Predictors of postpartum depression: Prospective study of 264 women followed during pregnancy and postpartum
Introduction
Postpartum psychiatric disorders range from the mild and common postpartum “blues” to much rarer incidences of severe postpartum psychosis. The most commonly studied postpartum disorder is postpartum depression (PPD). Although the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) criteria for symptom onset of postpartum depression are limited to 4 weeks after childbirth (APA, 1994), many clinicians and researchers in the field consider symptoms within 12 months after delivery to be related to childbirth (Gaynes et al., 2005). PPD prevalence is considered as high, ranging between 5.5% and 33.1% depending on studies, cultures, samples, instruments and statistical methods (Le Strat et al., 2011, O’Hara and Swain, 1996, Yonkers et al., 2004).
PPD has some specific outcomes. Although suicide attempt is less frequent in PPD than in non-postpartum Major Depressive Episode (Warner, 1996), PPD is associated with low quality of life and poor mental health in mothers. PPD also has pervasive effects on mother–infant bonding, and affects the emotional, cognitive and behavioral development of the child (Field, 2010). In long term studies, PPD is associated with an increased risk for psychiatric disorders in adolescence (Murray et al., 2011).
In addition to the classical symptomatology associated with a Major Depressive Episode, women with PPD often report having a lack of confidence in their abilities to take care for their child. Sleep disturbances and fatigue are common after childbirth and during the postpartum period, making it harder to diagnose PPD (Matthey and Ross-Hamid, 2011). Consequently, a large percentage – estimated up to 50% – of PPD remains undetected (Ramsay and Torbet, 1993).
Some biological risk factors of PPD have been identified, including genetic (Mahon et al., 2009), epigenetic factors (Meltzer-Brody, 2011) and endocrine dysregulations (Yim et al., 2009). Many sociodemographic and psychosocial characteristics, as well as psychiatric disorders have been associated with PPD in the literature. Sociodemographic and psychosocial characteristics include low socio-economic status (e.g., low education level, poverty, low income, unemployment), lack of social support, lack of partner support, stressful life events, history of traumatic experiences, physical abuse by the partner (Beck, 1996, Robertson et al., 2004, Csatordai et al., 2007, Ludermir et al., 2010, Milgrom et al., 2008, Reck et al., 2008, Vesga-López et al., 2008). Psychological and psychiatric predictors include depression or anxiety during pregnancy, as well as severe postpartum blues (Heron et al., 2004, Leigh and Milgrom, 2008, Saisto et al., 2001). Although numerous studies have described these sociodemographic and psychosocial determinants, only a few studies investigated the role of complication during pregnancy or delivery in postpartum depression.
The consequences of obstetrical factors, such as mode of delivery, pain during delivery (Eisenach et al., 2008, Kumar, 1997), pregnancy or delivery complications, parity, unfavorable pregnancy case history, unwanted pregnancy (Boyce and Todd, 1992, Csatordai et al., 2007, Johnstone et al., 2001) have been described but remain uncertain. Some studies suggest that emergency cesarean section or assisted vaginal delivery are associated with a higher risk for PPD (Xie et al., 2011, Blom et al., 2010, Yang et al., 2011), some do not (Carter et al., 2006, Patel et al., 2005, Term Breech Trial Collaborative Group Source, 2004). Pain intensity during delivery and absence of epidural anesthesia has been found to increase postpartum blues (Boudou et al., 2007, Hiltunen et al., 2004) but not PPD. For some, unplanned pregnancy is considered as a predictor of vulnerability to PPD (Csatordai et al., 2007, Eastwood et al., 2012, Ludermir et al., 2011), other studies report conflicting results (Blom et al., 2010). Discrepancies may be explained by methodological differences. As an example, some studies did not use a prospective design (e.g. Edwards et al., 1994, Culp and Osofsky, 1989) and did not evaluate mood during pregnancy (e.g. Xie et al., 2011, Yang et al., 2011, Blom et al., 2010). Some studies examining the impact of cesarean section did not differentiate emergency and elective cesarean section (Carter et al., 2006). Moreover, time assessment for PPD ranges from 2 weeks to 6 months after delivery.
Depression during pregnancy is a major predictor of PPD but few studies have examined separately antenatal depression continuing after childbirth (antenatal onset PPD) and postpartum onset PPD (Heron et al., 2004, Milgrom et al., 2008, Leigh and Milgrom, 2008).
The aim of our study is to estimate the role of sociodemographic, psychosocial characteristics and obstetrical risk factors on PPD, using a prospective, two-wave design in a middle class community sample and to test whether these factors are related to postpartum onset PPD controlling for the presence of antenatal depression.
Section snippets
Design
In this prospective study, data was collected on two occasions, namely between 32 and 41 weeks gestation (wave 1), and a second time between 6 and 8 weeks after delivery (wave 2).
Participants
Between November 2007 and November 2009, 312 pregnant outpatients were consecutively enrolled at a single public maternity unit (Louis Mourier Hospital, Colombes, France). Colombes is a 85,000 inhabitants city in the suburbs of Paris. Its population is mostly middle class community. Two thousand three hundred
Sample characteristics
A total of 312 women were enrolled during pregnancy and 17 refused the protocol. Of those included, 264 (84.6%) were followed up through the second month postpartum.
Women who dropped out and women who were followed-up did not significantly differ in terms of antenatal depression rate, mean age, marital status, health insurance and unplanned pregnancy. Women who dropped out had a lower education level (50.0% without high school graduation vs. 32.3%; p=0.018), a lower employment rate (46.8% vs.
Discussion
Our prospective study assessing factors associated with PPD in 264 women suggests that non-obstetrical risk factors – including depression during pregnancy, migrant status and history of physical abuse are independently associated with PPD when considered together. In terms of obstetrical risk factors, only physical complications remained significant, controlling for antenatal depression.
These results are consistent with other studies (Heron et al., 2004, Ludermir et al., 2010, Milgrom et al.,
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