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Living with parents or with parents-in-law and postpartum depression: A preliminary investigation in China
Author’s Accepted Manuscript Living with parents or with parents-in-law and postpartum depression: a preliminary investigation in China Yue-Yun Wang, Hui Li, You-Jie Wang, Hong Wang, Yan- Ru Zhang, Lin Gong, Jian Ma, Yan Wang, Ming-Zhen Wang, Shi-Xian Qiu, Shi-Xin Yuan
PII: DOI: Reference:
www.elsevier.com/locate/jad
S0165-0327(16)31475-6 http://dx.doi.org/10.1016/j.jad.2017.04.052 JAD8926
To appear in: Journal of Affective Disorders Received date: 23 August 2016 Revised date: 4 April 2017 Accepted date: 24 April 2017 Cite this article as: Yue-Yun Wang, Hui Li, You-Jie Wang, Hong Wang, YanRu Zhang, Lin Gong, Jian Ma, Yan Wang, Ming-Zhen Wang, Shi-Xian Qiu and Shi-Xin Yuan, Living with parents or with parents-in-law and postpartum depression: a preliminary investigation in China, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2017.04.052 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Living with parents or with parents-in-law and postpartum depression: a preliminary investigation in China Yue-Yun Wanga, Hui Lib, You-Jie Wangb, Hong Wanga, Yan- Ru Zhanga,c, Lin Gonga , Jian Mad, Yan Wange , Ming-Zhen Wangf, Shi-Xian Qiua , Shi-Xin Yuana,* a
Shenzhen Maternity and Child Health Hospital, Guangdong, China
b
Department of Maternal and Child Health, School of Public Health, Tongji Medical
College, Huazhong University of Science and Technology, Wuhan, China c
Department of Epidemiology and Biostatistics, School of Public Health, Tongji
Medical College, Huazhong University of Science and Technology, Wuhan, China d
e
Futian District Maternity and Child Health Hospital, Guangdong, China
Longgang District Maternity and Child Health Hospital, Guangdong, China
f
Yantian District Maternity and Child Health Hospital, Guangdong, China
ABSTRACT Background Few studies have investigated the association between puerperal women’s living situation and postpartum depression. The aim of this study was to examine the association between living with parents or with parents-in-law and postpartum depression among Chinese puerperal women. Methods A total of 1,126 participants who completed questionnaire were included in our
analysis. Postpartum depression status was assessed using the Edinburgh Postnatal Depression Scale. Logistic regression models were used to estimate the association between living with puerperal women’s parents or with parents-in-law and risk of postpartum depression after adjustment for potential confounders. Results The prevalence of postpartum depression among participants was 11.8%. Of the 1126 participants, 524 (46.5%) lived only with their husbands, 387 (34.4%) lived with their parents-in-law, and 215 (19.1%) lived with their parents. Compared with those living only with their husbands, puerperal women living with their parents-in-law had a higher risk of postpartum depression after adjustment for potential confounders (OR=2.48; 95% CI: 1.20, 5.15). No association between living with puerperal women’s parents and postpartum depression was found after adjustment for confounders (OR=1.05; 95%CI: 0.42, 2.65). Limitations Although we adjusted for a wide range of potential confounders, we cannot rule out the possibility of residual confounding by other unmeasured factors, such as breastfeeding, intimate partner violence, and marital relationship. Conclusions Our findings suggest that living with parents-in-law may be a risk factor for postpartum depression among Chinese puerperal women. Future preventive interventions should include strategies that target the puerperal women who lived with parents-in-law.
Abbreviations EPDS, Edinburgh Postnatal Depression Scale; PPD, Postpartum depression; PSRS, Pregnancy Stress Rating Scale; SSRS, Social Support Rate Scale;
Keywords: EPDS, Postpartum depression, Parents-in-law
1. Introduction Postpartum depression (PPD) refers to depressive episodes that are prevalent during the first year after delivery (O'Hara and McCabe, 2013). Evidence suggests that PPD has adverse effects on both mothers and their offspring (O'Hara and McCabe, 2013; Stewart and Vigod, 2016). A literature review of 143 research studies conducted in 40 countries demonstrated that the prevalence of PPD ranged from almost 0.5% to over 61.5% (Halbreich and Karkun, 2006), depending on the samples, screening instruments used, and the time assessed. In China, grandparents usually are the first choice for childcare providers (Lau,
2011; Li et al., 2015). Therefore, puerperal women are likely to choose to live with their parents or parents-in-law after childbirth. Puerperal women who experienced stressful events such as childbirth may get support from their parents (Heh et al., 2004). In contrast to the relationship between puerperal women and their biological parents, the in-law relationship (the relationship between puerperal women and their parents-in-law) is based on circumstance, not blood relation. Puerperal women often complain of having a difficult relationship with their in-laws (Chan and Levy, 2004). This poor in-law relationship is a common phenomenon in China. Few studies have investigated the association between living with puerperal women’s parents or with parents-in-law and PPD, and the results remain inconsistent (Abou‐Saleh and Ghubash, 1997; Rahman et al., 2003). The aim of this study was to examine the potential association between living with their parents or their parents-in-law and risk of PPD among Chinese puerperal women. 2. Methods 2.1. Study participants This study was carried out in Shenzhen Maternity and Child Health Hospital, located in Guangdong province, in the south of China. Shenzhen had 10.55 million population by the end of 2013. Its per capita GDP was $22,198 as of 2013. Shenzhen Maternity and Child Health Hospital is the biggest maternity hospital in Shenzhen city. There are around 20,000 deliveries occurred in this hospital each year. A total of 3,071 deliveries were occurred during November 1, 2013 and December 30,
