- Email: [email protected]
Depression and its risk factors among pregnant women in 2008 Sichuan earthquake area and non-earthquake struck area in China
Journal of Affective Disorders 151 (2013) 566–572
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Depression and its risk factors among pregnant women in 2008 Sichuan earthquake area and non-earthquake struck area in China Xuehan Dong a, Zhiyong Qu b,n, Fangnan Liu a, Xiaoing Jiang a, Yang Wang a, Cheryl Hiu Kwan Chui c, Xiaohua Wang b, Donghua Tian b, Xiulan Zhang a a
School of Social Development and Public Policy, Beijing Normal University, Beijing, China School of Social Development and Public Policy, China Institute of Health, Beijing Normal University, Beijing, China c Department of Social Work and Social Administration, University of Hong Kong, Hong Kong, China b
art ic l e i nf o
a b s t r a c t
Article history: Received 14 March 2013 Received in revised form 26 June 2013 Accepted 26 June 2013 Available online 18 July 2013
Background: On May 12, 2008, a powerful 8.0 magnitude earthquake struck China's Sichuan province. While some studies have assessed the mental and physical wellbeing of disaster victims, few have examined the long-term impact of natural disasters on pregnant women's mental health. As such, this study aims to assess whether the Sichuan earthquake continues to negatively affect women's mental health, 4 years since its occurrence. In addition, predictive and protective risk factors of depressive symptoms among pregnant women were also identified. Methods: From June 2012 to October 2012, 520 pregnant women were interviewed, of whom 253 were from an earthquake struck area and 267 were from a non-earthquake struck area. Symptoms of antenatal depression were measured using the Edinburgh Postnatal Depression Scale (EPDS) with a cutoff of≥10. Results: The prevalence rate of depression among pregnant women in the earthquake area was 34.5% (95% CI, 28.9–40.6), while the rate in the non-earthquake area was 39.6% (95% CI, 33.9–45.5). The perceived stresses associated with pregnancy and social support from husbands are significantly correlated with antenatal depression. Limitations: Lack of diagnosis for antenatal depression and it is a self-report evaluation. Conclusions: This study found that the Sichuan earthquake does not necessarily have a long-lasting effect on pregnant women who were once victims of the disaster. It was found that pregnant women who experience high levels of pressures from the pregnancy and receive medium support from husbands are more susceptible to experience antenatal depression than pregnant women who perceive higher levels of support from husbands. & 2013 Elsevier B.V. All rights reserved.
Keywords: Sichuan earthquake Pregnant women Depression Mental health
1. Introduction On the afternoon of May 12, 2008, an earthquake measuring 8.0 on the Richter scale hit Sichuan province in western China. One of the many consequences of natural disasters is the negative impact on health and wellbeing. Previous studies have shown that mental health disorders such as post-traumatic stress disorder (PTSD), depression and anxiety are common psychological symptoms following natural disasters (Ehring et al., 2011; Grant et al., 2008; Harville et al., 2009a; Kar and Bastia, 2006; Onder et al., 2006). Unsurprisingly, these symptoms were also identified among victims of the Sichuan earthquake. For example, Wang and associates (Wang et al., 2009a) found that the prevalence rates of PTSD among the earthquake survivors were between 13.0% to
n
Corresponding author. Tel.: +8610 5880 1518; fax: +8610 5880 0366. E-mail address: [email protected] (Z. Qu).
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2013.06.048
84.8%, while Fan and associates(Fan et al., 2011) observed that the prevalence rates of PTSD, anxiety and depressive symptoms were 15.8%, 40.5%, and 24.5% respectively 6 months after the earthquake. Additionally, there are several studies that illustrate how natural disasters may affect their victims differently as time lapses. One study conducted among survivors over 16 years of age in Taiwan (Chou et al., 2007)showed that the prevalence of major depression decreased from 11.6% to 6.9% at 2 years and to 6.5% at 3 years after the Chi-Chi earthquake. The prevalence of PTSD or major depression was higher in the first 2 years, then significantly decreased in the third year. Similarly, in a sample of 957 adults survivors of the 2009 earthquake in L'Aquila, Italy, Gigantesco (Gigantesco et al., 2013) reported that more than one year after the earthquake, the prevalence rates of PTSD and major depression (MD) were 4.1% and 5.8% respectively. Psychological symptoms are frequent even 14–19 months after the L'Aquila earthquake.
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Another study (Chan et al., 2012) indicated that the estimated rates of clinically significant PTSD and depressive symptoms among bereaved survivors approximately 7.5 months after the 2008 Sichuan earthquake were 50.2% and 55.8% respectively. While some studies indicate that psychological symptoms tend to abate with time, some studies suggest otherwise. For example, a study (Zhang et al., 2011) found that among 1195 adult earthquake survivors in the Sichuan earthquake, PTSD, anxiety and depression remained at an elevated level 1 year after the earthquake. These observations were particularly acute in areas that were hard-hit by the quake. Despite these illuminating results, few researches have examined the impact of natural disasters on mental health beyond the first or second year since the occurrence of the disaster, and even fewer have investigated how disasters can affect pregnant women in the long-run. Nevertheless, several studies have shown that pregnant women's overall mental and physical health were significantly related to the severity of their experiences with natural disasters (Chang et al., 2002; Harville et al., 2009a; Xiong et al., 2008). These one-time, cross-sectional studies, however, were conducted within one or two years of the earthquake and therefore lack a long-term perspective. Only two studies conducted by Qu and associates (Qu et al., 2012a, 2012b) have assessed the mental health impact of the Sichuan earthquake on pregnant women at different time intervals. It was posited that the incidences of depression and PTSD were still high among pregnant women at 6 and 18 months after the earthquake. Aside from the lack of time-perspective, another limitation of previous studies on the effects of disaster on pregnant women's mental health is the lack of comparison group from areas that were not struck by disaster. As such, the objectives of the present study are: (i) to analyze whether the Sichuan earthquake has continued to negatively impact pregnant women's mental health even after 4 years since the disaster; (ii) to compare the mental health of pregnant women who experienced the earthquake with pregnant women who did not; and (iii) to identify and examine the predictive and protective risk factors of depressive symptoms among pregnant women.
2. Methods 2.1. Study design and participants An exploratory and comparative cross-sectional survey was conducted in Mianzhu County and Gaobeidian County. The former area is located about 30 km away from the epicenter while the latter area is a county of Hebei province, which is not struck by the 2008 Sichuan Earthquake. It was chosen as a comparison group. The study was sponsored by the Project 985 fund of Beijing Normal University and was approved by the institutional review board of the School of Social Development and Public Policy at Beijing Normal University. Ten volunteers who were divided into two teams were trained to collect data for the present study. These volunteers were graduate students who majored in psychology. They attended a two-days training course before conducting the interview. Data was collected twice, once in June 2012 and once in October 2012, with each data collection period lasting for about 8 days. A self-rating questionnaire was distributed to pregnant women who were receiving routine prenatal care at three hospitals. They completed the self-report instruments in approximately 30 min, while waiting for a routine antenatal check-up. Informed oral consent was obtained from participators in the study, and the aim and significance of the survey were explained in detail.
