Abstract
Background:
The magnitude of postpartum depression in Jordan is under documented, and little is known about its potential sociodemographic and clinical correlates.
Purpose:
The aim of this study was to explore the prevalence and risk factors associated with postpartum depression among Jordanian mothers in the first 18 months after delivery.
Method:
This descriptive cross-sectional study was carried out from April to June 2020 in Jordan. A web-based survey was used for recruiting eligible participants. An Arabic version of the validated self-administered Edinburgh Postnatal Depression Scale questionnaire was used to measure postpartum depression with a cut-off score of ⩾12 which indicates probable depression.
Results:
A total of 1,071 Jordanian women participated in the study. Of those, 567 women had postpartum depression (52.9%). Multivariate logistic regression analysis revealed that postpartum depression was significantly associated with marital conflict (OR: 4.91; 95% CI: 2.36–10.20), negative attitude from the pregnancy (OR: 0.67; 95% CI: 0.45–0.99), unplanned pregnancies (OR: 1.73; 95% CI: 1.16–2.60), lack of social support (OR: 1.93; 95% CI: 1.12–3.32), time from last delivery (OR: 0.99; 95% CI: 0.98–1.00), insomnia (OR: 0.53; 95% CI: 0.35–0.82), and depression during the pregnancy (OR: 0.51; 95% CI: 0.33–0.78). Most of the participants (65.7%) sought social support to avoid, reduce, or treat postpartum depression.
Conclusions:
Postpartum depression among Jordanian women was the highest in comparison to that of women in other countries in the region. Therefore, screening for the presence of depressive symptoms should be implemented during regular pregnancy care visits. Social support should be encouraged in order to avoid, reduce, or treat postpartum depression.
Introduction
Postpartum depression (PPD) is one of the depressive disorders affecting postpartum women. The other types are postpartum blues and postpartum psychosis (American Psychiatric Association, 2006). Postpartum blues occur in 40% to 80% of women during the first month after delivery (Higginbottom et al., 2013). It peaks around the fourth day and resolves by the tenth day following delivery. Symptoms are usually mild and self-limiting and with little consequence to the health of both the mother and child (Cohen et al., 2010). Postpartum psychosis is a rare but serious condition, with a prevalence of 0.1% to 0.2%. It peaks in the first two postpartum weeks and requires emergency treatment because of the risk of infanticide and suicide (Cohen et al., 2010).
PPD is a non-psychotic depressive episode that begins 4 weeks following child birth (American Psychiatric Association, 2006, 2013). However, it may start earlier during the pregnancy or may start after the first postpartum month (Gavin et al., 2005). Besides, PPD onset symptoms can extend to 1 year following delivery (Gaynes et al., 2005). Symptoms of sleep disturbance, mood swings, appetite disturbance, loss of energy, feelings of worthlessness, sadness or guilt, diminished concentration, loss of interest, and thoughts of suicide represent the clinical manifestation of PPD (Patel et al., 2012). The diagnosis of PPD depends mainly on self-report measures which are used as surrogates for clinical assessment. The Edinburgh Postnatal Depression Scale (Cox et al., 1987) is an example of self-report screening measure. It is a validated and widely used 10-item questionnaire, available in many languages. An Edinburgh Postnatal Depression Scale score of ⩾12 is indicative of probable PPD.
If PPD is to be prevented, its risk factors need to be reliably identified (Warner et al., 1996). Moreover, obtaining data on the incidence and prevalence of this condition is an important first step in future managing and delivery of mental health services. Unfortunately, in Jordan, research on maternal mental health is largely neglected. The magnitude of PPD is under documented, and little is known about its potential sociodemographic and clinical correlates. Therefore, the aim of this study was to explore the prevalence and risk factors associated with PPD among Jordanian mothers in the first 18 months after delivery.
Method
This descriptive cross-sectional study was carried out from April to June 2020 in Jordan. The required sample size for the current study was estimated to be approximately 1,064, based on the Jordan Ministry of Health statistical report on the number of deliveries (N = 207,900) in 2018 (khaberni, 2020) with a 95% confidence interval (CI) and a 5% error in estimating the prevalence of depression. The inclusion criteria were Jordanian resident postpartum women who delivered between the months of January 2019 and May 2020. The exclusion criteria were postpartum women who had other than Jordanian nationalities, were non-permanent residents of the area, or had delivered before January 2019 or beyond May 2020.
