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Prevalence and risk factors for postpartum depression in Sri Lanka: A population-based study
Asian Journal of Psychiatry 47 (2020) 101855
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Prevalence and risk factors for postpartum depression in Sri Lanka: A population-based study
T
Qiping Fana,b,*, Qian Longb, Vijitha De Silvaa,b,c, Nishan Gunarathnad, Upul Jayathilakae, Thushani Dabrerad, Henry Lynnf, Truls Østbyea,b a
Duke University, Durham, North Carolina, United States Global Health Research Center, Duke Kunshan University, Jiangsu, China c Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka d Regional Director of Health Service Office, Puttalam, Sri Lanka e Medical Office of Health in Dankotuwa, Puttalam, Sri Lanka f School of Public Health, Fudan University, Shanghai, China b
A R T I C LE I N FO
A B S T R A C T
Keywords: Postpartum depression Risk factors Prevalence Mental health Sri Lanka
Background: Previous studies in Sri Lanka have shown a high prevalence of postpartum depression (PPD). Postpartum depression screening using the Edinburgh Postnatal Depression Scale (EPDS) has been validated and included in routine postnatal care in 2012. Objectives: This study aimed to estimate the prevalence of PPD at 10 days and 4 weeks postpartum in 2017 in two medical officer of health (MOH) areas in Sri Lanka, and to assess the association between risk factors and postpartum depression. Methods: An EPDS total score higher than 9 was used to estimate the prevalence of postpartum depression. PPD outcomes were assessed by mothers’ responses to the EPDS. Potential risk factors were extracted from routine paper-based medical records. The associations were examined using simple and multivariable linear regression and multivariate logistic regression models. Results: A total of 1349 mothers in the two areas, 523 from Dankotuwa and 826 from Bope Poddala, were included. The prevalence of PPD was 15.5% and 7.8% among mothers assessed 10 days postpartum (in Dankotuwa) and 4 weeks postpartum (in Bope Poddala), respectively. EPDS total scores were positively related to delivery age of mothers. Presence of postpartum depression was significantly associated with delivery age over 35, having more than 4 living children and mothers’ diseases. Mothers who attended prenatal sessions and whose partners were employed were less likely to report postpartum depression. Conclusion: The prevalence of PPD in Sri Lanka was 15.5% at 10 days and 7.8% at 4 weeks postpartum. Future studies on the effect of time since delivery on postpartum depression screening outcomes are warranted.
1. Introduction Depression is the leading cause of disability and overall global burden of disease worldwide, and it affects more women than men (Friedrich, 2017; WHO, 2018). Postpartum depression refers to a moderate to severe depressive episode that typically begins within four weeks after delivery, according to The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (APA, 2013). Symptoms of postpartum depression include anxiety, depressed mood, sleep
disturbance, appetite disturbance, loss of energy, confusion, feeling guilty or worthless, and thoughts of suicide (APA, 2013). Postpartum depression and depressive symptoms can have profound influence on the mothers and infants, and they may affect the mother-infant relationship and child growth and development (Grace et al., 2003; Blackmore, 2008; Parsons et al., 2011). Postpartum depression occurs in 10–15 % of women within one year after delivery worldwide (Halbreich and Karkun, 2006). A recent systematic review of 291 studies from 56 countries indicated an even
⁎ Corresponding author at: Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University, College Station, TX77843-1266, United States. E-mail addresses: [email protected] (Q. Fan), [email protected] (Q. Long), [email protected] (V. De Silva), [email protected] (N. Gunarathna), [email protected] (U. Jayathilaka), [email protected] (T. Dabrera), [email protected] (H. Lynn), [email protected] (T. Østbye).
https://doi.org/10.1016/j.ajp.2019.101855 Received 16 September 2019; Received in revised form 21 October 2019; Accepted 21 October 2019 1876-2018/ © 2019 Elsevier B.V. All rights reserved.
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around ten days after delivery. In both areas, the EPDS was completed by the mothers on paper forms, then collected and kept by the PHMs. We recorded the relevant data elements from paper records in the PHM offices, MOH offices or district offices where medical records and the EPDS forms were stored.
higher pooled prevalence of postpartum depression -17.7% (HahnHolbrook et al., 2018). Prevalence of postpartum depression is higher in low and middle- income countries than that in high-income countries (Woody et al., 2017; Hahn-Holbrook et al., 2018). In Asian Countries, the prevalence r of postpartum depression ranges from 7% to 33% (Gelaye et al., 2016; Hahn-Holbrook et al., 2018; Jha et al., 2018). Sri Lanka has been held up as an example for its positive record in maternal and child health care, and the country is distinguished in having achieved Millennium Development Goals 4 and 5 (Senanayake et al., 2011). However, a study conducted in 2004 indicated a prevalence as high as 32.1% for postpartum depression in Puttalam District (T. C. Agampodi et al., 2011). Another cross-sectional study conducted in 18 districts of Sri Lanka in 2011 estimated a prevalence of 27% for this condition and called for urgent attention to postpartum depression in the country (Norhayati et al., 2015). Various self-report instruments have been used to screen for postpartum depression, with the Edinburgh Postnatal Depression Scale (EPDS) the most widely used (Cox et al., 1987). EPDS is a 10-item questionnaire with four response categories for each item, with each response assigned a score ranging from 0 to 3. A specific cutoff of the total score is often used to indicate possible depression (Brummelte and Galea, 2016). The cut-off scores used in different studies range from 9 to 14 for detection of depressive illnesses (Rowel et al., 2008). The EPDS was translated into Sinhalese and validated in Sri Lanka in a large-scale study in Puttalam district, and a cut-off value of 9/10 for depression was proposed in 2004 (D. Rowel et al., 2008). Since then, the validated version of EPDS has been used in other studies in Sri Lanka, and it was included as a part of routine postpartum care in 2012 (Agampodi and Agampodi, 2013). Although several studies indicated that the prevalence of PPD was high in Sri Lanka before 2011, the prevalence of postpartum depression after EPDS was included in routine postnatal care is unknown. Investigating risk factors for postpartum depression (PPD) is important for early detection and prevention of postpartum depression (Patel et al., 2018). Previously identified risk factors for PPD can be classified as psychological, biological, or social (Cox et al., 1987). In a study conducted in Puttalam district in 2004, potential risk factors included unplanned pregnancy, conflicts with husband, physical abuse during pregnancy, partner’s use of harsh words, death of a friend, normal vaginal delivery, low birth weight, illness, and poor night sleeping pattern of babies (D. D. S. Rowel, 2004). This study aimed to 1) estimate the prevalence of postpartum depression, at 10 days and 4 weeks postpartum, in two medical offices of health areas in Sri Lanka; and 2) to examine the association of potential socio-demographic, prenatal, clinical, delivery, and postnatal risk factors recorded in routine medical records with postpartum depression and EPDS total scores.
