Frequency of perinatal depression in Serbia and associated risk factors

Abstract

Objective:

To screen 212 women for depression symptoms during pregnancy and postpartum in Serbia.

Methods:

Questionnaires that covered key demographic and obstetric information and Edinburgh Postnatal Depression Scale (EPDS) were administered at the third trimester of pregnancy and at 8 weeks postpartum.

Results:

In all, 21% of the sample was screened as depression positive during pregnancy. Subsequently, efforts were made to follow up 195 women through postpartum. Of the 195 women, 11% were screened positive during postpartum. Risk factors were low education level, low satisfaction with financial situation, high-risk pregnancy and depression during pregnancy. Logistic regression with backward elimination showed that women who had high-risk pregnancy have threefold increased risk of postpartum depression, and women who had antenatal depressive symptoms have 10-fold increased risk of postpartum depression.

Conclusion:

In countries where screening tool for depression is not applied routinely in obstetrics settings, clinicians should be aware of risk factors, frequency and level of depressive symptoms during pregnancy and postpartum.

Keywords

Perinatal depression psychosocial factors obstetric factors screening

Introduction

Perinatal depression refers to major and minor episodes during pregnancy (termed antenatal) and/or within the first 12 months after delivery (termed postpartum or postnatal). Perinatal depression is a great public health problem. It affects women in most countries around the globe, but women in developing countries bear the greatest burden (Almond, 2009). Antenatal depression has low detection rate, and many women remain under-diagnosed (Milgrom et al., 2009). Depression during pregnancy has negative impact on course of pregnancy and fetal and neonatal outcome (Alder et al., 2011). These include growth restriction (Diego et al., 2006), preterm birth (Moncuso, Schetter, Rini, Roesch, & Hobel, 2004), low birth weight and small for gestational age (SGA; Field et al., 2004). Studies have also shown that children born to depressed mothers are more likely to have behavioural problems and/or disruptions in cognitive and emotional development (Weinberg and Tronick, 1998).

There is no information on prevalence of perinatal depressive disorders in Serbian women.

This study is the first one in Serbia estimating the frequency of depressive disorder during pregnancy and postpartum. For females in Serbia, depressive disorders are the third leading cause of global burden of disease (GBD; Jankovic et al., 2006). Since pregnancy is not a protective factor against depressive disorder, we aimed to estimate the frequency and risk factors of perinatal mood disorders in Serbia and verify previously confirmed risk factors on our population.

If providers know the clinical significance of risk factors for depression in pregnancy, they may be able to identify more easily women with the highest chance for developing this condition. Early identification by routine data could play an important role in preventing maternal morbidity and mortality and morbidity of the whole family.

Methods

The research was performed at the inpatient department of Obstetrics and Gynecology Clinics at the Clinical Center of Serbia, The Faculty of Medicine – University of Belgrade and at the outpatient department of Primary Health Centre Zvezdara from June 2011 until June 2012. It was designed as a cross-sectional population study with follow-up. Ethical Committees of both institutions have approved the research.

Population under study

Survey participants were pregnant women in the third trimester of pregnancy, who were hospitalized at the Obstetrics and Gynecology Institute of The Faculty of Medicine – University of Belgrade, when the research was done, or who had their second trimester check-up at the Primary Health Centre Zvezdara.

Pregnant women were asked to participate in this prospective study from July 2011 until June 2012. The aims and procedures of the study were explained to women at the first visit. At the beginning, 250 women were informed, but 36 refused to participate. A total number of 212 women (108 from outpatient and 104 from inpatient unit), who provided written consent, were included in the study. Only 195 were followed during the postnatal period.

Measurements

Semi-structured questionnaire was designed to obtain socio-demographic data (age, education, occupation, place of birth and marriage status), obstetric variables (mode of conception (naturally or in vitro fertilization (IVF))), course of pregnancy (high-risk pregnancy or not), number of fetuses, mode of delivery (caesarean section or vaginal delivery) and gender of the baby. Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987) has been used as a screening tool for depression during pregnancy and postpartum. The Hamilton depression scale (17 item) was used to rate the severity of depressive symptoms.

Women would be identified to be at high risk of depression if the scores were above a cut-off score of 12. After being informed and giving their consent to participate, screening for depressive symptoms was done during last trimester of the pregnancy (>28 gestational weeks). Follow-up was performed 6–8 weeks postpartum. EPDS was obtained via email, together with the obstetric data (mode of the delivery and gender of the baby). Women who were screened positive were referred to psychiatrist for further evaluation.

Statistical analysis

Data were analysed using Student’s t-test or Fisher’s χ² test according to the characteristics of the variables. Spearman’s rank correlation was used to check correlation between variables. Predictors were tested with logistic regression analyses. SPSS 12.0 processed all data.

Results

This study reports the findings of the first epidemiological survey, using EPDS, of the perinatal depression and the associated risk factors in Serbia.

In this survey, we found elevated levels of the detersive symptoms at the 21.7% of the sample during the pregnancy and at the 11.8% of the sample in postpartum (Table 1). None of the women who were screened had severe depressive symptoms or suicidal thoughts. They had mostly mild (76%) and moderate (4.6%) depressive symptoms. At 6 months follow-up, only two of them (8.6%) had to receive pharmacotherapy; both have had depressive disorder early in life.