Online recruitment via the Google Forms platform was used for recruiting eligible participants. This method enabled a nationwide recruitment. Study participants completed a web-based survey through a Facebook group that targets mothers in Jordan; mommy to be – Jordan. This group, has around 290,000 members, was created to discuss topics on pregnancy, motherhood and childhood among Jordanian married women. Discussions on politics, religion, negativities, or any topic outside the group theme are prohibited. The survey consisted of three sections. The first section included the sociodemographic, medical, and obstetric characteristics of the participants. The second part was the Arabic version of the self-administered 10-item Edinburgh Postnatal Depression Scale (EPDS) questionnaire which was used to measure PPD. Research evidence has suggested that Arabic version is reliable and valid and even superior to other screening tools (Ghubash et al., 1997; Naja et al., 2019). For instance, the sensitivity and specificity of the questionnaire as measured by Ghubash et al. (1997) were 73% and 90%, respectively. Using a cut-off score >13, 87% sensitivity and 90% specificity allowed for great division between depressed and non-depressed participants as mentioned by Naja et al. (2019). Each question of the questionnaire was scored from 0 to 3 with a total score ranging from 0 to 30. A score greater than 13 was considered to indicate probable PPD. The last section included the preventive and treatment strategies that have been used by participants to avoid or decrease postpartum depressive symptoms.
This study was approved by the Ethics Committee of the School of Pharmacy at Isra University, Jordan. It was clearly mentioned that the completion of the questionnaire was considered a consent from participants before their participation in the study.
Data were analyzed using the Statistical Package for the Social Sciences (SPSS), Version 26 (IBM Corp., Chicago, IL, USA). Continuous data were presented in mean and standard deviation while categorical data were presented in percentage and frequency. All variables were subjected to univariate analysis using either Pearson’s Chi-squared test or Student t-test to determine associations between PPD and sociodemographic characteristics. Significance was determined at p value <.05 and a confidence level of 95%. Multivariate logistic regression was performed for variables that showed significant associations with PPD at the p ⩽ .05 level.
Results
A total of 1,071 Jordanian women participated in the study. The mean age of the participants was 27.4 years (range: 18–42 years old). More than half of the participants (58.1%) had a Bachelor’s or postgraduate university qualification. The majority of participants were housewives (82.9%). The majority of the participating women (88.0%) reported a satisfactory relationship with no marital conflict. More than half of the women (58.2%) stated that their pregnancies were unplanned, around a third (34.2%) had a negative attitude from the last pregnancy, and a small percentage (4.3%) were annoyed about the baby’s gender.
About half of the participants (55.0%) have 2 to 3 children in total. The majority of the new babies weighed 2.5 to 4.5 kg (91.6%) and were healthy (99.2%) while only 12.7% needed admission to the PICU. One third of the new babies (33.8%) depended on breastmilk for feeding (Table 1).
Sociodemographic characteristics of participants and their babies (N = 1,071).
In terms of medical status, a history of miscarriage/abortion was reported by 71.2% of the participants. Obstetric problems before pregnancy and infertility were reported by 17.6% and 11.6%, respectively. A previous history of depression before and during pregnancy was reported by 25.9% and 45.1% of the participants, respectively. The medical and obstetric data are showed in Table 2.
Clinical characteristics of participants (N = 1,071).
The EPDS scores (Figure 1) ranged from 10 to 30 (mean: 13.7 ± 5.5). A total of 567 women had postpartum depression (52.9%). A Univariate analysis, with Bonferroni correction to overcome type 1 error, showed that postpartum depression was significantly associated with many sociodemographic and clinical variables (Table 3).
EPDS scores for participants.
Significant associations between postpartum depression and clinical and sociodemographic variables (N = 1,071).
Multivariate logistic regression analysis revealed that postpartum depression was significantly associated with marital conflict (OR: 4.91; 95% CI: 2.36–10.20), negative attitude from the pregnancy (OR: 0.67; 95% CI: 0.45–0.99), unplanned pregnancies (OR: 1.73; 95% CI: 1.16–2.60), lack of social support (OR: 1.93; 95% CI: 1.12–3.32), time from last delivery (OR: 0.99; 95% CI: 0.98–1.00), insomnia (OR: 0.53; 95% CI: 0.35–0.82), and depression (OR: 0.51; 95% CI: 0.33–0.78) during pregnancy (Table 4).
Logistic regression analysis of risk factors for postpartum depression.
Note. OR = odds ratio; CI = confidence interval.
The follow-up question about the strategies used to avoid or treat postpartum depression revealed that the majority of the participants (65.7%) sought for social support while only 0.7% used antidepressant medications (Figure 2). Some women reported other unremarkable strategies which were analyzed and categorized into three themes: work and leisure time activities, creation of good vibes, and religious practices.
Used strategies to avoid/treat postpartum depression.
Discussion
The prevalence of postpartum depression in the studied group of Jordanian women was unexpectedly the highest in the region, that is, higher than findings from Saudi Arabia (31.9%), Syria (28.2%), Oman (24.3%), and Morocco (19.2%; Alami et al., 2006; Al-Azri et al., 2016; Al-Hejji et al., 2019; Roumieh et al., 2019). Additionally, the prevalence was higher than results reported from Bangladesh, Turkey, Australia, the UK, and South Africa (Govender et al., 2020; Gulseren et al., 2006; Leigh & Milgrom, 2008; Nasreen et al., 2010; Pawlby et al., 2009).