567
Participants from Mianzhu were interviewed in the Mianzhu People's Hospital and the Mianzhu Maternal and Child Health Hospital, where nearly 70% of the pregnant women in this county receive antenatal care and post-delivery services. Participants from Gaobeidian were interviewed in Gaobeidian County's Hospital, where nearly 50% of the pregnant women in this county receive antenatal care and post-delivery services. Nonprobabilistic convenience sampling was adopted because of resource constraints. 530 pregnant women at 13 to 28 weeks' gestation agreed to participate in the interview. Among them, 254 were from Mianzhu County, 276 were from Gaobeidian County. A total of 520 (98.1%) women completed the depression assessment. 2.2. Main outcomes measures Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). The EPDS developed by Cox and associates(Cox et al., 1987) consists of 10 items, each of which is a 4-point Likert scale. The minimum and maximum total scores are 0 and 30, respectively. A Chinese version of the EPDS was tested and validated in Hong Kong and Sichuan, and demonstrated good reliability with a cutoff point score of ≥10 has been recommended (Lee et al., 1998; Wang et al., 2009a; Wang et al., 2009b). The EPDS has been used in other Chinese studies and has been found to be reliable in measuring prenatal and postnatal women's depression (Lau et al., 2010a, 2010b; Qu et al., 2012a). The internal consistency coefficient (Cronbach's alpha) of the EPDS was 0.70 in this study. 2.3. Risk factors measures Perceived pressures of pregnancy were rated using an 11-item self-assessment scale which was a short-form of Pregnancy Pressure Scale (PPS) developed by Zhanghui Chen et al., and the Cronbach's alpha coefficient was reported to be 0.84 (Chen et al., 1991; Qu et al., 2012a). It contains 3 subscales: (1) pressure from identification of the parents role; (2) pressure from the concerns of maternal and child health; (3) pressure from the change of the body shape or physical activities. The scale measured the perceived stresses of major pregnancy-related events using a 4-point Likert scale from 1 (none or little) to 4 (high). The mean score was used as an index of perceived stress. Possible stressful experiences included: fears about significant people disliking the baby, concerns about reduced leisure time with a baby, fears about the safe delivery of the baby, anxiety about birth defects, fears about complications during delivery, fears about pain during delivery, concern about changes in body shape, fears about competence as a mother, fears about the negative impact of the baby on the marital relationship, concerns about providing a healthy living environment for the child, and other pregnancyrelated stresses. Agreement on relationship matters such as finances were assessed by 8 items, and thoughts and feelings regarding the marriage and one's spouse were rated by 6 items. The two dimensions were chosen from the Locke–Wallace Marital Adjustment scale (Locke and Wallace, 1959)to measure the marital adjustment, whose validity and reliability have been confirmed in the Chinese population (Ying, 1991). Marital Satisfaction was estimated by the Kansas marital satisfaction scale (KMS), an assessment scale established by Schumm and associates (Schumm et al., 1986). It is a short, three-item direct measure of relationship satisfaction. Respondents describe their satisfaction with their spouse, their marriage, and their relationship with their spouse on a 7-point scale. The minimum and maximum total scores are 3 and 21. We used a Chinese version
568
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
(C-KMS) to estimate marital satisfaction which has been tested in a Chinese population and demonstrated satisfactory concurrent validity (Hong and Chan, 2002; Shek and Tsang, 1993). The Cronbach's alpha in this study was 0.93. Social support from husband, parents and parents-in-law were assessed by 3 questions, from 1(none) to 5 (full). The three questions consist of (1) How much support can you get from your husband? (2) How much support can you get from your parents? (3) How much support can you get from your parents-in-law? Participants were asked to assess their life satisfaction on a 7point scale, from 1 (strongly disagree) to 7 (strongly agree). Other socio-demographic and health behavior data were collected as part of this study, which included the participants' age (18–24 years; 25–29 years; ≥30 years), living situation (village/ city), level of education (primary school or lower; middle school; high school; college or above), parity (primigravida/others), monthly family income (USD o160; USD 160–320; USD 321– 801; USD ≥802), whether the pregnancy was planned (yes/non), the stage of gestation (12–28 weeks; 428 weeks), quality of sleep (poor, fair, good), smoking history (yes/non), their history of alcohol use (yes/non), body mass index (BMI) ( o23; ≥23), husband is migrant worker (yes/non) and employment status (unemployed; part-time job; full-time job). 2.4. Data analysis The SPSS 17.0 (SPSS Inc,Chicago,IL) was used for statistical analysis. The descriptive analyses of the data were performed for demographic characteristics (age, levels of education, living site, average household income, employment status), parity, gestation stage, planned pregnancy, sleep quality, BMI, husbandis migrant worker, smoking and drinking behaviors and depressive symptoms. Chi-square tests and bivariate correlate analysis were performed so as to examine the correlation between outcome variable and independent variables and socio-demographic factors. Multivariate logistic regression was employed to identify predictors of and antenatal depression. All estimates were accompanied by the odds ratios (OR) and 95% confidence interval.
3. Results As shown in Table 1, the mean age of the participants was 25.5 (min¼ 18, max¼42, standard deviation [SD] ¼3.9), most of the participants of Mianzhu (86.2%) and Gaobeidian (78.8%) were 18– 29 years old. Nearly 61.1% of women in the earthquake struck area completed at least high school, while only 42.6% of women in the non-earthquake area got at least high school education. Most participants (82.1%) had a family monthly income lower than 802 USD, and 80.3% resided in rural areas. More than half (52.3%) of the pregnancies in the earthquake struck area were planned, while less than half (48.8%) were planned in the non-disaster area. More than half of them (59.0%) were primigravida. Most of the participants were unemployed (86.8%), non-smoker (98.3%), and nondrinker (94.6%). Only 38.8% of the participants reported that they slept well. About a quarter (27.1%) of the sample were in the second trimester. Only less than a quarter (21.5%) of them had a normal weight. More than half (55.1%) of their husbands were migrant workers. It was also found that most women reported high levels of support from their husbands (87.4%) and parents (87.2%). The EPDS cutoff point recommended by the validity study was a score of ≥10. According to this criterion, the prevalence of depressive symptoms of pregnant women in the earthquake area (Mianzhu) was 34.5% (95% CI, 28.9–40.6). The prevalence of depressive symptoms of pregnant women in the non-earthquake
Table 1 Description and comparison of the variables between pregnant women in the earthquake area (Mianzhu) and non-earthquake struck area (Gaobeidian) (n¼ 520). Characteristics
Mianzhu(n¼252)
Gaobeidian(n¼ 268)
N
%
N
%
Age 18–24 25–29 ≥30
140 77 35
55.6 30.6 13.9
105 106 57
39.2 39.6 21.3
Education Middle school or lower High school College or above
98 111 43
38.9 44.0 17.1
154 61 53
57.5 22.8 19.8
Monthly family income(USD) o160 160–320 321–801 ≥802
20 75 112 42
8.0 30.1 45.0 16.9
20 54 141 50
7.5 20.4 53.2 18.9
Living site village City
219 33
86.9 13.1
197 70
73.8 26.2
Employment Unemployed part-time job full-time job
214 9 25
86.3 3.6 10.1
227 11 22
87.3 4.2 8.5
BMI o23 ≥23
62 173
26.4 73.6
41 204
16.7 83.3
Planned pregnancy Planned Unplanned
126 115
52.3 47.7
126 132
48.8 51.2
Gestation stage 13–28weeks 428weeks
77 159
32.6 67.4
48 177
21.3 78.7
Parity Primigravida Others
147 105
58.3 41.7
159 108
59.6 40.4
Sleep quality Poor Fair Good
23 129 100
9.1 51.2 39.7
21 145 102
7.8 54.1 38.1
Smoking history Non Yes
246 6
97.6 2.4
265 3
98.9 1.1
Alcohol use history Non Yes
235 16
93.6 6.4
256 12
95.5 4.5
Husband is a migrant worker Yes Non
143 98
59.3 40.7
134 128
51.1 48.9
Social support from husband Lower Medium Higher
2 24 224
0.8 9.6 89.6
5 33 221
1.9 12.7 85.3
Social support from parents Lower Medium Higher
5 22 224
2.0 8.8 89.2
6 32 220
2.3 12.4 85.3
Social support from parents-in-law Lower Medium Higher
18 42 188
7.3 16.9 75.8
19 59 180
7.4 22.9 69.8
Depression o10 ≥10
165 87
65.5 34.5
162 106
60.4 39.6
Note: some variables have missing value.
struck area (Gaobeidian) was 39.6% (95% CI, 33.9–45.5). The prevalence of prenatal depression was lower in the earthquake struck area (relative to comparison group).
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Table 2 and 3 show that the depressive symptoms of pregnant women were not correlated with region (p¼ 0.236). Depression was significantly correlated with sleep quality, social support from husband and parents, stresses of pregnancy, life satisfaction, marital satisfaction, thoughts and feelings regarding the marriage and one's spouse and agreement on relationship matters. Table 4 shows the final results of multivariate logistic regression analysis for predicting variables of antepartum depression. Variables were chosen based on previous researches indicating their potential impact on depression during pregnancy (Lancaster et al., 2010; Lee et al., 2007; Luke et al., 2009; Mirza and Jenkins, 2004). As shown in the table, significant risk factors for prenatal depression included stresses of pregnancy, general social support from husbands. The risk of depression grew as the stresses of pregnancy increased (OR, 1.15; 95% CI, 1.07–1.21; p o0.001). Women who receive medium levels of support from their husbands had a higher risk of depression than women who receive higher levels of social support from husbands (OR, 3.57; 95% CI, 1.37–9.57; p o0.001). Region was not significantly correlated with depression.