2013. However, not all women who gave birth in this hospital would be back to take postpartum checkup. We invited all women (1,329 in total) who came to this hospital to take postpartum checkup at 14–60 days after delivery. A total of 1,204 (90.6%) women agreed to complete a questionnaire by a face-to-face interview. We collected information on demographic characteristics, obstetric information, pregnancy stress and socio-cultural factors. For current analysis, we excluded 78 participants with missing information regarding living situation or PPD. Finally, 1,126 participants were included in our study. The study protocol was approved by the ethics committee of the Shenzhen Maternity and Child Health Hospital. Written informed consent at enrollment was provided by all participants. 2.2. Assessment of postpartum depression Postpartum depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), a 10-item self-reported screening tool for PPD. Respondents was asked to rate the intensity of their depressive symptoms in the past seven days using 4-point Likert-type scales. The categories of responses range from 0 (i.e., not at all) to 3 (i.e., quite often). Total possible score ranged from 0 to 30, with higher scores indicating worse postpartum depression. The Chinese version of the EPDS was used to ascertain postpartum depression levels, with a threshold of 13. Lee validated the Chinese version of EPDS and found that its sensitivity and specificity were 0.82 and 0.86, respectively (Lee et al., 1998). 2.3. Assessment of puerperal women’s living situation
Information on puerperal women’s living status was obtained via a question asking: who did you live with after delivery? (a) Only with my husband, (b) With my parents, (c) With my parents-in-law. 2.4. Assessment of stress during pregnancy The Pregnancy Stress Rating Scale (PSRS) was used to measure women’s perceptions to stressful situation (Chen et al., 1983). The scale contains 30 items. A 4-point Likert scale was used to score each item, for a total potential score of 90 points (0 = none; 1 = slight; 2 = moderate; 3 = extremely severe). A higher score shows higher perceived stress during pregnancy. The Cronbach’s α value for this scale was 0.89. 2.5. Assessment of social support Social support was evaluated using the 10-item social support rate scale (SSRS) (Xiao, 1994; Xiao, 1999). The scale was developed to reflect Chinese environmental and cultural conditions, and can be separated into three dimensions: subjective support (3 items), objective support (3 items) and support utilization (3 items). Item scores were added up to generate a total score, with a higher score reflecting a higher level of social support. The scale had been validated with a Cronbach’s α value ranging between 0.89 and 0.94 and a test–retest reliability of 0.92. 2.6. Assessment of covariates Demographic characteristics on age, household registration (native or immigrant), education level (junior high school or below, high school or above), occupation (employed or unemployed), household income (<10,000 or >10,000 RMB per month)
and medical insurance (yes or no) were collected via questionnaire. Caregiver of puerperal women in the first month after childbirth (mother-in-law, mother, yuesao (yuesao is an in-house professional nurse for mother and infant), other relatives) and obstetric information on parity (primiparous or parous), mode of delivery (vaginal or caesarean
section),
infant’s
sex,
and
infant’s
birth
weight
(<2,500g,
2,500-4,000g, >4,000g) were also obtained from the questionnaire. 2.7 Statistical analysis Continuous variables were summarized as mean + standard deviation (SD). Student t-tests were used to examine difference in means for continuous variables among participants with PPD and those without PPD. Categorical variables were presented as proportion (%) and compared using Chi-square tests. Logistic regression analyses were performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) of the association between living with puerperal women’s parents or with parents-in-law and risk of PPD. The puerperal women living only with husbands were used as the reference group. Model 1 examined the association between living with puerperal women’s parents or with parents-in-law and PPD without adjustment for any covariates. Model 2 included demographic characteristics (age, household registration, education level, occupation, household income, and medical insurance). Model 3 made an additional adjustment for obstetric information (parity, mode of delivery, infant’s sex, and infant’s birth weight) and pregnancy stress. Finally, Model 4, the fully adjusted model, included the covariates in Model 3 plus socio-cultural factors (caregiver of puerperal women in the first month after childbirth, social
support in the postpartum period). These covariates have previously been reported to be associated with the risk of PPD (Gaillard et al., 2014; O'Hara and Wisner, 2014; Xie et al., 2007). The statistical analyses were performed using SAS 9.4 software (SAS Institute Inc., Cary, NC, USA). All the statistical tests were two-tailed, and the cutoff of significant level was defined as P<0.05. 3. Results Of the 1126 puerperal women, 133 (11.8%) had PPD. The mean age of the participants was 27.88 + 4.50 years. The proportion of puerperal women who lived only with their husbands, lived with their parents-in-law, and lived with their parents was 46.5%, 34.4%, and 19.1%, respectively. Characteristics of the participants according to PPD are presented in Table 1. Primipara with lower educational levels and worse economic status were more likely to develop PPD (all P< 0.05). Depressed women had higher scores for stress during pregnancy and lower scores for social support in the postpartum period (all P< 0.001). Table 2 shows the unadjusted and multivariate-adjusted OR and 95% CI of PPD according to whether puerperal women live with their parents or with their parents-in-law. Compared with those who lived only with their husbands, puerperal women who lived with their parents-in-law were at higher risk of PPD (OR=1.50; 95%CI: 1.02, 2.23) in the unadjusted model. After adjustment for demographic characteristics (Model 1), a similar association still was observed (OR=1.56; 95%CI: 1.01, 2.40). After additional adjustment for obstetric information and stress during pregnancy (Model 2), the association did not change (OR=2.03; 95 %CI: 1.06, 3.88).
