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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 66
| Issue : 4 | Page : 473-479 |
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Postpartum depression and its clinico-social correlates – A community-based study in aligarh
Mehnaz Aslam1, Tabassum Nawab2, Anees Ahmad3, Ali Jafar Abedi2, Suhail Ahmed Azmi4
1 Junior Resident, Department of Community Medicine, J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Assistant Professor, Department of Community Medicine, J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3 Professor and Chairperson, Department of Community Medicine, J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
4 Professor, Department of Psychiatry, J. N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| Date of Submission | 24-Aug-2021 |
| Date of Decision | 25-Jul-2022 |
| Date of Acceptance | 25-Oct-2022 |
| Date of Web Publication | 31-Dec-2022 |
Correspondence Address:
Tabassum Nawab
Department of Community Medicine, J. N. Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijph.ijph_1694_21
 Abstract | | |
Context: Postpartum depression (PPD) is onset of depressive symptoms in postpartum period from 2 weeks to 1 year. It causes maternal morbidity and long-term negative effects on growth and development of infant and child. It is often unreported and underdiagnosed. Aims: (1) To estimate the prevalence of PPD, (2) To determine socio-demographic, clinical, and obstetric correlates of the same. Settings and Design: A cross-sectional study was done in urban and rural areas of District Aligarh. Methods: A total of 304 females between 6 weeks and 6 months' postpartum period giving consent were included in this study. Sociodemographic, obstetric, and clinico-social factors were recorded using predesigned, pretested questionnaire. Edinburgh Postnatal Depression Scale (EPDS) score ≥10 was used to screen for PPD and International Classification of Disease (ICD-10) criteria for confirmation. Statistical Analysis Used: Correlates of PPD were determined using logistic regression analysis. Results: The prevalence of PPD was 9.5% using EPDS and was confirmed by ICD-10 criteria. History of abortion (adjusted odds ratio [AOR]: 6.0, 95% Confidence Interval [CI] 2.2–16.5), poor relationship with in-laws (AOR: 5.1; 95% CI 1.3–20.5), marital conflict (AOR: 13.3; 95% CI 2.2–77.6), and substance abuse in husband (AOR: 3.1; 95% CI 1.1–9.0) were found to be significant correlates for PPD. Conclusions: About one in every 10 postpartum females suffered from depression but did not seek health care for the same. Women facing social pathologies such as substance abuse in husband, marital conflict, and poor relationship with in-laws are more at risk of PPD. Screening for PPD should be included in the maternal and child health care programs to ensure early diagnosis and treatment.
Keywords: Community-based study, Edinburg postnatal depression scale, Postpartum depression
How to cite this article:
Aslam M, Nawab T, Ahmad A, Abedi AJ, Azmi SA. Postpartum depression and its clinico-social correlates – A community-based study in aligarh. Indian J Public Health 2022;66:473-9 |
How to cite this URL:
Aslam M, Nawab T, Ahmad A, Abedi AJ, Azmi SA. Postpartum depression and its clinico-social correlates – A community-based study in aligarh. Indian J Public Health [serial online] 2022 [cited 2023 Mar 29];66:473-9. Available from: https://www.ijph.in/text.asp?2022/66/4/473/366576 |
| Introduction | |  |
Postpartum depression (PPD) is a common psychiatric disorder starting from 2 weeks after childbirth to 1 year.[1] PPD presents as sleep disturbances, mood swings, change in appetite, fear of harming, extreme concern or worry about the baby, sadness or excessive crying, feeling of doubt, guilt and helplessness, difficulty concentrating, loss of interest in usual activities, and recurrent thoughts of death including suicidal ideation.[2] It has negative effects on the growth and development of infants[3] but often remains unreported and hence untreated.[1] Untreated PPD can cause chronic maternal depression and contribute to child's emotional, behavioral, cognitive, and interpersonal problems in later life.[3]
The prevalence of PPD ranges from 3% in Singapore to 38% in Chile with 17.7% global pooled prevalence.[4] In India, pooled prevalence is 22%.[5]
Poverty, poor relationship with mother-in-law, birth of a female baby, unplanned pregnancy, antenatal psychiatric morbidity, infant's hospital admission, husband's unemployment, and lack of social support have been recognized as risk factors for PPD.[6],[7],[8]
Due to the dearth of studies in Uttar Pradesh, a community-based study was undertaken with objectives – (1) To estimate the prevalence of PPD in urban and rural Aligarh. (2) To determine the socio-demographic and maternal correlates of the same.
| Materials and Methods | | |
Study settings
The registered field study areas under the department of community medicine, of the urban health training center (population − 11,453) and six registered villages of the rural health training center (population − 17,434) located in the district Aligarh.
