Prevalence of postpartum depression in a hospital setting among Malaysian mothers

Transcription

1 bs_bs_banner Offi cial journal of the Pacifi c Rim College of Psychiatrists Asia-Pacific Psychiatry ISSN ORIGINAL ARTICLE Prevalence of postpartum depression in a hospital setting among Malaysian mothers Nor Zuraida Zainal 1 MD, Anandjit Singh Kaka 2 MD, Chong Guan Ng 1 MD, Rosy Jawan 3 MD & Jesjeet Singh Gill 1 MD 1 Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2 Hospital Bahagia Ulu Kinta, Ipoh, Perak, Malaysia 3 Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia Keywords breastfeeding, depression, Malaysia, postnatal, prevalence Correspondence Nor Zuraida Zainal MD, Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur Malaysia. Tel: Fax: zuraida@ummc.edu.my Received 8 February 2011 Accepted 25 December 2011 DOI: /j x Abstract Introduction: Postpartum depression (PPD) is a disorder that affects not only mothers, but also can lead to family, social, economic and vocational breakdown. The objective of this study was to determine the prevalence and factors associated with postpartum depression among mothers in an urban hospital setting in Malaysia. Methods: In this cross-sectional study, mothers attending routine visits at six to eight weeks postpartum at a postnatal clinic were assessed on socio-demographic data, obstetric history, social support, breastfeeding status and psychiatric history. Mini International Neuropsychiatric Interview (M.I.N.I.) was administered to establish a diagnosis of postpartum depression. Results: A total of 411 subjects participated in the study. The prevalence rate of postpartum depression was 6.8%. Univariate analysis found that being a housewife, having a cesarian section, low social support, family history of depression, previous history of depression and non-exclusive breastfeeding were significantly associated with postpartum depression. Predictors for postpartum depression were non-exclusive breastfeeding (P < 0.01, OR = 23.7, 95% CI ) and previous history of depression (P < 0.05, OR = 82.3, 95% CI ). Discussion: The prevalence rate of postpartum depression in urban Malaysian mothers was comparable to the rates in other countries. Mothers who did no exclusively breast feeding their babies appeared to have more risk for postpartum depression. Therefore, screening for depression should become a routine during postpartum period and mothers must be encouraged to exclusively breastfeed their babies. Introduction According to the Diagnostic Statistical Manual (DSM IV) (APA, 2000) postpartum depression (PPD) is a major depressive episode with modified specifier of onset occurring within one month of postpartum. PPD affects not only the mother, but also the partner, infant and family, and has possible adverse socioeconomic consequences (Murray and Cooper, 1996). The prevalence of postpartum depression varies from country to country. It is possible that the prevalence rate of PPD is grossly under-reported due to symptoms being hidden by mothers from their health professionals and sometimes, by failure of trained health professionals to recognize PPD (Williamson and McCutcheon, 2002). Most countries report a prevalence of postpartum depression between 5.5 and 25% (Affonso et al., 2000; Beck and Garble, 2001a, 2001b; Patel et al., 2002; Regmi et al., 2002; Berle et al., 2003; Garcia-Esteve et al, 2003; Aydin et al., 2004; Lee et al., 2004; Agoub et al., 2005; Teng et al., 2005). In a rural area in northern Peninsular Malaysia, the prevalence of postpartum depression was reported to be 9.4% (Wan Rushidi, 2002). However, the prevalence of 144 Asia-Pacific Psychiatry 4 (2012)