Finally, in the fully adjusted model (Model 3) for demographic characteristics, obstetric information, stress during pregnancy and socio-cultural factors, the OR was 2.48 (95%CI: 1.20, 5.15) for puerperal women who lived with their parents-in-law compared with those who lived with their husbands. There was no association between living with the puerperal women’s parents and PPD after adjustment for potential confounders (OR=1.05; 95%CI: 0.42, 2.65). 4. Discussion In this study, we found that puerperal women living with their parents-in-law had a higher risk of PPD, compared with those living with their husbands. Even after adjustment for demographic characteristics, obstetric information, stress during pregnancy and socio-cultural factors, the association did not change. No association between living with puerperal women’s parents and PPD was observed. Few studies have explored the effect of living with puerperal women’s parents or with parents-in-law on the development of PPD, and the findings have been inconsistent. The current study’s findings were consistent with those of a cross-sectional Dubai study, which reported that living with a puerperal woman’s parents-in-law was associated with an increased risk of PPD, compared with living alone with their husbands (Abou‐Saleh and Ghubash, 1997). On the contrary, a Pakistani study suggested that for puerperal women, living with their mothers-in-law was a protective factor for PPD (Rahman et al., 2003). These inconsistent results may be due to differences of study design, sample size, demographic characters and socio-cultural factors. Furthermore, the association between living with parents-in-law
and PPD was not the primary interest in these studies and the findings were not discussed comprehensively. The reasons underlying the association between living with puerperal women’s parents-in-law and PPD are unclear. In traditional Chinese culture, puerperal women living with their parents-in-law are supposed to respect and obey the opinions of their parents-in-law regarding how to take care of their own family and children (Leung et al., 2005; Siu et al., 2012), whereas contemporary young women desire to assert modern values of independence and autonomy (Leung et al., 2005; Mellor et al., 2014). In-law conflicts (the conflicts between puerperal women and their parents-in-law) would then emerge if puerperal women hold different views from those of their parents-in-law, and these conflicts act as chronic stressors in the development of PPD (Lau, 2011; Siu et al., 2012). Furthermore, in China, son is closely tied to his family of origin and naturally more inclined to support his parents in in-law conflicts (Xie et al., 2007). The lack of husband support can lead to a poor marital relationship (Lau and Wong, 2008; Siu et al., 2012) , which is an important risk factor for PPD (Clout and Brown, 2015; Siu et al., 2012). Therefore, we speculated that the increased risk of PPD for puerperal women living with their parents-in-law might be due to poor marital relationship induced by in-law conflicts. Our study had no information on the quality of participants’ marital relationship, which prevented us from exploring whether living with their parents-in-law or the quality of marital relationship have an effect on PPD. Further studies are need to explore the association between living with parents-in-law
and PPD independent of the quality of marital relationship. Our findings indicated that living with puerperal women’s parents was not related to PPD, compared with those living only with their husbands. Puerperal women who lived with their parents could receive more support than those who lived with their parents-in-law (Heh et al., 2004). Epidemiological studies suggest that sufficient support was associated with a lower risk of depression and predicted a more rapid recovery from depression, compared with those lacking support (Heh et al., 2004; Mohammed et al., 2014). The relationship between living with puerperal women’s parents and family support might explain the lack of association between living with puerperal women’s parents and PPD to some extent. The strengths of our study included large sample size, and abundant potential confounders. Furthermore, interviews were performed in a hospital, by trained nurses, and used specific scales based on Chinese culture to make the data more reliable. Some limitations should be acknowledged. First, our study was cross-sectional; therefore, although we demonstrated that higher risk of PPD in puerperal women who lived with their parents-in-law, causal and temporal relationships could not be inferred. Second, we utilized EPDS to assess PPD without confirming the diagnosis with DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). The self-reported method yielded significantly higher estimates of PPD than the clinical psychiatric interview based method (Halbreich and Karkun, 2006). Third, it has been reported that PPD may be present in the first week after delivery (Faisal-cury et al., 2008). In China, the puerperal women usually are asked
back to hospital or community health center to take postpartum checkup at 14–60 days. So, in this study, we only evaluated the PPD happened during 14–60 days after delivery, which may introduce bias. Therefore, our results may not be generalizable to puerperal women who had PPD outside of this range. Fourth, although we adjusted for a wide range of potential confounders, we cannot rule out the possibility of residual confounding by other unmeasured factors such as breastfeeding, intimate partner violence, and marital relationship, which were associated with PPD (Dias and Figueiredo, 2015; Faisal-Cury et al., 2013; Rahman et al., 2003). Additionally, it has been reported that some women with PPD had already shown depressive symptoms during pregnancy (Faisal-Cury and Menezes, 2012). Unfortunately, we did not know if these women were already living with their parents-in-law during their pregnancy, which may confound the association between living with parents-in-law and PPD. Fifth, stress during pregnancy has been shown to be implicated in the development of PPD (Clout and Brown, 2015). In our study, stress during pregnancy was retrospectively assessed, thus recall bias might have occurred. In conclusion, our study suggests that living with parents-in-law is a risk factor for PPD among Chinese puerperal women. These findings enhance our understanding of risk factors for PPD and emphasized the need to address the risk of PPD in Chinese puerperal women who live with their parents-in-law.