4. Discussion This study intends to identify the long-term impact of the Sichuan earthquake on the antepartum depression more than 4 years later. Findings indicate that compared with the general population living in the non-earthquake struck area, the incidence of depression among pregnant women in the earthquake area is not significantly different, suggesting that depression does not necessarily have long-lasting effects on pregnant women who once experienced the earthquake. This result can help researchers and health care professionals to better understand the long-term impact of natural disasters on pregnant women living in the earthquake area; it may also inform the development of modest disaster-related psychological health interventions to help care for these pregnant women. There are several interesting findings that warrant specific attention. Firstly, this study found that the prevalence rate of prenatal depression was 34.5% among pregnant women in earthquake struck area versus 39.6% among women living in Gaobeidian after 4 years the 2008 Sichuan earthquake. Compared with our previous study (Qu et al., 2012a), the prevalence of depression among pregnant women was also lower than the rate (40.8%) estimated in Mianzhu 18 months after the earthquake. This suggests that the impact of earthquakes on depression decreases significantly after a few years. One possible interpretation of this is that the Chinese government rapidly developed a national, multidisciplinary training program after the Sichuan earthquake (Ng et al., 2009) to improve the psychological well-being of pregnant women through psychosocial crisis intervention. Another possible explanation might be that post-disaster effects could reduce the incidence of long-term anxiety and depression for women who survived earthquakes (Jasim Anwar et al., 2011). However, in making this comparison, differences between this study and our previous study in terms of the diagnostic tools and sample size must be considered. Secondly, this study reveals the associations between the selected risk factors and the outcome variable regarding antenatal depression. Among all the variables investigated in this study, perceived pressures of pregnancy and medium levels of social support received from husbands were the only two variables that are significantly correlated with depression. The results are consistent with previous studies, which attributed social support as an important factor related to the depressive symptoms during
569
Table 2 The prevalence of prenatal depression by demographic and phychosocial factors. Depression Scoreo10 n(%)
Depression Score≥10 n(%)
Region Gaobeidian Mianzhu
162(60.4) 165(65.5)
106(39.6) 87(34.5)
0.236
Age 18–24 25-29 ≥30
146(59.6) 124(67.8) 57(62.0)
99(40.4) 59(32.2) 35(38.0)
0.219
Education Middle school or lower High school College or above
162(64.3) 98(57.0) 67(69.8)
90(35.7) 74(43.0) 29(30.2)
0.093
Monthly family income(USD) o 160 160-320 321-801 ≥802
28(70.0) 70(54.3) 164(64.8) 61(66.3)
12(30.0) 59(45.7) 89(35.2) 31(33.7)
0.120
Living site village City
256(61.5) 70(68.0)
160(38.5) 33(32.0)
0.227
Employment Unemployed part-time job full-time job
282(63.9) 9(45.0) 27(57.4)
159(36.1) 11(55.0) 20(42.6)
0.172
BMI o 23 ≥23
56(54.4) 244(64.7)
47(45.6) 133(35.3)
0.054
Planned pregnancy Planned Unplanned
165(65.5) 151(61.1)
87(34.5) 96(38.9)
0.314
Gestation stage 13-28weeks 428weeks
77(61.6) 210(62.5)
48(38.4) 126(37.5)
0.859
Parity Primigravida Others
202(66.0) 125(58.7)
104(34.0) 88(41.3)
0.089
Sleep quality Poor Fair Good
23(52.3) 161(58.8) 143(70.8)
21(47.7) 113(41.2) 59(29.2)
0.009
Smoking history Non Yes
323(63.2) 4(44.4)
188(36.8) 5(55.6)
0.248
Alcohol use history Non Yes
312(63.5) 14(50.0)
179(36.5) 14(50.0)
0.149
Husband is migrant worker Yes Non
179(64.6) 134(59.3)
98(35.4) 92(40.7)
0.220
Social support from husband Lower Medium Higher
3(42.9) 19(33.3) 297(66.7)
4(57.1) 38(66.7) 148(33.3)
0.000
Social support from parents Lower Medium Higher
5(45.5) 26(48.1) 287(64.6)
6(54.5) 28(51.9) 157(35.4)
0.031
Social support from parents-in-law Lower Medium Higher
17(45.9) 60(59.4) 240(65.2)
20(54.1) 41(40.6) 128(34.8)
0.052
P
pregnancy (Lancaster et al., 2010; Seguin et al., 1995, 1999; Spoozak et al., 2009; Toyabe et al., 2006; Wang et al., 2009a). Another interpretation is that the lack of partner support is
570
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Table 3 Bivariate correlate analysis of the scores of antenatal depression, stresses of pregnancy, life satisfaction and marital satisfaction. Depression Stresses of pregnancy Depression(n ¼520) 1 Stresses of pregnancy(n¼ 499) Marital satisfaction (n¼ 511) Thoughts and feelings regarding the marriage and one's spouse(n¼489) Agreement on relationship matters (n¼509)
nn
0.41nn 1
Marital satisfaction
Thoughts and feelings regarding the marriage and one's spouse
Agreement on relationship matters
Life satisfaction
0.30nn 0.22nn 1
0.25nn 0.32nn 0.31nn 1
0.30nn 0.24nn 0.38nn 0.31nn
0.25nn 0.23nn 0.41nn 0.31nn
1
0.31nn
p o0.01
Table 4 Multivariate logistic regression analysis of demographic and psychosocial factors for antenatal depression. Depression OR(95% CI)
p
1.74(0.99–3. 04)
0.054
0.96(0.41–2.27) 0.60(0.25–1.43)
0.927 0.246
0.56(0.24–1.32) 1.29(0.55–3.02)
0.186 0.565
0.98(0.31–3.04) 1.72(0.76–3.89) 0.80(0.39–1.64) 1.57(0.69–3.59)
0.965 0.194 0.540 0.285
0.54(0.21–1.39) 2.97(0.58–13.85) 1.89(0.99–3.64) 0.92(0.54–1.55) 1.06(0.56–2.01) 0.54(0.29–1.01)
0.201 0.196 0.056 0.743 0.857 0.055
2.38(0.95–5.99) 1.58(0.89–2.81) 0.54(0.07–4.33) 1.35(0.42–4.31)
0.064 0.120 0.560 0.615
1.08(0.64–1.83)
0.781
1.75(0.16–19.28) 3.57(1.36–9.38)
0.646 0.010
0.56(0.06–5.13) 1.34(0.49–3.67)
0.603 0.564
Stresses of pregnancy Marital satisfaction
0.74(0.24–2.23) 0.51(0.24–1.08) 4.55(2.36–8.77) 0.97(0.90–1.05)
0.588 0.076 0.000 0.434
Thoughts and feelings regarding the marriage and one's spouse
0.99(0.97–1.02)
0.776
Agreement on relationship matters Life satisfaction
0.99(0.96–1.02) 0.97(0.93–1.02)
0.401 0.267
Region Age
Education
Monthly family income
Living site Employment
BMI Planned pregnancy Gestation stage Parity Sleep quality
Smoking history Alcohol use history Husband is migrant a worker Social support from husband
Social support from parents
Social support from parents-in-law
significantly associated with increased risk of depressive symptoms in the prenatal period (Collins et al., 1993; Lancaster et al., 2010). Pregnancy is a time where significant changes occur, meaning that it requires major psychological adjustment. Hence, perceived lack of social support clearly has a detrimental impact on maternal psychological wellbeing (Spoozak et al., 2009). Furthermore, this study suggests that the stress of pregnancy is significantly related with the incidence of antenatal depression.
Mainzhu: Gaobeidian Ref: ≥30 18–24 25–29 Ref: College or above Middle school or lower High school Ref: ≥802 USD o 160 160–320 321–801 Village: City Ref: full-time job Unemployed part-time job o 23:≥23 Planned: unplanned 13–28weeks: 428weeks Primigravida: Others Ref: Good Poor Fair Non: Yes Non: Yes Non: Yes Ref: Higher Lower Medium Ref: Higher Lower Medium Ref: Higher Lower Medium
High scores in terms of stresses of pregnancy are associated with high risks of depression. Thirdly, following the rapid increase in the number of migrant workers, the number of “left-behind wife”(“left-behind wife” refers to women whose husbands are migrant workers) is also rising fast in China. This may undermine the support system of pregnant women. In this study, more than half of the husbands are migrant workers. Future research should further examine whether short-
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
term or long-term absence of social support from one's spouse has significant effect on pregnant women's antenatal depression. Finally, this study introduced a comparison group from areas that were not struck by the earthquake, which enabled us to investigate whether the prevalence rates of depression among pregnant women in the earthquake area are higher, or similar to other non-earthquake struck regions. This also covers the weakness of our previous study conducted by Qu and associates (Qu et al., 2012a, 2012b) and other relevant studies (Harville et al., 2009b; Hibino et al., 2009).
5. Limitation of study Our study has several limitations. Firstly, the EPDS is only a screening tool and cannot be used to diagnose antenatal depression. Secondly, although the questionnaire was conducted adequately by trained investigators using face-to-face interviews, it was a self-report evaluation, and therefore at risk of possible bias. Thirdly, three questions for the social support from husband assessment are too general to be able to distinguish between high, medium and low level of support received from husbands. Furthermore, in the two areas, many pregnant women in the first trimester were working away from home in large cities as longterm or temporary workers. This may have resulted in sampling bias. Future research should redress these issues.
6. Conclusions In summary, the results of the current study showed that the impact of earthquake on the mental health of survivors disappeared four years after the 2008 Sichuan earthquake. High levels of pressures from pregnancy and medium levels of social support received from husband are significant predictors of depressive symptoms and antenatal depression. Other social-demographic and health behavior characteristics are not significantly associated with the depressive symptoms.
Role of funding source Funding sources had no input to the study described in the article.
Conflict of interest No conflict declared.
Acknowledgments In the process of data collection, the Mianzhu People's Hospital, the Mianzhu Maternal and Child Health Hospital, the Gaobeidian County's Hospital, and volunteers from Sichuan Normal University offered great support in assisting us with sampling and interviews.
