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Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study
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Original Research
Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study E.S. Mohammed*, F.A. Mosalem, E.M. Mahfouz, M.A. Abd ElHameed Faculty of Medicine, El-Minia University, El-Minia, Egypt
article info
abstract
Article history:
Objectives: To study the prevalence of postpartum depression (PPD) in a certain rural area in
Received 19 November 2012
Upper Egypt, identifying the factors that might be involved in its genesis.
Received in revised form
Study design: The current study is a cross-sectional community-based study.
21 May 2014
Methods: The study was conducted in El-Burgaia village, 5 km north to El-Minia city over a
Accepted 9 June 2014
period of three months. Systematic random sampling was used to interview 200 female sub-
Available online 9 September 2014
jects, who gave birth within the last 14 months preceding interview. The Edinburgh Postnatal Depression Scale (EPDS) was applied to these females to identify the presence of PPD.
Keywords:
Results: The sample size analysed was 200 females, 99 (49.5%) of them had PPD (29.5% had
Postpartum depression
minor PPD and 20% had major PPD). The age of the study subjects ranged between 19 and
Females
45 years old (mean age 29 ± 5.2 years). PPD occurred more significantly among wives of less
Epidemiology
educated husbands (P ¼ 0.03). PPD was more common among those previously diagnosed
Predictors
of having depression or prescribed antidepressants (P ¼ 0.02), in addition to those females experiencing financial problems after delivery (P ¼ 0.0001). PPD was even more common among females having complications after delivery (P ¼ 0.01). Using logistic regression analysis, total household income, child sleeping hours, complications after delivery and support of husband after delivery were found to be statistically associated with PPD. Conclusions: PPD is relatively common among rural females of El-Minia Governorate. Certain factors in these females, in the mere gestation and delivery after which they become depressed, and in the environment in which they live in, may all come to play a part in the emergence of their psychiatric illness. © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Postpartum depression (PPD) is a form of clinical depression that can affect women and, less frequently, men after childbirth.1 Reported prevalence rates for PPD among women range
from 5% to 25%, but methodological differences between studies make it difficult to determine the actual prevalence rate.1 A recent review of 143 studies from 40 countries demonstrated that reported prevalence of PPD ranged from almost 0%e60%.2 PPD may last for several months, and
* Corresponding author. Department of Public Health, Faculty of Medicine, El-Minia University, University St., El-Minia 1666, Egypt. Tel.: þ20 086 2296790. E-mail address: [email protected] (E.S. Mohammed). http://dx.doi.org/10.1016/j.puhe.2014.06.006 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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symptoms generally include sadness, fatigue, hopelessness, low self-esteem, guilt, changes in sleeping and eating patterns, reduced libido, becoming easily frustrated, spells of anger towards others, and irritability.3 PPD has a large negative impact on both the mother and her child, including child development and the probable later appearance of behavioural disturbance.4,5 While the causes of PPD are not fully understood, a number of factors have been identified as predictive, such as childcare stress which causes profound lifestyle changes, first pregnancy, prenatal depression during pregnancy, life stress, low social support, poor marital relationship, infant temperament problems, single parenthood, low socio-economic status, unwanted pregnancy and lack of social support.6,7 Early identification and intervention improve the long-term prognosis for most women. Women should be screened by their physician to determine their risk for acquiring PPD.8 If the cause of PPD can be identified, treatment should aim to mitigate the root cause of the problem, including increased partner support, additional help with childcare, cognitive therapy, etc.9,10
Justification of the study Depression is a very common mental health problem among women, and has a major effect on the quality of life of those who are affected and their families.11 The magnitude of this common mental health problem, which is somewhat hidden or not diagnosed, should be recognized and measured in order to take action and develop strategies based on recent local data. Despite the fact that mental health problems are prevalent in the Egyptian community, they have not received as much attention as physical health problems, and there is a paucity of recent local data regarding depression among women, particularly in rural areas of Upper Egypt, and regarding the factors that may be implicated. A large study of the epidemiology of depressive disorders was conducted in Burgaia in 2004; this study did not address PPD in particular, and studied the epidemiology rather than going through the factors implicated in the occurrence of the illness.
of the total number of residents, the total number of homes and the total number of women who had given birth within the previous 14 months; this served as the sampling frame for the study. In total, 954 women had given birth within the previous 14 months.
Inclusion criteria Women who had given birth within the previous 14 months, lived in El-Burgaia and were willing to participate were included in the study. Women who had given birth within the previous 14 months were included because PPD is an overarching concept that encompasses several mood disorders that follow childbirth, from Day 5 in the case of baby blues up to 12e18 months in other types of PPD. Women up to 14 months postpartum were included because it was expected that PPD would be underdiagnosed and would extend beyond 12 months in this rural community in Upper Egypt with relatively suboptimal health services and delayed health care seeking. Numerous published studies have used the first 14 months postpartum for screening of PPD. It has been reported that one-third of women scoring within a depressive range at eight months postpartum were still depressed 12e18 months later.12 Another study showed that PPD can become apparent after the first weeks of giving birth and can last as long as 14 months.13
Exclusion criteria Exclusion criteria were: single women or married women who had not given birth, women who had given birth more than 14 months previously, urban women who happened to be present in the village during the study period, and women who did not wish to participate in the study. Unmarried women were not included in this study as the Egyptian community has certain customs and traditions that do not allow women to have children outside marriage.
Sample size
Methods Study design This cross-sectional community-based study was conducted in a random sample of women who had given birth within the previous 14 months. The study population lived in the village of El-Burgaia, which is 5 km north of El-Mina, and has 5188 households and a population of 25,938 population (Central Agency of Population Mobilization and Statistics 2006, ElMinia Governorate). This study was conducted to determine the prevalence of PPD among these women, and to determine the risk factors leading to PPD.
Administrative design The local council of El-Burgaia gave their approval for the authors to obtain demographic data about the village, in terms
Data were collected from 200 women, selected using systematic random sampling by numbering the houses in the village, choosing the first house at random and then every fifth house thereafter. The sample size was calculated using EpiInfo 2000 by entering the average estimate of PPD (15%), the number of women who had given birth within the previous 14 months (n ¼ 954) and the confidence level at 99.99%. Two hundred and twelve women were selected, 200 of whom agreed to be interviewed and to participate in the study. The remaining 12 (5.7%) women declined to participate in the study. The response rate was 94.3%. The study was undertaken between 1 December 2011 and 29 February 2012. Data were collected over four weeks in January 2012. The average time taken to interview and examine each woman was 40 minutes. Questionnaires were verified to exclude vague and incomplete responses. Data entry and analysis were performed after the whole sample
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had been interviewed and the participants' sheets had been reviewed.
