European Journal of Cardiovascular Medicine

Pregnancy and childbirth are major life events, and the puerperium is a period of heightened vulnerability to mood disorders. Postpartum depression (PPD) is a non-psychotic depressive episode of variable severity that begins within the first year after delivery, most often in the first few weeks. Its features – persistent low mood, loss of interest, fatigue, sleep and appetite disturbance, guilt, difficulty in concentrating and, in some women, thoughts of self-harm – are similar to depression at other times, but they occur while the woman is expected to care for a newborn. It differs from the transient “baby blues”, which settle within about two weeks and need no treatment. A meta-analysis of studies from mostly high-income countries estimated the prevalence of PPD at about 13% [1], and a systematic review reported point prevalence of major and minor depression ranging from 6.5% to 12.9% at different time points in the first postpartum year [2].

The burden is considerably higher in low- and middle-income countries (LMICs). A systematic review of 34 studies from low- and lower-middle-income countries found a mean weighted prevalence of postnatal common mental disorders of nearly 20% [3]. Indian community-based studies have reported figures within the same range. In Goa, nearly one in four mothers was depressed at six to eight weeks after delivery, and the risk was linked to poverty and to having a female infant [4]. In a rural cohort from Tamil Nadu, the incidence of PPD in the first three months was about 11%, with the risk related to adverse life events, a poor relationship with the husband and lack of support [5]. A hospital-based study from North India likewise documented a substantial burden of PPD and several modifiable risk factors [6].

PPD has consequences that go beyond the mother. Infants of depressed mothers are at greater risk of impaired cognitive and emotional development [7]. Evidence from South Asia indicates that maternal depression in the postnatal period is associated with underweight and stunting in infants, higher rates of diarrhoeal illness and poorer growth and development [8–10]. Maternal psychological morbidity has also been linked to low birth weight in India [11]. Since India continues to carry a high burden of child undernutrition, the mental health of mothers is directly relevant to child survival and development goals.

Despite this, PPD is rarely detected in routine Indian health care. Postnatal visits concentrate on uterine involution, wound healing, breastfeeding and immunisation of the baby, and the emotional state of the mother is seldom asked about. Women themselves may regard low mood as an expected part of motherhood, or may fear stigma. Simple screening tools can help to bridge this gap. The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report questionnaire developed specifically for the postnatal period [12], and it has been validated in community samples [13]. It takes less than five minutes, does not require a trained mental health professional and is therefore suited to busy outpatient clinics.

Postnatal follow-up visits are one of the few occasions on which a mother returns to a health facility within the first three months after delivery, which makes them a logical point for case-finding. Local data on the magnitude of the problem and its correlates are required to justify and design screening in such clinics. Therefore, this study was undertaken to determine the prevalence of postpartum depressive symptoms and to identify the sociodemographic, obstetric and psychosocial factors associated with them among women attending postnatal follow-up at a tertiary care teaching hospital.

1.1 Objectives

To estimate the prevalence of postpartum depressive symptoms among women attending postnatal follow-up. To identify the sociodemographic, obstetric and psychosocial factors associated with postpartum depressive symptoms.

.1 Study design, setting and period

A hospital-based, analytical cross-sectional study was carried out in the postnatal follow-up clinic of the Department of Obstetrics and Gynaecology of a tertiary care teaching hospital in India. The hospital receives referrals from both urban and rural catchment areas. The study was conducted over six months, from January to June 2018.

2.2 Study population and eligibility

All women who had delivered at the study hospital and attended the postnatal clinic between 4 and 12 weeks after delivery were eligible. This window was selected because depressive symptoms commonly emerge and are most frequent in the first three months after childbirth [14]. Women were included if they were aged 18 years or above, had a live-born infant, were residents of the area for at least six months and gave written informed consent. Women with a documented psychotic disorder or bipolar disorder, those who were too unwell to be interviewed, those who had a stillbirth or neonatal death, and those who were unable to understand the local language or Hindi were excluded.

2.3 Sample size and sampling technique

The sample size was calculated using the formula n = Z²pq/d², with Z = 1.96 at 95% confidence, an expected prevalence (p) of 23% based on an earlier Indian study [4], and an absolute precision (d) of 5%. This gave a minimum of 264 women. After allowing for a 10% non-response rate, the required sample was 290, and 300 women were finally enrolled. Women attending the clinic on each working day were listed in order of registration, and every second woman who met the eligibility criteria was selected by systematic random sampling until the daily quota was reached.