References Anwar, Jasim, Mpofu, Elias, Matthews, Lynda R., Shadoul, A.F., Brock, K.E., 2011. Reproductive health and access to healthcare facilities: risk factors for depression and anxiety in women with an earthquake experience. BMC public health 11, 523. Chan, C.L., Wang, C.W., Ho, A.H., Qu, Z.Y., Wang, X.Y., Ran, M.S., Mao, W.J., Lu, B.Q., Zhang, B.Q., Zhang, X.L., 2012. Symptoms of posttraumatic stress disorder and depression among bereaved and non-bereaved survivors following the 2008 Sichuan earthquake. Journal of Anxiety Disorders 26, 673–679. Chang, H.L., Chang, T.C., Lin, T.Y., Kuo, S.S., 2002. Psychiatric morbidity and pregnancy outcome in a disaster area of Taiwan 921 earthquake. Psychiatry and clinical neurosciences 56, 139–144. Chen, Z., Chen, H., Huang, D., 1991. Pregnant women's psychological pressure. Kaohsiung Journal of MedicalSciences 5, 505–509. Chou, F.H., Wu, H.C., Chou, P., Su, C.Y., Tsai, K.Y., Chao, S.S., Chen, M.C., Su, T.T., Sun, W.J., Ou-Yang, W.C., 2007. Epidemiologic psychiatric studies on post-disaster impact among Chi-Chi earthquake survivors in Yu-Chi, Taiwan. Psychiatry and Clinical Neurosciences 61, 370–378.
571
Collins, N.L., Dunkel-Schetter, C., Lobel, M., Scrimshaw, S.C., 1993. Social support in pregnancy: psychosocial correlates of birth outcomes and postpartum depression. Journal of Personality and Social Psychology 65, 1243–1258. Cox, J.L., Holden, J.M., Sagovsky, R., 1987. Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. British Journal of Psychiatry: The Journal of Mental Science 150, 782–786. Ehring, T., Razik, S., Emmelkamp, P.M., 2011. Prevalence and predictors of posttraumatic stress disorder, anxiety, depression, and burnout in Pakistani earthquake recovery workers. Psychiatry Research 185, 161–166. Fan, F., Zhang, Y., Yang, Y., Mo, L., Liu, X., 2011. Symptoms of posttraumatic stress disorder, depression, and anxiety among adolescents following the 2008 Wenchuan earthquake in China. Journal of Traumatic Stress 24, 44–53. Gigantesco, A., Mirante, N., Granchelli, C., Diodati, G., Cofini, V., Mancini, C., Carbonelli, A., Tarolla, E., Minardi, V., Salmaso, S., D’Argenio, P., 2013. Psychopathological chronic sequelae of the 2009 earthquake in L'Aquila,Italy. Journal of Affective Disorders 148. Grant, D.M., Beck, J.G., Marques, L., Palyo, S.A., Clapp, J.D., 2008. The structure of distress following trauma: posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. Journal of Abnormal Psychology 117, 662–672. Harville, E.W., Xiong, X., Buekens, P., 2009a. Hurricane Katrina and perinatal health. Birth 36, 325–331. Harville, E.W., Xiong, X., Pridjian, G., Elkind-Hirsch, K., Buekens, P., 2009b. Postpartum mental health after Hurricane Katrina: a cohort study. BMC Pregnancy and Childbirth 9, 21. Hibino, Y., Takaki, J., Kambayashi, Y., Hitomi, Y., Sakai, A., Sekizuka, N., Ogino, K., Nakamura, H., 2009. Health impact of disaster-related stress on pregnant women living in the affected area of the Noto Peninsula earthquake in Japan. Psychiatry and Clinical Neurosciences 63, 107–115. Hong, L., Chan, K., 2002. Normative data of the Chinese kansas marital satisfaction scale:findings based on Hong Kong and Beijing samples. Psychological Development and Education 4, 82–85. Kar, N., Bastia, B.K., 2006. Post-traumatic stress disorder, depression and generalised anxiety disorder in adolescents after a natural disaster: a study of comorbidity. Clinical Practice and Epidemiology in Mental Health: CP & EMH 2, 17. Lancaster, C.A., Gold, K.J., Flynn, H.A., Yoo, H., Marcus, S.M., Davis, M.M., 2010. Risk factors for depressive symptoms during pregnancy: a systematic review. American Journal of Obstetrics and Gynecology 202, 5–14. Lau, Y., Wong, D.F., Chan, K.S., 2010. The utility of screening for perinatal depression in the second trimester among Chinese: a three-wave prospective longitudinal study. Archives of Women's Mental Health 13, 153–164. Lau, Y., Yin, L., Wang, Y., 2011. Antenatal depressive symptomatology, family conflict and social support among Chengdu Chinese women. Maternal and Child Health Journal 15, 1416–1426. Lee, A.M., Lam, S.K., Lau, Sze Mun, Chong, S.M., Chui, C.S., Fong, D.Y., H.W., 2007. Prevalence, course, and risk factors for antenatal anxiety and depression. OBSTETRICS and Gynecology 110, 1102–1112. Lee, D.T., Yip, S.K., Chiu, H.F., Leung, T.Y., Chan, K.P., Chau, I.O., Leung, H.C., Chung, T.K., 1998. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh postnatal depression scale. The British journal of Psychiatry: The Journal of Mental Science 172, 433–437. Locke, H.J., Wallace, M., 1959. Short marital adjustment and prediction test; reliability and validity. Marriage and Family Living 21, 251–255. Luke, S., Salihu, H.M., Alio, A.P., Mbah, A.K., Jeffers, D., Berry, E.L., Mishkit, V.R., 2009. Risk factors for major antenatal depression among low-income African American women. J Womens Health (Larchmt) 18, 1841–1846. Mirza, I., Jenkins, R., 2004. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. British Medical Journal 328, 794. Ng, C., Ma, H., Raphael, B., Yu, X., Fraser, J., Tang, D., 2009. China–Australia training on psychosocial crisis intervention: response to the earthquake disaster in Sichuan. Australasian Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists 17, 51–55. Onder, E., Tural, U., Aker, T., Kilic, C., Erdogan, S., 2006. Prevalence of psychiatric disorders three years after the 1999 earthquake in Turkey: Marmara Earthquake Survey (MES). Social Psychiatry and Psychiatric Epidemiology, 41; , pp. 868–874. Qu, Z., Tian, D., Zhang, Q., Wang, X., He, H., Zhang, X., Huang, L., Xu, F., 2012a. The impact of the catastrophic earthquake in China's Sichuan province on the mental health of pregnant women. Journal of Affective Disorders 136, 117–123. Qu, Z., Wang, X., Tian, D., Zhao, Y., Zhang, Q., He, H., Zhang, X., Xu, F., Guo, S., 2012b. Posttraumatic stress disorder and depression among new mothers at 8 months later of the 2008 Sichuan earthquake in China. Archives of Women's Mental Health 15, 49–55. Schumm, W.R., Paff-Bergen, L.A., Hatch, R.C., O.F., C., C.J.M., Meens, L.D., A, B.M., 1986. Concurrent and discriminant validity of the Kansas Marital Satisfaction Scale. Journal of Marriage and Family 48, 381–387. Seguin, L., Potvin, L., St-Denis, M., Loiselle, J., 1995. Chronic stressors, social support, and depression during pregnancy. Obstetrics and Gynecology 85, 583–589. Seguin, L., Potvin, L., St-Denis, M., Loiselle, J., 1999. Socio-environmental factors and postnatal depressive symptomatology: a longitudinal study. Women and Health 29, 57–72. Shek, D.T.L., Tsang, S.K.M., 1993. The development of the Chinese version of the Kansas Marital Satisfaction Scale in Hong Kong. Social Behavior and Personality: An International Journal 21 (205-214), 210.
572
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Spoozak, L., Gotman, N., Smith, M.V., Belanger, K., Yonkers, K.A., 2009. Evaluation of a social support measure that may indicate risk of depression during pregnancy. Journal of Affective Disorders 114, 216–223. Toyabe, S., Shioiri, T., Kuwabara, H., Endoh, T., Tanabe, N., Someya, T., Akazawa, K., 2006. Impaired psychological recovery in the elderly after the Niigata– Chuetsu earthquake in Japan:a population-based study. BMC Public Health 6, 230. Wang, L., Zhang, Y., Wang, W., Shi, Z., Shen, J., Li, M., Xin, Y., 2009a. Symptoms of posttraumatic stress disorder among adult survivors three months after the Sichuan earthquake in China. Journal of Traumatic Stress 22, 444–450.