2.3. Sample size Based on previous estimates of the prevalence of postpartum depression in Sri Lanka- 32.1% in 2004 and 27% in 2012 (T. C. Agampodi et al., 2011; D. D. S. Rowel, 2004), we assumed predicted prevalence of postpartum depression to be 30% with a margin of error less than 0.04. Using a 95% confidence level, we needed a minimum sample size of 505 (Diez et al., 2012). 2.4. Data collection Potential risk factors were extracted from the routine paper-based medical records and gathered responses of depressive symptoms using Edinburgh Postnatal Depression Scale (EPDS) recorded on paper. Potential risk factors were selected according to the literature and availability in the existing paper forms. Most responses were in numerical form with some of the text was in Sinhalese. The free text responses in Sinhalese in the paper medical records and the EPDS were translated by the two research assistants who were proficient both in English and Sinhalese. 2.5. Data management Data was double entered into REDCap, a password-protected, internet-based, data-management system supported by the School of Medicine at Duke University. 2.6. Measurement The prevalence of postpartum depression was estimated as the proportion of mothers who had an EPDS score above 9 (EPDS > 9). Subsequently the associations between potential factors and EPDS were examined. The two outcome variables were: 1) total EPDS scores as a continuous variable, and 2) the presence of postpartum depression (EPDS > 9), a dichotomous variable. The independent variables considered were social-demographic, prenatal, clinical, delivery, and postnatal factors relating to the mothers as listed in Table 1. The variables were recategorized before examination of their associations with the outcome variables. 1) Age refers to the age of the mothers at the time point of first prenatal care session. Age was classified into three groups: “15-19”, “20-34”, and “35-49”. 2) Mothers’ or their partners’ educational levels were based as the highest grade that people attended. They were classified into two groups: “ > grade 10” and “ < =grade 10”; 3) Parity was defined as the number of living children prior the current pregnancy. 4) Mothers’ body mass index (BMI) at first antenatal visit was recorded, and it was categorized according to the criteria of underweight (< 18.5), normal weight (18.5–24.9) and overweight or obese (> 24.9) from World Health Organization (WHO, 2000), which were adopted by Sri Lanka. 5) Prenatal care sessions are often provided by public health midwives and medical doctors for mothers in pregnancy in the medical offices of health (MOH) to provide prenatal checks and maternal health related workshops. Mothers’ and their partners’ number of sessions attended were noted, and the two variables were each coded as a dichotomous variable “yes” or “no”. 6) Mothers’ diseases before, during and after pregnancy were recorded
2. Method 2.1. Study design The study is a population-based study in which mothers who delivered in 2017 from two selected medical offices of health (MOH) areas in Sri Lanka were included. 2.2. Study setting The two medical offices of health (MOH) areas, Bope Poddala in Galle district located in the Southern Province, and Dankotuwa in Puttalam district located in the North Western Province, were selected because the Edinburgh Postnatal Depression Scale (EPDS) is administered at different time points in the two areas. In Bope Poddala, mothers filled out the EPDSs with the help of public health midwives (PHMs) at around four weeks after delivery, whereas in Dankotuwa, Edinburgh Postnatal Depression Scale was filled out during PHM’s home visits 2
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continuous EPDS scores, t-tests, one-way ANOVA, and linear regression were conducted to examine associations with dichotomous, categorical, and continuous risk factors, respectively. All risk factors that were statistically significantly (p < 0.1) associated with the outcome at the univariable level, or those were deemed important based on interviews with local health professionals and the literature review, were selected for inclusion into multivariable regression models. Coefficients and p-values for EPDS scores, and odds ratios (OR with 95% CI) for postpartum depression, are presented.
Table 1 Characteristics of mothers by time of EPDS administration. Background Characteristics
Mothers administered around 10 days postpartum % (N)
Age 15-19 6.3% (33) 20-34 79.5% (416) 35-49 14.2% (74) Mother’s educational level < = grade 10 27.0% (141) > grade10 73.0% (382) Missing 0 Mother being 29.1% (152) employed Partner’s educational level < = grade 10 32.9% (172) > grade 10 66.7% (349) Missing 0.4% (2) Partner being 98.1% (513) employed Parity 0 36.7% (192) 1 42.1% (220) 2-3 19.9% (104) > =4 1.3% (7) BMI at first antenatal visit < 18.5 16.6% (87) 18.5-24.9 51.8% (271) > 24.9 29.4% (153) Missing 2.3% (12) Number of prenatal sessions attended by mothers 0 7.8% (41) 1-2 45.8% (239) 3 20.8% (109) Missing 25.6% (134) Number of prenatal sessions attended by partners 0 58.5% (306) 1-2 11.3% (59) 3 4.0% (21) Missing 26.2% (137) Mothers’ other diseases 20.5% (107) Baby’s health problems 0.4% (2) Establishment of breast 99.6% (521) feeding Postnatal clinic visit 99.4% (520) In total 38.8% (523)
Mothers administered around 4 weeks postpartum % (N)
5.2% (43) 76.0% (628) 18.8% (155)
2.8. Quality control
49.8% (411) 50.0% (413) 0.2% (2) 24.7% (204)
The data extraction sheet was back translated independently by two research assistants. The data extraction sheet was pretested in adjacent MOH areas. During data collection process, all text data was double translated by the researchers and the midwives, and all the data was double entered. If data was missing in the paper medical records, the public health midwives (PHMs) who had collected the data from the mothers were re-contacted, and important data that could be confidently ensured such as gender of the baby was retrieved. Mothers missing values on the Edinburgh Postnatal Depression Scale were excluded, and the reasons for incomplete records were clarified by the midwives.
42.1% (348) 57.1% (472) 0.7% (6) 96.6% (798)
23.6% (195) 35.5% (293) 36.1% (298) 4.8% (40)
2.9. Ethical statement
15.1% (125) 46.4% (383) 30.6% (253) 7.9% (65)
Ethical clearance was provided by the Institutional Review Board at Duke Kunshan University in China, the Ethical Review Committee at Faculty of Community Medicine of University of Ruhuna in Sri Lanka, and the Ethical Review Committee at Department of Health Services of Northwestern Province in Sri Lanka.
24.2% (200) 51.4% (424) 21.4% (177) 3.0% (25)
3. Results
50.4% (416) 42.3% (349) 1.6% (13) 5.8% (48) 24.9% (206) 13.7% (113) 99.8% (824)
3.1. Characteristics of participants All mothers delivered throughout 2017 in the two medical offices of health (MOH) areas were included in the analyses. Seven mothers were excluded because of extremely incomplete medical records or unfinished Edinburgh Postnatal Depression Scale (EPDS). 826 mothers who had been screened around four weeks postpartum from Bope Poddala and 523 mothers screened around ten days postpartum in Dankotuwa were included for data analysis, giving a total sample size of 1349. The participants’ characteristics are shown in Table 1.