2 N.Z. Zainal et al. Postpartum depression in Malaysia postpartum depression among mothers in a big urban city like Kuala Lumpur is not available. Research might have been conducted but has probably not been published. In contrast, the prevalence of PPD in a large neighboring city, Singapore, was reported to be 6.8% (Chee et al., 2005). There have been many attempts to identify the socio-demographic characteristics that might explain the risk for women to develop postpartum depression. However, none have been found to be consistently associated with this illness (Zekoski, 1988). An earlier study found that the mother s social class, education, race, age or parity has not been associated with postnatal depressive symptoms (Watson and Eliot, 1984). On the other hand, Segre et al found that income, occupational prestige, marital status, and number of children were significant predictors of postpartum depression when the effects of other related demographic characteristics are controlled for. In addition, Mayberry et al reported age, income, education, and employment had significant negative associations with depression symptom severity, and parity had a significant positive association with depression symptom severity. Similarly, studies on the relationship between obstetric history and postpartum depression failed to reveal consistent findings. Adewuya et al found that cesarian section was a predictor for postpartum depression and Agoub et al reported that complicated pregnancy in Moroccan women was associated with depressive disorder. However, Fairbrother and Woody (2007) did not find obstetric complications as predictors for depression. Interestingly, breastfeeding is associated with reduced perceived stress and negative mood in mothers, while women who exclusively bottle-fed had almost twice the depression rate of women who had done some breastfeeding, even briefly (Mezzacappa and Katkin, 2002). Unlike their Western counterparts, most Malaysian mothers still live within an extended family. During the postpartum period the mother is looked after either by her husband, mother, mother-in-law or a confinement lady. This would likely provide some form of social support to the postpartum mother. It is known that good psychosocial support is one of the most important protective factors against postpartum depression (Dennis, 2003). Due to lack of consistent findings in previous studies and limited data on postpartum depression among urban Malaysians, it is timely to see how the prevalence and factors associated with postpartum depression in women in a Malaysian city differs from that of other studies. Methods This was a cross-sectional study conducted at the Postnatal Clinic of the University Malaya Medical Centre, Kuala Lumpur, Malaysia, from December 2008 to April 2009 on postpartum mothers attending their sixth to eighth-week postnatal care appointment. The mothers were assessed during this period because they were given a follow-up date by their obstetrician six to eight weeks post-delivery. According to DSM-IV psychiatric diagnosis, PPD is a major depressive disorder with postpartum onset where the depressive symptoms begin within four weeks postpartum. International Classification of Diseases (ICD-10) recognizes PPD as a mild mental and behavioral disorder commencing within six weeks of delivery. The study was approved by the Ethics Committee Board of the Malaya Medical Centre and was performed in accordance to the ethical standards laid down in the 1964 Declaration of Helsinki. Participants The sample size was calculated based on the estimated prevalence of 20%, together with the power of 0.8 and a confidence interval of 95%. The number of subjects needed for the study was 361. We estimated that there would be about 10% of subjects with missing values during data collection, so the total sample size needed was 400 patients. Consecutive postpartum mothers who were attending postnatal check-up and neonatal immunization during the study period at the place of study and during the pre-determined appointment days of the week, and had fulfilled all the selection criteria were selected. A total of 510 women were approached from 34 bi-weekly postnatal clinics at the obstetrics department. Informed consent was obtained prior to inclusion. Ninety-nine women (19%) declined to participate in the study. However, socio-demographically they were comparable with the 411 mothers who participated. The inclusion criteria for the study were postpartum women attending postnatal check-up or neonatal immunization after 4 weeks post-delivery, who were literate in English and Bahasa Malaysia, and had consented to participate in the study. Postpartum mothers who were intellectually disabled, had a history of drug abuse, or had been diagnosed with a depressive illness in the third trimester of current delivery (confirmed from patient records) were excluded from the study. Asia-Pacific Psychiatry 4 (2012)