Wang, Y., Guo, X., Lau, Y., Chan, K.S., Yin, L., Chen, J., 2009b. Psychometric evaluation of the Mainland Chinese version of the Edinburgh Postnatal Depression Scale. International Journal of Nursing Studies 46, 813–823. Xiong, X., Harville, E.W., Mattison, D.R., Elkind-Hirsch, K., Pridjian, G., Buekens, P., 2008. Exposure to Hurricane Katrina, post-traumatic stress disorder and birth outcomes. The American journal of the medical sciences 336, 111–115. Ying, Y.W., 1991. Marital satisfaction among San Francisco Chinese–Americans. The International Journal of Social Psychiatry 37, 201–213. Zhang, Z., Shi, Z., Wang, L., Liu, M., 2011. One year later: mental health problems among survivors in hard-hit areas of the Wenchuan earthquake. Public Health 125, 293–300.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Depression and its risk factors among pregnant women in 2008 Sichuan earthquake area and non-earthquake struck area in China Xuehan Dong a, Zhiyong Qu b,n, Fangnan Liu a, Xiaoing Jiang a, Yang Wang a, Cheryl Hiu Kwan Chui c, Xiaohua Wang b, Donghua Tian b, Xiulan Zhang a a
School of Social Development and Public Policy, Beijing Normal University, Beijing, China School of Social Development and Public Policy, China Institute of Health, Beijing Normal University, Beijing, China c Department of Social Work and Social Administration, University of Hong Kong, Hong Kong, China b
art ic l e i nf o
a b s t r a c t
Article history: Received 14 March 2013 Received in revised form 26 June 2013 Accepted 26 June 2013 Available online 18 July 2013
Background: On May 12, 2008, a powerful 8.0 magnitude earthquake struck China's Sichuan province. While some studies have assessed the mental and physical wellbeing of disaster victims, few have examined the long-term impact of natural disasters on pregnant women's mental health. As such, this study aims to assess whether the Sichuan earthquake continues to negatively affect women's mental health, 4 years since its occurrence. In addition, predictive and protective risk factors of depressive symptoms among pregnant women were also identified. Methods: From June 2012 to October 2012, 520 pregnant women were interviewed, of whom 253 were from an earthquake struck area and 267 were from a non-earthquake struck area. Symptoms of antenatal depression were measured using the Edinburgh Postnatal Depression Scale (EPDS) with a cutoff of≥10. Results: The prevalence rate of depression among pregnant women in the earthquake area was 34.5% (95% CI, 28.9–40.6), while the rate in the non-earthquake area was 39.6% (95% CI, 33.9–45.5). The perceived stresses associated with pregnancy and social support from husbands are significantly correlated with antenatal depression. Limitations: Lack of diagnosis for antenatal depression and it is a self-report evaluation. Conclusions: This study found that the Sichuan earthquake does not necessarily have a long-lasting effect on pregnant women who were once victims of the disaster. It was found that pregnant women who experience high levels of pressures from the pregnancy and receive medium support from husbands are more susceptible to experience antenatal depression than pregnant women who perceive higher levels of support from husbands. & 2013 Elsevier B.V. All rights reserved.
Keywords: Sichuan earthquake Pregnant women Depression Mental health
1. Introduction On the afternoon of May 12, 2008, an earthquake measuring 8.0 on the Richter scale hit Sichuan province in western China. One of the many consequences of natural disasters is the negative impact on health and wellbeing. Previous studies have shown that mental health disorders such as post-traumatic stress disorder (PTSD), depression and anxiety are common psychological symptoms following natural disasters (Ehring et al., 2011; Grant et al., 2008; Harville et al., 2009a; Kar and Bastia, 2006; Onder et al., 2006). Unsurprisingly, these symptoms were also identified among victims of the Sichuan earthquake. For example, Wang and associates (Wang et al., 2009a) found that the prevalence rates of PTSD among the earthquake survivors were between 13.0% to
n
Corresponding author. Tel.: +8610 5880 1518; fax: +8610 5880 0366. E-mail address: [email protected] (Z. Qu).
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2013.06.048
84.8%, while Fan and associates(Fan et al., 2011) observed that the prevalence rates of PTSD, anxiety and depressive symptoms were 15.8%, 40.5%, and 24.5% respectively 6 months after the earthquake. Additionally, there are several studies that illustrate how natural disasters may affect their victims differently as time lapses. One study conducted among survivors over 16 years of age in Taiwan (Chou et al., 2007)showed that the prevalence of major depression decreased from 11.6% to 6.9% at 2 years and to 6.5% at 3 years after the Chi-Chi earthquake. The prevalence of PTSD or major depression was higher in the first 2 years, then significantly decreased in the third year. Similarly, in a sample of 957 adults survivors of the 2009 earthquake in L'Aquila, Italy, Gigantesco (Gigantesco et al., 2013) reported that more than one year after the earthquake, the prevalence rates of PTSD and major depression (MD) were 4.1% and 5.8% respectively. Psychological symptoms are frequent even 14–19 months after the L'Aquila earthquake.
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Another study (Chan et al., 2012) indicated that the estimated rates of clinically significant PTSD and depressive symptoms among bereaved survivors approximately 7.5 months after the 2008 Sichuan earthquake were 50.2% and 55.8% respectively. While some studies indicate that psychological symptoms tend to abate with time, some studies suggest otherwise. For example, a study (Zhang et al., 2011) found that among 1195 adult earthquake survivors in the Sichuan earthquake, PTSD, anxiety and depression remained at an elevated level 1 year after the earthquake. These observations were particularly acute in areas that were hard-hit by the quake. Despite these illuminating results, few researches have examined the impact of natural disasters on mental health beyond the first or second year since the occurrence of the disaster, and even fewer have investigated how disasters can affect pregnant women in the long-run. Nevertheless, several studies have shown that pregnant women's overall mental and physical health were significantly related to the severity of their experiences with natural disasters (Chang et al., 2002; Harville et al., 2009a; Xiong et al., 2008). These one-time, cross-sectional studies, however, were conducted within one or two years of the earthquake and therefore lack a long-term perspective. Only two studies conducted by Qu and associates (Qu et al., 2012a, 2012b) have assessed the mental health impact of the Sichuan earthquake on pregnant women at different time intervals. It was posited that the incidences of depression and PTSD were still high among pregnant women at 6 and 18 months after the earthquake. Aside from the lack of time-perspective, another limitation of previous studies on the effects of disaster on pregnant women's mental health is the lack of comparison group from areas that were not struck by disaster. As such, the objectives of the present study are: (i) to analyze whether the Sichuan earthquake has continued to negatively impact pregnant women's mental health even after 4 years since the disaster; (ii) to compare the mental health of pregnant women who experienced the earthquake with pregnant women who did not; and (iii) to identify and examine the predictive and protective risk factors of depressive symptoms among pregnant women.
2. Methods 2.1. Study design and participants An exploratory and comparative cross-sectional survey was conducted in Mianzhu County and Gaobeidian County. The former area is located about 30 km away from the epicenter while the latter area is a county of Hebei province, which is not struck by the 2008 Sichuan Earthquake. It was chosen as a comparison group. The study was sponsored by the Project 985 fund of Beijing Normal University and was approved by the institutional review board of the School of Social Development and Public Policy at Beijing Normal University. Ten volunteers who were divided into two teams were trained to collect data for the present study. These volunteers were graduate students who majored in psychology. They attended a two-days training course before conducting the interview. Data was collected twice, once in June 2012 and once in October 2012, with each data collection period lasting for about 8 days. A self-rating questionnaire was distributed to pregnant women who were receiving routine prenatal care at three hospitals. They completed the self-report instruments in approximately 30 min, while waiting for a routine antenatal check-up. Informed oral consent was obtained from participators in the study, and the aim and significance of the survey were explained in detail.