Collection of data Data were collected using a structured questionnaire, including the Edinburgh Postnatal Depression Scale (EPDS). Each participant was interviewed during a home visit, the aim of the study was explained and the answers to the questionnaire were filled in by the researcher. The questionnaire included: personal demographic characteristics (name, age, woman's and husband's education and occupation, total household income); data related to the child (rank of birth, age, sex, weight at birth, breast feeding, sleeping habits); data related to the pregnancy, especially weight gain; data concerning delivery (type and place of delivery, assistant and who attended the delivery, any complications or health difficulties due to or following delivery); and previous history of depression or its treatment, and the support of husband, family or friends after delivery. The EPDS was used as a psychological screening tool. It is sensitive to changes during the course of pregnancy and after childbirth. A review of validation studies of the EPDS concluded that most studies reported high sensitivity for the detection of PPD.14 The Arabic version of the EPDS has been validated among Egyptian women, and its psychometric performance is comparable to the original scale.15 The EPDS contains 10 items, all rated on a four-point scale (0e3), giving a maximum score of 30. A score of 13 or more is considered to indicate major PPD, scores of 10e12 represent 'borderline' or minor PPD, and scores of 0e9 indicate no depression. In doubtful cases, it may be useful to repeat the tool two weeks later. However, the EPDS is not designed to detect mothers with anxiety neuroses, phobias or personality disorders.
Pilot study The questionnaire was initially tested on 10 women, not included in the sample, to investigate its clinical application of the questionnaire. The pilot study also tested the reliability of the questions (testeretest) and the time needed to conduct an interview. Proper corrections and adjustments were applied; the data for these 10 women were not included in the study results.
Statistical analysis Statistical Package for the Social Sciences Version 11 (SPSS Inc., Chicago, IL, USA) was used for data entry and analysis, and Microsoft Excel (Microsoft Corp., Redmond, WA, USA) was used for graphics. Quantitative data were presented as mean and standard deviation, and qualitative data were presented as a frequency distribution. Chi-squared test and Student's ttest were used. A multivariate analysis was also undertaken. P < 0.05 was considered to indicate significance.
Results Two hundred women were included in this study. The age of the subjects ranged between 19 and 45 years {mean 29 [standard deviation (SD) 5.2] years}. The median time since birth was eight months, and the range was 13 months [mean 8 (SD 4.4) months]. More than half (67.5%) of the women in this study had a vaginal delivery. Doctors and midwives assisted the birth in 65.5% and 31% of cases, respectively. The woman's husband attended the delivery in 49.5% of cases, and no one attended the delivery in 4% of cases. Fifty-four percent of women delivered in hospitals and 4% delivered in private clinics. Most (71%) women had no complications after delivery. Contraception was used by 76% of women after delivery, and the most common method was contraceptive injection (Table 1). Table 2 shows that PPD was significantly more common among women married to less-educated men, and women with a low total household income (P ¼ 0.03 and 0.0001, respectively). PPD was more common among women who had previously been diagnosed with depression or prescribed antidepressants, women who experienced financial problems after delivery, women who experienced complications after delivery, and women who did not have support from their husband after delivery (Table 3). This table also shows that women who had experienced domestic violence during pregnancy or in the previous year had a higher prevalence of PPD compared with their counterparts. Women with low birth-weight (LBW) babies and babies who did not sleep for a sufficient number of hours were significantly
Table 1 e Descriptive data related to delivery. Delivery data Type of delivery Vaginal Caesarean section Assistance of delivery Doctor Midwife Other Personnel attending the delivery Husband Relatives Husband and relatives No one Place of delivery Hospital Mother and child health centre House Private clinic Complications after delivery Yes No Method of contraception None Intra-uterine device Pills Injection Norplant
n
%
135 65
67.5 32.5
131 62 7
65.5 31 3.5
33 93 66 8
16.5 46.5 33 4
108 18 66 8
54 9 33 4
58 142
29 71
48 32 53 61 6
24 16 26.5 30.5 3
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Table 2 e Relationship between socio-economic factors and postpartum depression (PPD). Socio-economic factors
PPD
Total
None
Woman's education level Illiterate Able to read and write Below university University or higher Husband's education level Illiterate Able to read and write Below university University or higher Total household income Low Middle High Total
Chi-squared P-value
Minor/major
n
(%)
n
30 7 60 4
(50.8) (33.3) (52.2) (80)
29 14 55 1
10 6 74 11
(32.3) (37.5) (53.6) (73.3)
19 74 8 101
(24.7) (64.3) (100) (50.5)
n
(%)
(49.2) (66.7) (47.8) (20)
59 21 115 5
(100) (100) (100) (100)
4.35 0.2
21 10 64 4
(67.7) (62.5) (46.4) (26.7)
31 16 138 15
(100) (100) (100) (100)
8.88 0.03
58 41 0 99
(75.3) (35.7) (0) (49.5)
77 115 8 200
(100) (100) (100) (100)
37.2 0.0001
more likely to experience PPD compared with their counterparts (P ¼ 0.002 and 0.0001, respectively) (Table 4). Half (50.5%) of the women in this study did not have PPD, and half (49.5%) did have PPD (29.5% had minor PPD and 20% had major PPD) (Fig. 1). Table 5 shows the adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between the
(%)
combined effect of independent variables and the outcome variable (PPD). These estimates were obtained by logistic regression analysis. Total household income, child sleeping hours, complications after delivery and husband's support after delivery were statistically associated with PPD. Total household income was found to be the most important determinant. Women with a low household income were
Table 3 e Relationship between maternal characteristics and postpartum depression (PPD). Maternal characteristics
PPD None n
Parity Multiparous 78 Primiparous 23 Pregnancy weight gain Inadequate 11 Recommended 71 Excessive 19 Previous diagnosis of depression/prescription Yes 26 No 75 Financial problems after delivery Yes 26 No 75 Complications after delivery Yes 21 No 80 Support of family and friends after delivery Most of the time 64 Some of the time 29 None of the time 8 Support of husband after delivery Most of the time 60 Some of the time 37 None of the time 4 Victim of domestic violence Yes 14 No 87 Total 101
Total
Chi-squared P-value
Minor/major PPD (%)
n
(47.9) (62.2)
85 14
(45.8) 13 (50) 71 (55.9) 15 of antidepressants (39.4) 40 (56) 59 (32.9) (62)
(%)
n
(%)
(52.1) (37.8)
163 37
(100) (100)
2.47 0.1
(54.2) (50) (44.1)
24 142 34
(100) (100) (100)
0.6 0.7
(60.6) (44)
66 134
(100) (100)
4.86 0.02
53 46
(67.1) (38)
79 121
(100) (100)
16.2 0.0001
(36.2) (56.3)
37 62
(63.8) (43.7)
58 142
(100) (100)
6.68 0.01
(53.8) (49.2) (36.4)
55 30 14
(46.2) (50.8) (63.6)
119 59 22
(100) (100) (100)
2.31 0.3
(60.6) (48.1) (16.7)
39 40 20
(39.4) (51.9) (83.3)
99 77 24
(100) (100) (100)
15.2 0.0001
(36.8) (53.7) (50.5)
24 75 99
(63.2) (46.3) (49.5)
38 162 200
(100) (100) (100)
3.5 0.06
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Table 4 e Relationship between child's characteristics and postpartum depression (PPD). Child's characteristics
PPD No n
Sex Male 55 Female 46 Low birth weight Yes 44 No 57 Baby in NICU Yes 9 No 92 Sleeping sufficient number of hours Yes 81 No 20 Total 101
Total
Chi-squared P-value
Minor/major PPD (%)
n
(%)
(48.7) (52.9)
58 41
(51.3) (47.1)
113 87
(100) (100)
0.35 0.6
(40.4) (62.6)
65 34
(59.6) (37.4)
109 91
(100) (100)
9.8 0.002
(45) (51.1)
11 88
(55) (48.9)
20 180
(100) (100)
0.27 0.6
(64.3) (27) (50.5)
45 54 99
(35.7) (73) (49.5)
126 74 200
(100) (100) (100)
25.9 0.0001
NICU, neonatal intensive care unit.