2.4 Data collection tools

Data were collected by a trained female interviewer in a private room using two instruments. The first was a pre-tested, semi-structured questionnaire with sections on sociodemographic characteristics (age, residence, education, occupation, type of family and socioeconomic status by the modified Kuppuswamy scale), obstetric characteristics (parity, mode of delivery, planning of pregnancy, complications during pregnancy, sex of the baby and admission of the baby to the neonatal intensive care unit) and psychosocial characteristics (past history of depression, domestic violence or marital conflict in the past year, husband's support and alcohol use by the husband). Husband's support was assessed on three questions relating to help with the baby, emotional support and involvement in decisions; a woman answering “no” to two or more was classified as having poor support.

The second instrument was the EPDS in the local language and Hindi, using translated versions that had been used in earlier studies. The scale consists of ten items scored from 0 to 3, giving a total of 0 to 30. Women were asked to select the response that best described their feelings during the previous seven days. In line with the original validation [12, 13], a total score of 10 or more was taken to indicate the presence of depressive symptoms, and a score of 13 or more to indicate probable major depression. Item 10 (thoughts of self-harm) was reviewed separately for every participant. Women scoring above zero on item 10 or 13 and above in total were counselled by the study psychiatrist on the same day and referred for clinical evaluation.

2.5 Operational definitions

• Postpartum depressive symptoms: EPDS score ≥10 at the time of interview.
• Planned pregnancy: a pregnancy that the woman reported as wanted at the time of conception.
• Domestic violence or marital conflict: any physical, verbal or emotional abuse by the husband or in-laws, or repeated serious marital quarrels, reported during the preceding 12 months.
• Pregnancy complications: hypertensive disorders, gestational diabetes, severe anaemia, antepartum haemorrhage or any other condition needing hospital admission during the index pregnancy.

2.6 Statistical analysis

Data were entered in Microsoft Excel and analysed with SPSS version 26. Categorical variables are presented as frequencies and percentages, and continuous variables as mean ± standard deviation (SD) or median with interquartile range. The prevalence of depressive symptoms is given with its 95% confidence interval (CI). The association between each independent variable and PPD was tested with Pearson's chi-square test. Variables showing a p-value <0.05 in bivariate analysis were entered in a multivariable binary logistic regression model, and the results are given as adjusted odds ratios (aOR) with 95% CI. Model fit was assessed with the Hosmer–Lemeshow test. A two-sided p-value <0.05 was considered statistically significant.

2.7 Ethical considerations

The study protocol was approved by the Institutional Ethics Committee. Written informed consent was taken from every participant after explaining the purpose of the study. Confidentiality was maintained by using coded identifiers. Women found to be at risk were referred to the Department of Psychiatry.

3.1 Participation and characteristics of the participants

During the study period, 324 eligible women were approached. Fourteen declined to participate and ten gave incomplete responses, so 300 women (response rate 92.6%) were included in the analysis. The mean age of participants was 25.8 ± 4.1 years (range 18–38 years), and the mean duration since delivery was 7.4 ± 2.3 weeks. Table 1 shows the sociodemographic profile. About 71% of women were aged 20–29 years, 46.0% lived in rural areas, 84.0% were homemakers and 54.0% belonged to nuclear families. Nearly 40% had completed only primary or secondary schooling or less, and 43.0% were in the lower or upper-lower socioeconomic classes.

Table 1: Sociodemographic characteristics of the study participants (N = 300)

Percentages are column percentages.

The obstetric and psychosocial profile of the women is given in Table 2. Nearly half (46.0%) were primiparous, 38.0% had delivered by caesarean section and 32.0% reported that the pregnancy was unplanned. Complications during pregnancy were noted in 24.0%, and 12.0% of the newborns had needed admission to the neonatal intensive care unit (NICU). A past history of depression was reported by 8.0% of women, 15.0% had experienced domestic violence or marital conflict, 22.0% described their husband's support as poor, and 18.0% of husbands used alcohol regularly.

Table 2: Obstetric, infant and psychosocial characteristics of the participants (N = 300)

Percentages are column percentages.

3.2 Prevalence of postpartum depressive symptoms

The mean EPDS score of the participants was 7.6 ± 5.0 (median 7, interquartile range 4–11, range 0–24). Seventy-eight of the 300 women scored 10 or above, giving an overall prevalence of postpartum depressive symptoms of 26.0% (95% CI: 21.0–31.0%). Thirty-nine women (13.0%) scored 13 or above, which suggests probable major depression. Fourteen women (4.7%) gave a positive response (score >0) on item 10 – thoughts of self-harm – and 13 of them were in the group with an EPDS score of 10 or more. The distribution of EPDS scores is shown in Table 3.

Table 3: Distribution of EPDS scores among the participants (N = 300)

EPDS: Edinburgh Postnatal Depression Scale. Mean ± SD = 7.6 ± 5.0.