References Abou ‐ Saleh, M.T., Ghubash, R., 1997. The prevalence of early postpartum psychiatric morbidity in Dubai: a transcultural perspective. Acta Psychiatr Scand 95, 428-432. Chan, S., Levy, V., 2004. Postnatal depression: a qualitative study of the experiences of a group of Hong Kong Chinese women. J Clin Nurs 13, 120-123. Chen, C., Yu, Y., Hwang, K., 1983. Psychological stressors perceived by pregnant women during their third trimester. Formosan Journal of Public Health 10, 88-98. Clout, D., Brown, R., 2015. Sociodemographic, pregnancy, obstetric, and postnatal predictors of postpartum stress, anxiety and depression in new mothers. J Affect Disord 188, 60-67. Cox, J.L., Holden, J.M., Sagovsky, R., 1987. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150, 782-786. Dias, C.C., Figueiredo, B., 2015. Breastfeeding and depression: a systematic review of the literature. J Affect Disord 171, 142-154. Faisal-Cury, A., Menezes, P.R., 2012. Antenatal Depression Strongly Predicts Postnatal Depression in Primary Health Care. Rev Bras Psiquiatr 34, 446-450. Faisal-Cury, A., Menezes, P.R., d'Oliveira, A.F., Schraiber, L.B., Lopes, C.S., 2013. Temporal relationship between intimate partner violence and postpartum depression in a sample of low income women. Matern Child Health J 17, 1297-1303. Faisal-cury, A., Menezes, P.R., Tedesco, J.J., Kahalle, S., Zugaib, M., 2008. Maternity
"blues": prevalence and risk factors. Span J Psychol 11, 593-599. Gaillard, A., Le, S.Y., Mandelbrot, L., Keïta, H., Dubertret, C., 2014. Predictors of postpartum depression: prospective study of 264 women followed during pregnancy and postpartum. Psychiatry Res 215, 341. Halbreich, U., Karkun, S., 2006. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 91, 97-111. Heh, S.-S., Coombes, L., Bartlett, H., 2004. The association between depressive symptoms and social support in Taiwanese women during the month. Int J Nurs Stud 41, 573-579. Lau, Y., 2011. A longitudinal study of family conflicts, social support, and antenatal depressive symptoms among Chinese women. Arch Psychiatr Nurs 25, 206-219. Lau, Y., Wong, D.F., 2008. The role of social support in helping Chinese women with perinatal depressive symptoms cope with family conflict. J Obstet Gynecol Neonatal Nurs 37, 556–571. Lee, D., Yip, S., Chiu, H., Leung, T., Chan, K., Chau, I., Leung, H., Chung, T., 1998. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. Br J Psychiatry 172, 433-437. Leung, S.S.K., Arthur, D., Martinson, I.M., 2005. Perceived Stress and Support of the Chinese Postpartum Ritual “Doing the Month”. Health Care Women Int 26, 212-224. Li, B., Adab, P., Cheng, K.K., 2015. The role of grandparents in childhood obesity in China-evidence from a mixed methods study. Int J Behav Nutr Phys Act 12, 91. Mellor, D., Xu, X., Wong, J., Richardson, B., 2014. The factor structure of the
Chinese family assessment instrument adapted for parent report. Assessment 21, 60-66. Mohammed, E., Mosalem, F., Mahfouz, E., ElHameed, M.A., 2014. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public health 128, 817-824. O'Hara, M.W., McCabe, J.E., 2013. Postpartum depression: current status and future directions. Annu Rev Clin Psychol 9, 379-407. O'Hara, M.W., Wisner, K.L., 2014. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol 28, 3-12. Rahman, A., Iqbal, Z., Harrington, R., 2003. Life events, social support and depression in childbirth: perspectives from a rural community in the developing world. Psychol Med 33, 1161-1167. Siu, B.W., Leung, S.S., Ip, P., Hung, S.F., O’Hara, M.W., 2012. Antenatal risk factors for postnatal depression: a prospective study of chinese women at maternal and child health centres. BMC Psychiatry 12, 22. Stewart, D.E., Vigod, S., 2016. Postpartum Depression. N Engl J Med 375, 2177-2186. Xiao, S., 1994. Theoretical principle and application of social support scale. J Clin Psychiatry 4, 98-100. Xiao, S., 1999. Social support rating scale. Chinese Mental Health Journal 13, 127-131. Xie, R.H., He, G., Liu, A., Bradwejn, J., Walker, M., Wen, S.W., 2007. Fetal gender
and postpartum depression in a cohort of Chinese women. Soc Sci Med 65, 680-684.