found to be approximately three times more likely to experience PPD than women with a high household income (OR 3.56, 95% CI 2.15e5.89; P < 0.001). Similarly, women who had complications after delivery were 2.84 times more likely to experience PPD than women who did not have complications after delivery (OR 2.84, 95% CI 1.18e6.81; P ¼ 0.02).
Discussion Depression is a prevalent health problem among women of childbearing age. Mothers of infants and young children are at particular risk, partly due to the routine demands of parenting. Maternal depressive symptoms are common in early infancy, and contribute to unfavourable parenting practices. Longitudinal studies of pregnant and postpartum women consistently find that 9e12% of women have depressive symptoms.16,17 Half (49.5%) of the women in this study were diagnosed with PPD (20% had major PPD and 29.5% had minor PPD). These figures seem high. A multicentre study by Gorman et al. estimated that the prevalence of perinatal depression during the first six months postpartum ranged from 2.1% to 31.6%. There were significant differences between the rates for different centres engaged in the study.18 The prevalence rates of PPD in studies that use randomly selected samples of women generally fall between 10% and 15%. A meta-analysis of 59 studies estimated that the average
29.0% 0-9 (Normal)
50.5%
10-12 (Minor PPDS) 13-30 (Major PPDS)
20.5%
Fig. 1 e Prevalence of postpartum depression (based on Edinburgh Postnatal Depression Scale) among women in the village of El-Burgaia, El-Minia Governorate, 2012. PPDS, postpartum depression syndrome.
prevalence of PPD was 13%.19 Rates vary between studies due to the length of the postnatal period examined and the method of assessment.20 The present study had a relatively long (14 months) period of assessment, and this may help to explain the relatively high prevalence of PPD. The EPDS is a self-rating measure that was developed to screen and identify women who may be experiencing PPD. Self-rating measures are reported to be associated with high prevalence of PPD.19 However, although the measure was developed as a screening instrument, a cut-off score of 12/13 identifies women who are most likely to be experiencing PPD.20 The measure has also been validated as a screening measure for depression during pregnancy.21 As the EPDS was originally designed to screen for, rather than diagnose, PPD, high scorers are generally referred to as ‘probable’ cases of PPD. The EPDS is increasingly used in largescale PPD studies to avoid burdening staff with timeconsuming diagnostic interviews.22 The high prevalence of PPD found in this study may be explained by the low standard of living in Burgaia; most women (n ¼ 192, 96%) in the sample had low or moderate socio-economic status. This finding was in agreement with the observations of Saleh et al., who studied the predictors of PPD in a sample of Egyptian women and found correlation between the severity of depression and socio-economic status.23 Women married to less-educated men were significantly more vulnerable to PPD compared with women married to more-educated men. In addition, husband's educational level was a significant determinant of the occurrence of PPD on multiple regression analysis (P ¼ 0.05). A few research studies have addressed the importance of husband's education as a risk factor for PPD, including the study by Lee et al.24 It could be argued that husbands with a higher level of education may be more willing to support and appreciate the efforts of their wives, as well as providing more time and money for health issues and home atmosphere. Women with a low total household income were significantly more likely to develop PPD than women with a higher
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Table 5 e Logistic regression analysis of factors independently associated with postpartum depression in 200 women. Risk factors
OR (95% CI)
Total household income High 1.00 (reference) Middle 1.36 (0.76e2.42) Low 3.56 (2.15e5.89) Child sleeping sufficient number of hours No 1.00 (reference) Yes 0.21 (0.09e0.48) Complications after delivery No 1.00 (reference) Yes 2.84 (1.18e6.81) Support of husband after delivery Most of the time 1.00 (reference) Some of the time 0.43 (0.12e1.76) None of the time 0.18 (0.05e0.74) Financial problems after delivery No 1.00 (reference) Yes 2.04 (0.95e4.35) Low-birthweight baby No 1.00 (reference) Yes 1.96 (0.92e4.19) History of depression or treatment of depression No 1.00 (reference) Yes 0.79 (0.34e1.86) Husband's level of education University or more 1.00 (reference) Below university 3.17 (0.73e13.79) Able to read and write 3.81 (0.55e26.25) Illiterate 4.61 (0.79e26.77)
P-value <0.001ª
<0.001ª
0.02ª
0.02ª
0.06
0.08
0.6
0.4
OR, odds ratio; CI, confidence interval. Dependent variable was postpartum depression. R2 ¼ 0.51. a Statistically significant.
