POSTPARTUM DEPRESSION IN MALAYSIAN WOMEN: THE ASSOCIATION WITH THE TIMING OF PREGNANCY AND SENSE OF PERSONAL CONTROL DURING CHILDBIRTH

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1 Siti R.M. Arifin, A. Ahmad, Rasnah A. Rahman, Huai S. Loh, Chong G. Ng. Postpartum depression in Malaysian women: the association with the timing of pregnancy and sense of personal control during childbirth. International Journal of Academic Research Part B; 2014; 6(3), DOI: / /6-3/B.21 Library of Congress Classification: R5-920, RT1-120 POSTPARTUM DEPRESSION IN MALAYSIAN WOMEN: THE ASSOCIATION WITH THE TIMING OF PREGNANCY AND SENSE OF PERSONAL CONTROL DURING CHILDBIRTH Siti Roshaidai Mohd Arifin 1, Aini Ahmad 2, Rasnah Abdul Rahman 2, Huai Seng Loh 3, Chong Guan Ng 4 1 Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, 2 Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, 3 Clinical Academic Unit, Newcastle University of Medicine, 4 Department of Psychological Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur (MALAYSIA) s: roshaidai@iium.edu.my, aini57@um.edu.my, rasnah@um.edu.my, huaiseng@gmail.com, chong_guan1975@yahoo.co.uk ABSTRACT DOI: / /6-3/B.21 Received: 04 Feb: 2014 Accepted: 22 May, 2014 Objective: To determine the prevalence of postpartum depression (PPD) in Malaysian women and its association with unplanned pregnancy and experience of control during childbirth. Methods: A cross-sectional study involving women hours after delivery. PPD was measured with the Edinburg Postpartum Depression Scale and the timing of pregnancy was assessed with a four question scale. Sense of personal control during childbirth was measured with the Labour Agentry Scale. Other relevant clinical and demographic data were collected. Results: Of the 347 women included, the prevalence of PPD was 31.7%. There were higher risks in women with unplanned pregnancies [45% vs. 26.3%; χ 2 = , df = 1 p < 0.01]. Lower score of childbirth control was associated with PPD [CI , p < 0.01]. Conclusion: Screening for women with unplanned pregnancies and education for those with low sense of control during childbirth help to reduce the risk of PPD. Key words: depressive symptoms, postpartum depression, personal control, unplanned pregnancy 1. INTRODUCTION Careful planning of a pregnancy is a positive step toward enhancing pregnancy outcome and providing prospective parents with options that may not be available once a pregnancy is confirmed (1). Since an unplanned pregnancy could possibly lead to negative emotion and land a woman in high risk pregnancy, it is generally considered as one of the major reproductive health problems. It also contributes to poor maternal health, as well as adverse effects in social outcome. Unfortunately, many women are still not aware of the importance of a well-planned pregnancy. In fact, out of the estimated figure of 210 million worldwide women who become pregnant each year, 80 million (38%) of these pregnancies are unplanned. Though some of these are carried through to term, many others end up in spontaneous or induced abortions (2). In Asia, 34% of the 83 million pregnancies each year are unplanned and sadly 17% of these end up as abortions (2). Obviously, these figures show that more than one-third of the pregnant women worldwide do not actually plan to conceive. The major concern is that unplanned pregnancy can potentially affect a woman s personal health and well-being in an adverse manner, and that includes her psychological health during the postpartum period (3). Profound ambivalence, emotional disturbance, conflicting behaviours and feelings are triggered during this critical period (4). Those alterations in maternal mood may precipitate the development of postpartum depressive symptoms (5) which subsequently lead to a more debilitating condition, thus causing a major health impact on many women around the world known as postpartum depression (PPD) (6). There were a number of literatures in the past which had demonstrated the relationship between unplanned pregnancy and psychological impact in mothers with PPD (7-9). Childbirth is a multidimensional experience. One of the influential aspects is the sense of self or personal control over one s behaviour and environment during childbirth (10). There were reports on the association between the feeling of control of a pregnant mother, the expectation of the birth process and the experience after delivery. It is believed that having a better sense of control will lead to a pregnant woman feeling more confident of the birth process and therefore less risk of developing PPD (11). Baku, Azerbaijan 143