99.4% (820) 61.23% (826)
and included hypertension, diabetes, subfertility, heart diseases, kidney diseases, anemia, infected episiotomy, upper abdominal pain, diarrhea, vomiting, visual or respiratory problems and delivery complications. These were also coded as dichotomous variables indicating presence or absence of disease. 7) Babies’ health problems included birth complications, prematurity, abnormalities, fever, and umbilical cord infection. 8) Establishment of breastfeeding was defined as whether the mothers had been able to establish breastfeeding by the time of the EPDS report. 9) Mothers are expected to visit postnatal clinic four weeks postpartum to check their and their babies’ health, and whether this had taken place was recorded.
3.2. The prevalence of postpartum depression Table 2 shows the prevalence of postpartum depression using the EPDS total score cut-off of 9/10, which was validated in Sri Lanka in 2004 (Rowel et al., 2008). Of the 826 mothers who were screened around 4 weeks after delivery (Bope Poddala), 7.8 % had an EPDS score greater than 9. Of the 523 mothers who had been screened around 10 days after delivery (Dankotuwa), 15.5% had an EPDS greater than 9. The mean total EPDS score was 3.49 among mothers screened at 4 weeks, and 5.75 among mothers 10 days postpartum. Table 2 also shows the percentage of the mothers who reported depressive symptoms. The responses were re-coded according to their actual responses. The responses referring to a score of “0” and “1” were coded as “no”, while “2” and “3” were coded as “yes”. From Q3 to Q9, the percentage of mothers who reported symptoms was 2–6 times higher than in the group who had reported at four weeks. Q1, Q2 and Q10 showed slight differences between the two groups. Q1 and Q2 indicate anhedonia, Q3-Q6 indicate anxiety, Q7-10 depression, and Q10 self-harm(S. B. Agampodi and Agampodi, 2013). As shown in Table 2, mothers who were screened at 10 days postpartum were more likely to have symptoms of anxiety and depression than those screened
2.7. Data analysis Stata version 15.0 was used for data analysis. The associations of the potential risk factors in the clinical records with the presence of postpartum depression (PPD) and EPDS scores were examined in univariable and multivariable models. Univariable analysis was first conducted. For the dichotomous PPD outcome, chi-square tests were conducted to compare the prevalence of PPD between different levels of the categorical risk factors. For the 3
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Table 2 Prevalence of specific depressive symptoms according to Edinburgh Postnatal Depression Scale. Items in EPDS
Mothers screened at 10 days postpartum
Table 3 The relationships of the potential predictors with EPDS scores and postpartum depression (Adjusted analyses).
Mothers screened at 4 weeks postpartum
Background Characteristics
Q1: I have been able to laugh and see the funny side of things No 4.6% 5.0% Q2: I have looked forward with enjoyment to things No 5.9% 4.5% Q3: I have blamed myself unnecessarily when things went wrong Yes 39.9% 6.3% Q4: I have been anxious or worried for no good reason Yes 24.9% 6.0% Q5: I have felt scared or panicky for no very good reason Yes 23.9% 3.2% Q6: Things have been getting on top of me Yes 15.8% 3.3% Q7: I have been so unhappy that I have had difficulty sleeping Yes 16.4% 2.5% Q8: I have felt sad or miserable Yes 8.2% 1.8% Q9: I have been so unhappy that I have been crying Yes 4.8% 2.9% Q10: The thought of harming myself has occurred to me Yes 1.6% 1.9% EPDS Total Score > 9 15.5% 7.8% Mean EPDS score (95% CI) 5.75 (5.40-6.11) 3.49 (3.2-3.73)
Multivariable Linear Regression
Multivariable Logistic Regression
EPDS Scores
EPDS Scores > 9
Beta Co-efficient
AOR (95% CI)
Administering time (Ref: 4 weeks after delivery) < 10 days after 2.59*** 3.39 (2.08-5.51)*** delivery Age (Ref: 15-19) 20-34 0.17*** 2.58 (0.59-11.24) 35-49 7.73 (1.69-35.37)** Mother’s educational level (Ref: < =grade 10) > grade 10 −0.40 1.16 (0.65-2.08) Mother being employed (Ref: No) Yes 0.25 0.99 (0.61-1.60) Partner’s educational level (Ref: < = grade 10) > grade 10 0.01 0.82 (0.46-1.46) Partner being employed (Ref: No) Yes −2.08** 0.36 (0.13-0.99)* Parity (Ref: 0) 1 −0.12 1.14 (0.66-1.98) 2-3 −0.19 1.19 (0.65-2.17) > =4 3.14*** 6.62 (2.76-15.89)*** BMI at first antenatal visit (Ref: < 18.5) 18.5-24.9 −0.002 0.97(0.52-1.79) > 24.9 1.05 (0.56-1.97) Mother attending prenatal sessions (Ref: No) Yes −0.90** 0.53 (0.32-0.90)* Partner attending prenatal sessions (Ref: No) Yes 0.57* 1.29 (0.80-2.09) Mothers’ illness before and after pregnancy (Ref: No) Yes 0.23 1.85 (1.18-2.90)** Baby’s problem (Ref: No) Yes −0.73 0.50 (0.18-1.38)
at 4 weeks postpartum. 3.3. Risk factors for postpartum depression Table 3 shows the relationship of the predictors with EPDS scores and postpartum depression. The EPDS scores were positively related to earlier administration time (β = 2.59, p < 0.001) and age at delivery (β = 0.17, p < 0.001). Mothers with over four living children (β = 3.14, p < 0.001), and those whose partners attended prenatal sessions (β = 0.57, p = 0.017) were more likely to have higher EPDS scores. EPDS scores were likely to be lower if they attended prenatal sessions (β= -0.90, p = 0.002) or their partners were employed (β= -2.08, p = 0.003). The presence of postpartum depression was associated with delivery age over 35 (AOR = 7.73, 95% CI 1.69–35.37), over four living children (AOR = 6.62, 95% CI 2.76–15.89), and mothers’ illnesses before or during pregnancy (AOR = 1.85, 95% CI 1.18–2.90). Mothers who attended prenatal care sessions (AOR = 0.53, 95% CI 0.32-0.90) and whose partners were employed (AOR = 0.36, 95% CI 0.13-0.99) were less likely to report postpartum depression.