total household income. Using multiple regression analysis, low total household income was found to be one of the most important determinants for PPD. This finding may reflect vulnerability to PPD triggered by stresses of poverty, unemployment, low level of employment and lower social support among people of lower socio-economic status.25,26 The mean age of women in this study was 29 (SD 5.2) years, with a range of 19e45 years; the results seem to be in agreement with the results of Fawzy et al., who observed that PPD occurred significantly more often in older mothers.27 Such findings could be attributed to the term ‘multipara’ in this study, which tends to refer to women that have generally delivered four times or more. This has a negative effect on their general health, as well as the crowdedness index of their houses and their state of welfare. PPD was more common among women who had previously been diagnosed with depression or prescribed antidepressants. This seems to agree with the observation by O'Hara and Swain that there is a close connection between antenatal depressive mood and PPD.19 This was also reported by Chandran et al.28 PPD was more common among women with financial problems after delivery. This supports the study of Bernazzani et al., who found that women who experienced more severe life adversity in the form of acute negative life events and chronic daily stresses during their pregnancy and after
delivery were more likely to be diagnosed with PPD compared with their counterparts.29 Women who experienced complications after delivery were more likely to suffer from PPD; this applied to 29% (n ¼ 58) of women in this study, which is a relatively high proportion. It should be noted that rural women in Upper Egypt do not usually engage in proper antenatal care due to scarcity of available health resources, poverty and decreased education. PPD was more common among women who did not receive sufficient support from their husbands. In addition, the level of husband's support after delivery was found to be one of the most important determinants of PPD on multiple regression analysis. This has been reported in several studies, indicating the importance of husband's support in the prevention of PPD.28,30 In addition, poor emotional support following delivery was a psychosocial variable associated with higher prevalence of PPD in the systemic review of perinatal mental disorders in low- and loweremiddle income countries conducted by Fisher et al.31 Women in poor agricultural villages in Upper Egypt are still considered to be inferior to males and to their husbands. They are often treated as workers in the fields and at home, burdened with responsibilities and without acknowledgement of their efforts. In addition, many of these women have husbands who work abroad. Thus, these women often give birth in the absence of their husbands. Of the 200 women included in this study, the husband attended the birth in 99 (49.5%) cases (either alone or with other relatives). Bener et al. reported that dissatisfaction in marital life and a poor marital relationship were significantly associated with higher prevalence of PPD.32 Women with low birth weight (LBW) babies and babies who did not sleep for a sufficient number of hours were significantly more likely to have PPD than their counterparts. Insufficient sleep of babies was found to be a highly significant determinant of PPD on multiple regression analysis. This could be attributed to the additional effort and decreased rest associated with such conditions, especially in the case of insufficient support from their husband and other relatives. Singer et al. reported that mothers of very LBW infants felt significantly more personal stress and family stress under conditions of low social support. In addition, such mothers had greater child-related stress than term mothers. In this study, some, but not all, of the LBW infants were very LBW.33
Conclusions PPD is not a rare condition in women living in rural areas of ElMinia Governorate. Various factors associated with gestation, delivery and the living environment play a part in the emergence of PPD.
Implications of the study It is recommended that emotional health and well-being should be assessed routinely during pregnancy and over the first year postpartum; this can be integrated into women's regular health checks. Due to increased risk of PPD, women facing socio-economic hardship and women with poor
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pregnancy outcomes should be targeted for depression screening, prevention and treatment. The major clinical implications of the findings are that PPD is common and a largely undetected public health problem. There is a need for women to be screened for depression in the postpartum period, by domiciliary health workers or at the immunization clinic, and this service should be incorporated into maternal and child health programmes.
Author statements The authors wish to thank all the women who participated in this study. Many thanks to Mrs. OLa Labed and Mr. Mohammed Sameh for language revision.
Ethical approval The Departments of Psychiatry and Community, and Minia Faculty of Medicine approved this study. All data for the women included in the study were kept confidential. All women included in the study were given a code number before data were entered into the computer system, and this procedure was undertaken by the researchers. Full written, informed consent was obtained from all participants.
Funding None declared.
Competing interests None declared.
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1. Paulson JF. Focusing on depression in expectant and new fathers: prenatal and postpartum depression not limited to mothers. Psychiatry Times 2010;27. 2. Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006;91:97e111. 3. Jones HW, Venis JA. Identification and classification of postpartum psychatric disorders. J Psychosoc Nurs Ment Health Serv 2001;39:23e47. 4. Poobalan AS, Aucott LS, Ross L, Smith WCS, Helms PJ, Williams JHG. Effects of treating postnatal depression on mothereinfant interaction and child development: systematic review. Br J Psychiatry 2007;191:378e86. S, Sherr L, Senior R, Nazareth I. Associations between 5. Dave parental depression and behavior problems in children of 4e6 years. Eur Child Adolesc Psychiatry 2008;17:306e15. 6. Breese McCoy SJ. Risk factors for postpartum depression: a retrospective investigation at 4-weeks postnatal and a review of the literature. J Am Osteopath Assoc 2006;106:193e8. 7. Beck CT. Predictors of postnatal depression: an update. Nurs Res 2001;50:275e85. 8. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstetr Gynecol 2009;200:357e64.
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9. Dennis CE, Stewart DE. Treatment of postpartum depression, part 1: a critical review of biological interventions. J Clin Psychiatry 2004;65:1242e51. 10. Honey K, Morgan M, Bennett P. A stress-coping transactional model of low mood following childbirth. J Reprod Infant Psychol 2003;21:129e43. 11. Podgornik N. Depression e a sociocultural way of manifesting women's psychological crises. Anthropol Noteb 2012;18:55e67. 12. Thurgood S, Avery DM, Williamson L. Postpartum depression (PPD). Am J Clin Med 2009;6:17e22. 13. Lanes A, Kuk JL, Tamim H. Prevalence and characteristics of postpartum depression symptomatology among Canadian women: a cross-sectional study. BMC Public Health 2011;11:302. 14. Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, Samuelsen SO. Review of validation studies of the Edinburgh postnatal depression scale. Acta Psychiatr Scand 2001;104:243e9. 15. Ghubash R, Abou-Saleh MT, Daradkeh TK. The validity of the Arabic Edinburgh postnatal depression scale. Psychiatr Epidemiol 1997;32:474e6. 16. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. Br Med J 2001;323:257e9. 17. Luoma I, Tamminen T, Kaukonem P, Laippala P, Puura K, Salmelin R, Almqvist F. Longitudinal study of maternal depressive symptoms and child well-being. J Am Acad Child Adolesc Psychiatry 2001;40:1367e74. 18. Gorman LL, O'Hara MW, Figueiredo B, Hayes S, Jacquemain F, Kammerer MH, Klier CM, Rosi S, Seneviratne G, SutterDallay ALTCS-PND Group. Adaptation of the structured clinical interview for DSMeIV disorders for assessing depression in women during pregnancy and post-partum across countries and cultures. Br J Psychiatry Suppl 2004;46:s17e23. 19. O’Hara KW, Swain AM. Rates and risk of postpartum depression e meta-analysis. Int Rev Psychiatry 1996;8:37e54. 20. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry 1987;150:782e6. 21. Murray L, Cox JL. Screening for depression during pregnancy with the Edinburgh depression scale (EPDS). J Reprod Infant Psychol 1990;8:99e107. 22. Warner R, Appleby L, Whitton A, Faragher B. Demographic and obstetric risk factors for postnatal psychiatric morbidity. Br J Psychiatry 1996;168:607e11. 23. Saleh ES, El-Bahei W, El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013;9:15e24. 24. Lee DTS, Yip ASK, Leung TYS, Chung TKH. Ethnoepidemiology of postnatal depression: prospective multivariate study of sociocultural risk factors in a Chinese population in Hong Kong. Br J Psychiatry 2004;184:34e40. 25. Ballard CG, Davis R, Cullen PC, Mohan RN, Dean C. Prevalence of postnatal psychiatric morbidity in mothers and fathers. Br J Psychiatry 1994;164:782e8. 26. Stansfeld SA, Head J, Marmot MG. Explaining social class differences in depression and well-being. Soc Psychiatry Psychiatr Epidemiol 1998;33:1e9. 27. Fawzy N, Raya Y, Negm M, Youssef U, Hussin R. Mood changes affecting husband and wife in postpartum period: epidemiological and risky factors study. Curr Psychiatry 2010;17:35e40. 28. Chandran M, Tharyan P, Muliyil J, Abraham S. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India: incidence and risk factors. Br J Psychiatry 2002;181:499e504.