Study duration
The duriation of the study was 1 year, i.e., April 2019–March 2020.
Study subject
Females between 6 weeks and 6 months' postpartum period, residing in the field study areas and who gave consent were included. Females with a history of any psychiatric illness during the antenatal period or suffering from other severe medical illnesses, or mental retardation were excluded. Females who had stillbirth or IUD or neonatal death were also excluded from the study.
Sample size
It was calculated for a study with 80% power and alpha error 5%, using the formula:
Sample size (n) = ([Z1-α/2]2 p [1-p])/d2
Taking 12%[9] prevalence rate of PPD and 4% allowable error, and adding 10% non-response rate, a sample size of 279 was calculated. However, 304 females who delivered during the study period of one year and satisfied the inclusion/exclusion criteria were included in the study and analyzed.
Data collection
A list of recently delivered females was obtained from vital records data collected by medico-social workers of the department of community medicine and information by Accredited Social Health Activist (ASHA) of the area. These females were visited at home between 6 weeks and 6 months postpartum period. This long window of period was taken keeping in mind the fact that most of women go for delivery or just after delivery to their maternal home (mayka) and return back after variable periods of time. Females were invited to take part in the study and informed consent was taken. If consent was not given, or female was not found at home on two visits due to any reason, then the next female on the list was approached.
Interviews were conducted at home in a confidential and nonjudgmental manner. A pretested predesigned questionnaire was used to collect sociodemographic information such as age, place of residence, religion, caste, type of family, educational status and occupation of female, and husband's education and occupation status. Socioeconomic status was determined by per capita per month income using Modified B.G. Prasad Classification 2020.[10]
Obstetric history and history related to index pregnancy was included – parity, total number of children, number of boys and girl child, history of abortion, stillbirth and infant death in past, gestational age at delivery, place and mode of delivery, any complication during pregnancy, during and after delivery, any complication in neonate, birth weight and sex of neonate, whether pregnancy was planned and wanted or unwanted.
Clinico-social factors included were past history and family history of any psychiatric illness, history of any substance abuse in female or in husband, financial dependence of husband on others, any perceived pressure to deliver a male child, domestic violence, marital conflict, in-cordial relationship with in-laws and perceived lack of family support.
The assessment of PPD was done using Edinburg postnatal depression Scale (EPDS)[11] which was administered orally by the interviewer to the female in the local language. Females screened as having possible PPD on EPDS (score ≥10) were subjected to confirmation of the diagnosis of PPD by International Classification of Disease (ICD-10) criteria.[12]
Ethical approval was obtained from the institutional ethics committee before the study. Informed consent was taken from study participants. Confidentiality of the given information was maintained. Appropriate health education, counseling, and referral were done.
Data management and analysis
Data were entered into MS excel and imported to and analyzed using IBM SPSS Statistics Version 20.0 (IBM Corporation, Armonk, NY). Descriptive statistics was done showing frequency distribution and sociodemographic characteristics. Univariate analysis and logistic regression analysis were applied to study independent determinants of PPD.