*** < 0.001. ** < 0.01. * < 0.05.
indicated that mothers’ educational level and diseases during pregnancy, were significant predictors of PPD (Fisher et al., 2013). Other risk factors demonstrated in other studies for postpartum depression include antenatal depression, difficulty of marital relationship, lack of family support or social support, stressful events, mothers’ physical health problems (Barbadoro et al., 2012; Fisher et al., 2013; Gaillard et al., 2014; Katon et al., 2014; Lara et al., 2016; Munk-Olsen et al., 2009). We identified mothers’ attendance of prenatal care sessions and their partners’ employment as protective factors for postpartum depression. Besides, we found women whose partners attended prenatal care sessions tended to have higher EPDS scores and higher probability of postpartum depression, which may be explained by comments from the PHMs indicating partners were usually more likely to attend prenatal sessions if they were unemployed. Importantly, higher EPDS scores and presence of postpartum depression appear to be more common early rather than late after birth, even after adjustment for differences in background characteristics among mothers in two areas. Mothers who were screened around 10 days postpartum were more likely to both have higher EPDS scores and have a score greater than 9 compared with 4 weeks postpartum. Previous studies have shown that the onset of depressive symptoms is related to hormone fluctuations such as changes of estradiol and progesterone levels after delivery (Buckwalter et al., 1999; Heidrich et al., 1994; O’Hara et al., 1991). Thus, higher EPDS scores and a higher likelihood of PPD around 10 days postpartum might have resulted from the hormone fluctuations in the first week postpartum when “postpartum blues” affects 50%–70 % of mothers (Cherif et al., 2017). Future
4. Discussion 4.1. Main findings The study showed a prevalence of postpartum depression (PPD) 7.8% for mothers screened at around four weeks postpartum in Bope Poddala, and 15.5% for mothers screened at around 10 days in Dankotuwa in 2017. Higher age of mothers, having more than four living children, and mothers’ illnesses before and after pregnancy were significantly associated with PPD. Furthermore, mothers’ attendance of antenatal care sessions and partners’ employment were protective factors for postpartum depression. Higher Edinburgh Postnatal Depression Scale (EPDS) scores and presence of PPD were associated with earlier screening time. The findings relating to risk factors in this study are consistent with other studies (Cherif et al., 2017; Do et al., 2018; Strelow et al., 2018). A descriptive cross-sectional study conducted in Tunisia indicated that PPD was associated with maternal age above 35, parity, and difficulties in accepting the pregnancy (Cherif et al., 2017). A study in Vietnam 4
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Acknowledgement
research on the effect of time since delivery on the occurrence of and screening for postpartum depression is warranted. A higher percentage of mothers who live in rural and isolated areas, and an overall lower economic level in Dankotuwa, might also have contributed to the higher unadjusted prevalence of PPD in Dankotuwa.
The authors would like to acknowledge the contribution of Ms. Prabodha Lakmali in the process of data collection, and the support and advice from Dr. Joseph Egger, Dr. Ashley Price, and Dr. Amila Chandrasiri, and Ms. Jingru Tan.
4.2. Strengths and limitations
References
This study has several strengths. First, this is the largest study of postpartum depression in Sri Lanka since the inclusion of Edinburgh Postnatal Depression Scale in routine postnatal care in 2012. Second, nearly all mothers (99.5%) who delivered in 2017 in the two MOH areas had completed records and thus were included in this study, and there was very little missing data on outcome variables and the exposure variables (except for attendance of seminars), thus minimizing non-response bias. Third, the study included a range of potential risk factors extracted from medical records, including several not investigated previously, such as the attendance of prenatal care sessions and disease history. Finally, we examined the association of potential risk factors with the EPDS both as a continuous variable and dichotomized. There are also several limitations. First, the prevalence of postpartum depression could have been overestimated using the Edinburgh Postnatal Depression Scale because self-reported usually leads to a higher prevalence than diagnosis established through clinical interviews (O’Hara and Swain, 1996; Woody et al., 2017). Second, postpartum exposure variables were underreported in Dankotuwa due to less meticulous recording by PHMs of certain factors including babies’ health problems, establishment of breastfeeding, and mothers’ other postpartum diseases. This may be the reason for the unexpected inverse relationship of babies’ health problems with EPDS scores and PPD. Third, we were not able to separate the effect of time of screening and differences between areas. Area could also have been an effect modifier in this study. However, when stratifying the subjects by area to examine the associations between the other risk factors and the EPDS outcomes, the impact of having more than 4 living children on EPDS scores and PPD remained significant in both areas (p < 0.001), and the direction of association between the significant risk and protective factors identified in this study with EPDS scores and PPD remained the same. Finally, the results may not be fully generalizable to other parts of Sri Lanka
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Psychiatry 8. https://doi.org/10.3389/fpsyt.2017.00248. Halbreich, U., Karkun, S., 2006. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J. Affect. Disord. 91 (2-3), 97–111. https://doi.org/10.1016/j.jad.2005.12.051. Heidrich, A., Schleyer, M., Spingler, H., Albert, P., Knoche, M., Fritze, J., Lanczik, M., 1994. Postpartum blues: relationship between not-protein bound steroid hormones in plasma and postpartum mood changes. J. Affect. Disord. 30 (2), 93–98. https://doi. org/10.1016/0165-0327(94)90036-1. Jha, S., Salve, H.R., Goswami, K., Sagar, R., Kant, S., 2018. Burden of common mental disorders among pregnant women: a systematic review. Asian J. Psychiatr. 36, 46–53. https://doi.org/10.1016/j.ajp.2018.06.020. Katon, W., Russo, J., Gavin, A., 2014. Predictors of postpartum depression. J. Womens Health 23 (9), 753–759. https://doi.org/10.1089/jwh.2014.4824. Lara, M.A., Navarrete, L., Nieto, L., 2016. Prenatal predictors of postpartum depression and postpartum depressive symptoms in Mexican mothers: a longitudinal study. Arch. Womens Ment. Health 19 (5), 825–834. https://link.springer.com/article/10. 1007/s00737-016-0623-7.