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29. Bernazzani O, Conroy S, Marks MN, Siddle KA, Guedeney N, Bifulco A, Asten P, Figueiredo B, Gorman LL, Bellini S, Glatigny-Dallay E, Hayes S, Klier CM, Kammerer MH, Henshaw CA. Contextual assessment of the maternity experience: development of an instrument for crosscultural research. Br J Psychiatry 2004;184(Suppl. 46):s24e30. 30. Abou-Saleh MT, Ghubash R. The prevalence of early postpartum psychiatric morbidity in Dubai: a transcultural perspective. Acta Psychiatr Scand 1997;95:428e32. 31. Fisher J, de Mello MC, Patel V, Rahman A, Tran T, Holton S, Holmes W. Prevalence and determinants of common
perinatal mental disorders in women in low- and lowermiddle-income countries: a systematic review. Bull World Health Organ 2012;90:139e49. 32. Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012;43:325e37. 33. Singer LT, Fulton S, Kirchner HL, Eisengart S, Lewis B, Short E, Min MO, Satayathum S, Kercsmar C, Baley JE. Longitudinal predictors of maternal stress and coping after very low-birthweight birth. Arch Pediatr Adolesc Med 2010;164:518e24.
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Original Research
Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study E.S. Mohammed*, F.A. Mosalem, E.M. Mahfouz, M.A. Abd ElHameed Faculty of Medicine, El-Minia University, El-Minia, Egypt
article info
abstract
Article history:
Objectives: To study the prevalence of postpartum depression (PPD) in a certain rural area in
Received 19 November 2012
Upper Egypt, identifying the factors that might be involved in its genesis.
Received in revised form
Study design: The current study is a cross-sectional community-based study.
21 May 2014
Methods: The study was conducted in El-Burgaia village, 5 km north to El-Minia city over a
Accepted 9 June 2014
period of three months. Systematic random sampling was used to interview 200 female sub-
Available online 9 September 2014
jects, who gave birth within the last 14 months preceding interview. The Edinburgh Postnatal Depression Scale (EPDS) was applied to these females to identify the presence of PPD.
Keywords:
Results: The sample size analysed was 200 females, 99 (49.5%) of them had PPD (29.5% had
Postpartum depression
minor PPD and 20% had major PPD). The age of the study subjects ranged between 19 and
Females
45 years old (mean age 29 ± 5.2 years). PPD occurred more significantly among wives of less
Epidemiology
educated husbands (P ¼ 0.03). PPD was more common among those previously diagnosed
Predictors
of having depression or prescribed antidepressants (P ¼ 0.02), in addition to those females experiencing financial problems after delivery (P ¼ 0.0001). PPD was even more common among females having complications after delivery (P ¼ 0.01). Using logistic regression analysis, total household income, child sleeping hours, complications after delivery and support of husband after delivery were found to be statistically associated with PPD. Conclusions: PPD is relatively common among rural females of El-Minia Governorate. Certain factors in these females, in the mere gestation and delivery after which they become depressed, and in the environment in which they live in, may all come to play a part in the emergence of their psychiatric illness. © 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Postpartum depression (PPD) is a form of clinical depression that can affect women and, less frequently, men after childbirth.1 Reported prevalence rates for PPD among women range
from 5% to 25%, but methodological differences between studies make it difficult to determine the actual prevalence rate.1 A recent review of 143 studies from 40 countries demonstrated that reported prevalence of PPD ranged from almost 0%e60%.2 PPD may last for several months, and
* Corresponding author. Department of Public Health, Faculty of Medicine, El-Minia University, University St., El-Minia 1666, Egypt. Tel.: þ20 086 2296790. E-mail address: [email protected] (E.S. Mohammed). http://dx.doi.org/10.1016/j.puhe.2014.06.006 0033-3506/© 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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symptoms generally include sadness, fatigue, hopelessness, low self-esteem, guilt, changes in sleeping and eating patterns, reduced libido, becoming easily frustrated, spells of anger towards others, and irritability.3 PPD has a large negative impact on both the mother and her child, including child development and the probable later appearance of behavioural disturbance.4,5 While the causes of PPD are not fully understood, a number of factors have been identified as predictive, such as childcare stress which causes profound lifestyle changes, first pregnancy, prenatal depression during pregnancy, life stress, low social support, poor marital relationship, infant temperament problems, single parenthood, low socio-economic status, unwanted pregnancy and lack of social support.6,7 Early identification and intervention improve the long-term prognosis for most women. Women should be screened by their physician to determine their risk for acquiring PPD.8 If the cause of PPD can be identified, treatment should aim to mitigate the root cause of the problem, including increased partner support, additional help with childcare, cognitive therapy, etc.9,10
Justification of the study Depression is a very common mental health problem among women, and has a major effect on the quality of life of those who are affected and their families.11 The magnitude of this common mental health problem, which is somewhat hidden or not diagnosed, should be recognized and measured in order to take action and develop strategies based on recent local data. Despite the fact that mental health problems are prevalent in the Egyptian community, they have not received as much attention as physical health problems, and there is a paucity of recent local data regarding depression among women, particularly in rural areas of Upper Egypt, and regarding the factors that may be implicated. A large study of the epidemiology of depressive disorders was conducted in Burgaia in 2004; this study did not address PPD in particular, and studied the epidemiology rather than going through the factors implicated in the occurrence of the illness.
of the total number of residents, the total number of homes and the total number of women who had given birth within the previous 14 months; this served as the sampling frame for the study. In total, 954 women had given birth within the previous 14 months.