| Results | | |
Socio-demographic characteristics, obstetric and clinico-social history among study subjects
As shown in [Table 1], majority of mothers were in 21–25 years of age group (49%), residing in urban area, were Muslim by religion and belonged to other backward class, were homemakers, and lived in joint family systems. About half of the females were illiterate or just literate with majority having socio-economic status (SES) as lower middle class. Husbands of majority of females were illiterate or just literate and were unskilled workers. | Table 1: Sociodemographic profile of study subjects and its association with postpartum depression on univariate analysis (n=304)
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[Table 2] shows the distribution of various obstetric factors. About two-thirds of females were multipara. About 20.1%, 4.3%, and 11.5% of females gave a history of abortion, stillbirth, and child death, respectively, whereas, 65.5% of females reported any complication before, during or after pregnancy. Only 3.6% of the study participants reported any complication in the baby. Most of the deliveries were institutional and through vaginal route. 53.6% of the babies born were female, 46.4% were male. 17.1% of females reported that the sex of baby was not as desired. Only 5.3% females had a perceived pressure to deliver male baby, while 10.9% females reported that their pregnancy was unplanned. | Table 2: Obstetric factors among study subjects and their association with postpartum depression on univariate analysis (n=304)
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As shown in [Table 3], 2% of females had a family history of psychiatric illness. Only 5.6% females gave a history of substance abuse, while husbands of 50% of females had a history of substance abuse. 9.5% of the women reported domestic violence whereas 5.6% gave a history of marital conflict. 8.2% females had in-cordial relationship with in-laws, on the other hand, 32.6% had lack of family support. 3% females reported that their husband were not financially independent. 4.3% of females gave a history of recent stressful life events in the past 1 year. | Table 3: Clinico-social factors of study subjects and their association with postpartum depression on univariate regression analysis (n=304)
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Prevalence of postpartum depression
The prevalence of PPD was found to be 9.5% (29 out of 304) on screening using EPDS and the same number was diagnosed by applying ICD-10 criteria. The prevalence in urban areas was 9.4% (16 out of 170) and in rural 9.7% (13 out of 134). No statistically significant difference was found in urban and rural areas (Chi-square = 0.007, df = 1, P = 0.932).
Determinants of postpartum depression
On univariate analysis, no significant association was found between any sociodemographic factor and PPD [Table 1]. Among various obstetric factors only a history of abortion was found to be significantly associated with PPD, both in univariate and multivariate analysis, as shown in [Table 2] and [Table 4], respectively. | Table 4: Independent risk factors for postpartum depression on multivariate logistic regression analysis (n=304)
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Among the various clinico-social factors, substance abuse in husband, domestic violence, marital conflict, in-cordial relationship with in-laws, perceived lack of family support, and lack of financial independence of husband were found to have a significant association with PPD on univariate analysis [Table 3]. These factors were entered into a multivariate logistic regression analysis to determine independent risk factors for PPD. Substance abuse in husband, marital conflict, and in-cordial relationship with in-laws were found to be independent risk factors of PPD, as shown in [Table 4].
| Discussion | | |
This study reports community-based prevalence of PPD among recently delivered females of Aligarh, Uttar Pradesh. Out of every ten postpartum females, one suffers from PPD as found in this study. These females had not sought any help for their ailment, thus pointing towards under-reported and under-diagnosed nature of this disease.
This prevalence (9.5%) is comparable to the prevalence reported by other community-based study done by Hirani and Bala in Gujarat (12%)[9] and Shrestha et al., in Haryana (12%).[13] However, the prevalence found in our study is much less than the pooled prevalence of PPD in India (22%) reported in a systematic review done by Upadhyay et al.[5] This may be because it included mostly hospital-based studies. In a community setting females may be reluctant to tell about the symptoms of mental illness, they are going through because of the social stigma and fear of husband/in-laws, whereas they may be more forthcoming in sharing such information at the hospital/clinic, leading to a higher prevalence reported by hospital-based studies.
In this study, no significant rural–urban variation was found in the prevalence of PPD. In a study done in Bihar, Singh et al., have also not found any significant urban–rural differential.[14] Upadhyay et al., in their systematic review, have reported a higher prevalence in urban areas (24%), as compared to the rural areas (17%), but the difference was not statistically significant.[5]
In our study, no significant association of PPD was found with sociodemographic factors such as age, education, and occupation of females and their husbands and SES. These findings are consistent with various studies done in India by Singh et al., in Bihar,[14] Basu et al., in Delhi,[15] Jija in Kerala,[16] Shriraam et al., in Tamil Nadu,[17] and Desai et al., in Gujarat;[18] and worldwide by Adama et al;[19] Adamu and Adinew[20] in Africa.
Some authors have found the prevalence of PPD to increase with increasing age of females,[21] whereas others have found it more in younger females[22] and many have not found age to be associated with PPD.[14],[17] Lower education level was found to be a risk factor by some researchers[23],[24] but others have reported a higher prevalence in more educated females.[25] More educated females are likely to be more aware and seek help for their ailments including mental health problems and thus leading to higher prevalence of PPD reported in them. On the other hand, some authors[22] did not find any significant association between mother's education and PPD, as also reported by us.
Some researchers in India,[15],[21],[23] Nepal,[24] and Brazil[25] have found a positive association between PPD and low SES. Economic constraints may increase mental stress and promote marital conflict, thus contributing to the development of PPD. However, in our study, no significant association was found with SES.