567
Participants from Mianzhu were interviewed in the Mianzhu People's Hospital and the Mianzhu Maternal and Child Health Hospital, where nearly 70% of the pregnant women in this county receive antenatal care and post-delivery services. Participants from Gaobeidian were interviewed in Gaobeidian County's Hospital, where nearly 50% of the pregnant women in this county receive antenatal care and post-delivery services. Nonprobabilistic convenience sampling was adopted because of resource constraints. 530 pregnant women at 13 to 28 weeks' gestation agreed to participate in the interview. Among them, 254 were from Mianzhu County, 276 were from Gaobeidian County. A total of 520 (98.1%) women completed the depression assessment. 2.2. Main outcomes measures Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). The EPDS developed by Cox and associates(Cox et al., 1987) consists of 10 items, each of which is a 4-point Likert scale. The minimum and maximum total scores are 0 and 30, respectively. A Chinese version of the EPDS was tested and validated in Hong Kong and Sichuan, and demonstrated good reliability with a cutoff point score of ≥10 has been recommended (Lee et al., 1998; Wang et al., 2009a; Wang et al., 2009b). The EPDS has been used in other Chinese studies and has been found to be reliable in measuring prenatal and postnatal women's depression (Lau et al., 2010a, 2010b; Qu et al., 2012a). The internal consistency coefficient (Cronbach's alpha) of the EPDS was 0.70 in this study. 2.3. Risk factors measures Perceived pressures of pregnancy were rated using an 11-item self-assessment scale which was a short-form of Pregnancy Pressure Scale (PPS) developed by Zhanghui Chen et al., and the Cronbach's alpha coefficient was reported to be 0.84 (Chen et al., 1991; Qu et al., 2012a). It contains 3 subscales: (1) pressure from identification of the parents role; (2) pressure from the concerns of maternal and child health; (3) pressure from the change of the body shape or physical activities. The scale measured the perceived stresses of major pregnancy-related events using a 4-point Likert scale from 1 (none or little) to 4 (high). The mean score was used as an index of perceived stress. Possible stressful experiences included: fears about significant people disliking the baby, concerns about reduced leisure time with a baby, fears about the safe delivery of the baby, anxiety about birth defects, fears about complications during delivery, fears about pain during delivery, concern about changes in body shape, fears about competence as a mother, fears about the negative impact of the baby on the marital relationship, concerns about providing a healthy living environment for the child, and other pregnancyrelated stresses. Agreement on relationship matters such as finances were assessed by 8 items, and thoughts and feelings regarding the marriage and one's spouse were rated by 6 items. The two dimensions were chosen from the Locke–Wallace Marital Adjustment scale (Locke and Wallace, 1959)to measure the marital adjustment, whose validity and reliability have been confirmed in the Chinese population (Ying, 1991). Marital Satisfaction was estimated by the Kansas marital satisfaction scale (KMS), an assessment scale established by Schumm and associates (Schumm et al., 1986). It is a short, three-item direct measure of relationship satisfaction. Respondents describe their satisfaction with their spouse, their marriage, and their relationship with their spouse on a 7-point scale. The minimum and maximum total scores are 3 and 21. We used a Chinese version
568
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
(C-KMS) to estimate marital satisfaction which has been tested in a Chinese population and demonstrated satisfactory concurrent validity (Hong and Chan, 2002; Shek and Tsang, 1993). The Cronbach's alpha in this study was 0.93. Social support from husband, parents and parents-in-law were assessed by 3 questions, from 1(none) to 5 (full). The three questions consist of (1) How much support can you get from your husband? (2) How much support can you get from your parents? (3) How much support can you get from your parents-in-law? Participants were asked to assess their life satisfaction on a 7point scale, from 1 (strongly disagree) to 7 (strongly agree). Other socio-demographic and health behavior data were collected as part of this study, which included the participants' age (18–24 years; 25–29 years; ≥30 years), living situation (village/ city), level of education (primary school or lower; middle school; high school; college or above), parity (primigravida/others), monthly family income (USD o160; USD 160–320; USD 321– 801; USD ≥802), whether the pregnancy was planned (yes/non), the stage of gestation (12–28 weeks; 428 weeks), quality of sleep (poor, fair, good), smoking history (yes/non), their history of alcohol use (yes/non), body mass index (BMI) ( o23; ≥23), husband is migrant worker (yes/non) and employment status (unemployed; part-time job; full-time job). 2.4. Data analysis The SPSS 17.0 (SPSS Inc,Chicago,IL) was used for statistical analysis. The descriptive analyses of the data were performed for demographic characteristics (age, levels of education, living site, average household income, employment status), parity, gestation stage, planned pregnancy, sleep quality, BMI, husbandis migrant worker, smoking and drinking behaviors and depressive symptoms. Chi-square tests and bivariate correlate analysis were performed so as to examine the correlation between outcome variable and independent variables and socio-demographic factors. Multivariate logistic regression was employed to identify predictors of and antenatal depression. All estimates were accompanied by the odds ratios (OR) and 95% confidence interval.
3. Results As shown in Table 1, the mean age of the participants was 25.5 (min¼ 18, max¼42, standard deviation [SD] ¼3.9), most of the participants of Mianzhu (86.2%) and Gaobeidian (78.8%) were 18– 29 years old. Nearly 61.1% of women in the earthquake struck area completed at least high school, while only 42.6% of women in the non-earthquake area got at least high school education. Most participants (82.1%) had a family monthly income lower than 802 USD, and 80.3% resided in rural areas. More than half (52.3%) of the pregnancies in the earthquake struck area were planned, while less than half (48.8%) were planned in the non-disaster area. More than half of them (59.0%) were primigravida. Most of the participants were unemployed (86.8%), non-smoker (98.3%), and nondrinker (94.6%). Only 38.8% of the participants reported that they slept well. About a quarter (27.1%) of the sample were in the second trimester. Only less than a quarter (21.5%) of them had a normal weight. More than half (55.1%) of their husbands were migrant workers. It was also found that most women reported high levels of support from their husbands (87.4%) and parents (87.2%). The EPDS cutoff point recommended by the validity study was a score of ≥10. According to this criterion, the prevalence of depressive symptoms of pregnant women in the earthquake area (Mianzhu) was 34.5% (95% CI, 28.9–40.6). The prevalence of depressive symptoms of pregnant women in the non-earthquake
Table 1 Description and comparison of the variables between pregnant women in the earthquake area (Mianzhu) and non-earthquake struck area (Gaobeidian) (n¼ 520). Characteristics
Mianzhu(n¼252)
Gaobeidian(n¼ 268)
N
%
N
%
Age 18–24 25–29 ≥30
140 77 35
55.6 30.6 13.9
105 106 57
39.2 39.6 21.3
Education Middle school or lower High school College or above
98 111 43
38.9 44.0 17.1
154 61 53
57.5 22.8 19.8
Monthly family income(USD) o160 160–320 321–801 ≥802
20 75 112 42
8.0 30.1 45.0 16.9
20 54 141 50
7.5 20.4 53.2 18.9
Living site village City
219 33
86.9 13.1
197 70
73.8 26.2
Employment Unemployed part-time job full-time job
214 9 25
86.3 3.6 10.1
227 11 22
87.3 4.2 8.5
BMI o23 ≥23
62 173
26.4 73.6
41 204
16.7 83.3
Planned pregnancy Planned Unplanned
126 115
52.3 47.7
126 132
48.8 51.2
Gestation stage 13–28weeks 428weeks
77 159
32.6 67.4
48 177
21.3 78.7
Parity Primigravida Others
147 105
58.3 41.7
159 108
59.6 40.4
Sleep quality Poor Fair Good
23 129 100
9.1 51.2 39.7
21 145 102
7.8 54.1 38.1
Smoking history Non Yes
246 6
97.6 2.4
265 3
98.9 1.1
Alcohol use history Non Yes
235 16
93.6 6.4
256 12
95.5 4.5
Husband is a migrant worker Yes Non
143 98
59.3 40.7
134 128
51.1 48.9
Social support from husband Lower Medium Higher
2 24 224
0.8 9.6 89.6
5 33 221
1.9 12.7 85.3
Social support from parents Lower Medium Higher
5 22 224
2.0 8.8 89.2
6 32 220
2.3 12.4 85.3
Social support from parents-in-law Lower Medium Higher
18 42 188
7.3 16.9 75.8
19 59 180
7.4 22.9 69.8
Depression o10 ≥10
165 87
65.5 34.5
162 106
60.4 39.6
Note: some variables have missing value.
struck area (Gaobeidian) was 39.6% (95% CI, 33.9–45.5). The prevalence of prenatal depression was lower in the earthquake struck area (relative to comparison group).
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Table 2 and 3 show that the depressive symptoms of pregnant women were not correlated with region (p¼ 0.236). Depression was significantly correlated with sleep quality, social support from husband and parents, stresses of pregnancy, life satisfaction, marital satisfaction, thoughts and feelings regarding the marriage and one's spouse and agreement on relationship matters. Table 4 shows the final results of multivariate logistic regression analysis for predicting variables of antepartum depression. Variables were chosen based on previous researches indicating their potential impact on depression during pregnancy (Lancaster et al., 2010; Lee et al., 2007; Luke et al., 2009; Mirza and Jenkins, 2004). As shown in the table, significant risk factors for prenatal depression included stresses of pregnancy, general social support from husbands. The risk of depression grew as the stresses of pregnancy increased (OR, 1.15; 95% CI, 1.07–1.21; p o0.001). Women who receive medium levels of support from their husbands had a higher risk of depression than women who receive higher levels of social support from husbands (OR, 3.57; 95% CI, 1.37–9.57; p o0.001). Region was not significantly correlated with depression.