Table 1.

Frequency of antenatal and postpartum depression.

	Antenatal period	Postpartum
	N (%)	N (%)
Non-depressed	166 (78.3)	172 (88.2)
Depressed	46 (21.7)	23 (11.8)
Total	212 (100)	195 (100)

Depression rate

Depression rate significantly differs in pregnancy and postpartum (p < .001). The level of depressive symptoms decreases from late pregnancy to puerperium (Table 2).

Table 2.

Depression rate through pregnancy and postpartum.

	N	χ	Median	Min.	Max.	Interval	SD
Antenatal period	195	6.99	6.00	0	22	22	4.487
Postpartum	195	5.62	5.00	0	21	21	4.041

SD: standard deviation.

Wilcoxon’s test: Z = −3.657; p < .001.

Estimating the socio-demographic factors, we found out that only low educational attainment was associated with higher rates of depressive symptoms during pregnancy. Other socio-demographic factors were not statistically significant (Table 3).

Table 3.

Socio-demographic characteristics and depressive symptoms.

	N	χ	Median	Min.	Max.	SD	N	p
Education	Low	8	9.62	8.50	4.00	17.00	4.63	.046*
	Middle	88	7.60	7.50	.00	22.00	4.41
	High	116	6.56	6.00	.00	21.00	4.43
Place of birth	Town	130	6.95	6.00	.00	17.00	4.26	.739
Place of birth	Village	82	7.35	7.00	.00	22.00	4.79	.739
Occupation	Yes	158	6.92	6.00	.00	22.00	4.43	.284
Occupation	No	54	7.65	7.00	.00	22.00	4.58	.284
Marital status	Married	165	7.09	6.50	.00	22.00	4.45	.309
	Single	20	8.60	8.50	1.00	22.00	5.55
	Cohabitation	27	6.11	6.00	1.00	12.00	3.46

SD: standard deviation. *p<0.05.

Spearman’s rank correlation revealed that low satisfaction with material situation correlates both with antenatal (ρ = .159; p < .05) and postnatal depression (ρ = .192; p < .01; Table 4).

Table 4.

Correlation between low satisfaction with material status and depressive symptoms.

	r	p
Low satisfaction with material status/AnD	ρ = .159	<.05
Low satisfaction with material status/PPD	ρ = .192	<.01
AnD/PPD	r = .445	<.001

PPD: postpartum depression; AnD: antenatal depression

Among all obstetric variables measured, only course of pregnancy was found to be significantly different (χ² = 5.290; p = .021) between depressed and non-depressed women (Table 5).

Table 5.

Obstetric features and depressive symptoms in postpartum.

		N (%)	N (%)
Mode of conception	Naturally	160 (89.4%)	19 (10.6%)
	IVF	12 (75.0%)	4 (25.0%)
Total		172 (88.2%)	23 (11.8%)
Parity	0	125 (88.7%)	16 (11.3%)
	1	41 (85.4%)	7 (14.6%)
	2	4 (100.0%)	0 (.0%)
	4	1 (100.0%)	0 (.0%)
Total		171 (88.1%)	23 (11.9%)
Gender of baby	Male	83 (91.2%)	8 (8.8%)
	Male twins	2 (100.0%)	0 (.0%)
	Mix twins	3 (75.0%)	1 (25.0%)
	Female	82 (86.3%)	13 (13.7%)
	Female twins	1 (50.0%)	1 (50.0%)
Total		171 (88.1%)	23 (11.9%)
Mode of delivery	Vaginally	89 (89.9%)	10 (10.1%)
	Caesarean section	83 (86.5%)	13 (13.5%)
Total		172 (88.2%)	23 (11.8%)
Number of babies	1	167 (88.8%)	21 (11.2%)
	2	5 (71.4%)	2 (28.6%)
Total		172 (88.2%)	23 (11.8%)
Course of pregnancy	Normal course	81 (94.2%)	5 (5.8%)
χ² = 5.290; p = .021*	High-risk pregnancy	91 (83.5%)	18 (16.5%)

IVF: in vitro fertilization. *p<0.05.

Antenatal depression strongly correlates with postpartum depression (r = .445; p < .001).

Strong predictor of postpartum depression is antenatal depression (t = 6.911; p < .001).

Multivariate regression with backward elimination revealed that complications during pregnancy increase the risk of postpartum depression three times, and antenatal depression increases the risk of postpartum depression 10 times (Table 6).

Table 6.

Multivariate linear regression.

		p	OR	95% IP	OR
				Lower	Upper
	Mode of conception	.941	1.074	.164	7.048
	Course of pregnancy	.051	3.320	.995	11.073
	Age	.331	1.060	.943	1.191
	Education	.563	1.306	.529	3.225
	Number of babies	.478	2.255	.238	21.364
	Satisfaction	.695	1.099	.686	1.759
	AnD	.000	10.611	3.856	29.197
Backward	Course of pregnancy	.047	3.060	1.014	9.228
	AnD	.000	10.151	3.841	26.827

OR: odds ratio; IP: confidence interval; AnD: antenatal depression.