Table 1 Characteristics of the participants according to postpartum depression status. Characteristics Age
Depressed
Non-depressed
(N=133)
(N=993)
27.62+4.68
27.92+4.48
Living situation
P 0.478 0.024
Living only with husband (%)
56 (42.1)
468 (47.1)
Living with puerperal women’s parents-in-law (%)
59 (44.4)
328 (33.0)
Living with puerperal women’s parents (%)
18 (13.5)
197 (19.8)
Native (%)
45 (34.6)
277 (28.9)
Immigrant (%)
85 (65.4)
682 (71.1)
Household registration
0.179
Educational level
0.012
Junior high school or below (%)
45 (33.8)
235 (23.8)
High school or above (%)
88 (66.2)
753 (76.2)
Occupation
0.537 Employed (%)
97 (74.0)
696 (71.5)
Housewife (%)
34 (26.0)
278 (28.5)
Household income (Yuan per month)
0.003
<10,000 (%)
99 (77.3)
605 (64.0)
>10,000 (%)
29 (22.7)
341 (36.0)
No (%)
56 (43.8)
430 (45.0)
Yes (%)
72 (56.3)
526 (55.0)
Medical insurance
Parity
0.793 0.003
Primiparous (%)
34 (26.4)
151 (15.8)
Parous (%)
95 (73.6)
805 (84.2)
Mode of delivery
0.938 Vaginal delivery (%)
79 (62.2)
595 (61.9)
Caesarean section (%)
48 (37.8)
367 (38.1)
Infant’s sex
0.214 Boy (%)
44 (50.6)
351 (57.6)
Girl (%)
43 (49.4)
258 (42.4)
Infant’s weight (g)
0.835 <2,500 (%)
4 (3.1)
23 (2.4)
2,500–4,000 (%)
112 (86.2)
853 (87.8)
>4,000 (%)
14 (10.8)
96 (9.9)
30.54 + 15.15
14.85 + 13.18
Stress during pregnancy Caregiver of puerperal women
0.000 0.983
Mother-in-law (%)
60 (45.5)
428 (44.1)
Mother (%)
48 (36.4)
366 (37.7)
Social support
Yuesaoa (%)
15 (11.4)
106 (10.9)
Other relatives (%)
9 (6.8)
71 (7.3)
37.63 + 6.87
42.20 + 6.90
0.000
Categorical variables are presented as number (%) and continuous variables are summarized as mean ± SD. a
An in-house professional nurse for mother and infant.
Table 2 OR (95% CI) of postpartum depression according to puerperal women’s living situation. Living only with
Living with puerperal
Living with puerperal
husband
women’s parents-in-law
women’s parents
No. of participants
524 (46.5%)
387 (34.4)
215 (19.1)
Unadjusted model
1.00 (Ref)
1.50 (1.02, 2.23)
0.76 (0.44, 1.33)
Model 1
1.00 (Ref)
1.56 (1.01, 2.40)
0.80 (0.44, 1.44)
Model 2
1.00 (Ref)
2.03 (1.06, 3.88)
1.07 (0.45, 2.56)
Model 3
1.00 (Ref)
2.48 (1.20, 5.15)
1.05 (0.42, 2.65)
OR, odds ratio; CI, confidence interval. Model 1: Age, household registration, education, occupation, household income, and medical insurance; Model 2: Model 1+parity, mode of delivery, infant’s sex, infant’s birth weight, and pregnancy stress Model 3: Model 2 +Caregiver of puerperal women and social support
Highlights Puerperal women living with their parents-in-law had a higher risk of postpartum depression compared with those living only with their husbands. No association between living with puerperal women’s parents and postpartum depression was found.
PII: DOI: Reference:
www.elsevier.com/locate/jad
S0165-0327(16)31475-6 http://dx.doi.org/10.1016/j.jad.2017.04.052 JAD8926
To appear in: Journal of Affective Disorders Received date: 23 August 2016 Revised date: 4 April 2017 Accepted date: 24 April 2017 Cite this article as: Yue-Yun Wang, Hui Li, You-Jie Wang, Hong Wang, YanRu Zhang, Lin Gong, Jian Ma, Yan Wang, Ming-Zhen Wang, Shi-Xian Qiu and Shi-Xin Yuan, Living with parents or with parents-in-law and postpartum depression: a preliminary investigation in China, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2017.04.052 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Living with parents or with parents-in-law and postpartum depression: a preliminary investigation in China Yue-Yun Wanga, Hui Lib, You-Jie Wangb, Hong Wanga, Yan- Ru Zhanga,c, Lin Gonga , Jian Mad, Yan Wange , Ming-Zhen Wangf, Shi-Xian Qiua , Shi-Xin Yuana,* a
Shenzhen Maternity and Child Health Hospital, Guangdong, China
b
Department of Maternal and Child Health, School of Public Health, Tongji Medical
College, Huazhong University of Science and Technology, Wuhan, China c
Department of Epidemiology and Biostatistics, School of Public Health, Tongji
Medical College, Huazhong University of Science and Technology, Wuhan, China d
e
Futian District Maternity and Child Health Hospital, Guangdong, China
Longgang District Maternity and Child Health Hospital, Guangdong, China
f
Yantian District Maternity and Child Health Hospital, Guangdong, China
ABSTRACT Background Few studies have investigated the association between puerperal women’s living situation and postpartum depression. The aim of this study was to examine the association between living with parents or with parents-in-law and postpartum depression among Chinese puerperal women. Methods A total of 1,126 participants who completed questionnaire were included in our
analysis. Postpartum depression status was assessed using the Edinburgh Postnatal Depression Scale. Logistic regression models were used to estimate the association between living with puerperal women’s parents or with parents-in-law and risk of postpartum depression after adjustment for potential confounders. Results The prevalence of postpartum depression among participants was 11.8%. Of the 1126 participants, 524 (46.5%) lived only with their husbands, 387 (34.4%) lived with their parents-in-law, and 215 (19.1%) lived with their parents. Compared with those living only with their husbands, puerperal women living with their parents-in-law had a higher risk of postpartum depression after adjustment for potential confounders (OR=2.48; 95% CI: 1.20, 5.15). No association between living with puerperal women’s parents and postpartum depression was found after adjustment for confounders (OR=1.05; 95%CI: 0.42, 2.65). Limitations Although we adjusted for a wide range of potential confounders, we cannot rule out the possibility of residual confounding by other unmeasured factors, such as breastfeeding, intimate partner violence, and marital relationship. Conclusions Our findings suggest that living with parents-in-law may be a risk factor for postpartum depression among Chinese puerperal women. Future preventive interventions should include strategies that target the puerperal women who lived with parents-in-law.