4. Discussion This study intends to identify the long-term impact of the Sichuan earthquake on the antepartum depression more than 4 years later. Findings indicate that compared with the general population living in the non-earthquake struck area, the incidence of depression among pregnant women in the earthquake area is not significantly different, suggesting that depression does not necessarily have long-lasting effects on pregnant women who once experienced the earthquake. This result can help researchers and health care professionals to better understand the long-term impact of natural disasters on pregnant women living in the earthquake area; it may also inform the development of modest disaster-related psychological health interventions to help care for these pregnant women. There are several interesting findings that warrant specific attention. Firstly, this study found that the prevalence rate of prenatal depression was 34.5% among pregnant women in earthquake struck area versus 39.6% among women living in Gaobeidian after 4 years the 2008 Sichuan earthquake. Compared with our previous study (Qu et al., 2012a), the prevalence of depression among pregnant women was also lower than the rate (40.8%) estimated in Mianzhu 18 months after the earthquake. This suggests that the impact of earthquakes on depression decreases significantly after a few years. One possible interpretation of this is that the Chinese government rapidly developed a national, multidisciplinary training program after the Sichuan earthquake (Ng et al., 2009) to improve the psychological well-being of pregnant women through psychosocial crisis intervention. Another possible explanation might be that post-disaster effects could reduce the incidence of long-term anxiety and depression for women who survived earthquakes (Jasim Anwar et al., 2011). However, in making this comparison, differences between this study and our previous study in terms of the diagnostic tools and sample size must be considered. Secondly, this study reveals the associations between the selected risk factors and the outcome variable regarding antenatal depression. Among all the variables investigated in this study, perceived pressures of pregnancy and medium levels of social support received from husbands were the only two variables that are significantly correlated with depression. The results are consistent with previous studies, which attributed social support as an important factor related to the depressive symptoms during
569
Table 2 The prevalence of prenatal depression by demographic and phychosocial factors. Depression Scoreo10 n(%)
Depression Score≥10 n(%)
Region Gaobeidian Mianzhu
162(60.4) 165(65.5)
106(39.6) 87(34.5)
0.236
Age 18–24 25-29 ≥30
146(59.6) 124(67.8) 57(62.0)
99(40.4) 59(32.2) 35(38.0)
0.219
Education Middle school or lower High school College or above
162(64.3) 98(57.0) 67(69.8)
90(35.7) 74(43.0) 29(30.2)
0.093
Monthly family income(USD) o 160 160-320 321-801 ≥802
28(70.0) 70(54.3) 164(64.8) 61(66.3)
12(30.0) 59(45.7) 89(35.2) 31(33.7)
0.120
Living site village City
256(61.5) 70(68.0)
160(38.5) 33(32.0)
0.227
Employment Unemployed part-time job full-time job
282(63.9) 9(45.0) 27(57.4)
159(36.1) 11(55.0) 20(42.6)
0.172
BMI o 23 ≥23
56(54.4) 244(64.7)
47(45.6) 133(35.3)
0.054
Planned pregnancy Planned Unplanned
165(65.5) 151(61.1)
87(34.5) 96(38.9)
0.314
Gestation stage 13-28weeks 428weeks
77(61.6) 210(62.5)
48(38.4) 126(37.5)
0.859
Parity Primigravida Others
202(66.0) 125(58.7)
104(34.0) 88(41.3)
0.089
Sleep quality Poor Fair Good
23(52.3) 161(58.8) 143(70.8)
21(47.7) 113(41.2) 59(29.2)
0.009
Smoking history Non Yes
323(63.2) 4(44.4)
188(36.8) 5(55.6)
0.248
Alcohol use history Non Yes
312(63.5) 14(50.0)
179(36.5) 14(50.0)
0.149
Husband is migrant worker Yes Non
179(64.6) 134(59.3)
98(35.4) 92(40.7)
0.220
Social support from husband Lower Medium Higher
3(42.9) 19(33.3) 297(66.7)
4(57.1) 38(66.7) 148(33.3)
0.000
Social support from parents Lower Medium Higher
5(45.5) 26(48.1) 287(64.6)
6(54.5) 28(51.9) 157(35.4)
0.031
Social support from parents-in-law Lower Medium Higher
17(45.9) 60(59.4) 240(65.2)
20(54.1) 41(40.6) 128(34.8)
0.052
P
pregnancy (Lancaster et al., 2010; Seguin et al., 1995, 1999; Spoozak et al., 2009; Toyabe et al., 2006; Wang et al., 2009a). Another interpretation is that the lack of partner support is
570
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Table 3 Bivariate correlate analysis of the scores of antenatal depression, stresses of pregnancy, life satisfaction and marital satisfaction. Depression Stresses of pregnancy Depression(n ¼520) 1 Stresses of pregnancy(n¼ 499) Marital satisfaction (n¼ 511) Thoughts and feelings regarding the marriage and one's spouse(n¼489) Agreement on relationship matters (n¼509)
nn
0.41nn 1
Marital satisfaction
Thoughts and feelings regarding the marriage and one's spouse
Agreement on relationship matters
Life satisfaction
0.30nn 0.22nn 1
0.25nn 0.32nn 0.31nn 1
0.30nn 0.24nn 0.38nn 0.31nn
0.25nn 0.23nn 0.41nn 0.31nn
1
0.31nn
p o0.01
Table 4 Multivariate logistic regression analysis of demographic and psychosocial factors for antenatal depression. Depression OR(95% CI)
p
1.74(0.99–3. 04)
0.054
0.96(0.41–2.27) 0.60(0.25–1.43)
0.927 0.246
0.56(0.24–1.32) 1.29(0.55–3.02)
0.186 0.565
0.98(0.31–3.04) 1.72(0.76–3.89) 0.80(0.39–1.64) 1.57(0.69–3.59)
0.965 0.194 0.540 0.285
0.54(0.21–1.39) 2.97(0.58–13.85) 1.89(0.99–3.64) 0.92(0.54–1.55) 1.06(0.56–2.01) 0.54(0.29–1.01)
0.201 0.196 0.056 0.743 0.857 0.055
2.38(0.95–5.99) 1.58(0.89–2.81) 0.54(0.07–4.33) 1.35(0.42–4.31)
0.064 0.120 0.560 0.615
1.08(0.64–1.83)
0.781
1.75(0.16–19.28) 3.57(1.36–9.38)
0.646 0.010
0.56(0.06–5.13) 1.34(0.49–3.67)
0.603 0.564
Stresses of pregnancy Marital satisfaction
0.74(0.24–2.23) 0.51(0.24–1.08) 4.55(2.36–8.77) 0.97(0.90–1.05)
0.588 0.076 0.000 0.434
Thoughts and feelings regarding the marriage and one's spouse
0.99(0.97–1.02)
0.776
Agreement on relationship matters Life satisfaction
0.99(0.96–1.02) 0.97(0.93–1.02)
0.401 0.267
Region Age
Education
Monthly family income
Living site Employment
BMI Planned pregnancy Gestation stage Parity Sleep quality
Smoking history Alcohol use history Husband is migrant a worker Social support from husband
Social support from parents
Social support from parents-in-law
significantly associated with increased risk of depressive symptoms in the prenatal period (Collins et al., 1993; Lancaster et al., 2010). Pregnancy is a time where significant changes occur, meaning that it requires major psychological adjustment. Hence, perceived lack of social support clearly has a detrimental impact on maternal psychological wellbeing (Spoozak et al., 2009). Furthermore, this study suggests that the stress of pregnancy is significantly related with the incidence of antenatal depression.
Mainzhu: Gaobeidian Ref: ≥30 18–24 25–29 Ref: College or above Middle school or lower High school Ref: ≥802 USD o 160 160–320 321–801 Village: City Ref: full-time job Unemployed part-time job o 23:≥23 Planned: unplanned 13–28weeks: 428weeks Primigravida: Others Ref: Good Poor Fair Non: Yes Non: Yes Non: Yes Ref: Higher Lower Medium Ref: Higher Lower Medium Ref: Higher Lower Medium
High scores in terms of stresses of pregnancy are associated with high risks of depression. Thirdly, following the rapid increase in the number of migrant workers, the number of “left-behind wife”(“left-behind wife” refers to women whose husbands are migrant workers) is also rising fast in China. This may undermine the support system of pregnant women. In this study, more than half of the husbands are migrant workers. Future research should further examine whether short-
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
term or long-term absence of social support from one's spouse has significant effect on pregnant women's antenatal depression. Finally, this study introduced a comparison group from areas that were not struck by the earthquake, which enabled us to investigate whether the prevalence rates of depression among pregnant women in the earthquake area are higher, or similar to other non-earthquake struck regions. This also covers the weakness of our previous study conducted by Qu and associates (Qu et al., 2012a, 2012b) and other relevant studies (Harville et al., 2009b; Hibino et al., 2009).
5. Limitation of study Our study has several limitations. Firstly, the EPDS is only a screening tool and cannot be used to diagnose antenatal depression. Secondly, although the questionnaire was conducted adequately by trained investigators using face-to-face interviews, it was a self-report evaluation, and therefore at risk of possible bias. Thirdly, three questions for the social support from husband assessment are too general to be able to distinguish between high, medium and low level of support received from husbands. Furthermore, in the two areas, many pregnant women in the first trimester were working away from home in large cities as longterm or temporary workers. This may have resulted in sampling bias. Future research should redress these issues.
6. Conclusions In summary, the results of the current study showed that the impact of earthquake on the mental health of survivors disappeared four years after the 2008 Sichuan earthquake. High levels of pressures from pregnancy and medium levels of social support received from husband are significant predictors of depressive symptoms and antenatal depression. Other social-demographic and health behavior characteristics are not significantly associated with the depressive symptoms.
Role of funding source Funding sources had no input to the study described in the article.
Conflict of interest No conflict declared.
Acknowledgments In the process of data collection, the Mianzhu People's Hospital, the Mianzhu Maternal and Child Health Hospital, the Gaobeidian County's Hospital, and volunteers from Sichuan Normal University offered great support in assisting us with sampling and interviews.