Inclusion criteria Women who had given birth within the previous 14 months, lived in El-Burgaia and were willing to participate were included in the study. Women who had given birth within the previous 14 months were included because PPD is an overarching concept that encompasses several mood disorders that follow childbirth, from Day 5 in the case of baby blues up to 12e18 months in other types of PPD. Women up to 14 months postpartum were included because it was expected that PPD would be underdiagnosed and would extend beyond 12 months in this rural community in Upper Egypt with relatively suboptimal health services and delayed health care seeking. Numerous published studies have used the first 14 months postpartum for screening of PPD. It has been reported that one-third of women scoring within a depressive range at eight months postpartum were still depressed 12e18 months later.12 Another study showed that PPD can become apparent after the first weeks of giving birth and can last as long as 14 months.13
Exclusion criteria Exclusion criteria were: single women or married women who had not given birth, women who had given birth more than 14 months previously, urban women who happened to be present in the village during the study period, and women who did not wish to participate in the study. Unmarried women were not included in this study as the Egyptian community has certain customs and traditions that do not allow women to have children outside marriage.
Sample size
Methods Study design This cross-sectional community-based study was conducted in a random sample of women who had given birth within the previous 14 months. The study population lived in the village of El-Burgaia, which is 5 km north of El-Mina, and has 5188 households and a population of 25,938 population (Central Agency of Population Mobilization and Statistics 2006, ElMinia Governorate). This study was conducted to determine the prevalence of PPD among these women, and to determine the risk factors leading to PPD.
Administrative design The local council of El-Burgaia gave their approval for the authors to obtain demographic data about the village, in terms
Data were collected from 200 women, selected using systematic random sampling by numbering the houses in the village, choosing the first house at random and then every fifth house thereafter. The sample size was calculated using EpiInfo 2000 by entering the average estimate of PPD (15%), the number of women who had given birth within the previous 14 months (n ¼ 954) and the confidence level at 99.99%. Two hundred and twelve women were selected, 200 of whom agreed to be interviewed and to participate in the study. The remaining 12 (5.7%) women declined to participate in the study. The response rate was 94.3%. The study was undertaken between 1 December 2011 and 29 February 2012. Data were collected over four weeks in January 2012. The average time taken to interview and examine each woman was 40 minutes. Questionnaires were verified to exclude vague and incomplete responses. Data entry and analysis were performed after the whole sample
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had been interviewed and the participants' sheets had been reviewed.
Collection of data Data were collected using a structured questionnaire, including the Edinburgh Postnatal Depression Scale (EPDS). Each participant was interviewed during a home visit, the aim of the study was explained and the answers to the questionnaire were filled in by the researcher. The questionnaire included: personal demographic characteristics (name, age, woman's and husband's education and occupation, total household income); data related to the child (rank of birth, age, sex, weight at birth, breast feeding, sleeping habits); data related to the pregnancy, especially weight gain; data concerning delivery (type and place of delivery, assistant and who attended the delivery, any complications or health difficulties due to or following delivery); and previous history of depression or its treatment, and the support of husband, family or friends after delivery. The EPDS was used as a psychological screening tool. It is sensitive to changes during the course of pregnancy and after childbirth. A review of validation studies of the EPDS concluded that most studies reported high sensitivity for the detection of PPD.14 The Arabic version of the EPDS has been validated among Egyptian women, and its psychometric performance is comparable to the original scale.15 The EPDS contains 10 items, all rated on a four-point scale (0e3), giving a maximum score of 30. A score of 13 or more is considered to indicate major PPD, scores of 10e12 represent 'borderline' or minor PPD, and scores of 0e9 indicate no depression. In doubtful cases, it may be useful to repeat the tool two weeks later. However, the EPDS is not designed to detect mothers with anxiety neuroses, phobias or personality disorders.
Pilot study The questionnaire was initially tested on 10 women, not included in the sample, to investigate its clinical application of the questionnaire. The pilot study also tested the reliability of the questions (testeretest) and the time needed to conduct an interview. Proper corrections and adjustments were applied; the data for these 10 women were not included in the study results.
Statistical analysis Statistical Package for the Social Sciences Version 11 (SPSS Inc., Chicago, IL, USA) was used for data entry and analysis, and Microsoft Excel (Microsoft Corp., Redmond, WA, USA) was used for graphics. Quantitative data were presented as mean and standard deviation, and qualitative data were presented as a frequency distribution. Chi-squared test and Student's ttest were used. A multivariate analysis was also undertaken. P < 0.05 was considered to indicate significance.
