Postnatal Depression and Associated Factors among Puerperal Women in Lahore City, Pakistan: Analytical Cross-Sectional Study

Postnatal Depression (PND) is defined as the presence of at least five of the following symptoms for a continuous period of about two weeks in puerperium: feeling low, sudden increase or decrease in weight, disturbed sleep pattern, irritability, inability to focus, lack of ability to make decisions and suicidal thoughts or tendency to commit suicide [1]. Becoming mother is a complex process and includes remarkable variations in mental, communal and functional domains so is associated with enhanced tendency to suffer from mental diseases [2,3]. 

In developed countries the frequency of Post-natal depression is found to be approximately 13% [4]. A meta-analysis was done on post-natal depression that included 25 studies, out of which 10 studies were conducted in countries belonged to continent Africa and it concluded that rate of PND was higher in developing countries compared to developed countries. Another review of 35 PND studies done in Africa assessed prevalence of pre-natal depression to be 11.3% while post-natal depression as 18.3% [5,6]. Similarly, another meta-analysis including 13 studies estimated prevalence of PND as 19.8% in developing countries [7,8]. 

Many factors have been identified that are known to play a vital role in onset of PND. Women who undergo difficult labour or suffer from labour for increased length of time, have high intensity pain or need medical aid in delivery(vacuum forceps) are likely to face stress and are more vulnerable to develop Post-natal depression(PND) [9,10].Women who become mother for first time have less confidence and have ambiguities and fear of unknown in mind and these factor interact to expose her to PPD [10].Some more factors like less age of mother, have a little or no education and  low socio-economic status can lead to development of depression in post-natal period [11,12]. 

PND has become an emerging issue of community health that needs attention to be addressed and it is estimated that it will be the disease-causing highest morbidity and death rate due to suicides by year 2020 [13]. It is one of most dreadly consequences of birth of baby and is related to deficiencies in bonding of baby with mother and can have adverse effects on baby in the form of increased visits to hospital, delayed milestones and mental retardation [14].The present study had objective to find prevalence of PND and factors that are related to its onset in mothers during post-partum period in Lahore, Pakistan.

Study design, setting and population

This study was conducted as a population based cross sectional study from May to August, 2019 at primary health centres (PHCs) and comprehensive/secondary health facilities in Lahore. The definition of puerperium or post-partum depression according to WHO is the period beginning from one hour after delivery of placenta and continues for a period of six weeks [15]. All women in the study area irrespective of whether they are a resident of the village or   accessing postnatal clinics either for immunization services or check-up were enrolled in the study. The present study enrolled women who were at four to twelve weeks post-partum.  Many other related studies have also included women at similar duration of post-partum period [16]. 

Women with already known depressive disorder on history of chronic medical disorders (Diabetes Mellitus, Hypertension, Rheumatoid arthritis and Cancer on history) were excluded from the study.

Sample size and determination procedure

The sample size in this study was estimated using a single proportion approach. Considering 11.3% Post-natal depression prevalence and with 5% margin of error and 95% level of significance, the calculated sample size was 155 [17]. Sampling method used was Non-probability convience sampling. The post-natal mothers who were visiting   postnatal clinics either for immunization services or check-up and agreed to participate in our study were interviewed by the researcher.

Data collection

Outcome variables

Depressive symptomatology was assessed in women during puerperium by means of Edinburgh Postnatal Depression Scale (EPDS) [18]. It is a questionnaire that includes 10 questions and estimates depression of the person being assessed for a period of seven days before the evaluation. The answers are given scores within a range of 0-3; higher score shows that person is having more symptoms of depression. The maximum score of EPDS is 30.A number of studies report that EPDS has good mental illness detecting properties and also has got very good sensitivity and specificity. A woman having score 12 or more on EPDS is likely to have depression [19-22]. EPDS has remarkable validity and reliability. In current study we used EPDS score of 13 or more to be indicator of depression. An EPDS score of 13 in hospitals also is a level sufficient to indicate women with PPD [23].  But the women at EPDS score of 13 require additional assessment by psychiatrist. EPDS can be given to participants for filling them individually but interviews with the help of directions of researcher is similarly effective [24].

Measures of associated factors

Based on the findings of previous studies, we assessed the associated factors of depressive and anxiety symptoms in postpartum women [25,26]. Maternal demographic characteristics such as age, marital status, level of education, residence and standard of living. Pregnancy and Birth-related Factors include health facility type attended, parity, no of miscarriages & still-births, Number of live children, gender of child, mode of delivery, wish to have last pregnancy, plan with husband to have last pregnancy and medical care during birth. All were collected through standard questions.

Data analysis

Data was processed and analysed by means of spss 24. Respondent’s background characteristics were evaluated by use of percentages, means and standard deviation.  A cut-off value of 13 was set for existence of depression. Pearson Chi-square test was applied for evaluating relationship between PPD   and relevant risk factors. All variables at p-value of less than 0.05 were considered significant.

Ethical Consideration

Permission was taken for data collection from ethical committee of Punjab University Lahore, Pakistan. The aim of study was told to participants and informed consent was taken from them in written form. Inclusion of participants in our research completely based upon their willingness. Carefulness was observed to sustain Privacy of whole acquired material and names of participants was not mentioned on the questionnaires in order to ensure the confidentiality.

Demographic characteristics of respondents

The mean age of the sample was 29.37 years (SD=4.237) and range of ages was 20 -45 years. According to the study results, more than half of the study participants (96%) were married, 54.2% was belong from rural residence and 24.4% were illiterate. The result of present study showed that 38.7% had secondary education and 63.2% had low standard of living (Table 1).

Table 1: Demographic Characteristics of respondents.