5. Conclusion The prevalence of postpartum depression was 7.8% at 4 weeks (Bope Poddala) and 15.5% at 10 days (Dankotuwa) postpartum, respectively. Risk factors for postpartum depression include higher age of mothers, more than four living children, and mothers’ illnesses around pregnancy. Protective factors include mothers’ attending prenatal care sessions and their partners’ employment. In particular, mothers who have more than 4 living children are at higher risk and deserve special attention. Future studies of the effect of time since delivery on postpartum depression are warranted. Financial disclosure The first author received financial support for on-site fieldwork in Sri Lanka from Global Health Research Center at Duke Kunshan University, China Declaration of competing interest The authors declare that they have no competing interests with respect to the research, authorship, and/or publication of this article. 5
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Rowel, D., 2004. Prevalence, Incidence and Correlates of Postpartum Depression in the Puttalam District. Post Graduate Institute of Medicine, Colombo. PGIM. Retrieved from http://imsear.searo.who.int/handle/123456789/128168 on Sep 2019. Rowel, D., Jayawardena, P., Fernando, N., 2008. Validation of the sinhala translation of edinburgh postnatal depression scale. Ceylon Med. J. 53 (1), 10. https://doi.org/10. 4038/cmj.v53i1.219. Senanayake, H., Goonewardene, M., Ranatunga, A., Hattotuwa, R., Amarasekera, S., Amarasinghe, I., 2011. Achieving millennium development goals 4 and 5 in Sri Lanka. Bjog Int. J. Obstet. Gynaecol. 118, 78–87. https://doi.org/10.1111/j.14710528.2011.03115.x. Strelow, B., Fellows, N., Fink, S.R., OʼLaughlin, D.J., Radke, G., Stevens, J., Tweedy, J.M., 2018. Postpartum depression in older women. J. Am. Acad. Physician Assist. 1. https://insights.ovid.com/pubmed?pmid=29401116. Woody, C.A., Ferrari, A.J., Siskind, D.J., Whiteford, H.A., Harris, M.G., 2017. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J. Affect. Disord. 219, 86–92. https://doi.org/10.1016/j.jad.2017.05.003. World Health Organization, 2000. Obesity: Preventing and Managing the Global Epidemic (No. 894). World Health Organization. Text link from Google Books. World Health Organization, 2018. Fact Sheets of Depression. Retrieved from. https:// www.who.int/en/news-room/fact-sheets/detail/depression.
Munk-Olsen, T., Laursen, T.M., Mendelson, T., Pedersen, C.B., Mors, O., Mortensen, P.B., 2009. Risks and Predictors of Readmission for a Mental Disorder During the Postpartum Period. Arch. Gen. Psychiatry 66 (2), 189. https://jamanetwork.com/ journals/jamapsychiatry/article-abstract/210201. Norhayati, M.N., Nik Hazlina, N.H., Asrenee, A.R., Wan Emilin, W.M.A., 2015. Magnitude and risk factors for postpartum symptoms: a literature review. J. Affect. Disord. 175, 34–52. https://doi.org/10.1016/j.jad.2014.12.041. O’Hara, M.W., Swain, A.M., 1996. Rates and risk of postpartum depression—a metaanalysis. Int. Rev. Psychiatry 8 (1), 37–54. https://doi.org/10.3109/ 09540269609037816. O’Hara, M.W., Schlechte, J.A., Lewis, D.A., Varner, M.W., 1991. Controlled prospective study of postpartum mood disorders: psychological, environmental, and hormonal variables. J. Abnorm. Psychol. 100 (1), 63–73. https://doi.org/10.1037/0021-843X. 100.1.63. Parsons, C.E., Young, K.S., Rochat, T.J., Kringelbach, M.L., Stein, A., 2011. Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries. Br. Med. Bull. 101 (1), 57–79. https://doi.org/10.1093/ bmb/ldr047. Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., et al., 2018. The Lancet Commission on global mental health and sustainable development. Lancet 392 (10157), 1553–1598. https://doi.org/10.1016/s0140-6736(18)31612-x.
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Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Prevalence and risk factors for postpartum depression in Sri Lanka: A population-based study
T
Qiping Fana,b,*, Qian Longb, Vijitha De Silvaa,b,c, Nishan Gunarathnad, Upul Jayathilakae, Thushani Dabrerad, Henry Lynnf, Truls Østbyea,b a
Duke University, Durham, North Carolina, United States Global Health Research Center, Duke Kunshan University, Jiangsu, China c Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka d Regional Director of Health Service Office, Puttalam, Sri Lanka e Medical Office of Health in Dankotuwa, Puttalam, Sri Lanka f School of Public Health, Fudan University, Shanghai, China b
A R T I C LE I N FO
A B S T R A C T
Keywords: Postpartum depression Risk factors Prevalence Mental health Sri Lanka
Background: Previous studies in Sri Lanka have shown a high prevalence of postpartum depression (PPD). Postpartum depression screening using the Edinburgh Postnatal Depression Scale (EPDS) has been validated and included in routine postnatal care in 2012. Objectives: This study aimed to estimate the prevalence of PPD at 10 days and 4 weeks postpartum in 2017 in two medical officer of health (MOH) areas in Sri Lanka, and to assess the association between risk factors and postpartum depression. Methods: An EPDS total score higher than 9 was used to estimate the prevalence of postpartum depression. PPD outcomes were assessed by mothers’ responses to the EPDS. Potential risk factors were extracted from routine paper-based medical records. The associations were examined using simple and multivariable linear regression and multivariate logistic regression models. Results: A total of 1349 mothers in the two areas, 523 from Dankotuwa and 826 from Bope Poddala, were included. The prevalence of PPD was 15.5% and 7.8% among mothers assessed 10 days postpartum (in Dankotuwa) and 4 weeks postpartum (in Bope Poddala), respectively. EPDS total scores were positively related to delivery age of mothers. Presence of postpartum depression was significantly associated with delivery age over 35, having more than 4 living children and mothers’ diseases. Mothers who attended prenatal sessions and whose partners were employed were less likely to report postpartum depression. Conclusion: The prevalence of PPD in Sri Lanka was 15.5% at 10 days and 7.8% at 4 weeks postpartum. Future studies on the effect of time since delivery on postpartum depression screening outcomes are warranted.
1. Introduction Depression is the leading cause of disability and overall global burden of disease worldwide, and it affects more women than men (Friedrich, 2017; WHO, 2018). Postpartum depression refers to a moderate to severe depressive episode that typically begins within four weeks after delivery, according to The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (APA, 2013). Symptoms of postpartum depression include anxiety, depressed mood, sleep
disturbance, appetite disturbance, loss of energy, confusion, feeling guilty or worthless, and thoughts of suicide (APA, 2013). Postpartum depression and depressive symptoms can have profound influence on the mothers and infants, and they may affect the mother-infant relationship and child growth and development (Grace et al., 2003; Blackmore, 2008; Parsons et al., 2011). Postpartum depression occurs in 10–15 % of women within one year after delivery worldwide (Halbreich and Karkun, 2006). A recent systematic review of 291 studies from 56 countries indicated an even
⁎ Corresponding author at: Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University, College Station, TX77843-1266, United States. E-mail addresses: [email protected] (Q. Fan), [email protected] (Q. Long), [email protected] (V. De Silva), [email protected] (N. Gunarathna), [email protected] (U. Jayathilaka), [email protected] (T. Dabrera), [email protected] (H. Lynn), [email protected] (T. Østbye).
https://doi.org/10.1016/j.ajp.2019.101855 Received 16 September 2019; Received in revised form 21 October 2019; Accepted 21 October 2019 1876-2018/ © 2019 Elsevier B.V. All rights reserved.