2 However, to our best knowledge there is no published data to look at the association of PPD with unplanned pregnancy and the sense of personal control during childbirth in Malaysia. The most recent study conducted by Ng et al. in University Malaya Medical Center found that 50% of the women admitted that their pregnancies were unplanned (12). Since women with unplanned pregnancies tend to develop PPD, and the rate of unplanned pregnancies in Malaysia is relatively high, it is vital for us to look into the effects of unplanned pregnancies on PPD among women in Malaysia. We conducted this study in view of the need to screen for unplanned pregnancies during antenatal assessments and to follow up the mothers during postpartum period. The objective of this study is to explore the association between unplanned pregnancy and sense of personal control among Malaysian women with PPD. 2. METHODS Design This is a cross-sectional study conducted from January 2010 to February 2011 at a teaching hospital in Malaysia. Participants and Procedure Medical Ethical Approval, University Malaya Medical Centre was obtained prior to the commencement of this study. All women admitted to the postnatal wards in University Malaya Medical Centre during the study period were approached for the study. They were informed about the study and written informed consents were obtained. The obstetric unit of the medical centre has about 3190 deliveries per year with an average of 266 deliveries per month. In general, all postnatal women without post-delivery complication are admitted to postnatal ward for observation. They will be discharged after 24 to 36 hours if no complication is observed. The inclusion criteria include: (1) age more than 18 years old; (2) postpartum woman with a live-born baby through spontaneous vaginal delivery; (3) woman who consented to the study and (4) able to understand and speak Malay or English. Exclusion criteria are: (1) woman with history of mental health disorder (2) delivery with complication including Caesarian section. The eligible women were assessed with a predesigned set of questionnaires. The obstetric history was obtained from the patient information record. The completed questionnaires were collected and then sealed in an envelope. Measures The questionnaire has four parts comprising parts A, B, C, and D. Part A consists of socio-demographic data such as age, race, marital status, educational level, employment status, parity and gestational age. Part B comprises four responses to determine whether the pregnancy is planned or unplanned (8). Participants will be asked, Thinking back to just before you got pregnant, how do you feel about becoming pregnant?. The responses are: (1) first response: this pregnancy was at the right time (2) second response: I wanted to be pregnant sooner (3) third response: I wanted a child, but the pregnancy was too soon (4) fourth response: I didn't want to be pregnant then or at any time in the future. The researcher classified responses 1 and 2 as planned pregnancy, response 3 as mistimed pregnancy and response 4 as unwanted pregnancy. Responses of either mistimed (response 3) or unwanted (response 4) will be merged and considered as unplanned pregnancy. Thus, these variables were arranged into two categories planned and unplanned pregnancy. Part C is to measure the childbirth experience. This variable was determined by the 29-item Labour Agentry Scale (LAS) (13). The childbirth experience was measured with a five-point Likert scale, from one to five corresponding to always, frequently, sometimes, very rarely and never, respectively. Participants who have positive feelings during labour achieve higher scores. Low score indicates low expectancies or experiences of personal control during child birth, while high scores indicate high expectancies and experiences. Part D is to measure PPD using the Malay Version of Edinburgh Postpartum Depression Scale (EPDS) (14). The EPDS was developed by Cox et al in 1987 to determine the risk of PPD (15). It is a four-point, selfreport Likert scale composed of 10 items. Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptoms. It can be used for screening but not for the diagnosis of depression (16). The Malay version of the scale was validated in the local setting and the cut off of 11/12 was used to determine a woman at risk of developing PPD (14). Analysis All the data were analysed using the Statistical Package of Social Sciences (SPSS) version Descriptive statistics were the baseline characteristic of the study subjects. Chi Square test was used for the univariate analysis of the associated factors with PPD. The significant factors with p value < 0.1 were included into the multivariate analysis. Logistic regression test with enter method was used for multivariate analysis. All the tests were two sided and had level of significance, alpha values of RESULTS Baseline clinical and demographic characteristics The study revealed that the mean age of the participants was years. Among the 347 women, close to three-quarter were Malays. Most of the subjects were married. More than half of the participants had tertiary education, and three-quarter of them were still employed. In terms of obstetric history, about 405 of the subjects were primiparous. See Table PART B. SOCIAL SCIENCES AND HUMANITIES

3 Table 1. Characteristics of the study subjects (N=347) Demographic characteristics Age(years), mean (SD) (4.75) Race, n (%) Malay 249 (71.8) Chinese 43 (12.4) Indian 33 (9.5) Others 22 (6.3) Marital status, n (%) Married 338 (97.4) Single 8 (2.3) Widow 1 (0.3) Education, n (%) Primary 9 (2.6) Secondary 158 (45.5) Tertiary 180 (51.9) Occupation, (%) Housewife 89 (25.6) Employed 258 (74.4) Obstetric history, n (%) Parity Primipara (1) 137 (39.5) Multipara (2-4) 193 (55.6) Grandmultipara ( 5) 17 (4.9) Gestational age, n (%) Preterm delivery 31 (8.9) Full term delivery 316 (91.1) The results indicated that nearly half of the women felt that the pregnancies were at the right time (47.3%). 23.9% of the subjects felt that their pregnancies should have been sooner, and both these pregnancy timing were categorized as planned pregnancies (71.2%). 23.1% of them perceived their pregnancies to be too soon and a minority of these women did not want to get pregnant (5.8%).The scores of the Labour Agentry Scale were relatively high with the means of (sd = 15.48). Based on Edinburg Postnatal Depression Scale, 31.7% of the subjects were having post natal depression (score more than 11). See Table 2. Table 2. The perceived timing of pregnancy, scores of Labour Agentry Scale and Edinburg Postnatal Depression scale of the subjects Pregnancy Timing, n (%) Right time 164 (47.3) Wanted sooner 83 (23.9) Too soon 80 (23.1) Did not want 20 (5.8) Labour Agentry Scale score, mean (SD) (15.48) EPDS score, mean (SD) 9.15 (4.61) Postpartum depression, n (%) Yes 110 (31.7) No 237 (68.3) Postpartum depression = >11 in the score of Edinburg Postnatal Depression Scale Associated factors with postpartum depression Univariate analysis showed that only occupation status, childbirth experience and timing of pregnancy were associated with postnatal depression among the study subjects. The odds were 1.3 among the housewives as compared to the working mothers. Those with lower childbirth experience had 3 times odds of having postnatal depression. There were 2.3 times odds of having depression in unplanned pregnancies as compared to planned pregnancies. There was no association of age, race, marital status, educational level, parity and gestational age with postnatal depression among the study subjects (Table 3). Baku, Azerbaijan 145

4 Table 3. Univariate analysis of associated factors with postnatal depression among the subjects Postnatal depression, n (%) Odds ratio 95% CI p value Yes No Age (years) < (32.8) 125 (67.2) (30.4) 112 (69.6) Race Malay 75 (30.2) 173 (69.8) Non Malay 35 (35.4) 64 (64.6) Marital status Married 106 (31.4) 232 (6.86) * Not married 4 (4.44) 5 (55.6) Education Secondary or lower 58 (34.7) 109 (65.3) Higher than secondary 52 (28.9) 128 (71.1) Occupation Housewife 35 (39.3) 54 (60.7) Employed 75 (29.1) 183 (70.9) Parity Primipara 43 (35.5) 78 (64.5) Multipara 67 (29.6) 159 (70.4) Gestational age Preterm 9 (29.0) 22 (71.0) Full term 101 (32.0) 215 (68.0) Childbirth experience LAS (43.9) 96 (56.1) <0.01 LAS > (19.9) 141 (80.1) Timing of pregnancy Unplanned pregnancy 45 (45.0) 55 (55.0) <0.01 Planned pregnancy 65 (26.3) 182 (73.7) Postpartum depression = >11 in the score of Edinburg Postnatal Depression Scale LAS = Labour Agentry Scale *Fisher s Exact test The significant associated factors were included in the multivariate analysis. The results showed that unplanned pregnancy (adjusted odds ratio = 2.04) and low child birth experience (adjusted odds ratio = 3.02) were significant associated with postnatal depression (Table 4). Table 4. Multivariate analysis of the associated factor with