Abbreviations EPDS, Edinburgh Postnatal Depression Scale; PPD, Postpartum depression; PSRS, Pregnancy Stress Rating Scale; SSRS, Social Support Rate Scale;
Keywords: EPDS, Postpartum depression, Parents-in-law
1. Introduction Postpartum depression (PPD) refers to depressive episodes that are prevalent during the first year after delivery (O'Hara and McCabe, 2013). Evidence suggests that PPD has adverse effects on both mothers and their offspring (O'Hara and McCabe, 2013; Stewart and Vigod, 2016). A literature review of 143 research studies conducted in 40 countries demonstrated that the prevalence of PPD ranged from almost 0.5% to over 61.5% (Halbreich and Karkun, 2006), depending on the samples, screening instruments used, and the time assessed. In China, grandparents usually are the first choice for childcare providers (Lau,
2011; Li et al., 2015). Therefore, puerperal women are likely to choose to live with their parents or parents-in-law after childbirth. Puerperal women who experienced stressful events such as childbirth may get support from their parents (Heh et al., 2004). In contrast to the relationship between puerperal women and their biological parents, the in-law relationship (the relationship between puerperal women and their parents-in-law) is based on circumstance, not blood relation. Puerperal women often complain of having a difficult relationship with their in-laws (Chan and Levy, 2004). This poor in-law relationship is a common phenomenon in China. Few studies have investigated the association between living with puerperal women’s parents or with parents-in-law and PPD, and the results remain inconsistent (Abou‐Saleh and Ghubash, 1997; Rahman et al., 2003). The aim of this study was to examine the potential association between living with their parents or their parents-in-law and risk of PPD among Chinese puerperal women. 2. Methods 2.1. Study participants This study was carried out in Shenzhen Maternity and Child Health Hospital, located in Guangdong province, in the south of China. Shenzhen had 10.55 million population by the end of 2013. Its per capita GDP was $22,198 as of 2013. Shenzhen Maternity and Child Health Hospital is the biggest maternity hospital in Shenzhen city. There are around 20,000 deliveries occurred in this hospital each year. A total of 3,071 deliveries were occurred during November 1, 2013 and December 30,
2013. However, not all women who gave birth in this hospital would be back to take postpartum checkup. We invited all women (1,329 in total) who came to this hospital to take postpartum checkup at 14–60 days after delivery. A total of 1,204 (90.6%) women agreed to complete a questionnaire by a face-to-face interview. We collected information on demographic characteristics, obstetric information, pregnancy stress and socio-cultural factors. For current analysis, we excluded 78 participants with missing information regarding living situation or PPD. Finally, 1,126 participants were included in our study. The study protocol was approved by the ethics committee of the Shenzhen Maternity and Child Health Hospital. Written informed consent at enrollment was provided by all participants. 2.2. Assessment of postpartum depression Postpartum depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), a 10-item self-reported screening tool for PPD. Respondents was asked to rate the intensity of their depressive symptoms in the past seven days using 4-point Likert-type scales. The categories of responses range from 0 (i.e., not at all) to 3 (i.e., quite often). Total possible score ranged from 0 to 30, with higher scores indicating worse postpartum depression. The Chinese version of the EPDS was used to ascertain postpartum depression levels, with a threshold of 13. Lee validated the Chinese version of EPDS and found that its sensitivity and specificity were 0.82 and 0.86, respectively (Lee et al., 1998). 2.3. Assessment of puerperal women’s living situation
Information on puerperal women’s living status was obtained via a question asking: who did you live with after delivery? (a) Only with my husband, (b) With my parents, (c) With my parents-in-law. 2.4. Assessment of stress during pregnancy The Pregnancy Stress Rating Scale (PSRS) was used to measure women’s perceptions to stressful situation (Chen et al., 1983). The scale contains 30 items. A 4-point Likert scale was used to score each item, for a total potential score of 90 points (0 = none; 1 = slight; 2 = moderate; 3 = extremely severe). A higher score shows higher perceived stress during pregnancy. The Cronbach’s α value for this scale was 0.89. 2.5. Assessment of social support Social support was evaluated using the 10-item social support rate scale (SSRS) (Xiao, 1994; Xiao, 1999). The scale was developed to reflect Chinese environmental and cultural conditions, and can be separated into three dimensions: subjective support (3 items), objective support (3 items) and support utilization (3 items). Item scores were added up to generate a total score, with a higher score reflecting a higher level of social support. The scale had been validated with a Cronbach’s α value ranging between 0.89 and 0.94 and a test–retest reliability of 0.92. 2.6. Assessment of covariates Demographic characteristics on age, household registration (native or immigrant), education level (junior high school or below, high school or above), occupation (employed or unemployed), household income (<10,000 or >10,000 RMB per month)
and medical insurance (yes or no) were collected via questionnaire. Caregiver of puerperal women in the first month after childbirth (mother-in-law, mother, yuesao (yuesao is an in-house professional nurse for mother and infant), other relatives) and obstetric information on parity (primiparous or parous), mode of delivery (vaginal or caesarean
section),
infant’s
sex,
and
infant’s
birth
weight
(<2,500g,