Pregnancy and Birth-related Factors

According to the study results, 71.8% deliveries were take place at health facility, 72.9% respondents were multigravida, and 80.1% had no history of miscarriages and still-births while 52.9% of study participants had more male babies. The mode of delivery was SVD in 63.9% women while 58.70% received medical care during birth (Table 2).

Table 2: Pregnancy and Birth-related Factors. 

Prevalence of Post-natal Depression among the Women

The prevalence of depression among the study women (an EPDS score of 10 and above) was found to be 48.3% (75/155). The prevalence of major depression (a score 13 and above) was found to be 31.6% (49/155) (Table 3). 

Table 3: Edinburgh postnatal depression scale score of the study women (n=155). 

The demographic characteristics of age (p-value=0.001), educational status (p-value=0.001) and residence (p-value=0.001) were found to be associated with the prevalence of postpartum depression (Table 4). 

Table 4: Prevalence of postpartum depression based on demographic characteristics. 

Based on delivery characteristics, place of birth, mode of delivery and gender of children were found to be associated with the prevalence of postpartum depression section (p < 0.05) (Table 5).

Table 5: Prevalence of postpartum depression based on delivery characteristics.

Psychiatric illnesses were highest contributor adding to Global Burden of Disease (GBD) as evident from 1990 and 2000 studies. As said by World Health Organization (WHO) psychiatric diseases would be second highest contributor to global burden of disease by 2020.PND is affecting ladies of low income countries more badly because of reduced focus on psychiatric problems and culture and traditions of these areas. In low-income countries reasons of maternal deaths are being stressed but factors leading to physical and mental illnesses are being ignored [27,28]. 

Depression is in constituent of global burden of diseases in developing countries. PND is a critical illness and is disturbing because it develops at stage when mother requires special and additional look after and care and this along with anxiety of memory of pain of birth expose her to threat of onset of depression. PND require focus because if it occurs mother becomes dependent for her care and also for look after of baby on others. Frequency of depression found in present research is 31% which is same as in other studies done in South Asian countries but very high compared to developed countries. The prevalence of depression in this study was different from that found in the studies done in Pakistan (23%), Bangladesh (22%), North Gonder (24.1%) and Bahir Dar (21.5%) [31-33]. 

The mean age of the sample was 29.37 years (SD=4.237) and range of ages was 20 -45 years. According to the study results, more than half of the study participants were married, belong from rural residence and were illiterate and 63.2% had low standard of living [34-36]. It may be because of design of current study which is cross-sectional and change in methodology, period in which data was collected in relation to delivery and also variations in living circumstances of women being studied. In reference to demographic characteristics, our results showed a strong association between age, educational status and residence and possibility to develop the prevalence of postnatal depression. These findings are consistent with the previous studies who reported an association between mothers’ sociodemographic factors and depressive disorders [38-40]. This can be explained on the basis of low levels of education in women living in villages, exploitation and misconduct by health-care providing staff in the course of delivery and obstructions to good quality health centres in Pakistan. 

With respect to delivery characteristics, place of birth, mode of delivery and gender of children were found to be associated with the high prevalence of postpartum depression [41-43]. Different geographic regions and cultures have variable priorities for desired gender of the new-born. Researches done in India and China indicated that risk of PPD increase if the newborn is female by gender [45,46]. Some studies show that mode of delivery is also linked to risk of onset of depression like ladies who underwent vaginal delivery were more prone to suffer from depression compared to ladies who gave birth by C-section. This may be explained by the fact that women with vaginal births started their household chores and took responsibilities earlier compared to ladies with c-section who enjoyed longer rest periods. 

Many researchers suggest that increase in provided care and look after reduces frequency of PND and aids in detection of PND at initial stage. PND results in reduced collaboration of mother with baby, husband, family and society. The above-mentioned factors need to be addressed drastically to decrease prevalence of disease. Because of recent distressing frequency and assumed enhanced increase disease burden in coming days community must be made alert of the indications of the PND for diagnosis at an early stage to improve outcome.

The current study puts stress on postnatal depression which is a neglected issue of our society. The strength of study is that all the tests, scales and instruments used for evaluation of study variables have good ability to detect psychiatric issues. There are a few confines faced by our research. Medical therapy within 42 days of birth of baby is received commonly by women of low- and middle-income groups. So, the results of present study cannot be generalized to upper class as there can be a difference of social, psychological and life-style. EPDS was used for evaluation and detection of depression in ladies during post-natal period. It is a standard questionnaire. Though EPDS is having high sensitivity and specificity and can easily be applied by a health care personnel yet depression should be confirmed by clinical assessment once a participant is suspected by EPDS to be suffering from depression. Being a cross-sectional study, number of women with depression was small we, cannot generalize the result of present study.

The results of present study concluded that PND is highly prevalent issue which indicates that it is a problem of public health importance. It is suggested that gynae department should be equipped with trained midwives; nurses etc that can guide mother and attendants about initial symptoms of PND and about danger signs that need medical intervention. MCH programme should screen depression routinely in expecting ladies (by collaboration with psychiatry department) as researches show that women who develop PND are at high risk of having prenatal depression.

Drafting of the manuscript: Rabia Nazim, Khadija Tahira, Khunsa Junaid, Hassan Ali, Concept and design of study or acquisition of data or analysis and interpretation of data: Shoaib Muhammad, Taimoor Akram Khan, Aabish Mehreen Khan, Ali Akram Khan. Critical revision of the manuscript for important intellectual content and final approval of the version to be published: all authors.

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

The authors are grateful to the women for their participation in the study, and to their teachers for their assistance with collecting the data. There were no funding sources.

The authors declare that there is no conflict of interest.