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around ten days after delivery. In both areas, the EPDS was completed by the mothers on paper forms, then collected and kept by the PHMs. We recorded the relevant data elements from paper records in the PHM offices, MOH offices or district offices where medical records and the EPDS forms were stored.
higher pooled prevalence of postpartum depression -17.7% (HahnHolbrook et al., 2018). Prevalence of postpartum depression is higher in low and middle- income countries than that in high-income countries (Woody et al., 2017; Hahn-Holbrook et al., 2018). In Asian Countries, the prevalence r of postpartum depression ranges from 7% to 33% (Gelaye et al., 2016; Hahn-Holbrook et al., 2018; Jha et al., 2018). Sri Lanka has been held up as an example for its positive record in maternal and child health care, and the country is distinguished in having achieved Millennium Development Goals 4 and 5 (Senanayake et al., 2011). However, a study conducted in 2004 indicated a prevalence as high as 32.1% for postpartum depression in Puttalam District (T. C. Agampodi et al., 2011). Another cross-sectional study conducted in 18 districts of Sri Lanka in 2011 estimated a prevalence of 27% for this condition and called for urgent attention to postpartum depression in the country (Norhayati et al., 2015). Various self-report instruments have been used to screen for postpartum depression, with the Edinburgh Postnatal Depression Scale (EPDS) the most widely used (Cox et al., 1987). EPDS is a 10-item questionnaire with four response categories for each item, with each response assigned a score ranging from 0 to 3. A specific cutoff of the total score is often used to indicate possible depression (Brummelte and Galea, 2016). The cut-off scores used in different studies range from 9 to 14 for detection of depressive illnesses (Rowel et al., 2008). The EPDS was translated into Sinhalese and validated in Sri Lanka in a large-scale study in Puttalam district, and a cut-off value of 9/10 for depression was proposed in 2004 (D. Rowel et al., 2008). Since then, the validated version of EPDS has been used in other studies in Sri Lanka, and it was included as a part of routine postpartum care in 2012 (Agampodi and Agampodi, 2013). Although several studies indicated that the prevalence of PPD was high in Sri Lanka before 2011, the prevalence of postpartum depression after EPDS was included in routine postnatal care is unknown. Investigating risk factors for postpartum depression (PPD) is important for early detection and prevention of postpartum depression (Patel et al., 2018). Previously identified risk factors for PPD can be classified as psychological, biological, or social (Cox et al., 1987). In a study conducted in Puttalam district in 2004, potential risk factors included unplanned pregnancy, conflicts with husband, physical abuse during pregnancy, partner’s use of harsh words, death of a friend, normal vaginal delivery, low birth weight, illness, and poor night sleeping pattern of babies (D. D. S. Rowel, 2004). This study aimed to 1) estimate the prevalence of postpartum depression, at 10 days and 4 weeks postpartum, in two medical offices of health areas in Sri Lanka; and 2) to examine the association of potential socio-demographic, prenatal, clinical, delivery, and postnatal risk factors recorded in routine medical records with postpartum depression and EPDS total scores.
2.3. Sample size Based on previous estimates of the prevalence of postpartum depression in Sri Lanka- 32.1% in 2004 and 27% in 2012 (T. C. Agampodi et al., 2011; D. D. S. Rowel, 2004), we assumed predicted prevalence of postpartum depression to be 30% with a margin of error less than 0.04. Using a 95% confidence level, we needed a minimum sample size of 505 (Diez et al., 2012). 2.4. Data collection Potential risk factors were extracted from the routine paper-based medical records and gathered responses of depressive symptoms using Edinburgh Postnatal Depression Scale (EPDS) recorded on paper. Potential risk factors were selected according to the literature and availability in the existing paper forms. Most responses were in numerical form with some of the text was in Sinhalese. The free text responses in Sinhalese in the paper medical records and the EPDS were translated by the two research assistants who were proficient both in English and Sinhalese. 2.5. Data management Data was double entered into REDCap, a password-protected, internet-based, data-management system supported by the School of Medicine at Duke University. 2.6. Measurement The prevalence of postpartum depression was estimated as the proportion of mothers who had an EPDS score above 9 (EPDS > 9). Subsequently the associations between potential factors and EPDS were examined. The two outcome variables were: 1) total EPDS scores as a continuous variable, and 2) the presence of postpartum depression (EPDS > 9), a dichotomous variable. The independent variables considered were social-demographic, prenatal, clinical, delivery, and postnatal factors relating to the mothers as listed in Table 1. The variables were recategorized before examination of their associations with the outcome variables. 1) Age refers to the age of the mothers at the time point of first prenatal care session. Age was classified into three groups: “15-19”, “20-34”, and “35-49”. 2) Mothers’ or their partners’ educational levels were based as the highest grade that people attended. They were classified into two groups: “ > grade 10” and “ < =grade 10”; 3) Parity was defined as the number of living children prior the current pregnancy. 4) Mothers’ body mass index (BMI) at first antenatal visit was recorded, and it was categorized according to the criteria of underweight (< 18.5), normal weight (18.5–24.9) and overweight or obese (> 24.9) from World Health Organization (WHO, 2000), which were adopted by Sri Lanka. 5) Prenatal care sessions are often provided by public health midwives and medical doctors for mothers in pregnancy in the medical offices of health (MOH) to provide prenatal checks and maternal health related workshops. Mothers’ and their partners’ number of sessions attended were noted, and the two variables were each coded as a dichotomous variable “yes” or “no”. 6) Mothers’ diseases before, during and after pregnancy were recorded
2. Method 2.1. Study design The study is a population-based study in which mothers who delivered in 2017 from two selected medical offices of health (MOH) areas in Sri Lanka were included. 2.2. Study setting The two medical offices of health (MOH) areas, Bope Poddala in Galle district located in the Southern Province, and Dankotuwa in Puttalam district located in the North Western Province, were selected because the Edinburgh Postnatal Depression Scale (EPDS) is administered at different time points in the two areas. In Bope Poddala, mothers filled out the EPDSs with the help of public health midwives (PHMs) at around four weeks after delivery, whereas in Dankotuwa, Edinburgh Postnatal Depression Scale was filled out during PHM’s home visits 2
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continuous EPDS scores, t-tests, one-way ANOVA, and linear regression were conducted to examine associations with dichotomous, categorical, and continuous risk factors, respectively. All risk factors that were statistically significantly (p < 0.1) associated with the outcome at the univariable level, or those were deemed important based on interviews with local health professionals and the literature review, were selected for inclusion into multivariable regression models. Coefficients and p-values for EPDS scores, and odds ratios (OR with 95% CI) for postpartum depression, are presented.