2,500-4,000g, >4,000g) were also obtained from the questionnaire. 2.7 Statistical analysis Continuous variables were summarized as mean + standard deviation (SD). Student t-tests were used to examine difference in means for continuous variables among participants with PPD and those without PPD. Categorical variables were presented as proportion (%) and compared using Chi-square tests. Logistic regression analyses were performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) of the association between living with puerperal women’s parents or with parents-in-law and risk of PPD. The puerperal women living only with husbands were used as the reference group. Model 1 examined the association between living with puerperal women’s parents or with parents-in-law and PPD without adjustment for any covariates. Model 2 included demographic characteristics (age, household registration, education level, occupation, household income, and medical insurance). Model 3 made an additional adjustment for obstetric information (parity, mode of delivery, infant’s sex, and infant’s birth weight) and pregnancy stress. Finally, Model 4, the fully adjusted model, included the covariates in Model 3 plus socio-cultural factors (caregiver of puerperal women in the first month after childbirth, social
support in the postpartum period). These covariates have previously been reported to be associated with the risk of PPD (Gaillard et al., 2014; O'Hara and Wisner, 2014; Xie et al., 2007). The statistical analyses were performed using SAS 9.4 software (SAS Institute Inc., Cary, NC, USA). All the statistical tests were two-tailed, and the cutoff of significant level was defined as P<0.05. 3. Results Of the 1126 puerperal women, 133 (11.8%) had PPD. The mean age of the participants was 27.88 + 4.50 years. The proportion of puerperal women who lived only with their husbands, lived with their parents-in-law, and lived with their parents was 46.5%, 34.4%, and 19.1%, respectively. Characteristics of the participants according to PPD are presented in Table 1. Primipara with lower educational levels and worse economic status were more likely to develop PPD (all P< 0.05). Depressed women had higher scores for stress during pregnancy and lower scores for social support in the postpartum period (all P< 0.001). Table 2 shows the unadjusted and multivariate-adjusted OR and 95% CI of PPD according to whether puerperal women live with their parents or with their parents-in-law. Compared with those who lived only with their husbands, puerperal women who lived with their parents-in-law were at higher risk of PPD (OR=1.50; 95%CI: 1.02, 2.23) in the unadjusted model. After adjustment for demographic characteristics (Model 1), a similar association still was observed (OR=1.56; 95%CI: 1.01, 2.40). After additional adjustment for obstetric information and stress during pregnancy (Model 2), the association did not change (OR=2.03; 95 %CI: 1.06, 3.88).
Finally, in the fully adjusted model (Model 3) for demographic characteristics, obstetric information, stress during pregnancy and socio-cultural factors, the OR was 2.48 (95%CI: 1.20, 5.15) for puerperal women who lived with their parents-in-law compared with those who lived with their husbands. There was no association between living with the puerperal women’s parents and PPD after adjustment for potential confounders (OR=1.05; 95%CI: 0.42, 2.65). 4. Discussion In this study, we found that puerperal women living with their parents-in-law had a higher risk of PPD, compared with those living with their husbands. Even after adjustment for demographic characteristics, obstetric information, stress during pregnancy and socio-cultural factors, the association did not change. No association between living with puerperal women’s parents and PPD was observed. Few studies have explored the effect of living with puerperal women’s parents or with parents-in-law on the development of PPD, and the findings have been inconsistent. The current study’s findings were consistent with those of a cross-sectional Dubai study, which reported that living with a puerperal woman’s parents-in-law was associated with an increased risk of PPD, compared with living alone with their husbands (Abou‐Saleh and Ghubash, 1997). On the contrary, a Pakistani study suggested that for puerperal women, living with their mothers-in-law was a protective factor for PPD (Rahman et al., 2003). These inconsistent results may be due to differences of study design, sample size, demographic characters and socio-cultural factors. Furthermore, the association between living with parents-in-law
and PPD was not the primary interest in these studies and the findings were not discussed comprehensively. The reasons underlying the association between living with puerperal women’s parents-in-law and PPD are unclear. In traditional Chinese culture, puerperal women living with their parents-in-law are supposed to respect and obey the opinions of their parents-in-law regarding how to take care of their own family and children (Leung et al., 2005; Siu et al., 2012), whereas contemporary young women desire to assert modern values of independence and autonomy (Leung et al., 2005; Mellor et al., 2014). In-law conflicts (the conflicts between puerperal women and their parents-in-law) would then emerge if puerperal women hold different views from those of their parents-in-law, and these conflicts act as chronic stressors in the development of PPD (Lau, 2011; Siu et al., 2012). Furthermore, in China, son is closely tied to his family of origin and naturally more inclined to support his parents in in-law conflicts (Xie et al., 2007). The lack of husband support can lead to a poor marital relationship (Lau and Wong, 2008; Siu et al., 2012) , which is an important risk factor for PPD (Clout and Brown, 2015; Siu et al., 2012). Therefore, we speculated that the increased risk of PPD for puerperal women living with their parents-in-law might be due to poor marital relationship induced by in-law conflicts. Our study had no information on the quality of participants’ marital relationship, which prevented us from exploring whether living with their parents-in-law or the quality of marital relationship have an effect on PPD. Further studies are need to explore the association between living with parents-in-law