The high PPD rate in the present study has been attributed to several factors. These factors include marital conflict, unwanted pregnancy, unplanned pregnancy, lack of social support, time from delivery, insomnia, and depression during pregnancy. In addition to the above-mentioned variables, country lockdown, social isolation and the fear from COVID-19 might result in decreasing the usual social behavior and support which can indirectly elevate the PPD rate during the period of the study and result in an unusual high prevalence rate.
Several studies have demonstrated an association between satisfaction with the marital relationship and PPD. In a Chinese study, multifactorial stepwise regression analyses identified the relationship between husband and wife as one of the predictors of PPD (Bernazzani et al., 2004). Similar results have been found among Australian (Matthey et al., 2000), Hong Kong (Lee et al., 2004), Turkish (Danaci et al., 2002), and Omani (Al-Azri et al., 2016) mothers.
Unplanned pregnancy was a significant risk factor for PPD in the present study. A woman with an unplanned pregnancy is less prepared for childbearing due to the difficulties in balancing maternal needs and other responsibilities. Dibaba et al. (2013) found that women reporting unwanted pregnancy are twice as likely to be depressed as compared to women with planned pregnancies.
Not only unplanned pregnancies but also negative attitudes toward pregnancy was a predictor of postnatal depression based on the current study. This finding was similar to a previous study which suggested a correlation between the negative attitudes toward pregnancy and postnatal depression (Kokubu et al., 2012). Mothers may have depressive symptoms such as a feeling of rejection toward the new baby and a negative attitude toward pregnancy and these can be listed as a candidate correlate.
The association between social support and PPD has been established by studies from both developing and developed countries. In the Dibaba et al. (2013) study, women with high social support were 0.26 times as likely as women with low/no social support to experience PPD. Similarly, the lack of social support was associated with PPD in the present study. It is clearly demonstrated that social support plays a buffering role against depression during pregnancy and after delivery (Collins et al., 1993; Elsenbruch et al., 2007).
Although PPD can start at any point in the first year after giving birth or even beyond, the present study showed that the women in a period close to delivery are experiencing depressive symptoms more significantly. This finding is only highlighted in the present study.
Although there has been less research conducted on the effect of a personal history of depression, anxiety, and insomnia on the relapse of PPD, the relapse rate has been reported as high as 50% (Andrews-Fike, 1999). In the present study, a personal history of depression and insomnia during pregnancy were significantly associated with the development of postpartum depressive symptoms. These findings were comparable with the Al-Hejji et al. (2019) study.
There is limited data relating to the impact of obstetric and post-delivery problems on the development of PPD (Parker, 2004). Available findings are mixed, with some researchers reporting that women who have more obstetric and post-delivery interventions have an increased risk of PPD (Creedy & Gamble, 2007) and other studies not fully supporting this (Chandran et al., 2002; Josefsson et al., 2002). In the present study, although having complications after delivery such as vaginitis and hemorrhoids were initially found to represent risk factors for PPD, these associations were not significant after multivariate analysis.
Different strategies were used to avoid, reduce, or treat postpartum depression. Social support, the most used method, helps women transition into motherhood, thus improving maternal well-being. Social support can come in many forms. In the Far East, the traditional practices aim to help new mothers recover from pregnancy and childbirth. The mother, receiving help from her family, remains at home for 40 days to rest and avoids physical work. In Taiwan, private hotel-like maternity centers are available with care from nurses (Cheng et al., 2006). In European countries, home visits are conducted by a health-care professional soon after childbirth (Cheng et al., 2006). In Jordan, postpartum mothers have support from their families and friends. In contrast, using antidepressant medication was rare among participants. This may be due to the belief of Arab people that depression is a social stigma. Thus, they may hide their condition and refuse to seek medical help (Al-Azri et al., 2016).
The current study is subjected to some limitations. First, the study relied on PPD symptomatology rather than clinical diagnosis of depression. Thus, there could be a tendency to overestimate its prevalence especially with the overlap between symptoms and common postpartum maternal discomforts. Second, the results of the present study were predominantly based on a retrospective self-report process to determine psychiatric/medical history. Lastly, although many studies indicate that mothers of multiples may be at elevated risk for symptoms of PPD (Sheard et al., 2007; Vilska et al., 2009), this part was not studied in the present research due to the small number.
Implications for practice and/or policy
The high prevalence of PPD in the present study is of a great concern; hence, pregnant women should be educated and aware about how to identify depression symptoms and the dangers of not getting it treated early. Screening of depressive symptoms should be introduced as part of regular care assessment to help identify women with depression or at risk of developing it since successful risk factors reduction will definitely reduce prevalence of PPD.
Conclusions
Findings indicated that PPD among Jordanian women was the highest compared to that of women in other countries in the Middle East. Considering this high rate of PPD and the above-mentioned risk factors, routine screening for the presence of depressive symptoms and other psychiatric illnesses should be implemented as part of regular pregnancy care services. Psychological and social support are recommended for those at risk for PPD. Moreover, women should be aware of appropriate contraceptive methods to avoid unplanned/unwanted pregnancies.
