Relationship between levels of postnatal depression and its correlates; neonate’s birth order and mother’s age among new mothers

ABSTRACT

Context:

Postnatal depression (PND) is a well-known cause of distress among new mothers depicting a significant public health problem affecting women, neonates, and the family.[1] During the postnatal period, there is a rise in the physical and emotional pressure on the mother, and the exhaustion associated with PND may affect her capacity as a mother to provide love and care to the newborn.

Aims:

To study the relationship between the levels of PND and new mothers’ age and birth order of the neonates.

Settings and Design:

Hospital setting and cross-sectional research design.

Methods and Material:

The cross-sectional study was conducted on 100 new mothers in the first week of their delivery by administering the Telugu version of the Edinburgh Postnatal Depression Scale (EPDS).

Statistical Analysis Used:

The data was analyzed using SPSS 27 (2019) for ANOVA, F test, and Chi-square test.

Results:

The majority (90%) of mothers had moderate PND with EPDS scores between 11–20 and 6% had high PND with EPDS scores between 21–30 and the sample mean EPDS scores ranged from 1.23 to 2.14. The results of the one-way analysis of variance indicated that the sample did not differ significantly (P = 0.5 and P > 0.05) in their levels of EPDS scores with regard to their age. On the contrary, there was a significant association found between the birth order of the neonate and levels of PND of new mothers (n = 100) under study.

Conclusions:

The findings of the study reiterates that the levels of PND among new mothers had no relationship with their age but showed a strong relationship with their neonate’s birth order and recommends screening new mothers for PND.

Introduction

To assess the levels of post-natal depression among new mothers and to examine the relationship between mothers age, birth order of newborn and postnatal depression (PND). Postnatal depression (PND) is a well-known cause of distress among new mothers depicting a significant public health problem affecting women, neonates, and the family.[1] During the postnatal period, there is a rise in the physical and emotional pressure on the mother, and the exhaustion associated with PND may affect her capacity as a mother to provide love and care for her newborn. In certain cases, the mother may be disinterested and may even neglect the child.[2] Postpartum depression can begin immediately after childbirth or may continue as an antenatal depression that requires treatment.[2] The world prevalence of postpartum depression has been assessed as 100‒150 per 1000 births.[3] Postpartum depression can lead to debility related to chronic depression, which may influence the postnatal women’s relationship with infant and child growth and development.[2,4,5,6] Children born to mothers having postpartum depression have significant cognitive, behavioral, and interpersonal problems when compared to children born to normal mothers.[4,5] The findings of a meta-analysis in developing nations revealed that the children born to mothers with postpartum depression were at higher risk for underweight and stunting.[5] In addition, depressed mothers are predisposed to discontinue breastfeeding their infants and avoid seeking health care services properly.[4] Maternal postpartum depression is found to be associated with unfavorable psychological outcomes in children till the age of 10 years or more.[7] The postpartum depression is an important health issue for many women, but this disorder continues to remain undiagnosed and thus untreated.[2,8] In India new mothers are not assessed for levels of PND in maternity and pediatric hospitals/clinics/wards as part of their regular protocol. There is every need to screen all postnatal mothers for depression by integrating screening for PND and coordinating this assessment as a protocol with the Psychiatry departments in those Tertiary care hospitals.

Materials and Methods

Study setting and design

A cross-sectional study was conducted on 100 new mothers who were in their first week of the postnatal period attending Maternity and Paediatric clinics in two tertiary care hospitals in Tirupati (AP) in the first quarter of 2019.

Study duration

The study was conducted for 3 months in the first quarter of 2019 in Tirupati (AP).

Sample frame and size

The study was carried out on a sub-sample (n = 100), from the sample selected for doctoral research having Institutional Ethical Clearance from Sri Padmavati Mahila Visvavidyalayam (SPMVV), Tirupati (AP). All the hundred new mothers who were willing to participate in the study were assessed for PND using Telugu version of the EPDS (Cox et al., 1987)[10] under the supervision of a psychiatrist.

Data collection

The EPDS has 10 items rated on a four-point scale and the items 1, 2, and 4 are scored from 0 to 3, the remaining seven items are reverse scored from 3 to 0. This scale is extensively used for screening PND among new mothers. The 10-item EPDS English version was translated into Telugu (vernacular language) and retranslated into English and then standardized by testing on a sample of 40 postnatal mothers (which was not included in the final study) for reliability using Chronbach’s Alpha coefficient (α =0.86). Based on their EPDS scores, the study sample was categorized into three groups: low (0–10), moderate (11–20), and high (21–30) levels of PND.