3 Postpartum depression in Malaysia N.Z. Zainal et al. Mothers with infants that were stillborn or had died immediately after birth were also excluded, as we sought to examine factors that correlate with typical PPD, rather than the grief that accompanies the loss of an infant. Measurement All socio-demographic data, including the patient s registration number, age, parity, marital status, weeks delivered, planned pregnancy, place and method of delivery, education level, employment and total household income were obtained in the demographic questionnaire. Breastfeeding status of the patients was also obtained: whether they were exclusively breastfeeding, mixed-feeding or not breastfeeding at all. The Mini International Neuropsychiatric Interview (M.I.N.I.) was used to establish a diagnosis of postpartum depression according to DSM IV criteria by face-to-face interview. M.I.N.I. was designed as a brief structured interview for major Axis I psychiatric disorders in DSM-IV and ICD-10. In this study, only module A (Major Depression) of the M.I.N.I. was used. M.I.N.I. has been shown to have high validity and reliability (Sheehan, 1997). The Oslo 3-item Social Support Scale was used to assess perceived social support received by the mothers during the postpartum period. The feasibility and predictive validity with respect to psychological stress has been confirmed by Dowrick (1998). As a measure of mental health, the Oslo-3 Scale was tested against the Hopkins Symptoms Checklist-25 (HSCL-25) and as a measure of perceived social support, 12 questions covering family, friends and neighborhood were administered. Three questions (one question from neighborhood item and two questions from family/friend support) were considered to be the best predictors of mental health, covering different fields of social support, and were put together into a composite index of social support by summarizing the standardized z-scores for each item. A sum index was made by summarizing the scores. The sum scores ranged from 3 to 14. A score of 3 8 represents poor support ; 9 11 represents moderate support and a score of indicates strong support. We categorically divided the outcome scores for the Oslo 3-item Social Support Scale as for analyses purposes later as those with scores 8 and below as low Oslo 3-item scale scores reflecting poor social support and those with scores 9 and above as high Oslo 3-item scale scores reflecting good social support. Statistical analysis Demographic characteristics were compared by ANOVA one-way test and independent t-test for parametric variables, and Pearson s c 2 test for nonparametric variables. Univariate and multivariate logistic binomial regression were used to analyze the covariates of the study. Results A total number of 411 mothers who had consented and fulfilled the inclusion and exclusion criteria were included in the study. Table 1 shows the sociodemographic characteristics and obstetric data of the mothers. The mean age ( SD) was years. All the mothers were married except for two who were divorced. About 48% (n = 197) of the mothers practiced exclusive breastfeeding, 12% (n = 49) did not breastfeed, and 40% (n = 165) practiced mixed feeding. The mean score of the Oslo 3-item Social Support Scale was ( , 95% CI). Of all the mothers, 93% had good social support. Only two mothers had a family history of depression and 2.2% (n = 9) had a previous history of depression. The prevalence of postpartum depression among mothers attending University Malaya Medical Centre Obstetrics Department for postpartum care between December 2008 and April 2009 was 6.8% (n = 28). Univariate analyses comparing socio-demographic characteristics between depressed and non-depressed mothers revealed significant differences in both groups except for working status. Mothers who were not working (housewives) were significantly associated with depression (P < 0.05, OR = 3.3, 95% CI ). In addition, low Oslo 3-item Social Support score (poor social support) was also significantly associated with postpartum depression (P < 0.001, OR = 5.8, 95% CI ). Comparison of the obstetric data is shown in Table 2. Postpartum mothers with previous history of depression and mothers with family history of depression were significantly associated with PPD (P < 0.001, OR = 20.6, 95% CI ) and (P < 0.01, OR = 15.4, 95% CI ), respectively. Further multivariate analyses found predictors for postpartum depression were mothers who did not exclusively breastfeed (P < 0.01, adjusted OR = 23.7, 95% CI ) and having a previous history of depression (P < 0.05, adjusted OR = 82.3, 95% CI 1.2 5,897.6). 146 Asia-Pacific Psychiatry 4 (2012)