Many researchers have found multi-parity as a risk factor for PPD,[18],[21],[25],[26],[27] while others reported primiparity to be a risk factor.[28] In our study, no significant association was found between parity and PPD. Among the various obstetric factors we studied, the history of abortion was found to be significant and increased the odds of PPD by six times. Our findings are consistent with the study conducted by Agarwala et al., in Karnataka[26] and Desai et al., in Gujarat[18] who have also reported 4.5 times higher odds of PPD with a history of abortion.
We found the odds of PPD increased about three times in females who gave a history of substance abuse in husband. Some researchers have found alcohol intake in husbands to increase risk of PPD by 3 to 5 times.[16],[21],[29] Substance abuse of husband can have an impact on the mental well-being of female, and thus, it may predispose her to PPD as well.
The most significant determinant of PPD in our study was found to be marital conflict. Panyayong et al., in Thai women[29] have also reported increased odds of PPD by 1.8 times, and Savarimuthu et al., in Tamil Nadu[30] have reported 9.38 times odds of PPD in women with unhappy marriage.
Lack of family support has been found to be a determinant of PPD by Singh et al.,[14] in Bihar (adjusted odds ratio: 2.56), Kolisetty and Jyothi[28] in Andhra Pradesh and was found to be significantly associated with PPD in univariate analysis in our study also.
The odds of PPD were about five times higher in those with poor relationship with in-laws. Our results are consistent with many other studies. Jija[16] reported 5.16 times higher odds and Suguna et al.[23] had found 3.4 times higher odds of PPD due to conflict with in-laws. Gupta et al.[21] have also reported that women who were not having an adequate relationship with in-laws were more likely to be suffering from PPD.
We found a statistically significant association between PPD and lack of husband's financial independence with 5 times increased odds on univariate analysis. However, after adjusting for other clinico-social factors, it was not found to be an independent risk factor. Although we studied SES, many a time SES (assessed by per capita income per month of a family) does not reflect the husband financial independence, especially in a joint family system. Hence, we explored this variable separately, as it can be a stressful factor contributing to mental illness. However, we could not find any other researcher exploring this variable.
Domestic violence among females has been associated with PPD in many studies in India.[10],[15],[23] It was found to increase the risk of PPD by 8.7 times in our study, although this association was not statistically significant in multivariate analysis.
Many social and cultural factors such as lack of family support, marital conflict, and in-cordial relationship with in-laws and substance abuse in husband have been found to be risk factors for PPD in our study. These social pathologies can show clustering in some communities more so among communities with low education status. With further analysis in our study, it was found that substance abuse in husband and marital conflict showed an inverse relationship with education level of husband. Despite the fact that females are at the receiving end of these social pathologies, they have little autonomy or power to change the circumstances on their own. Consequentially, females facing these social pathologies often suffer in silence and mental health problem like PPD also become part of this deadly silence. Due to the stigma around mental health diseases, it is often considered “part and parcel” of normal birthing process and something females have to endure. Given the consequences of PPD on maternal health and cognitive development of child with far-reaching consequences even in adolescence,[3] it is imperative that this silence be broken and false “normalization” of PPD be addressed. This may be achieved by creating awareness about PPD among communities and by including screening for PPD by ANM and ASHA in home-based postnatal care. Due to the dearth of mental health specialists especially in rural areas in India, other health-care providers such as primary care physicians, obstetricians, and pediatricians also need to be sensitized to the hidden burden of PPD. Growing recognition and sensitization to PPD may contribute towards timely detection and appropriate referral. Further, maternal and child health programs in India have focused largely on preventing maternal and neonatal mortality by far, but with emerging times, they also need to address morbidities that can have far-reaching consequences on maternal and child health, including PPD. The inclusion of mental health in maternal and child health programs is the need of the hour.
| Conclusions | | |
About one in every ten postpartum females suffered from depression but did not seek health care for the same. Women suffering from consequences of social pathologies like substance abuse in husband, marital conflict, and poor relationship with in-laws are more at risk of PPD. Screening for PPD should be included in the maternal and child health-care programs to address the hidden “iceberg” portion of this disease with far reaching consequences for both mother and child. Further research can be directed toward interventions for reducing PPD.
Acknowledgment
Authors are thankful to the women who participated in this study for their co-operation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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