postpartum depression in the study subjects B SE Adjusted Odds Ratio 95% CI p value Occupation Housewife Employed Childbirth experience <0.01 LAS 100 LAS >100 Timing of pregnancy Unplanned pregnancy Planned pregnancy Postpartum depression = >11 in the score of Edinburg Postnatal Depression Scale 4. DISCUSSION Nearly one-third (28.8%) of the women in this study were found to have unplanned pregnancies. In the earlier study, Ng et al. in UMMC found that half (50.5%) of the pregnancies were unplanned (12). This could have been most probably due to the differences in term of sample size and time of assessment. Ng et al. assessed 93 women at 1 month postpartum period, while we looked at 347 postpartum women at the time before they were discharged from the postnatal wards. As the earlier study recruited a smaller sample size, it might have affected the prevalence of unplanned pregnancy. Out of the 347 total number of study subjects, 100 (28.9%) of them actually had unplanned pregnancies. Of these 100, 80% of them experienced mistimed pregnancies while the remaining 20 in fact did not wish to be pregnant. This indicated that the cases of mistimed pregnancies were higher than that of unwanted pregnancies. Similar to our current findings, Cheng et al. also reported in their study that out of the 41.4% of mothers with unplanned pregnancies, 31.1% of them had mistimed pregnancies and 10.3% were actually unwanted pregnancies (8). In our current study, PPD was strongly correlated with unplanned pregnancies and negative childbirth experience. The LAS was used to determine the childbirth experience by postpartum women in this study. The higher the score, the more positive the childbirth experience was. Our study showed that participants developed more positive childbirth experience with higher mean score in LAS. Similarly, Goodman et al. also reported in their study that women experienced both high total childbirth satisfaction and better personal control during labour 146 PART B. SOCIAL SCIENCES AND HUMANITIES

5 (17). This study discovered that more than one-third (31.7%) of the postpartum women presented with PPD, which shared similar result reported by Howell et al (2010), whereby 39% of their patients reported to have PPD. However, the result was higher compared to that of other studies (18). The differences in these findings could have been due to differences in study settings and the characteristics of the women being studied (19). The higher prevalence of PPD could be secondary to self-reported method that had been employed in this study. According to O Hara and Swain, self-report measures yielded higher estimates of PPD than clinicianadministered assessments (20). Clearly, these findings were in line with previous studies which showed that women with unplanned pregnancies had higher risk of PPD during postpartum period as opposed to those with planned pregnancies (7-9, 21). Perceived level of control over the birth experience was also found to be related to the incidence and severity of PPD (22), and this finding was similar to our present study, showing an association between PPD and childbirth experience. We found that women with lower scores of childbirth experience were more likely to develop PPD in the early postpartum period as compared to those mothers with higher score. Interestingly, unplanned pregnancy was found to be one of the predictors of PPD. The findings indicated that women with unplanned pregnancies have 1.9 times the risk of PPD compared to women with planned pregnancies. Thus, this result confirmed the findings in previous studies which reported that unplanned pregnancy was a predictor of PPD (9, 23-25). Our study revealed similar finding that women with unplanned pregnancies were at higher risk of depression in the early postpartum period when compared to mothers with planned pregnancies. The higher risk of PPD among unplanned pregnancy might have been caused by the fact that they were not well-prepared to have babies at that time. Another predictor that had been identified in influencing PPD was childbirth experience. The finding showed that the lower the score of LAS, the higher the risk of a woman developing PPD. Similarly, a study done by Dencker et al. pointed to the evidence that negative childbirth experience increased the risk of PPD (26). Many years ago, Righetti-Veltema et al. suggested that the subjective feelings with regard to delivery were in fact relevant factors in influencing PPD (27). Our present study confirmed this previous