Results Two hundred women were included in this study. The age of the subjects ranged between 19 and 45 years {mean 29 [standard deviation (SD) 5.2] years}. The median time since birth was eight months, and the range was 13 months [mean 8 (SD 4.4) months]. More than half (67.5%) of the women in this study had a vaginal delivery. Doctors and midwives assisted the birth in 65.5% and 31% of cases, respectively. The woman's husband attended the delivery in 49.5% of cases, and no one attended the delivery in 4% of cases. Fifty-four percent of women delivered in hospitals and 4% delivered in private clinics. Most (71%) women had no complications after delivery. Contraception was used by 76% of women after delivery, and the most common method was contraceptive injection (Table 1). Table 2 shows that PPD was significantly more common among women married to less-educated men, and women with a low total household income (P ¼ 0.03 and 0.0001, respectively). PPD was more common among women who had previously been diagnosed with depression or prescribed antidepressants, women who experienced financial problems after delivery, women who experienced complications after delivery, and women who did not have support from their husband after delivery (Table 3). This table also shows that women who had experienced domestic violence during pregnancy or in the previous year had a higher prevalence of PPD compared with their counterparts. Women with low birth-weight (LBW) babies and babies who did not sleep for a sufficient number of hours were significantly
Table 1 e Descriptive data related to delivery. Delivery data Type of delivery Vaginal Caesarean section Assistance of delivery Doctor Midwife Other Personnel attending the delivery Husband Relatives Husband and relatives No one Place of delivery Hospital Mother and child health centre House Private clinic Complications after delivery Yes No Method of contraception None Intra-uterine device Pills Injection Norplant
n
%
135 65
67.5 32.5
131 62 7
65.5 31 3.5
33 93 66 8
16.5 46.5 33 4
108 18 66 8
54 9 33 4
58 142
29 71
48 32 53 61 6
24 16 26.5 30.5 3
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Table 2 e Relationship between socio-economic factors and postpartum depression (PPD). Socio-economic factors
PPD
Total
None
Woman's education level Illiterate Able to read and write Below university University or higher Husband's education level Illiterate Able to read and write Below university University or higher Total household income Low Middle High Total
Chi-squared P-value
Minor/major
n
(%)
n
30 7 60 4
(50.8) (33.3) (52.2) (80)
29 14 55 1
10 6 74 11
(32.3) (37.5) (53.6) (73.3)
19 74 8 101
(24.7) (64.3) (100) (50.5)
n
(%)
(49.2) (66.7) (47.8) (20)
59 21 115 5
(100) (100) (100) (100)
4.35 0.2
21 10 64 4
(67.7) (62.5) (46.4) (26.7)
31 16 138 15
(100) (100) (100) (100)
8.88 0.03
58 41 0 99
(75.3) (35.7) (0) (49.5)
77 115 8 200
(100) (100) (100) (100)
37.2 0.0001
more likely to experience PPD compared with their counterparts (P ¼ 0.002 and 0.0001, respectively) (Table 4). Half (50.5%) of the women in this study did not have PPD, and half (49.5%) did have PPD (29.5% had minor PPD and 20% had major PPD) (Fig. 1). Table 5 shows the adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between the
(%)
combined effect of independent variables and the outcome variable (PPD). These estimates were obtained by logistic regression analysis. Total household income, child sleeping hours, complications after delivery and husband's support after delivery were statistically associated with PPD. Total household income was found to be the most important determinant. Women with a low household income were
Table 3 e Relationship between maternal characteristics and postpartum depression (PPD). Maternal characteristics
PPD None n
Parity Multiparous 78 Primiparous 23 Pregnancy weight gain Inadequate 11 Recommended 71 Excessive 19 Previous diagnosis of depression/prescription Yes 26 No 75 Financial problems after delivery Yes 26 No 75 Complications after delivery Yes 21 No 80 Support of family and friends after delivery Most of the time 64 Some of the time 29 None of the time 8 Support of husband after delivery Most of the time 60 Some of the time 37 None of the time 4 Victim of domestic violence Yes 14 No 87 Total 101
Total
Chi-squared P-value
Minor/major PPD (%)
n
(47.9) (62.2)
85 14
(45.8) 13 (50) 71 (55.9) 15 of antidepressants (39.4) 40 (56) 59 (32.9) (62)
(%)
n
(%)
(52.1) (37.8)
163 37
(100) (100)
2.47 0.1
(54.2) (50) (44.1)
24 142 34
(100) (100) (100)
0.6 0.7
(60.6) (44)
66 134
(100) (100)
4.86 0.02
53 46
(67.1) (38)
79 121
(100) (100)
16.2 0.0001
(36.2) (56.3)
37 62
(63.8) (43.7)
58 142
(100) (100)
6.68 0.01
(53.8) (49.2) (36.4)
55 30 14
(46.2) (50.8) (63.6)
119 59 22
(100) (100) (100)
2.31 0.3
(60.6) (48.1) (16.7)
39 40 20
(39.4) (51.9) (83.3)
99 77 24
(100) (100) (100)
15.2 0.0001
(36.8) (53.7) (50.5)
24 75 99
(63.2) (46.3) (49.5)
38 162 200
(100) (100) (100)
3.5 0.06
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Table 4 e Relationship between child's characteristics and postpartum depression (PPD). Child's characteristics
PPD No n
Sex Male 55 Female 46 Low birth weight Yes 44 No 57 Baby in NICU Yes 9 No 92 Sleeping sufficient number of hours Yes 81 No 20 Total 101
Total
Chi-squared P-value
Minor/major PPD (%)
n
(%)
(48.7) (52.9)
58 41
(51.3) (47.1)
113 87
(100) (100)
0.35 0.6
(40.4) (62.6)
65 34
(59.6) (37.4)
109 91
(100) (100)
9.8 0.002
(45) (51.1)
11 88
(55) (48.9)
20 180
(100) (100)
0.27 0.6
(64.3) (27) (50.5)
45 54 99
(35.7) (73) (49.5)
126 74 200
(100) (100) (100)
25.9 0.0001
NICU, neonatal intensive care unit.
found to be approximately three times more likely to experience PPD than women with a high household income (OR 3.56, 95% CI 2.15e5.89; P < 0.001). Similarly, women who had complications after delivery were 2.84 times more likely to experience PPD than women who did not have complications after delivery (OR 2.84, 95% CI 1.18e6.81; P ¼ 0.02).
Discussion Depression is a prevalent health problem among women of childbearing age. Mothers of infants and young children are at particular risk, partly due to the routine demands of parenting. Maternal depressive symptoms are common in early infancy, and contribute to unfavourable parenting practices. Longitudinal studies of pregnant and postpartum women consistently find that 9e12% of women have depressive symptoms.16,17 Half (49.5%) of the women in this study were diagnosed with PPD (20% had major PPD and 29.5% had minor PPD). These figures seem high. A multicentre study by Gorman et al. estimated that the prevalence of perinatal depression during the first six months postpartum ranged from 2.1% to 31.6%. There were significant differences between the rates for different centres engaged in the study.18 The prevalence rates of PPD in studies that use randomly selected samples of women generally fall between 10% and 15%. A meta-analysis of 59 studies estimated that the average
29.0% 0-9 (Normal)
50.5%
10-12 (Minor PPDS) 13-30 (Major PPDS)
20.5%
Fig. 1 e Prevalence of postpartum depression (based on Edinburgh Postnatal Depression Scale) among women in the village of El-Burgaia, El-Minia Governorate, 2012. PPDS, postpartum depression syndrome.