Data analysis

The data collected, including mothers’ age, birth order of the newborn, and EPDS scores of the mothers, was subjected to statistical analysis using SPSS 27 (2019) for analysis of variance (ANOVA), F test, and chi-square test to study the association and difference among the sample with reference to; their age and EPDS, birth order of the neonate and EPDS scores.

Results

The research data was analyzed to study the difference among the mothers with regard to their age, birth order of the neonate, and EPDS scores of the sample using ANOVA to test the null hypothesis; “age of the mothers and birth order of the neonate has no relationship with the levels of PND among new mothers”. The mean scores for each item on the EPDS scale and total scores were displayed in Figure 1, which reveals that the minimum mean score was 1.23 for item 1 and the maximum mean score was 2.14 for item 6. The sample was categorized based on their EPDS scores into two groups as reflected in Table 1, as mild to moderate level of depression (<20):94% and high level (21–30): 6% as a high level of depression The difference among the postnatal mothers was studied with reference to their EPDS scores and their age and birth order of neonate using one-way analysis of variance the findings were presented in Table 2. The sample did not differ significantly (P > 0.05) concerning their age and levels of EPDS, on the contrary, they differed significantly (P < 0.005) with regard to the birth order of their neonate.

Figure 1.

Distribution of sample according to their EPDS scores

Table 1.

Levels of PND among new mothers

Levels of depression	Frequency	percentage
Mild to moderate <20	94	94
High score 21-30	6	6
Total	100	100

Table 2.

Difference among mothers with regard to their age and birth order of neonates

Predictor variable	Classification	Frequency	Percentage (%)	Mean	SD	F	P
Mother’s age	21–25	47	47	25.71	2.65	6.7173	0.5
	26–30	45	45
	31–35	8	8
Total		100	100
Birth order	1	42	42	16.17	2.97	14.28	0.005
	2	58	58
	3	0	0
Total		100	100

In addition, the F critical value was calculated by employing the F test, as the F critical value (5.143253) is specific to compare with the F-value (4.28209), to reject a null hypothesis as it is greater than the F critical value, as shown in Table 3. Furthermore, the mean between groups (8553.943) was greater than the mean within groups (1796.784) and the P value was significant (P < .005), which allows to reject the hypothesis.

Table 3.

Difference between and within groups with respect to predictor variables and EPDS scores (n=100)

Source of variation	SS	df	MS	F	P	F critical value
Between groups	8553.943	2	4276.971	14.28209	0.005231	5.143253
Within groups	1796.784	6	299.464
Total	10350.73	8

Similarly, the association between the two independent variables namely; the age of the mothers and the birth order of the child, and the criterion variable ‘the levels of PND’ was also examined using a chi-square test as shown in Table 4. The Table 4 denotes that there was no association (P = 0.5) found between the mother’s age and levels of PND, in contrast, there was a significant association (P = 0.005) found between the mother’s EPDS and birth order of neonates.

Table 4.

Association between mother’s age, birth order of neonate and levels of PND among new mothers

Predictor variables	Levels of PND among mothers			Total	Chi-square value	P
	Low <10	Medium 11-20	High 21-30
Age of mothers
21–25 years	1	46	0	47	9.547	0.5
26–30 years	1	44	0	45
31–35 years	2	0	6	8
Total	4	90	6	100
Birth order of the neonate
Firstborn	2	38	2	42	7.0409	0.005
Second born	2	52	4	58
Third born	0	0	0	0
Total	4	90	6	100

Discussion

The present study focused on levels of PND among women who delivered their babies recently (within the first week) and examined the relationship between their EPDS scores levels and their age and birth order of the neonate. Based on the EPDS scores the sample was categorized as; low to moderate PND:<20 and high PND: 21–30, care was taken to examine the score for item 10 (suicidal thoughts).

The mean EPDS scores of new mothers: The 10-item EPDS is the most popularly used PND screening tool in perinatal care; the cut-off values of 10 or higher and thirteen or higher are most often used to identify mothers with depression.[9,10,11,12,13] The Figure 1, reflects the mean EPDS scores of new mothers for each item, the sample lowest mean score (1.23) was for item 1 (I have been able to laugh and see the funny side of things) and the highest mean score (2.14) was for the item 6 (things have been getting on top of me), thus the EPDS mean scores ranged from 1.23 to 2.14. The sample mean score for the most important item 10 (the thought of harming myself has occurred to me) was 1.43 and four mothers scored 3 for this item, who were referred for further investigation and treatment to the Psychiatrist. Levis et al. (2020)[14] found that a cut-off value of eleven or higher for the EPDS score enhanced combined sensitivity and specificity. In clinical practice and trials other cut-off values could be used, in case either sensitivity or specificity is to be chosen.

