethical clearance obtained from permission from the ethic commission of Poltekkes Kemenkes Malang.

Results

Based on the table above, the variables of maternal parity, education, use of health service facilities, husband support, family support, and the role of health workers based on the results of statistical tests obtained p = 0.000 means (<0.05) it can be concluded that there is a significant relationship between these variables and the incidence of post-partum depression that occurs in postpartum mothers (Tables 1 and 2).

To see the variable that has the greatest influence on the risk of the incidence of post-partum depression in postpartum mothers, it can be seen from the value of Exponent B on a significant variable. In the results of the analysis above, the highest Exponent B value is the presence of maternal parity, so it can be interpreted that primigravida is the dominant factor that has the greatest influence on the risk of post-partum depression in postpartum mothers.

Discussion

Predisposing factors in relation to the risk of post partum depression in the postpartum mother

Predisposing factors include knowledge, attitudes, values, beliefs, confidence, individual characteristics (such as: age, education, occupation, income).¹¹ The results of the chi square analysis showed that the predisposing factors indicator obtained the p value that fulfilled the parity and education. Maternal parity and maternal education have an influence on the occurrence of post-partum depression.¹² This opinion is in line with the research of Ariesca (2018) which states that primiparous mothers are more at risk of being affected by the postpartum blues because they have no experience in caring for children, so they feel they are facing their own problems. They need people who accompany you during the postpartum period, so that the postpartum period will be passed properly.¹³ The readiness to become a mother starts from the readiness to welcome a pregnancy which is reflected in the readiness and emotional response in accepting pregnancy.¹⁴ The process of childbirth, the length of labor and complications experienced after delivery can affect a mother’s psychology.¹⁵ Where the greater the physical trauma experienced, the greater the psychological trauma that occurs and this is more severe for women who give birth to their child for the first time.¹⁶

According to Robbin (2006) perception is influenced by: attitudes, motives, interests, experiences, and expectations. Most of the postpartum mothers have a positive attitude, but this is not valid in forming a predisposing factor.¹⁷ The results of discussions conducted with respondents found that if there are symptoms or complaints that are felt during the postpartum period, it is a natural thing to happen and they think that it is normal even though the complaints they feel have entered the category of postpartum depression. Lack of knowledge and a positive attitude indicate that pregnant women in rural areas think that something is normal if there are problems that occur during childbirth and caring for newborns. Their role models are parents and hereditary habits that have been taught so far.¹⁸

Table 1.

Relationship between Independent variables and dependent variables incidence of post-partum depression in postpartum mothers in terms of maternal parity, education, income, maternal knowledge, attitudes, use of health care facilities, husband support, family support, and the role of health workers.

Variables	PPB	Non-PPB	Total	P Value	Odds Ratio (95%CI)
Mother's Parity
Primigravida	47	21	68		4.92
Multigravida	10	22	32	0.000
Education
Junior High	41	19	60	0.005	3.24
High school	16	43	40
Knowledge
Good	16	15	31	0.466	0.728
Less	41	28	69
Attitude
Positive	34	28	62	0.577	0.792
Negative	23	15	38
Medical facility
Good	50	25	75	0.001	5.143
Less	7	18	25
Husband's support
Good	39	20	59	0.027	2.492
Less	18	23	41
Family support
Good	13	16	29	0.016	0.499
Less	44	27	71
The role of the officer
Good	42	23	65	0.036	2.435
Less	15	20	35

Table 2.

Multivariate analysis of maternal parity variables, education, income, knowledge, attitudes, health facilities, husband support, family support, role of officers against risk factors for post partum depression in postpartum mothers.

