Risk Factors in Postpartum Depression Among Women from South-East of Romania: Importance of Early Diagnosis

INTRODUCTION

The changing effects on women’s lives are pregnancy and childbirth. The mother’s availability will decrease in the presence of a newborn, as the baby will become her priority [1]. Postpartum depression (PPD) represents a subtype of major depressive disorders that appear within the 4 weeks after childbirth [2] and can last up to 2 weeks [3]. It is a serious mental illness that involves physical and emotional changes and disturbs approximately 10-20% of mothers widespread [4]. This illness can reveal negative short and long-term features on motherhood and child growth having sometimes disastrous consequences [5-7]. Its frequency varies depending on different diagnostic tools [8-10].

Some studies showed that it depends on psychological stressors [11], and biological factors [12]. Therefore, women with endometriosis and infertility could have had a psychological condition that led them more easily to develop different disorders, like PPD [13]. Until now, its etiology is still not fully understood [14].

Postpartum depressive disorders represent the most often psychiatric conditions observed in women after childbirth, starting from the softer postpartum baby blues to PPD [15]. It emphasized the importance of the identification of depressed women in the immediate postpartum period, as they could develop a major mental disease in the later postpartum period [16, 17].

However, there has been little attention on early PPD among women with high-risk pregnancies such as those who are hospitalized or who suffered great physiological or emotional pressure during pregnancy [18].

 By using the Edinburgh postnatal depression scale (EPDS), 14% of American postpartum women were positive for depressive disorders [19]. Reck and contributors [20], reported a rate of 8.7% for depressive disorders measured by EPDS in the first 3 months after birth. Interestingly, the use of EPDS has been shown to increase the detection of women at risk for PPD in comparison with routine clinical tests [21].

Several studies have shown that prenatal depression, self-esteem, prenatal anxiety, marital relationship, infant behavior, socioeconomic status, or unplanned/unwanted pregnancy can be a risk for poor prenatal care [22-24]. Moreover, women with operative or adverse perinatal issues such as cesarean section [25], preterm childbirth [26], or gestational diabetes [27] have also been shown to express more often PPD. Women with a previous history of psychosis or a history of PPD presented also the highest risk for PPD [28, 29].

Nowadays, such studies are scarce worldwide, and we did not find a similar study in our country. More, there is not, up to our knowledge, a report of such a big number of patients, within a relatively short time frame (20 months) or results relative to the Rh blood group. We hypothesized that PPD is more frequent in less educated, younger, women and that it might be influenced by the residence (urban/rural), mode of delivery, parity, number of abortions, chronic diseases, and Rh blood type.

Based on this hypothesis, this study aimed to analyze the role of different risk factors for depression in the immediate postpartum period. Our results could contribute to the early detection and appropriate care of PPD.

MATERIALS AND METHODS

Participants and Data Collection Procedures

We conducted an observational prospective study on immediate postpartum period women who delivered in our Obstetrics & Gynecology Department from a tertiary university hospital. We analyzed the importance of demographic characteristics and clinical information in relation to PPD. All participants were informed regarding the aims and procedures, that the questionnaire was voluntary and confidential, and that they could withdraw from the study at any time. We obtained informed consent from all participants in the study as well as the Agreement of the Ethics Commission (No. 29726/31.05.2021). Between August 2019 and April 2021, we included 904 successive women in the postpartum period, who were divided into 2 groups: women with PPD (n=236) and control (i.e., women without PPD, n=668).

Edinburgh Postnatal Depression Scale (EPDS)

The EPDS was developed by Cox and contributors, for determining the risk for PPD [9]. It consists of a total of 10 questions, each item being scored differently. The lowest possible score is 0, and the highest score is 30. Scores of 0 through 9 indicate mild to moderate PPD, with little intervention required, while scores of 10 or higher suggest PPD, with immediate intervention required [30, 31]. The women were asked to complete the EPDS on the second day (D2) after delivery. The questionnaires were anonymous and took approximately 10-15 min. to fill in. In the cases in which women had difficulty understanding the questions, a nurse read and explained the questions to them, the women answered the questions, and the nurse helped write the responses. We considered the recommended cutoff score of 10 (sensitivity 82%; specificity 86%) [17] to evaluate the level of PPD.

The Demographic Characteristics and Clinical Information

The demographic and clinical features of the women were obtained from electronic records. Women’s age, urban or rural areas, level of education, Rh blood group, chronic diseases (i.e., pregnancy-induced hypertension, gestational diabetes), mode of delivery (vaginal delivery or caesarian section), women’s parity, and the number of abortions were collected.

Criteria for Inclusion and Exclusion

We included 18-45 years old women, without an identified physical or mental abnormality, who delivered a single baby. We excluded women with multiple pregnancies, those who had a psychiatric disorder that required treatment, those with alcohol or drug abuse, or those who couldn’t read or speak our language. All the participants completed the EPDS questionnaire.

Statistical Analysis

Statistical analysis in this study was carried out utilizing IBM SPSS statistics software version 28 as well as Microsoft Excel. The analytical techniques employed included descriptive statistics, visual representations in the form of graphs, and statistical assessments. Data were presented in various formats: mean and standard deviation values for continuous variables. For categorical variables, counts and percentages were used for representation. In terms of hypothesis testing, we employed various tests, namely the Independent Samples Mann-Whitney U test (for non-normally distributed data), Independent Samples T-test, and Chi-Square Test for the comparison of proportions. The choice of the test depended on the nature of the variables under analysis. The level of significance was predetermined at 0.05.

RESULTS AND DISCUSSION

Scores Obtained from the Applied Scales

From the total number of patients (n=904), the presence of PPD was noted in 26.10% (n=236) (Table 1). Of those, seven mothers (2.96%) answered positively (“sometimes”) to the last EPDS question: “The thought of harming myself has occurred to me.” The maximum obtained score was 22. Table 1 presents the scores obtained via the scales that the participants were given.

The Analysis of the Demographic Data

The average age of patients with PPD was 27.34±5.93 (mean±SD) years, and that of those without PPD was 28.23±95.95 years. The difference was statistically significant (Figure 1), (p=0.050), with a younger age being associated with a higher risk of depression.

Of the patients with PPD, 51.9% originated from urban areas and 48.1% from rural areas. In the control group (without PPD), 55% originated from an urban environment and 45% from a rural one. Patients with PPD originated from both areas, with almost similar values, and there was no statistical significance between the two groups (Table 2).

PPD = postpartum depression.

Among the patients with PPD, 36.9% had primary education (4 years, 8 years, and professional school), and 63.1% had higher education (high school and university) as compared with the group of patients without PPD: 26.4% and 73.5%, respectively (Table 2). The difference was statistically significant (p=0.002). Also, patients with PPD had fewer university studies when compared to patients without PPD (21.6% vs. 32.8%).

The presence of a negative Rh blood group, the history of chronic diseases (i.e., pregnancy-induced hypertension and gestational diabetes), the mode of delivery (vaginal vs. caesarian), and the parity were not statistically significantly correlated with the presence/absence of PPD (Table 2). The same was true for the influence of the number of abortions (Table 2 and Figure 2).

Among the patients with PPD, 49.6% were primipara and 8.89% were multiparous (i.e., more than 3 births). Among the patients without PPD, 47.9% were primipara and 5.98% were multiparous (Table 2 and Figure 3), (p=0.778). These results showed also that primipara women with PPD can be affected more by depression compared with the other categories of parity, but the difference did not reach statistical significance.