Mother’s age and levels of EPDS scores: In the present study the sample age ranged from 21 to 35 years and most of them had mild to moderate EPDS scores of less than 20 and 6% had scores between 21 and 30, indicating PND. Table 2, reflects the results of a one-way analysis of variance indicating that the sample did not differ significantly (P = 0.5 and P > 0.05) in their levels of EPDS scores with regard to their age.

Similarly, the findings from the chi-square test presented in Table 4 also denote that there was no significant association ((P = 0.5 and P > 0.05) found between the new mothers’ age and their levels of EPDS scores. This allows to accept part of the null hypothesis “There is no relationship between the age of the mothers and levels of PND”. Contrary to these findings, the results of ANOVA test conducted showed [Table 3] that the F-value (14.28209) was greater than the F critical value (5.143253) and the P value was 0.005 (P < 0.005), which allows to interpret that the variation between groups was greater than that of within groups, which also suggests rejection of null hypothesis. Considering the results of one-way analysis of variance [Table 2] and the chi-square [Table 4] tests, where the P value (P > 0.5) is not significant at 0.05, the null hypothesis” there is no relationship between the age of the mothers and levels of PND is accepted. The findings of a few studies[3,15,16] indicate that age of mothers and the age of the child were PND predictors; the higher the age of mothers, the lower their PND levels. This may be certainly attributed to higher levels of life experience and maturity. On the contrary, a review of several studies suggested a higher risk of depression in women of advanced maternal age.[17,18,19] This enhanced risk has been accredited to a number of factors, like the older women’s perception of the difficulties expected with regard to experiences and adjustments to be made during their motherhood.[20] Furthermore, the increased levels of depression among older women may be attributed to their fears regarding the biological process of childbearing and the pregnancy outcome.[21]

Birth order of neonates and levels of PND among the sample: The birth order of the neonate explains the mothers’ experience or lack of experience with the delivery process and related apprehensions. PND was found to have a strong relationship with the existence of antenatal depression.[3,22,23,24,25] and continues to be associated with the stress of parenting.[25]

Depression has been recognized as one of the health complications that occur in prenatal and postnatal women and found to have 10–15% prevalence among women of reproductive age.[26,27] Familiarity with the childbirth and mode of the delivery process may influence stress levels among women. Hence, the birth order of the neonate was included as an independent variable and its relationship with the mothers’ PND levels was studied using the F test and X2 test. The findings displayed in Table 2, indicate that there was a significant difference (P = 0.005 and P < 0.005) among EPDS scores of mothers and their neonates’ birth order. Similarly, there was a significant association found between the birth order of the neonate and levels of PND of new mothers (n = 100) under study.

These results recommend rejection of the null hypothesis that there is no relationship between the new mothers’ levels of PND and their neonates’ birth order. The PND is not only distressing for the new mother, but also affects the capacity of mother in providing care and performing her mothering role.[27,28,29]

Conclusions

The cross-sectional study conducted on 100 new mothers in the first week of their delivery by administering Telugu version of EPDS in two tertiary care hospitals in Tirupati (AP) revealed that the majority (90%) of mothers had mild to moderate PND with EPDS scores less than 20 and 6% had high PND with EPDS scores between 21 and 30 and the sample mean EPDS scores ranged from 1.23 to 2.14. the results of the one-way analysis of variance indicated that the sample did not differ significantly (P = 0.5 and P > 0.05) in their levels of EPDS scores with regard to their age. Similarly, the findings from the chi-square test presented in Table 3 also denote that there was no significant association (P = 0.5 and P > 0.05) found between the new mothers’ age and their levels of EPDS scores. This allows to accept part of the null hypothesis “there is no relationship between the age of the mothers and levels of PND”.

On contrary, there was a statistically significant association (P < 0.005) found between the birth order of the neonate and the levels of PND among the new mothers and the sample differed significantly in their EPDS scores with reference to the birth order of their neonates, which recommends rejection of null hypothesis “there is no relationship between the new mothers’ levels of PND and their neonates’ birth order”. Thus, the findings of the present study reiterates that the levels of PND among new mothers had no relationship with their age but showed a strong relationship with their neonate’s birth order.

Recommendations

This research recommends screening new mothers for levels of PND by integrating this assessment using EPDS in the regular protocol of every maternity hospital and including referral services to the Psychiatry department for further assessment and treatment.

Declaration of informed consent of the patients

All the participants of the pilot and main study gave informed consent

Ethical approval

The study was accorded Ethical Committee IEC no. SPMVV/Acad/IEC/CI/III/2019.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.