finding by showing that a lower score in LAS was indeed a significant predictor of PPD. These findings highlighted the need of early detection and screening tool for unplanned pregnancy. Researchers recommended that screening for unplanned pregnancy should be carried out during a woman s first antenatal visit. As the first antenatal visit is usually the most in-depth and thorough, it provides a key opportunity for vital communication between a woman and her healthcare provider. On the other hand, women who have unplanned pregnancies must be re-evaluated during each subsequent visit to the antenatal clinic. Following that, they should also be evaluated during their stay in the maternity units. This secondary evaluation appears to be very critical for healthcare practitioners because it serves as an additional screening for those women who have not been properly followed up, or those who are having problematic obstetric history such as late diagnosis due to denial of pregnancy. Such evaluation will later allow the clinicians to arrange multidisciplinary shared care for these high risk women, one of which is the involvement of community health nurses. Our study showed that nearly a third of postpartum women suffered from PPD, whom we subsequently referred for further proper treatment and care. Since some of the previous studies proposed that PPD at early postpartum period might continue on to later stage, early detection and an effective screening tool were both vital to prevent the development of PPD. Researchers strongly recommended early screening for PPD with a reliable instrument at first week of postpartum period in order to identify women with higher risk of developing PPD. For this reason, the practice of screening postpartum women before discharge should be incorporated into clinical practice, in order to identify mothers at high risk of developing PPD. Researchers also suggested reevaluation of PPD among mothers during the postnatal visits, so that the healthcare practitioners could identify women with high score at first screening who might be at risk of developing PPD. With continuous screening as the most vital step, it is our hope that intervention can be instituted as early as possible. Definitely, the screening for PPD should not be limited to just hospital setting though it is more commonly so. Advanced practice nurses (APNs) in the hospital usually see patients at 2 to 6 weeks postpartum and then not until another year or more. Yet, PPD may appear at any time during the first 6 to 12 months postpartum (1). Therefore, the community healthcare is the second setting where an effective PPD screening should take place. The APNs who work in the maternal and child health (MCH) clinics have the opportunity to evaluate a mother as many as six times during the first 6 months postpartum, and later during well-baby visits (28). As such, they will be the best forefront healthcare personnels to provide screening for PPD. In the effort of identifying risk factors or predictors in women with increased probability of developing PPD, this study concluded that two factors were involved, i.e. unplanned pregnancy and negative childbirth experience. Based on the presence of these factors, interventions can then be initiated before the onset of PPD in hope of preventing this debilitating mood disorder (29). The results from this study must be viewed with some limitations in mind. Firstly, selection bias was one of the possible limitations in our study as there was no randomization done. Secondly, as this was a cross sectional study, caution must be taken when interpreting the data. The nature of cross sectional study could not tell us about causal relationships, only correlation. Therefore, it could not be ascertained from these data if unplanned pregnancies preceded the onset of PPD or if women with PPD were more likely to interpret their pregnancies as unplanned. Thirdly, depression is also found to be strongly associated with suicidal ideation in most studies (30), however in this study the suicidal intent of the PPD women was not explored during the assessment. Fourthly, sampling bias might have occurred in this study as the participants were collected using convenience sampling, and they were not representative of the entire population. Nevertheless, researchers Baku, Azerbaijan 147