Discussion

A total of 212 women were involved in this survey, and 195 were followed during the postnatal period. Although EPDS assesses only the depressive symptoms and cannot lead to the diagnosis of perinatal depression, it is the most used screening test in this period.

Frequency

In this study, we found enhanced levels of depression during pregnancy in 21.7% of our sample and 11.8% in postpartum period. The observed rate of antenatal depression is comparable to other studies (Andersson et al., 2003; Bennett, Einarson, Taddio, Koren & Einarson, 2004; Boyce and Tood, 1992; Evans, Heron, Francomb, Oke, & Golding, 2001; Gavin et al., 2005), and the observed rate is in line with data that antenatal depression is twice more often than postpartum depression (Field, 2011). Unfairly neglected by researchers and clinical doctors, antenatal depression is one of the most confirmed risk factor and predictor of postpartum depression (Milgrom et al., 2009; O’Hara and Swain, 1996; Robertson et al., 2004). Antenatal depression is far more often than other physical risk factors (high blood pressure (HTN), hyperglycaemia, anaemia, etc.) that are routinely checked at every check-up (Honey et al., 2003). Unfortunately, detection rate is still very low. The observed rate of postpartum depression is comparable to other studies in region (Nakić, 2011), but lower than most estimated prevalence rate (O’Hara and Swain, 1996). In addition, the findings underline once more the importance of an early detection of antenatal depression in (developing) countries without systematic screening.

Depression rate

The level of depressive symptoms decreases from late pregnancy to puerperium. This finding brings full attention to pregnancy, confirming that pregnancy is the most vulnerable period of woman’s life. It is in contrast to previous knowledge stating that puerperium is a time of great vulnerability to affective illness (Alder et al., 2011). Depression rate significantly differs in pregnancy and postpartum (p < .001). Using the old diagnostic criteria, during pregnancy, women are more prone to neurosis and during postpartum to psychosis. However, the diagnostic criteria are changed, but the prevalence is still the same.

The aim of this study is to point out the socio-demographic, obstetric and psychological factors that play the role in developing the perinatal depression.

Risk factors

Estimating the socio-demographic factors, we found out that education level was associated with higher rates of depressive symptoms. There was a correlation found between lower satisfaction with material status and antenatal and postpartum depression. This finding was confirmed before for low socio-economic status (O’Hara and Swain, 1996; Robertson et al., 2004), but we thought that not only the amount of money matters, but a psychological aspect plays the role, as well. The differences in age, marriage, occupation, and place of birth were not statistically significant or associated with higher rate of depression.

Assessment of obstetric variables showed that only course of pregnancy significantly differed in both groups (p < .001). Antenatal depression affects the course of pregnancy and vice versa.

In addition, these data are in line with studies that include course of pregnancy in risk factors (Brandon et al., 2008), while other research groups did not confirm it (Nakić, 2011). Pregnancy and medical complications that can accompany it are stressful life events. It is known that two or more stressful life events in a year prior to delivery increase the risk of postpartum affective disorders (Brandon et al., 2008). All other obstetric variables (parity, mode of conception, mode of delivery, number of babies and baby’s gender) were not significantly different in depressed and non-depressed group.

Predictors

Predictors of postpartum depression are antenatal depression and high-risk pregnancy. This finding is consistent with some studies where these predictors were confirmed (Kim, Hur, Kim, Oh, & Shin, 2008; Milgrom et al., 2009; Nakić, 2011).

Multivariate logistic regression with backward elimination showed that the risk of developing perinatal depression increases the risk of postnatal depression three times and the risk of postnatal depression after having antenatal depression 10 times.

It is still hard to predict who will suffer perinatal depression and when, but antenatal depression and high-risk pregnancy increase the risk. It is said that socio-demographic and obstetric factors may not precisely predict who will suffer perinatal depression and when, so future research in this area will elucidate more clearly the underlying pathogenesis and the potential long-term impact of perinatal depression on developing fetus.

Conclusion

Therefore, it is important for clinical doctors to recognize mental health problems that can affect women in the perinatal period. Depression is only one of risk factors that can complicate pregnancy.

Multidisciplinary approach is needed when we are dealing with such an enemy that affects not only the mother but also the fetus and neonate, as well.

It is far more important to screen women for depression during pregnancy, in countries without regular screening procedure and in countries where seeing the psychiatrist is believed to be a shame, especially when it is known that only 25% of women having difficulties in postpartum sees psychiatrist and receives the appropriated treatment.

It is a reason more to screen women especially when antenatal depression can predict postpartum depression, and therefore prevent long-term social, emotional and behavioural disturbances of a newborn. Two limitations should be taken into account in interpreting the findings in this study: the small number of participants and use of the EPDS screening tool, which is not a diagnostic tool. Future studies are needed to clarify the roles of other compounding factors.

Footnotes

Acknowledgements

We are grateful to the pregnant women who took part in this study. We also thank authors who responded to requests for information regarding statistical design and analysis.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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