References Anwar, Jasim, Mpofu, Elias, Matthews, Lynda R., Shadoul, A.F., Brock, K.E., 2011. Reproductive health and access to healthcare facilities: risk factors for depression and anxiety in women with an earthquake experience. BMC public health 11, 523. Chan, C.L., Wang, C.W., Ho, A.H., Qu, Z.Y., Wang, X.Y., Ran, M.S., Mao, W.J., Lu, B.Q., Zhang, B.Q., Zhang, X.L., 2012. Symptoms of posttraumatic stress disorder and depression among bereaved and non-bereaved survivors following the 2008 Sichuan earthquake. Journal of Anxiety Disorders 26, 673–679. Chang, H.L., Chang, T.C., Lin, T.Y., Kuo, S.S., 2002. Psychiatric morbidity and pregnancy outcome in a disaster area of Taiwan 921 earthquake. Psychiatry and clinical neurosciences 56, 139–144. Chen, Z., Chen, H., Huang, D., 1991. Pregnant women's psychological pressure. Kaohsiung Journal of MedicalSciences 5, 505–509. Chou, F.H., Wu, H.C., Chou, P., Su, C.Y., Tsai, K.Y., Chao, S.S., Chen, M.C., Su, T.T., Sun, W.J., Ou-Yang, W.C., 2007. Epidemiologic psychiatric studies on post-disaster impact among Chi-Chi earthquake survivors in Yu-Chi, Taiwan. Psychiatry and Clinical Neurosciences 61, 370–378.
571
Collins, N.L., Dunkel-Schetter, C., Lobel, M., Scrimshaw, S.C., 1993. Social support in pregnancy: psychosocial correlates of birth outcomes and postpartum depression. Journal of Personality and Social Psychology 65, 1243–1258. Cox, J.L., Holden, J.M., Sagovsky, R., 1987. Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. British Journal of Psychiatry: The Journal of Mental Science 150, 782–786. Ehring, T., Razik, S., Emmelkamp, P.M., 2011. Prevalence and predictors of posttraumatic stress disorder, anxiety, depression, and burnout in Pakistani earthquake recovery workers. Psychiatry Research 185, 161–166. Fan, F., Zhang, Y., Yang, Y., Mo, L., Liu, X., 2011. Symptoms of posttraumatic stress disorder, depression, and anxiety among adolescents following the 2008 Wenchuan earthquake in China. Journal of Traumatic Stress 24, 44–53. Gigantesco, A., Mirante, N., Granchelli, C., Diodati, G., Cofini, V., Mancini, C., Carbonelli, A., Tarolla, E., Minardi, V., Salmaso, S., D’Argenio, P., 2013. Psychopathological chronic sequelae of the 2009 earthquake in L'Aquila,Italy. Journal of Affective Disorders 148. Grant, D.M., Beck, J.G., Marques, L., Palyo, S.A., Clapp, J.D., 2008. The structure of distress following trauma: posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. Journal of Abnormal Psychology 117, 662–672. Harville, E.W., Xiong, X., Buekens, P., 2009a. Hurricane Katrina and perinatal health. Birth 36, 325–331. Harville, E.W., Xiong, X., Pridjian, G., Elkind-Hirsch, K., Buekens, P., 2009b. Postpartum mental health after Hurricane Katrina: a cohort study. BMC Pregnancy and Childbirth 9, 21. Hibino, Y., Takaki, J., Kambayashi, Y., Hitomi, Y., Sakai, A., Sekizuka, N., Ogino, K., Nakamura, H., 2009. Health impact of disaster-related stress on pregnant women living in the affected area of the Noto Peninsula earthquake in Japan. Psychiatry and Clinical Neurosciences 63, 107–115. Hong, L., Chan, K., 2002. Normative data of the Chinese kansas marital satisfaction scale:findings based on Hong Kong and Beijing samples. Psychological Development and Education 4, 82–85. Kar, N., Bastia, B.K., 2006. Post-traumatic stress disorder, depression and generalised anxiety disorder in adolescents after a natural disaster: a study of comorbidity. Clinical Practice and Epidemiology in Mental Health: CP & EMH 2, 17. Lancaster, C.A., Gold, K.J., Flynn, H.A., Yoo, H., Marcus, S.M., Davis, M.M., 2010. Risk factors for depressive symptoms during pregnancy: a systematic review. American Journal of Obstetrics and Gynecology 202, 5–14. Lau, Y., Wong, D.F., Chan, K.S., 2010. The utility of screening for perinatal depression in the second trimester among Chinese: a three-wave prospective longitudinal study. Archives of Women's Mental Health 13, 153–164. Lau, Y., Yin, L., Wang, Y., 2011. Antenatal depressive symptomatology, family conflict and social support among Chengdu Chinese women. Maternal and Child Health Journal 15, 1416–1426. Lee, A.M., Lam, S.K., Lau, Sze Mun, Chong, S.M., Chui, C.S., Fong, D.Y., H.W., 2007. Prevalence, course, and risk factors for antenatal anxiety and depression. OBSTETRICS and Gynecology 110, 1102–1112. Lee, D.T., Yip, S.K., Chiu, H.F., Leung, T.Y., Chan, K.P., Chau, I.O., Leung, H.C., Chung, T.K., 1998. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh postnatal depression scale. The British journal of Psychiatry: The Journal of Mental Science 172, 433–437. Locke, H.J., Wallace, M., 1959. Short marital adjustment and prediction test; reliability and validity. Marriage and Family Living 21, 251–255. Luke, S., Salihu, H.M., Alio, A.P., Mbah, A.K., Jeffers, D., Berry, E.L., Mishkit, V.R., 2009. Risk factors for major antenatal depression among low-income African American women. J Womens Health (Larchmt) 18, 1841–1846. Mirza, I., Jenkins, R., 2004. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. British Medical Journal 328, 794. Ng, C., Ma, H., Raphael, B., Yu, X., Fraser, J., Tang, D., 2009. China–Australia training on psychosocial crisis intervention: response to the earthquake disaster in Sichuan. Australasian Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists 17, 51–55. Onder, E., Tural, U., Aker, T., Kilic, C., Erdogan, S., 2006. Prevalence of psychiatric disorders three years after the 1999 earthquake in Turkey: Marmara Earthquake Survey (MES). Social Psychiatry and Psychiatric Epidemiology, 41; , pp. 868–874. Qu, Z., Tian, D., Zhang, Q., Wang, X., He, H., Zhang, X., Huang, L., Xu, F., 2012a. The impact of the catastrophic earthquake in China's Sichuan province on the mental health of pregnant women. Journal of Affective Disorders 136, 117–123. Qu, Z., Wang, X., Tian, D., Zhao, Y., Zhang, Q., He, H., Zhang, X., Xu, F., Guo, S., 2012b. Posttraumatic stress disorder and depression among new mothers at 8 months later of the 2008 Sichuan earthquake in China. Archives of Women's Mental Health 15, 49–55. Schumm, W.R., Paff-Bergen, L.A., Hatch, R.C., O.F., C., C.J.M., Meens, L.D., A, B.M., 1986. Concurrent and discriminant validity of the Kansas Marital Satisfaction Scale. Journal of Marriage and Family 48, 381–387. Seguin, L., Potvin, L., St-Denis, M., Loiselle, J., 1995. Chronic stressors, social support, and depression during pregnancy. Obstetrics and Gynecology 85, 583–589. Seguin, L., Potvin, L., St-Denis, M., Loiselle, J., 1999. Socio-environmental factors and postnatal depressive symptomatology: a longitudinal study. Women and Health 29, 57–72. Shek, D.T.L., Tsang, S.K.M., 1993. The development of the Chinese version of the Kansas Marital Satisfaction Scale in Hong Kong. Social Behavior and Personality: An International Journal 21 (205-214), 210.
572
X. Dong et al. / Journal of Affective Disorders 151 (2013) 566–572
Spoozak, L., Gotman, N., Smith, M.V., Belanger, K., Yonkers, K.A., 2009. Evaluation of a social support measure that may indicate risk of depression during pregnancy. Journal of Affective Disorders 114, 216–223. Toyabe, S., Shioiri, T., Kuwabara, H., Endoh, T., Tanabe, N., Someya, T., Akazawa, K., 2006. Impaired psychological recovery in the elderly after the Niigata– Chuetsu earthquake in Japan:a population-based study. BMC Public Health 6, 230. Wang, L., Zhang, Y., Wang, W., Shi, Z., Shen, J., Li, M., Xin, Y., 2009a. Symptoms of posttraumatic stress disorder among adult survivors three months after the Sichuan earthquake in China. Journal of Traumatic Stress 22, 444–450.
Wang, Y., Guo, X., Lau, Y., Chan, K.S., Yin, L., Chen, J., 2009b. Psychometric evaluation of the Mainland Chinese version of the Edinburgh Postnatal Depression Scale. International Journal of Nursing Studies 46, 813–823. Xiong, X., Harville, E.W., Mattison, D.R., Elkind-Hirsch, K., Pridjian, G., Buekens, P., 2008. Exposure to Hurricane Katrina, post-traumatic stress disorder and birth outcomes. The American journal of the medical sciences 336, 111–115. Ying, Y.W., 1991. Marital satisfaction among San Francisco Chinese–Americans. The International Journal of Social Psychiatry 37, 201–213. Zhang, Z., Shi, Z., Wang, L., Liu, M., 2011. One year later: mental health problems among survivors in hard-hit areas of the Wenchuan earthquake. Public Health 125, 293–300.