Abstract
Background:
Transition to motherhood is associated with several emotional problems that can have long-term consequences on the mother and baby.
Aim:
To examine the association of various biomedical and cultural factors with the new onset of emotional problems during pregnancy and postpartum period.
Materials and Methods:
This prospective longitudinal study included 300 pregnant women interviewed in the third trimester.
Results:
The prevalence of emotional problems in the study group was 31.58%. The prevalence of anxiety disorder NOS and mixed anxiety and depressive disorder in the last trimester of pregnancy in our study was 4% and 1.33%, respectively, and 0.67% and 1.33%, respectively, at 4 days postpartum. At 6 weeks postpartum, the prevalence of anxiety disorder NOS was 1.33%, generalized anxiety disorder was 0.67%, and major depression was 1.33. The prevalence of postpartum blues in our study was 25.33%.
Conclusion:
There was a significant association between psychiatric disorders during and postpartum period and the following factors: higher parity, increased maternal age, low hemoglobin levels, cesarean section, planned pregnancy, and extended family. Postpartum blues was associated with higher parity and low blood pressure.
Keywords: Antenatal depression, postpartum blues, postpartum depression
Pregnancy and childbirth are some of the most important events in the life of a woman, producing a variety of psychological, physiological, and social consequences for the woman. The transition to motherhood is associated with depression and/or anxiety in 9–21% of women.[1] Various emotional problems during pregnancy and post-partum periods have been reported.[2]
In women, the prevalence of depression either during pregnancy or in the first 12 months postpartum is 10-20%.[3] The rates of anxiety disorders are higher during pregnancy than after delivery.[4]
Maternal age is considered one of the important risk factors for developing perinatal depression. Pregnancy in less than 25-year-old mothers represents an important risk factor. Socioeconomic status is another important risk factor. Lower socioeconomic groups have a higher prevalence of postpartum depression. History of mood and anxiety disorders, and familial history of psychiatric illness are other important risk factors.[5]
Various other factors such as the history of premenstrual mood changes, previous miscarriages or abortions, history of obstetric complications such as preeclampsia, gestational diabetes, cesarean section, and hormonal changes play a major role in mood changes in pregnancy.[6] Marital support, the lack of a partner, social support, and family support play an important role in developing perinatal emotional problems. Cultural background, an unplanned pregnancy, stressful life events, or chronic stressors are also important risk factors. In South Asian countries, birth of a female infant is associated with postpartum depression, especially in mothers who already had a girl child.[5,7] Not many Indian studies have been carried out. The present study aimed to examine the association of various biomedical and cultural factors, if any, with new onset of emotional problems during pregnancy and the postpartum period.
MATERIALS AND METHODS
This prospective, longitudinal study was undertaken at a Tertiary Care Medical College Hospital and research center in western Maharashtra from July 2011 to September 2013. Institute Ethics Committee clearance was obtained before the start of the study. Written informed consent was obtained, from all patients.
Sample
By purposive sampling, 300 women in third trimester attending antenatal clinic were included in the study.
Inclusion criteria: - Resident of urban and semi-urban areas.
Exclusion criteria: - Concomitant mental retardation, history of psychiatric illness, substance abuse, or organic brain syndrome.
Methodology
Women attending ANC clinic in their third trimester were approached, and after explaining the aims and objectives of the study, written informed consent was obtained for inclusion in the study. After the initial interview, all of them were given the screening proforma. Patients who were screened positive were taken for detailed interviews. All the patients were again screened within 4 days after delivery. Detailed psychiatric interviews were done for the patients screened positive. The second follow-up six weeks after delivery was done by telephone.
RESULTS
Out of the 300 women included in the study, 92% were less than 30 years and 8% were more than 30 years old; i.e. majority of the subjects were relatively young [Table 1]. Age ranged from 19 to 36 years. The preponderance of young mothers is probably because women from lower socioeconomic classes tend to marry early and become a mother early in comparison to their counterparts. The demographic characteristics of the sample are given in Table 1. The prevalence of emotional problems in the study group was 31.58% [Table 2] The prevalence of anxiety disorder NOS in the last trimester of pregnancy in our study was 4%, 0.72% at 4 days postpartum, and 1.57% at 6 weeks postpartum. The prevalence of postpartum blues in our study was 25.33% [Table 3]. The mean age of the study population with emotional problems is 25.44 years (S.D. 5.03) and without emotional problems is 23.68 years (S.D. 2.66). The association of age, age at menarche, blood pressure, hemoglobin, and blood sugar level in the study group is given in Table 4. The association between religion, socioeconomic class, and emotional problems in the study group is given in Table 5.