4 N.Z. Zainal et al. Postpartum depression in Malaysia Discussion The prevalence of postpartum depression (6.8%) found in this study is in keeping with the findings of other studies conducted in Singapore (Chee et al., 2005), Hong Kong (Lee et al., 2004), Morocco (Agoub et al., 2005), Turkey (Aydin et al., 2004), and Spain (Garcia-Esteve et al, 2003). However, this rate was lower than the prevalence reported in other countries, Table 1. Socio-demographic and obstetric data of postpartum mothers Socio-demographic and obstetric data % (n = 411) Age group (years) < (2) (96) (206) (90) > (17) Race Malay 58.7 (241) Chinese 18.3 (75) Indian 19.7 (81) Other 3.3 (14) Education level Primary 6.1 (25) Secondary 74.5 (306) Tertiary 19.5 (80) Occupation Housewife 14.8 (61) Employed 76.6 (315) Self-employed 8.5 (35) Total household income <RM (66) RM (291) RM (48) RM (6) Parity Single 66.7 (274) Multiple 33.3 (137) Number of weeks postpartum >8th week 0.5 (2) 8th week 7.3 (30) 7th week 71.5 (294) 6th week 20.2 (83) <6th week 0.5 (2) Planned pregnancy Yes 87.9 (360) No 12.1 (51) Hospital delivery Yes 99.8 (410) No 0.2 (1) Method of delivery Cesarean section 18.9 (79) Vaginal 80.2 (332) Baby health status Normal healthy baby 99.0 (407) Complicated 1.0 (4) such as the USA, which was 23.3% (Stuart et al., 1998); India, 23% (Patel et al., 2002); Ireland, % (Crotty and Sheehan, 2004); and Australia, 16.9% (Brown and Lumley, 2000). However, much higher prevalence rates of PPD were found in Taiwan, Guyana and Korea (Affonso et al., 2000). The difference in these rates can be attributed to the different criteria of measurement used, such as self-report instruments like the Beck Depression Inventory (BDI) (Beck et al., 1961), Center for Epidemiologic Studies Depression (CES-D) Scale (Radloff, 1977) and Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987); or assessment by clinical interview using Structured Clinical Interview for DSM disorder, DSM 1V criteria (APA, 2000). Our study and others (Garcia-Esteve et al, 2003; Aydin et al., 2004; Lee et al., 2004; Agoub et al., 2005) used DSM criteria to diagnose PPD, while studies in the USA (Stuart et al., 1998), India (Patel et al., 2002), Ireland (Crotty and Sheehan, 2004) and Australia (Brown and Lumley, 2000) used EPDS to screen PPD. Sampling methodology may have also contributed to the difference in prevalence rates of PPD. Some studies were conducted among first-time mothers only and other studies included both experienced and first-time mothers (Leahy-Warren and McCarthy, 2007). In this study we included both experienced and first-time mothers. The tradition of having someone looking after women following childbirth or at least during the confinement period is still widely practiced in Malaysia and the population of this study was not an exception. We found a high proportion (93%) of mothers reporting that they received good social support including the services of traditional birth assistants, who are normally located within their neighborhood. They are consulted especially during the early postpartum period to perform tasks such as daily massage to the new mother and to provide advice on how to take care of her health and body. Mothers with poor social support were more likely to develop PPD. However, negative thoughts associated with depression could make the depressed postnatal mothers perceive that they have nobody caring for them enough, therefore reporting that they have poor social support. Furthermore, being depressed may make them feel that they are a burden to others, hence they may stay away from family and friends to avoid troubling them further. Breastfeeding has always been universally accepted as the best method for feeding babies. Its benefits for both infants and mothers have been widely acknowledged, with a plethora of scientific evi- Asia-Pacific Psychiatry 4 (2012)