6 were convinced that the reported statistical findings deserved merits because they tended to support findings in numerous studies elsewhere. 5. CONCLUSION Early screening of unplanned pregnancy with a reliable tool is imperative in preventing PPD and therefore improves health and well-being of the mother and child. Nevertheless, the choice of a screening program for unplanned pregnancy depends on the national health program of the country where it is to be implemented. It also depends on local factors such as the centres involved. These findings therefore suggest for the prevention of PPD among the Malaysian population, amongst whom depression is rarely talked about. Since there is a consensus that PPD is a very treatable condition when it is detected early, it should therefore be identified the soonest possible among the pregnant mothers who are at risk (25). REFERENCES 1. Fraser D., Cooper M. The midwife. Myles textbook for midwives. 2003;14: Racherla S.J. Addressing unplanned pregnancies can reduce pregnancy and childbirth related deaths Arslan Özkan İ., Mete S. Pregnancy planning and antenatal health behaviour: findings from one maternity unit in Turkey. Midwifery. 2010;26(3): Cigoli V., Gilli G., Saita E. Relational factors in psychopathological responses to childbirth. Journal of Psychosomatic Obstetrics & Gynecology. 2006;27(2): Gao L., Chan S.W., You L., Li X. Experiences of postpartum depression among first time mothers in mainland China. Journal of Advanced Nursing. 2010;66(2): Wisner K.L., Parry B.L., Piontek C.M. Postpartum depression. New England Journal of Medicine. 2002;347(3): Iranfar S., Shakeri J., Ranjbar M., NazhadJafar P., Razaie M. Is unintended pregnancy a risk factor for depression in Iranian women. East Mediterr Health J. 2005;11(4): Cheng D., Schwarz E.B., Douglas E., Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception. 2009;79(3): Karaçam Z., Önel K., Gerçek E. Effects of unplanned pregnancy on maternal health in Turkey. Midwifery. 2011;27(2): Hodnett E.D., Simmons Tropea D.A. The Labour Agentry Scale: psychometric properties of an instrument measuring control during childbirth. Research in nursing & health. 1987;10(5): Berg M., Dahlberg K. A phenomenological study of women's experiences of complicated childbirth. Midwifery. 1998;14(1): Ng C., SA A., OH K. Bipolar Disorder and Other Associated Factors in Postnatal Depression. Malaysian Journal of Psychiatry. 2010;18(2). 13. Janssen P.A., Carty E.A., Reime B. Satisfaction with planned place of birth among midwifery clients in British Columbia. Journal of Midwifery & Women s Health. 2006;51(2): Mahmud R.W., Mohd W., Awang A., Mohamed M.N. Revalidation of the malay version of the edinburgh postnatal depression scale (EPDS) among malay postpartum women attending the bakar bata health center in alor setar, Kedah, north west of Peninsular Malaysia Cox J., Holden J., Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry. 1987;150(6): Vivilaki V., Dafermos V., Kogevinas M., Bitsios P., Lionis C. The Edinburgh Postnatal Depression Scale: translation and validation for a Greek sample. BMC Public Health. 2009;9(1): Goodman P., Mackey M.C., Tavakoli A.S. Factors related to childbirth satisfaction. Journal of Advanced Nursing. 2004;46(2): Dennis C.L. Can we identify mothers at risk for postpartum depression in the immediate postpartum period using the Edinburgh Postnatal Depression Scale? Journal of affective disorders. 2004;78(2): Heh S.S., Huang L.H., Ho S.M., Fu Y.Y., Wang L.L. Effectiveness of an exercise support program in reducing the severity of postnatal depression in Taiwanese women. Birth. 2008;35(1): O'hara M.W., Swain A.M. Rates and risk of postpartum depression-a meta-analysis. International review of psychiatry. 1996;8(1): Rosenberg K.D., Gelow J.M., Sandoval A.P. Pregnancy intendedness and the use of periconceptional folic acid. Pediatrics. 2003;111(Supplement 1): Bland M. The effect of birth experience on postpartum depression. Retrieved November. 1998;3: Blake S.M., Kiely M., Gard C.C., El Mohandes A.A.E., El Khorazaty M.N. Pregnancy intentions and happiness among pregnant black women at high risk for adverse infant health outcomes. Perspectives on sexual and reproductive health. 2007;39(4): Kheirabadi G.R., Maracy M.R., Barekatain M., Salehi M., Sadri G.H., Kelishadi M., et al. Risk factors of postpartum depression in rural areas of Isfahan Province, Iran. Archives of Iranian Medicine. 2009;12(5): Lau Y., Keung D.W.F. Correlates of depressive symptomatology during the second trimester of pregnancy among Hong Kong Chinese. Social Science & Medicine. 2007;64(9): PART B. SOCIAL SCIENCES AND HUMANITIES

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