Table 1.
Demographic characteristics of women included in the study group
| Characteristics | No of cases | Percentage |
|---|---|---|
| Age (In years) | ||
| <30 | 276 | 92 |
| ≥30 | 24 | 8 |
| Religion | ||
| Hindu | 232 | 77.33 |
| Muslim | 56 | 18.67 |
| Christian | 6 | 2 |
| Buddhist | 4 | 1.33 |
| Sikh | 2 | 0.67 |
| Socioeconomic class | ||
| Class I | 22 | 7.33 |
| Class II | 146 | 48.67 |
| Class III | 108 | 36 |
| Class IV | 22 | 7.33 |
| Class V | 2 | 0.67 |
| Type of family | ||
| Joint | 100 | 33.33 |
| Nuclear | 180 | 60 |
| Extended | 20 | 6.67 |
Table 2.
Emotional problem-wise distribution of cases in the study group
| Emotional problems | No. of cases | Percentage |
|---|---|---|
| Present | 84 | 31.58 |
| Absent | 12 | 68.42 |
| Total | 266 | 100 |
Table 3.
Distribution of psychiatric disorders in the study group
| Assessment | MINI Diagnosis | No. of cases | Percentage (n=300) |
|---|---|---|---|
| I | Anxiety disorder NOS | 12 | 4 |
| Mixed anxiety and depressive disorder | 4 | 1.33 | |
| II | Anxiety disorder NOS | 2 | 0.67 |
| Mixed anxiety and depressive disorder | 4 | 1.33 | |
| Baby blue | 76 | 25.33 | |
| Drop out | 22 | 7.33 | |
| III | Anxiety disorder NOS | 4 | 1.33 |
| Generalized anxiety disorder | 2 | 0.67 | |
| Mild-to-moderate depressive disorder | 4 | 1.33 | |
| Dropout | 46 | 15.33 |
Table 4.
Association of age, Hb., age at menarche, SBP, DBP, and BSL-R in the study group
| Parameter | Emotional problems |
Z | P | |||
|---|---|---|---|---|---|---|
| Present |
Absent |
|||||
| Mean | SD | Mean | SD | |||
| Age (Yrs) | 25.44 | 5.03 | 23.68 | 2.66 | 3.03 | <0.005 |
| Hb. (gm%) | 10.76 | 1.24 | 11.09 | 1.11 | 2.13 | <0.05 |
| Age at menarche | 12.49 | 1.02 | 12.36 | 1.07 | 0.96 | >0.05 |
| SBP (mmHg) | 119.1 | 10.8 | 120.9 | 12.5 | 1.22 | >0.05 |
| DBP (mmHg) | 77.19 | 6.60 | 78.81 | 8.78 | 1.67 | >0.05 |
| BSL-R | 90 | 14.3 | 93.2 | 14.5 | 1.69 | >0.05 |
Table 5.