5 Postpartum depression in Malaysia N.Z. Zainal et al. Table 2. Comparison of obstetric data between postpartum depressed mothers and non-depressed mothers Postpartum depression Yes No Crude Obstetric variable %(n) % (n) P-value OR 95% CI Planned pregnancy 6.1 (22) 93.9 (339) Unplanned pregnancy 12.0 (6) 88.0 (44) Cesarian section 14.1 (11) 85.9 (67) Vaginal delivery 5.1 (17) 94.9 (316) Single parity 6.6 (18) 93.4 (256) Multiparity 7.3 (10) 92.7 (127) Non-exclusive (mixed + never breastfed) 12.6 (27) 99.5 (196) < Exclusive breastfeeding 0.5 (1) 87.4 (187) dence to support its supremacy. Non-exclusive breastfeeding was found to be a strong predictor for postpartum depression in this study. In other words, exclusive breastfeeding may protect postpartum mothers from PPD. This finding has been observed by Gonidakis et al. (2008), who found a smaller number of women with PPD had breastfed their babies compared to those without PPD. However the causal link to depression is difficult to determine as postpartum depression has also been associated with early cessation of breastfeeding (Cooper et al., 1993; Misri et al., 1997). More prospective and longitudinal studies are needed to explore this further. A meta-analysis by Beck (1995) found strong evidence that history of depression is a moderate predictor of PPD. Studies by O Hara and Swain (1996) and Pfost et al. (1990) found that prenatal depression in particular, was a strong predictor of PPD. Both studies replicated the results of earlier work, and our results strongly concur with these findings, where previously diagnosed depressive illness is a strong predictor of postpartum depression in our study population. In conclusion, in this cohort of city mothers, the prevalence of postpartum depression was similar to findings in other studies that also used DSM criteria to diagnose major depressive episode. Two biological factors, namely exclusive breastfeeding and absence of previous history of depression had lower odds for vulnerability against postpartum depression. References Adewuya A.O., Fatoye F.O., Ola B.A., Ijaodola O.R., Ibigbami S.M. (2005) Sociodemographic and obstetric risk factors for postpartum depressive symptoms in Nigerian women. J Psychiatr Pract. 11(5), Affonso D.D., De A.K., Horowitz J.A., Mayberry L.J. (2000) An international study exploring levels of postpartum depressive symptomatology. J Psychosom Res. 49(3), Agoub M.D., Moussaoui D., Battas O. (2005) Prevalence of postpartum depression in a Moroccan sample. Arch Womens Ment Health. 8(1), American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, Text Revision, DSM-IV-TR, 4th edn. American Psychiatric Press Inc., Washington DC. Aydin N., Inandi T., Yigit A., Hodoglugil N.N. (2004) Validation of the Turkish version of the Edinburgh Postnatal Depression Scale among women within their first postpartum year. Soc Psychiatry Psychiatr Epidemiol. 39(6), Beck A., Ward C., Mendelson M., Erbaugh J. (1961) An inventory for measuring depression. Arch Gen Psychiatry. 4, Beck C. (1995) The effects of postpartum depression on maternal-infant interaction: a meta-analysis. Nurs Res. 44(5), Beck C., Garble R. (2001a) Comparative analysis of the performance of the Postpartum Depression Screening Scale with two other instruments. Nurs Res. 50(4), Beck C., Garble R. (2001b) Further validation of the Postpartum Depression screening Scale. Nurs Res. 50(3), Berle J.O., Aarre T.F., Mykletun A., Dahl A.A., Holsten F. (2003) Screening for postnatal depression. Validation of the Norwegian version of the Edinburgh Postnatal Depression Scale, and assessment of risk factors for postnatal depression. J Affect Disord. 76(1 3), Brown S., Lumley J. (2000) Physical health problems after childbirth and maternal depression at six to seven months postpartum. BJOG. 107, Asia-Pacific Psychiatry 4 (2012)