3.3 Factors associated with postpartum depressive symptoms

In bivariate analysis (Table 4), postpartum depressive symptoms were significantly more frequent among women who lived in rural areas (31.9% vs 21.0%; p = 0.032), those with education up to secondary level (33.3% vs 19.5%; p = 0.006), those living in nuclear families (31.5% vs 19.6%; p = 0.019) and those belonging to the lower or upper-lower socioeconomic classes (33.3% vs 20.5%; p = 0.012). Maternal age (p = 0.486) and occupation (p = 0.108) were not significantly associated with PPD.

Table 4: Association between sociodemographic factors and postpartum depressive symptoms (N = 300)

PPD: postpartum depressive symptoms (EPDS ≥10). Percentages are row percentages. *Statistically significant (p <0.05).

Table 5 presents the association of obstetric, infant and psychosocial factors with PPD. Parity was not significantly related to PPD (p = 0.197). Women who had delivered by caesarean section, whose pregnancy was unplanned, who had a female baby, who had complications during pregnancy or whose newborn needed NICU admission had significantly higher rates of depressive symptoms. The strongest associations were seen for the psychosocial factors. Two-thirds of the women (66.7%) with a past history of depression had PPD symptoms, compared with 22.5% of those without such a history (p <0.001). Similarly, 60.0% of women exposed to domestic violence or marital conflict and 50.0% of those with poor husband's support were depressed (both p <0.001), and the rate was also higher when the husband used alcohol regularly (44.4% vs 22.0%; p <0.001).

Table 5: Association between obstetric, infant and psychosocial factors and postpartum depressive symptoms (N = 300)

PPD: postpartum depressive symptoms (EPDS ≥10). Percentages are row percentages. *Statistically significant (p <0.05).

3.4 Multivariable analysis

All factors that were significant in bivariate analysis were entered into the logistic regression model (Table 6). After adjustment, seven factors remained independently associated with postpartum depressive symptoms: a past history of depression (aOR 5.12), domestic violence or marital conflict (aOR 4.38), poor husband's support (aOR 3.26), NICU admission of the newborn (aOR 2.62), unplanned pregnancy (aOR 2.14), complications during pregnancy (aOR 2.05) and education up to secondary level (aOR 1.98). Residence, family type, socioeconomic status, mode of delivery, sex of the baby and husband's alcohol use lost significance after adjustment. The model was well calibrated (Hosmer–Lemeshow χ² = 5.4, p = 0.62) and explained about 34% of the variance (Nagelkerke R² = 0.34).

Table 6: Multivariable logistic regression analysis of factors associated with postpartum depressive symptoms

OR: odds ratio; CI: confidence interval. *Statistically significant (p <0.05). Hosmer–Lemeshow p = 0.62; Nagelkerke R² = 0.34.

This cross-sectional study found that 26.0% of women attending postnatal follow-up had depressive symptoms on the EPDS, and that 13.0% had scores suggesting probable major depression. The prevalence is nearly double the 13% pooled estimate from largely high-income settings [1] and higher than the roughly 20% average reported for LMICs [3]. It is close to the 23% found among mothers in Goa [4] and higher than the 11% incidence in a rural Tamil Nadu cohort [5]. A North Indian hospital-based study has also described a substantial burden among postnatal women [6]. The prevalence in the present study is lower than the 36% reported from Pakistan [15], which shows how widely estimates vary within South Asia (Table 7). Reviews of Asian studies and cross-cultural comparisons have documented a similar spread, from single-digit percentages to more than 60%, which is explained by differences in the instruments, cut-off scores, timing of assessment and populations studied, as well as by genuine social and cultural differences [16, 17].

Table 7: Prevalence of postnatal depression in the present study compared with other studies

Figures are as reported by the respective authors; methods and cut-offs differ across studies.

The risk factors identified here are consistent with the wider studies. A meta-analysis of predictors of PPD found that the strongest associations were with prenatal depression, life stress, poor social support, marital dissatisfaction and a history of previous depression [18]. Another synthesis of antenatal risk factors reached comparable conclusions [19]. In the present study, a woman with a past history of depression had five times the adjusted odds of PPD symptoms. This suggests that a simple question on previous depressive episodes asked at the first antenatal visit could identify women who need closer follow-up.