Association between religion socioeconomic class and emotional problems in the study group
| Variables | Emotional problems |
Chi-square | P | |
|---|---|---|---|---|
| Present | Absent | |||
| Religion | ||||
| Hindu | 63 | 147 | 5.34 | >0.05 |
| Muslim | 15 | 29 | ||
| Christian | 2 | 4 | ||
| Buddhist | 2 | 2 | ||
| Sikh | 2 | 0 | ||
| Socioeconomic class | ||||
| Class I | 10 | 8 | 11.16 | >0.05 |
| Class II | 41 | 87 | ||
| Class III | 25 | 75 | ||
| Class IV | 6 | 12 | ||
| Class V | 2 | 0 | ||
| Family type | ||||
| Joint | 29 | 61 | 8.30 | <0.05 |
| Nuclear | 44 | 114 | ||
| Extended | 11 | 7 | ||
| Family H/O Psychiatric illness | ||||
| Yes | 4 | 4 | 1.29 | >0.05 |
| No | 80 | 178 | ||
| H/O substance abuse | ||||
| Yes | 4 | 6 | 0.34, | >0.05 |
| No | 80 | 176 | ||
| H/O menstrual problem | ||||
| Yes | 16 | 28 | 0.56 | >0.05 |
| No | 68 | 154 | ||
DISCUSSION
The study was designed to study the relationship between various biomedical and cultural factors with emotional problems in women during pregnancy and postpartum period who attended the antenatal OPD and delivered a baby in the hospital. They were interviewed thrice: once in the third trimester, then within 4 days of delivery, and finally at 6 weeks after delivery. A similar prospective study was conducted, where the subjects were assessed during third trimester, within 3 days of delivery and 4-8 weeks of delivery.[8]
The prevalence of anxiety disorder NOS in the last trimester of pregnancy in our study was 4%, 0.72% at 4 days postpartum, and 1.57% at 6 weeks postpartum. Our finding of anxiety disorder being higher during pregnancy than after delivery agrees with another study.[9] In contrast to our findings, in a large community sample of pregnant women, 21% had clinically significant anxiety symptoms[9,10]
The prevalence of postpartum blues in our study was 27.34%. The high prevalence of 30-75% of postpartum blues in the literature, though not comparable, is close to our findings.[2] The prevalence of postpartum depression in our study was 1.57%. The prevalence of postpartum depression varies among countries from almost 0% to 60%. In some countries like Singapore, Malta, Denmark, and Malaysia, there is a very low prevalence of postpartum depression (0.5-9%), whereas in other countries, e.g., Guyana, Turkey, Italy, Chile, South Africa, Korea, and Taiwan, postpartum depression is extremely prevalent (34-57%). Indian studies on postpartum depression reported a prevalence of 32.4%, 11.0%, and 23.0% respectively in the general population,[7,11,12] 21.51% in spouses of military persons[13] and 5.9% in rural population.[14]
The low prevalence rates obtained in our study could be because the subjects were interviewed in third trimester of the antenatal OPD when they were usually in a hurry to go for a clinical check-up or an investigation. Rapport was difficult to establish in those situations. Another observation was that the subjects who were accompanied by their mothers-in-law or husbands usually felt uncomfortable discussing their emotional problems. On the other hand, subjects who were accompanied by parents, siblings, or friends opened up more easily. The subjects were interviewed on the telephone for the second follow-up. This also could reduce the sensitivity of our screening tool, contributing to the low prevalence rate. Another important fact is most of the above-mentioned studies were conducted up to 3-6 months postpartum, whereas in our study the last follow-up was at 6 weeks. So, the subjects developing emotional problems after that period were not included.
Association with various demographic and cultural factors
Age: A significant statistical correlation was found between maternal age and emotional problems. The risk of emotional problems increased with increased maternal age (P < 0.005), consistent with the findings of earlier studies,[15,16] though one study reported significantly higher anxiety and depression among teenagers compared to older mothers.[17]
Socioeconomic class: There was no statistical correlation found between socioeconomic class and emotional problems in our study, though many other studies found a significant correlation.[18,19] The possible reason for this finding in our study could be due to the very less number of subjects belonging to Kuppuswamy class IV and class V. Only two subjects (0.67%) belonged to class V and 22 (7.33%) belonged to class IV, while class II was 48.67% and class III was 36%, making the comparison difficult.
Type of family: A significant statistical correlation was found between the type of family and emotional problems during pregnancy and postpartum period in our study (P < 0.05) [Table 5]. This finding is consistent with the findings of previous studies, which also found an increased risk of emotional problems in nuclear families having poor availability of people to depend on during pregnancy and postpartum period.[20,21,22]
Age of menarche and menstrual disturbances: No statistical correlation was found either with the age of menarche or with a history of menstrual disturbances. This finding is consistent with the findings of one study,[13] though other studies had a contrary finding.[23,24]
Hemoglobin: A significant statistical correlation was found between the level of hemoglobin and emotional problems in women. A similar finding was reported by earlier studies.[23,24]
Complications of pregnancy: No significant correlation was found between emotional problems and various complications of pregnancy such as high blood pressure and gestational diabetes. This was in agreement with three earlier studies[18,25,26] though one study had found a significant correlation.[27]
Parity: In our study, multiparity was found to be a risk factor for emotional problems during pregnancy and post partum period [Table 6]. Risk increases with an increase in parity. We had 26 P3 (out of 42), 10 P4 (out of 16), and 4 P5 (out of 4) subjects having emotional problems. A similar finding was reported by one study,[26] though other studies did not find any relation.[13,18]
Table 6.