Variable	Exp (B)	Wald	95% CI	P Value
Mother's Parity	5.744	8.485	1.987-12.201	0.000
Education	2.957	3.247	1.405-7.455	0.005
Income	.959	.005	.452-2.511	0.885
Knowledge	.965	.004	.311-1.709	0.466
Attitude	.839	.079	.349-1.799	0.577
Use of health care facilities	4.206	11.479	1.899-13.929	0.001
Husband's support	1.868	1.337	1.019-5.190	0.027
Family support	1.198	.093	.604-2.978	0.016
The role of the officer	2.516	2.976	1.050-5.643	0.036

Enabling factors in relation to the risk of post partum depression incidents in the postpartum mother

Enabling factors (supporting factors) manifest in the physical environment, whether health facilities or facilities are not available or are not available. Supporting factors include the use of health services, the environment, accessibility of health sources, government regulations, health skills.¹⁹ Limited online facilities during a pandemic caused some primary health services to experience difficulties. In this study the researchers took three indicators of supporting factors, namely accessibility to health services, husband support and family support.²⁰ The results of statistical analysis showed that there was a significant relationship between the variable enabling factors and the risk of post-partum depression in postpartum mothers.

The use of health services greatly influences the incidence of post-partum depression. In some developing countries, the use of health facilities is good. The results of the study Sampuna et al (2013) showed that factors related to health services were family and reference groups. Reference groups are all groups that have direct or indirect influence on a person’s attitude and behavior. ²¹ The results of Logen’s (2015) study indicate that the variables related to the utilization of health services are age and health care insurance. Nurzaeni’s research results (2015) show family support and information exposure are related to the use of health services. The results of Anggraheni’s (2012) study indicate that medical costs influence the decision-making for choosing health services.

The choice of using health service facilities is due to suitability or it can also be due to cost factors. Mothers who chose control to private health services felt that there was no change when they were brought to the puskesmas. There is also because they are used to doing medical treatment in private health services. In addition, there are mothers who keep bringing them to the puskesmas because they are free of charge. The use of good health services will increase the main constructs of perceived in the prevention of post-partum depression.

Reinforcing factors in relation to the risk of post partum blues incidence in postpartum mothers

Reinforcing factors (driving factors) are factors that strengthen behavior manifested in the attitudes and behavior of health workers, peers, parents, who are the reference group for community behavior. The driving factors consist of family, peers, teachers, co-workers, health workers, traditional leaders, decision makers. The results of the discussion with the toddler’s parents showed that there was a significant relationship between the enabling factors and risk of incidence of post-partum depression. The driving factor examined in this study was the role of health workers.

Research by Asri and Yuniwati (2013) shows that there is a relationship between the role of health workers and behavior change. The results of Wahyuningsih’s (2013) study show that there is a significant relationship between maternal perceptions of the role of officers and behavioral prevention of post-partum depression. The role of health workers is partly in good category.²² This can be seen from the existence of education about the prevention of post-partum depression, the frequency of education and the implementation of education. The results of the questionnaire for item number 57 indicated that some part of the postpartum mother agreed that the provision of information about post-partum depression prevention behavior was given gradually when doing integrated ANC.²³ Limited visits make it difficult for postpartum mothers to meet, but in the field innovation they are connected by the Whatsapp application for consultation between patient-health workers, this is done to reduce transmission of Covid-19 to postpartum mothers. Based on the results of discussions with postpartum mothers and the community health center, it shows that there is a need for harmony between the existing programs and the implementation in the community or in the field. So, it is hoped that postpartum mothers can get the right information from health workers about preventing the incidence of post-partum depression in postpartum mothers. The role of a good health worker will reduce the risk of the incidence of post-partum depression in postpartum mothers.²⁴

Conclusion

Predisposing factors (parity and education) will reduce the risk of post-partum depression in postpartum mothers. Reinforcing factors (health facilities, husband support and family support) will reduce the risk of post-partum depression in postpartum mothers. Enabling factors (support from good health workers) will reduce the risk of post-partum depression in postpartum mothers. The dominant factor that greatly influences the risk of the occurrence of ost partum blues in postpartum mothers is the presence of maternal parity.