Domestic violence or marital conflict and poor husband's support were among the strongest independent correlates. This agrees with a prospective cohort from Brazil, where intimate partner violence during pregnancy increased the risk of postnatal depression [20], and with a population-based study from Goa that identified violence and other adverse life circumstances as risk factors for common mental disorders in women [21]. In the Tamil Nadu cohort, the risk of PPD was likewise related to the quality of the marital relationship and to support available to the mother. In India, a woman's emotional well-being after childbirth depends heavily on her husband and the in-laws, with whom she often lives. Qualitative work from rural South India has highlighted interpersonal and family stressors in the experience of postpartum depression [22], and qualitative studies from Goa described how marital relationships, family expectations and the sex of the infant shape mothers' distress [23]. Although the sex of the baby lost significance after adjustment in our model, it was associated with PPD in the bivariate analysis, in line with the Goa findings in which having a female infant increased the risk. The effect may well be mediated through marital and family attitudes, which would explain why it weakened once the other psychosocial variables were included.

Obstetric factors also had a role. Complications during pregnancy and NICU admission of the newborn were independent correlates, which is plausible because such events increase anxiety, separate the mother from the baby and prolong hospital stay. Obstetric risk factors have likewise been reported for depression among pregnant women at a tertiary hospital in Navi Mumbai [24], and a systematic review identified an unintended pregnancy, poor social support, low income and lower education as risk factors for depressive symptoms in pregnancy [25]. Because antenatal depression is itself a strong predictor of postnatal depression, these early risks may carry forward into the postpartum period. Unplanned pregnancy was independently associated with PPD in our study (aOR 2.14), which highlights the importance of family planning services and of counselling women whose pregnancies were not wanted.

Lower educational attainment was an independent correlate of PPD, while socioeconomic status and residence were significant only in the unadjusted analysis. This pattern suggests that education may be a marker of health literacy, autonomy and decision-making power within the household, and that the effect of poverty is partly explained by the other variables in the model. A study of first-time mothers similarly demonstrated that low socioeconomic status substantially increased the risk of depressive symptoms both during pregnancy and after childbirth [26]. Parity, maternal age and occupation were not associated with PPD in the current analysis, in keeping with several Indian reports in which these factors have shown inconsistent relationships.

The findings have practical implications for maternal health services. First, since most of the significant risk factors – previous depression, marital discord, lack of spousal support, unplanned pregnancy and complications of pregnancy – can be elicited during routine antenatal or postnatal contact, a brief risk checklist can be incorporated into existing antenatal records and the Mother and Child Protection Card. Second, the EPDS is short, easy to administer and can be used by nurses and auxiliary health workers after minimal training. Third, evidence from low-resource settings shows that mothers with depression can be treated effectively by non-specialist health workers. A cluster randomised trial in rural Pakistan, in which community health workers delivered a cognitive behavioural intervention, improved maternal depression outcomes [27], and a systematic review concluded that interventions for common perinatal mental disorders delivered by non-specialists are effective in LMICs [28]. A Cochrane review has also shown that psychosocial interventions, especially individualised support delivered after delivery, can reduce the risk of PPD [29].

Timely detection is also important for the safety of mother and child. Thoughts of self-harm were reported by 4.7% of women in this study, and severe postpartum psychiatric illness can sometimes involve harmful thoughts towards the infant, as shown in Indian clinical studies [30]. The link between maternal mental health and child nutrition [31] adds a further reason to integrate mental health into maternal and child health programmes. Early detection at postnatal clinics, followed by counselling, family involvement and referral where needed, is a feasible way to do so.

4.2 Strengths and limitations

The strengths of this study include the use of a validated, widely used screening instrument, systematic random sampling, a good response rate (92.6%) and the inclusion of an extensive set of obstetric and psychosocial variables, analysed with multivariable methods. Certain limitations should be noted. The EPDS is a screening tool and does not provide a clinical diagnosis, so the prevalence represents depressive symptoms rather than confirmed depressive disorder. The cross-sectional design does not allow causal inference, and the temporal sequence between factors such as marital conflict and depression cannot be established. Women attending a tertiary hospital may differ from those in the community, and those who did not return for follow-up – who may be at higher risk – were not included, so the prevalence could be an underestimate or an overestimate. Finally, self-reported information on violence and past depression may be subject to recall and social desirability bias. Prospective community-based studies, starting during pregnancy, are needed to confirm these findings [32].

About one in four women attending postnatal follow-up in this study had depressive symptoms, and one in eight had scores suggestive of probable major depression. A past history of depression, domestic violence or marital conflict, poor husband's support, NICU admission of the newborn, unplanned pregnancy, complications during pregnancy and lower education were independently associated with postpartum depressive symptoms. Many of these risks can be recognised well before delivery. Routine screening with the EPDS at postnatal visits, antenatal identification of high-risk women, involvement of husbands and families in counselling, and a clear referral pathway to mental health services should be built into maternal health care.

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