Table 1 Characteristics of mothers by time of EPDS administration. Background Characteristics
Mothers administered around 10 days postpartum % (N)
Age 15-19 6.3% (33) 20-34 79.5% (416) 35-49 14.2% (74) Mother’s educational level < = grade 10 27.0% (141) > grade10 73.0% (382) Missing 0 Mother being 29.1% (152) employed Partner’s educational level < = grade 10 32.9% (172) > grade 10 66.7% (349) Missing 0.4% (2) Partner being 98.1% (513) employed Parity 0 36.7% (192) 1 42.1% (220) 2-3 19.9% (104) > =4 1.3% (7) BMI at first antenatal visit < 18.5 16.6% (87) 18.5-24.9 51.8% (271) > 24.9 29.4% (153) Missing 2.3% (12) Number of prenatal sessions attended by mothers 0 7.8% (41) 1-2 45.8% (239) 3 20.8% (109) Missing 25.6% (134) Number of prenatal sessions attended by partners 0 58.5% (306) 1-2 11.3% (59) 3 4.0% (21) Missing 26.2% (137) Mothers’ other diseases 20.5% (107) Baby’s health problems 0.4% (2) Establishment of breast 99.6% (521) feeding Postnatal clinic visit 99.4% (520) In total 38.8% (523)
Mothers administered around 4 weeks postpartum % (N)
5.2% (43) 76.0% (628) 18.8% (155)
2.8. Quality control
49.8% (411) 50.0% (413) 0.2% (2) 24.7% (204)
The data extraction sheet was back translated independently by two research assistants. The data extraction sheet was pretested in adjacent MOH areas. During data collection process, all text data was double translated by the researchers and the midwives, and all the data was double entered. If data was missing in the paper medical records, the public health midwives (PHMs) who had collected the data from the mothers were re-contacted, and important data that could be confidently ensured such as gender of the baby was retrieved. Mothers missing values on the Edinburgh Postnatal Depression Scale were excluded, and the reasons for incomplete records were clarified by the midwives.
42.1% (348) 57.1% (472) 0.7% (6) 96.6% (798)
23.6% (195) 35.5% (293) 36.1% (298) 4.8% (40)
2.9. Ethical statement
15.1% (125) 46.4% (383) 30.6% (253) 7.9% (65)
Ethical clearance was provided by the Institutional Review Board at Duke Kunshan University in China, the Ethical Review Committee at Faculty of Community Medicine of University of Ruhuna in Sri Lanka, and the Ethical Review Committee at Department of Health Services of Northwestern Province in Sri Lanka.
24.2% (200) 51.4% (424) 21.4% (177) 3.0% (25)
3. Results
50.4% (416) 42.3% (349) 1.6% (13) 5.8% (48) 24.9% (206) 13.7% (113) 99.8% (824)
3.1. Characteristics of participants All mothers delivered throughout 2017 in the two medical offices of health (MOH) areas were included in the analyses. Seven mothers were excluded because of extremely incomplete medical records or unfinished Edinburgh Postnatal Depression Scale (EPDS). 826 mothers who had been screened around four weeks postpartum from Bope Poddala and 523 mothers screened around ten days postpartum in Dankotuwa were included for data analysis, giving a total sample size of 1349. The participants’ characteristics are shown in Table 1.
99.4% (820) 61.23% (826)
and included hypertension, diabetes, subfertility, heart diseases, kidney diseases, anemia, infected episiotomy, upper abdominal pain, diarrhea, vomiting, visual or respiratory problems and delivery complications. These were also coded as dichotomous variables indicating presence or absence of disease. 7) Babies’ health problems included birth complications, prematurity, abnormalities, fever, and umbilical cord infection. 8) Establishment of breastfeeding was defined as whether the mothers had been able to establish breastfeeding by the time of the EPDS report. 9) Mothers are expected to visit postnatal clinic four weeks postpartum to check their and their babies’ health, and whether this had taken place was recorded.
3.2. The prevalence of postpartum depression Table 2 shows the prevalence of postpartum depression using the EPDS total score cut-off of 9/10, which was validated in Sri Lanka in 2004 (Rowel et al., 2008). Of the 826 mothers who were screened around 4 weeks after delivery (Bope Poddala), 7.8 % had an EPDS score greater than 9. Of the 523 mothers who had been screened around 10 days after delivery (Dankotuwa), 15.5% had an EPDS greater than 9. The mean total EPDS score was 3.49 among mothers screened at 4 weeks, and 5.75 among mothers 10 days postpartum. Table 2 also shows the percentage of the mothers who reported depressive symptoms. The responses were re-coded according to their actual responses. The responses referring to a score of “0” and “1” were coded as “no”, while “2” and “3” were coded as “yes”. From Q3 to Q9, the percentage of mothers who reported symptoms was 2–6 times higher than in the group who had reported at four weeks. Q1, Q2 and Q10 showed slight differences between the two groups. Q1 and Q2 indicate anhedonia, Q3-Q6 indicate anxiety, Q7-10 depression, and Q10 self-harm(S. B. Agampodi and Agampodi, 2013). As shown in Table 2, mothers who were screened at 10 days postpartum were more likely to have symptoms of anxiety and depression than those screened
2.7. Data analysis Stata version 15.0 was used for data analysis. The associations of the potential risk factors in the clinical records with the presence of postpartum depression (PPD) and EPDS scores were examined in univariable and multivariable models. Univariable analysis was first conducted. For the dichotomous PPD outcome, chi-square tests were conducted to compare the prevalence of PPD between different levels of the categorical risk factors. For the 3
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Table 2 Prevalence of specific depressive symptoms according to Edinburgh Postnatal Depression Scale. Items in EPDS
Mothers screened at 10 days postpartum
Table 3 The relationships of the potential predictors with EPDS scores and postpartum depression (Adjusted analyses).