prevalence of PPD was 13%.19 Rates vary between studies due to the length of the postnatal period examined and the method of assessment.20 The present study had a relatively long (14 months) period of assessment, and this may help to explain the relatively high prevalence of PPD. The EPDS is a self-rating measure that was developed to screen and identify women who may be experiencing PPD. Self-rating measures are reported to be associated with high prevalence of PPD.19 However, although the measure was developed as a screening instrument, a cut-off score of 12/13 identifies women who are most likely to be experiencing PPD.20 The measure has also been validated as a screening measure for depression during pregnancy.21 As the EPDS was originally designed to screen for, rather than diagnose, PPD, high scorers are generally referred to as ‘probable’ cases of PPD. The EPDS is increasingly used in largescale PPD studies to avoid burdening staff with timeconsuming diagnostic interviews.22 The high prevalence of PPD found in this study may be explained by the low standard of living in Burgaia; most women (n ¼ 192, 96%) in the sample had low or moderate socio-economic status. This finding was in agreement with the observations of Saleh et al., who studied the predictors of PPD in a sample of Egyptian women and found correlation between the severity of depression and socio-economic status.23 Women married to less-educated men were significantly more vulnerable to PPD compared with women married to more-educated men. In addition, husband's educational level was a significant determinant of the occurrence of PPD on multiple regression analysis (P ¼ 0.05). A few research studies have addressed the importance of husband's education as a risk factor for PPD, including the study by Lee et al.24 It could be argued that husbands with a higher level of education may be more willing to support and appreciate the efforts of their wives, as well as providing more time and money for health issues and home atmosphere. Women with a low total household income were significantly more likely to develop PPD than women with a higher
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Table 5 e Logistic regression analysis of factors independently associated with postpartum depression in 200 women. Risk factors
OR (95% CI)
Total household income High 1.00 (reference) Middle 1.36 (0.76e2.42) Low 3.56 (2.15e5.89) Child sleeping sufficient number of hours No 1.00 (reference) Yes 0.21 (0.09e0.48) Complications after delivery No 1.00 (reference) Yes 2.84 (1.18e6.81) Support of husband after delivery Most of the time 1.00 (reference) Some of the time 0.43 (0.12e1.76) None of the time 0.18 (0.05e0.74) Financial problems after delivery No 1.00 (reference) Yes 2.04 (0.95e4.35) Low-birthweight baby No 1.00 (reference) Yes 1.96 (0.92e4.19) History of depression or treatment of depression No 1.00 (reference) Yes 0.79 (0.34e1.86) Husband's level of education University or more 1.00 (reference) Below university 3.17 (0.73e13.79) Able to read and write 3.81 (0.55e26.25) Illiterate 4.61 (0.79e26.77)
P-value <0.001ª
<0.001ª
0.02ª
0.02ª
0.06
0.08
0.6
0.4
OR, odds ratio; CI, confidence interval. Dependent variable was postpartum depression. R2 ¼ 0.51. a Statistically significant.
total household income. Using multiple regression analysis, low total household income was found to be one of the most important determinants for PPD. This finding may reflect vulnerability to PPD triggered by stresses of poverty, unemployment, low level of employment and lower social support among people of lower socio-economic status.25,26 The mean age of women in this study was 29 (SD 5.2) years, with a range of 19e45 years; the results seem to be in agreement with the results of Fawzy et al., who observed that PPD occurred significantly more often in older mothers.27 Such findings could be attributed to the term ‘multipara’ in this study, which tends to refer to women that have generally delivered four times or more. This has a negative effect on their general health, as well as the crowdedness index of their houses and their state of welfare. PPD was more common among women who had previously been diagnosed with depression or prescribed antidepressants. This seems to agree with the observation by O'Hara and Swain that there is a close connection between antenatal depressive mood and PPD.19 This was also reported by Chandran et al.28 PPD was more common among women with financial problems after delivery. This supports the study of Bernazzani et al., who found that women who experienced more severe life adversity in the form of acute negative life events and chronic daily stresses during their pregnancy and after
delivery were more likely to be diagnosed with PPD compared with their counterparts.29 Women who experienced complications after delivery were more likely to suffer from PPD; this applied to 29% (n ¼ 58) of women in this study, which is a relatively high proportion. It should be noted that rural women in Upper Egypt do not usually engage in proper antenatal care due to scarcity of available health resources, poverty and decreased education. PPD was more common among women who did not receive sufficient support from their husbands. In addition, the level of husband's support after delivery was found to be one of the most important determinants of PPD on multiple regression analysis. This has been reported in several studies, indicating the importance of husband's support in the prevention of PPD.28,30 In addition, poor emotional support following delivery was a psychosocial variable associated with higher prevalence of PPD in the systemic review of perinatal mental disorders in low- and loweremiddle income countries conducted by Fisher et al.31 Women in poor agricultural villages in Upper Egypt are still considered to be inferior to males and to their husbands. They are often treated as workers in the fields and at home, burdened with responsibilities and without acknowledgement of their efforts. In addition, many of these women have husbands who work abroad. Thus, these women often give birth in the absence of their husbands. Of the 200 women included in this study, the husband attended the birth in 99 (49.5%) cases (either alone or with other relatives). Bener et al. reported that dissatisfaction in marital life and a poor marital relationship were significantly associated with higher prevalence of PPD.32 Women with low birth weight (LBW) babies and babies who did not sleep for a sufficient number of hours were significantly more likely to have PPD than their counterparts. Insufficient sleep of babies was found to be a highly significant determinant of PPD on multiple regression analysis. This could be attributed to the additional effort and decreased rest associated with such conditions, especially in the case of insufficient support from their husband and other relatives. Singer et al. reported that mothers of very LBW infants felt significantly more personal stress and family stress under conditions of low social support. In addition, such mothers had greater child-related stress than term mothers. In this study, some, but not all, of the LBW infants were very LBW.33
Conclusions PPD is not a rare condition in women living in rural areas of ElMinia Governorate. Various factors associated with gestation, delivery and the living environment play a part in the emergence of PPD.
Implications of the study It is recommended that emotional health and well-being should be assessed routinely during pregnancy and over the first year postpartum; this can be integrated into women's regular health checks. Due to increased risk of PPD, women facing socio-economic hardship and women with poor
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pregnancy outcomes should be targeted for depression screening, prevention and treatment. The major clinical implications of the findings are that PPD is common and a largely undetected public health problem. There is a need for women to be screened for depression in the postpartum period, by domiciliary health workers or at the immunization clinic, and this service should be incorporated into maternal and child health programmes.
Author statements The authors wish to thank all the women who participated in this study. Many thanks to Mrs. OLa Labed and Mr. Mohammed Sameh for language revision.
Ethical approval The Departments of Psychiatry and Community, and Minia Faculty of Medicine approved this study. All data for the women included in the study were kept confidential. All women included in the study were given a code number before data were entered into the computer system, and this procedure was undertaken by the researchers. Full written, informed consent was obtained from all participants.
Funding None declared.
Competing interests None declared.
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