and PPD independent of the quality of marital relationship. Our findings indicated that living with puerperal women’s parents was not related to PPD, compared with those living only with their husbands. Puerperal women who lived with their parents could receive more support than those who lived with their parents-in-law (Heh et al., 2004). Epidemiological studies suggest that sufficient support was associated with a lower risk of depression and predicted a more rapid recovery from depression, compared with those lacking support (Heh et al., 2004; Mohammed et al., 2014). The relationship between living with puerperal women’s parents and family support might explain the lack of association between living with puerperal women’s parents and PPD to some extent. The strengths of our study included large sample size, and abundant potential confounders. Furthermore, interviews were performed in a hospital, by trained nurses, and used specific scales based on Chinese culture to make the data more reliable. Some limitations should be acknowledged. First, our study was cross-sectional; therefore, although we demonstrated that higher risk of PPD in puerperal women who lived with their parents-in-law, causal and temporal relationships could not be inferred. Second, we utilized EPDS to assess PPD without confirming the diagnosis with DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). The self-reported method yielded significantly higher estimates of PPD than the clinical psychiatric interview based method (Halbreich and Karkun, 2006). Third, it has been reported that PPD may be present in the first week after delivery (Faisal-cury et al., 2008). In China, the puerperal women usually are asked
back to hospital or community health center to take postpartum checkup at 14–60 days. So, in this study, we only evaluated the PPD happened during 14–60 days after delivery, which may introduce bias. Therefore, our results may not be generalizable to puerperal women who had PPD outside of this range. Fourth, although we adjusted for a wide range of potential confounders, we cannot rule out the possibility of residual confounding by other unmeasured factors such as breastfeeding, intimate partner violence, and marital relationship, which were associated with PPD (Dias and Figueiredo, 2015; Faisal-Cury et al., 2013; Rahman et al., 2003). Additionally, it has been reported that some women with PPD had already shown depressive symptoms during pregnancy (Faisal-Cury and Menezes, 2012). Unfortunately, we did not know if these women were already living with their parents-in-law during their pregnancy, which may confound the association between living with parents-in-law and PPD. Fifth, stress during pregnancy has been shown to be implicated in the development of PPD (Clout and Brown, 2015). In our study, stress during pregnancy was retrospectively assessed, thus recall bias might have occurred. In conclusion, our study suggests that living with parents-in-law is a risk factor for PPD among Chinese puerperal women. These findings enhance our understanding of risk factors for PPD and emphasized the need to address the risk of PPD in Chinese puerperal women who live with their parents-in-law.
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Table 1 Characteristics of the participants according to postpartum depression status. Characteristics Age
Depressed
Non-depressed
(N=133)
(N=993)
27.62+4.68
27.92+4.48
Living situation
P 0.478 0.024
Living only with husband (%)
56 (42.1)
468 (47.1)
Living with puerperal women’s parents-in-law (%)
59 (44.4)
328 (33.0)
Living with puerperal women’s parents (%)
18 (13.5)
197 (19.8)
Native (%)
45 (34.6)
277 (28.9)
Immigrant (%)
85 (65.4)
682 (71.1)
Household registration
0.179
Educational level
0.012
Junior high school or below (%)
45 (33.8)
235 (23.8)
High school or above (%)
88 (66.2)
753 (76.2)
Occupation
0.537 Employed (%)
97 (74.0)
696 (71.5)
Housewife (%)
34 (26.0)
278 (28.5)
Household income (Yuan per month)
0.003
<10,000 (%)
99 (77.3)
605 (64.0)
>10,000 (%)
29 (22.7)
341 (36.0)
No (%)
56 (43.8)
430 (45.0)
Yes (%)
72 (56.3)
526 (55.0)
Medical insurance
Parity
0.793 0.003
Primiparous (%)
34 (26.4)
151 (15.8)
Parous (%)
95 (73.6)
805 (84.2)
Mode of delivery
0.938 Vaginal delivery (%)
79 (62.2)
595 (61.9)
Caesarean section (%)
48 (37.8)
367 (38.1)
Infant’s sex
0.214 Boy (%)
44 (50.6)
351 (57.6)
Girl (%)
43 (49.4)
258 (42.4)
Infant’s weight (g)
0.835 <2,500 (%)
4 (3.1)
23 (2.4)
2,500–4,000 (%)
112 (86.2)
853 (87.8)
>4,000 (%)
14 (10.8)
96 (9.9)
30.54 + 15.15
14.85 + 13.18
Stress during pregnancy Caregiver of puerperal women
0.000 0.983
Mother-in-law (%)
60 (45.5)
428 (44.1)
Mother (%)
48 (36.4)
366 (37.7)
Social support
Yuesaoa (%)
15 (11.4)
106 (10.9)
Other relatives (%)
9 (6.8)
71 (7.3)
37.63 + 6.87
42.20 + 6.90
0.000
Categorical variables are presented as number (%) and continuous variables are summarized as mean ± SD. a
An in-house professional nurse for mother and infant.
Table 2 OR (95% CI) of postpartum depression according to puerperal women’s living situation. Living only with
Living with puerperal
Living with puerperal
husband
women’s parents-in-law
women’s parents
No. of participants
524 (46.5%)
387 (34.4)
215 (19.1)
Unadjusted model
1.00 (Ref)
1.50 (1.02, 2.23)
0.76 (0.44, 1.33)
Model 1
1.00 (Ref)
1.56 (1.01, 2.40)
0.80 (0.44, 1.44)
Model 2
1.00 (Ref)
2.03 (1.06, 3.88)
1.07 (0.45, 2.56)
Model 3
1.00 (Ref)
2.48 (1.20, 5.15)
1.05 (0.42, 2.65)
OR, odds ratio; CI, confidence interval. Model 1: Age, household registration, education, occupation, household income, and medical insurance; Model 2: Model 1+parity, mode of delivery, infant’s sex, infant’s birth weight, and pregnancy stress Model 3: Model 2 +Caregiver of puerperal women and social support
Highlights Puerperal women living with their parents-in-law had a higher risk of postpartum depression compared with those living only with their husbands. No association between living with puerperal women’s parents and postpartum depression was found.