Mothers screened at 4 weeks postpartum
Background Characteristics
Q1: I have been able to laugh and see the funny side of things No 4.6% 5.0% Q2: I have looked forward with enjoyment to things No 5.9% 4.5% Q3: I have blamed myself unnecessarily when things went wrong Yes 39.9% 6.3% Q4: I have been anxious or worried for no good reason Yes 24.9% 6.0% Q5: I have felt scared or panicky for no very good reason Yes 23.9% 3.2% Q6: Things have been getting on top of me Yes 15.8% 3.3% Q7: I have been so unhappy that I have had difficulty sleeping Yes 16.4% 2.5% Q8: I have felt sad or miserable Yes 8.2% 1.8% Q9: I have been so unhappy that I have been crying Yes 4.8% 2.9% Q10: The thought of harming myself has occurred to me Yes 1.6% 1.9% EPDS Total Score > 9 15.5% 7.8% Mean EPDS score (95% CI) 5.75 (5.40-6.11) 3.49 (3.2-3.73)
Multivariable Linear Regression
Multivariable Logistic Regression
EPDS Scores
EPDS Scores > 9
Beta Co-efficient
AOR (95% CI)
Administering time (Ref: 4 weeks after delivery) < 10 days after 2.59*** 3.39 (2.08-5.51)*** delivery Age (Ref: 15-19) 20-34 0.17*** 2.58 (0.59-11.24) 35-49 7.73 (1.69-35.37)** Mother’s educational level (Ref: < =grade 10) > grade 10 −0.40 1.16 (0.65-2.08) Mother being employed (Ref: No) Yes 0.25 0.99 (0.61-1.60) Partner’s educational level (Ref: < = grade 10) > grade 10 0.01 0.82 (0.46-1.46) Partner being employed (Ref: No) Yes −2.08** 0.36 (0.13-0.99)* Parity (Ref: 0) 1 −0.12 1.14 (0.66-1.98) 2-3 −0.19 1.19 (0.65-2.17) > =4 3.14*** 6.62 (2.76-15.89)*** BMI at first antenatal visit (Ref: < 18.5) 18.5-24.9 −0.002 0.97(0.52-1.79) > 24.9 1.05 (0.56-1.97) Mother attending prenatal sessions (Ref: No) Yes −0.90** 0.53 (0.32-0.90)* Partner attending prenatal sessions (Ref: No) Yes 0.57* 1.29 (0.80-2.09) Mothers’ illness before and after pregnancy (Ref: No) Yes 0.23 1.85 (1.18-2.90)** Baby’s problem (Ref: No) Yes −0.73 0.50 (0.18-1.38)
at 4 weeks postpartum. 3.3. Risk factors for postpartum depression Table 3 shows the relationship of the predictors with EPDS scores and postpartum depression. The EPDS scores were positively related to earlier administration time (β = 2.59, p < 0.001) and age at delivery (β = 0.17, p < 0.001). Mothers with over four living children (β = 3.14, p < 0.001), and those whose partners attended prenatal sessions (β = 0.57, p = 0.017) were more likely to have higher EPDS scores. EPDS scores were likely to be lower if they attended prenatal sessions (β= -0.90, p = 0.002) or their partners were employed (β= -2.08, p = 0.003). The presence of postpartum depression was associated with delivery age over 35 (AOR = 7.73, 95% CI 1.69–35.37), over four living children (AOR = 6.62, 95% CI 2.76–15.89), and mothers’ illnesses before or during pregnancy (AOR = 1.85, 95% CI 1.18–2.90). Mothers who attended prenatal care sessions (AOR = 0.53, 95% CI 0.32-0.90) and whose partners were employed (AOR = 0.36, 95% CI 0.13-0.99) were less likely to report postpartum depression.
*** < 0.001. ** < 0.01. * < 0.05.
indicated that mothers’ educational level and diseases during pregnancy, were significant predictors of PPD (Fisher et al., 2013). Other risk factors demonstrated in other studies for postpartum depression include antenatal depression, difficulty of marital relationship, lack of family support or social support, stressful events, mothers’ physical health problems (Barbadoro et al., 2012; Fisher et al., 2013; Gaillard et al., 2014; Katon et al., 2014; Lara et al., 2016; Munk-Olsen et al., 2009). We identified mothers’ attendance of prenatal care sessions and their partners’ employment as protective factors for postpartum depression. Besides, we found women whose partners attended prenatal care sessions tended to have higher EPDS scores and higher probability of postpartum depression, which may be explained by comments from the PHMs indicating partners were usually more likely to attend prenatal sessions if they were unemployed. Importantly, higher EPDS scores and presence of postpartum depression appear to be more common early rather than late after birth, even after adjustment for differences in background characteristics among mothers in two areas. Mothers who were screened around 10 days postpartum were more likely to both have higher EPDS scores and have a score greater than 9 compared with 4 weeks postpartum. Previous studies have shown that the onset of depressive symptoms is related to hormone fluctuations such as changes of estradiol and progesterone levels after delivery (Buckwalter et al., 1999; Heidrich et al., 1994; O’Hara et al., 1991). Thus, higher EPDS scores and a higher likelihood of PPD around 10 days postpartum might have resulted from the hormone fluctuations in the first week postpartum when “postpartum blues” affects 50%–70 % of mothers (Cherif et al., 2017). Future
4. Discussion 4.1. Main findings The study showed a prevalence of postpartum depression (PPD) 7.8% for mothers screened at around four weeks postpartum in Bope Poddala, and 15.5% for mothers screened at around 10 days in Dankotuwa in 2017. Higher age of mothers, having more than four living children, and mothers’ illnesses before and after pregnancy were significantly associated with PPD. Furthermore, mothers’ attendance of antenatal care sessions and partners’ employment were protective factors for postpartum depression. Higher Edinburgh Postnatal Depression Scale (EPDS) scores and presence of PPD were associated with earlier screening time. The findings relating to risk factors in this study are consistent with other studies (Cherif et al., 2017; Do et al., 2018; Strelow et al., 2018). A descriptive cross-sectional study conducted in Tunisia indicated that PPD was associated with maternal age above 35, parity, and difficulties in accepting the pregnancy (Cherif et al., 2017). A study in Vietnam 4
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Acknowledgement
research on the effect of time since delivery on the occurrence of and screening for postpartum depression is warranted. A higher percentage of mothers who live in rural and isolated areas, and an overall lower economic level in Dankotuwa, might also have contributed to the higher unadjusted prevalence of PPD in Dankotuwa.
The authors would like to acknowledge the contribution of Ms. Prabodha Lakmali in the process of data collection, and the support and advice from Dr. Joseph Egger, Dr. Ashley Price, and Dr. Amila Chandrasiri, and Ms. Jingru Tan.
4.2. Strengths and limitations
References
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5. Conclusion The prevalence of postpartum depression was 7.8% at 4 weeks (Bope Poddala) and 15.5% at 10 days (Dankotuwa) postpartum, respectively. Risk factors for postpartum depression include higher age of mothers, more than four living children, and mothers’ illnesses around pregnancy. Protective factors include mothers’ attending prenatal care sessions and their partners’ employment. In particular, mothers who have more than 4 living children are at higher risk and deserve special attention. Future studies of the effect of time since delivery on postpartum depression are warranted. Financial disclosure The first author received financial support for on-site fieldwork in Sri Lanka from Global Health Research Center at Duke Kunshan University, China Declaration of competing interest The authors declare that they have no competing interests with respect to the research, authorship, and/or publication of this article. 5
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