6 N.Z. Zainal et al. Postpartum depression in Malaysia Chee C.Y.I., Lee D.T.S., Chong Y.S., Tan L.K., Ng T.P., Fones C.S.L. (2005) Confinement and other psychosocial factors in perinatal depression: a transcultural study in Singapore. J Affect Disord. 89(1), Cooper P.J., Murray L., Stein A. (1993) Psychosocial factors associated with the early termination of breast-feeding. J Psychosom Res. 37, Cox J., Holden J., Sagovsky R. (1987) Detection of postnatal depression: development of the 10-item Edinburgh Depression Scale. Br J Psychiatry. 150, Crotty F., Sheehan J. (2004) Prevalence and detection of postnatal depression in an Irish community sample. Ir J Psych Med. 21(4), Dennis C. (2003) The effect of peer support on postpartum depression: a pilot randomized control trial. Can J Psychiatry. 48(2), Dowrick C. (1998) Oslo health and quality of life survey 2002; Outcome of depression International Network. Br J Psychiatry. 172, Fairbrother N., Woody S.R. (2007) Fear of childbirth and obstetrical events as predictors of postnatal symptoms of depression and post-traumatic stress disorder. J Psychosom Obstet Gynaecol. 28(4), Garcia-Esteve L., Ascaso C., Ojuel J., Navarro P. (2003) Validation of the Edinburgh Postnatal Depression Scale (EPDS) in Spanish mothers. J Affect Dis. 75, Gonidakis F., Rabavilas A.D., Varsou E., Kreatsas G., Christodoulou G.N. (2008) A 6-month study of postpartum depression and related factors in Athens Greece. Compr Psychiatry. 49(3), Leahy-Warren P., McCarthy G. (2007) Postnatal depression: prevalence, mother s perspectives and treatments. Arch Psychiatr Nurs. 21(2), Lee D.T., Yip A.S.K., Leung T.Y.S., Chung T.K.H. (2004) Ethnoepidemiology of postnatal depression. Prospective multivariate study of sociocultural risk factors in a Chinese population in Hong Kong. Br J Psychiatry. 184, Mayberry L.J., Horowitz J.A., Declercq E. (2007) Depression symptom prevalence and demographic risk factors among U.S. women during the first 2 years postpartum. J Obstet Gynecol Neonatal Nurs. 36(6), Mezzacappa E.S., Katkin E.S. (2002) Breast-feeding is associated with reductions in perceived stress and negative mood in mothers. Health Psychol. 21, Misri S., Sinclair D., Kuan J. (1997) Breast-feeding and postpartum depression: is there a relationship? Can J Psychiatry. 42, Murray L., Cooper P.J. (1996) The impact of postpartum depression on child development. Int Rev Psychiatry. 8, O Hara M.W., Swain A.M. (1996) Rates and risk factors of postpartum depression a meta-analysis. Int Rev Psychiatry. 8, Patel V., Rodrigues M., DeSouza N. (2002) Gender, poverty, and postnatal depression: a study of mothers in Goa, India. Am J Psychiatry. 159, Pfost K.S., Stevens M.J., Lum C.U. (1990) The relationship of demographic variables, antepartum depression, and stress to postpartum depression. J Clin Psychol. 46, Radloff L. (1977) The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1, Regmi S., Sligl W., Carter D., Grut W., Seear M. (2002) A controlled study of post-partum depression among Nepalese women: validation of the Edinburgh postpartum depression scale in Kathmandu. Trop Med Int Health 7, Segre L.S., O Hara M.W., Arndt S., Stuart S. (2007) The prevalence of postpartum depression: the relative significance of three social status indices. Soc Psychiatry Psychiatr Epidemiol. 42(4), Sheehan D.V. (1997) Reliability and validity of the MINI according to the SCID-P. Eur Psychiatry. 12, Stuart S., Couser G., Schilder K., O Hara M., Gorman L. (1998) Postpartum anxiety and depression: onset and comorbidity in a community sample. J Nerv Ment Dis. 186(7), Teng H.W., Hsu C.S., Shih S.M., Lu M.I., Pan J.J., Shen W.W. (2005) Screening postpartum depression with the Taiwanese version of the Edinburgh Postnatal Depression scale. Compr Psychiatry. 46(4), Wan Rushidi W.M. (2002) Postpartum depression: a survey of the incidence and associated risk factors among Malay women in Beris Kubor Besar, Bachok, Kelantan. Malays J Med Sci. 9(1), Watson J.P., Eliot S.A. (1984) Psychiatric disorder in pregnancy and the first postnatal year. Br J Psychiatry. 144, Williamson V.H., McCutcheon H. (2002) Postnatal blues. Singap Nurs J. 29(2), Zekoski E.M., ed. (1988) Motherhood and Mental Illness: A Comprehensive Review. John Wright, London. Asia-Pacific Psychiatry 4 (2012)