Association between parity, live births, and emotional problems in the study group
| Variables | Emotional problems |
Chi-square test | P | |
|---|---|---|---|---|
| Present | Absent | |||
| Parity | ||||
| P1 | 36 | 94 | Fisher’s test | P=0.000 |
| P2 | 8 | 66 | ||
| P3 | 26 | 16 | ||
| P4 | 10 | 6 | ||
| P5 | 4 | 0 | ||
| Live births | ||||
| 0 | 38 | 102 | Fisher’s test | P 0.000 |
| 1 | 12 | 68 | ||
| 2 | 26 | 12 | ||
| 3 | 4 | 0 | ||
| 4 | 4 | 0 | ||
| Abortion | ||||
| 0 | 74 | 166 | 3.87 | P 0.168 |
| 1 | 10 | 12 | NS | |
| 2 | 0 | 4 | ||
| Stillbirth | ||||
| 0 | 80 | 178 | 1.29 | P 0.255, |
| 1 | 4 | 4 | NS | |
| Mode of delivery | ||||
| Normal | 46 | 128 | 6.16 | P 0.013, |
| Cesarean | 38 | 54 | S | |
| Pregnancy planned | ||||
| Yes | 41 | 59 | 6.58 | P 0.01, |
| No | 43 | 123 | S | |
| Rituals Followed | ||||
| Yes | 66 | 156 | 2.12 | P 0.145, |
| No | 18 | 26 | NS | |
| Sex of child | ||||
| Male | 45 | 97 | 0.002 | P 0.967, |
| Female | 39 | 85 | NS | |
Pregnancy and delivery complications: The finding of a lack of association between pregnancy and delivery complications with emotional problems in our study is in agreement with the findings of two large independent studies.[25,28] In addition, one study reported no association between obstetric history, labor and delivery, complications of pregnancy, and postpartum depression.[26] However, one study reported that women with severe antenatal complications were more likely to develop postpartum depression than those without complications.[29]
Mode of delivery: The present study found a significant correlation between lower-segment cesarean section and emotional problems, which is consistent with the findings of earlier studies.[26,30,31]
Planned/unplanned pregnancy: The most striking finding of our study is an association of planned pregnancy with emotional problems. Earlier studies had concluded that unplanned pregnancy was a risk factor for developing postpartum depression.[25] The discrepancy of this finding in our study could be due to the following characteristics of our subject group. Out of 300 subjects, 118 had a planned pregnancy. Out of these 118 women, only 16 were primipara, while the other 102 were multipara. Out of these 102 women, 76 already had 2 or more children. The majority of these women wanted a preferred sex of the baby. Their expectancy of the pregnancy outcome was high. They were more worried about the social consequences of delivery and the future of their children. Their average age was more in comparison with their counterpart further adding up to the health problems like anemia and obstetric complications. On the other hand, most of the primiparous women had unplanned pregnancies and low expectancy.
Sociocultural practices: No significant correlation was found between sociocultural practices and emotional problems, consistent with the findings of one study.[32] However, other studies mention cultural rituals as a protective factor against postpartum depression.[33,34]
Preferred sex of the baby: There was no statistical association between the preferred sex of the baby and emotional problems. This is in agreement with other studies.[13,18] On the other hand, a few studies concluded that constant pressure to bear a male child may predispose postpartum depression.[12,22]
Limitation
The second interview was carried out four days after delivery. Symptoms of postpartum blues and depression developing after fourth day were probably missed. The third interview was carried out telephonically due to which the sensitivity of our screening tool may be reduced.
CONCLUSION
Psychiatric disorders during and postpartum periods were significantly associated: with higher parity, increased maternal age, low hemoglobin levels, cesarean section, planned pregnancy, and extended family. Postpartum blues was associated with higher parity and low blood pressure.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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