Correlates of Perinatal Depression in Diverse Low-Income Women Judith M. Jarosinski, RN, Phd, CNE Salisbury University and Deborah Pollard RNC, PhD, IBCLC, CNE University of North Carolina Wilmington
Introduction Postpartum depression (PPD) continues to significantly impact women and their families during the perinatal period. Consequences of untreated PPD in the mother may lead to recurring psychiatric illness (Robertson, et. al, 2005), marital dysfunction (Robertson & Lyons, 2003), and suicide (Appleby, Mortensen, & Faragher, 1998). Infants of mothers experiencing PPD have been shown to be at risk for behavioral problems (Beck, 1999), delayed cognitive or psychosocial development (Beck, 1998; Grace, Evindar, & Stewart, 2003), and impaired mother-infant bonding (Beck, 1995).
Introduction Prevalence of PPD ranges from 10%-15% of mothers within the first year following birth (O Hara & Swain, 1996). Research studies report variations in prevalence based on geographic, demographic, and socio-behavioral variables. The CDC compiles information using the Pregnancy Risk Assessment Monitoring System (PRAMS) for the seventeen participating states. In this report the prevalence of self-reported postpartum depressive symptoms ranged from 11.7% in Maine to 20.4% in New Mexico (CDC, 2008).
Purpose The purpose of this study was to examine the prevalence of perinatal depression and the risk factors and related variables impacting the occurrence of postpartum depression in a group of diverse, low-income women in Southeast North Carolina. The study contrasted the relationship between sociodemographic variables, depression, postpartum depression, self-esteem, self-efficacy, social support, stress, and postpartum depression for this population during the last trimester of pregnancy and at 6-8 weeks postpartum.
Methodology Descriptive, longitudinal, correlational design Institutional Review Board approval Research instruments: Demographic questionnaire Beck Depression Inventory (BDI) Edinburgh Postnatal Depression Scale (EPDS) Rosenberg Self-Esteem Scale (RSES) General Self-Efficacy Scale (GSES) Maternal Confidence Questionnaire (MCQ) Multidimensional Scale of Perceived Social Support (MSPSS) Inclusion Criteria: between the ages of 18 and 40 participating in health department childbirth program
Total Sample N = 61 Mean age Race/Ethnicity: White Black Hispanic 25.41 years 32 (52.5%) 17 (27.9%) 12 (19.7%) Single marital status 67.2% First Pregnancy 54.1% Education Level: Less than high school Completed high school/ged Some college/college degree 16.4% 32.8% 50.8% Past History of Depression 26.2% Past History of Postpartum Depression Sample Characteristics 3.3%
Sample Characteristics Depression Diagnosed with this Pregnancy Self reports significant changes in mood such as depression, anxiety, or sadness before this pregnancy and did not seek medical attention Self reports significant changes in mood such as depression, anxiety during this pregnancy and did not seek medical attention 6.6% 23% 29.5%
Results Table 1. Comparison of Depression Scores during Pregnancy and Postpartum Third Trimester of Pregnancy 6-8 Weeks Postpartum Race/Ethnici ty BDI Mean Score EPDS Mean Score BDI Mean Score EPDS Mean Score White 12.97 7.97 9.44 7.33 Black 10.53 5.78 11.00 6.58 Hispanic 10.33 6.75 10.08 5.92 F = 0.997 F = 0.904 F = 0.051 F = 0.453 p = 0.375 p = 0.411 p = 0.950 p = 0.639
Results Positive correlation between the BDI and EPDS at both time periods (r =.582, p =.000 and r = 0.738, p =.000). 60.7% of the participants scored above 10 on the BDI during the 3 rd trimester (36.1% in the mild depression range and 24.6% in the moderate depression range). 44.2% of the participants scored above 10 on the BDI at 6-8 weeks postpartum (30.8% in the mild depression range, 11.5% in the moderate, and 1.9% in the severe). 32.7% of the participants scored >9 on the EPDS screening tool for postpartum depression.
Results Table 2. Relationship between Socio-demographic Variables, Self- Reports of Mood Changes, Depression, Self-Esteem, Self-Efficacy, and Social Support EPDS BDS RSE GSE MSPSS Age r =.182 r =.117 r = -.216 r = -.280* r = -.096 Race F =.453 F =.051 F =.840 F =.058 F =.969 Current Smoker Current Alcohol Use Use of Recreational Drugs Mood Changes before pregnancy Mood Changes during this pregnancy t = 21.54* t = 1.505 t = -.165 t = -.099 t = -.478 F = 5.879 F = 7.498 F = 21.34 F =.002 F =.481 F = 4.29* F = 4.09* F =.868 F =.083 F =.041 t = 1.509 t = 2.33* t = -2.94** t = -.967 t = -1.644 t = 2.176* t = 1.556 t = -1.648 t =.190 t = -1.666
Results Table 3. Correlations between Depression, Self-Esteem, Self-Efficacy, Maternal Confidence, and Social Support at 6-8 Weeks Postpartum EPDS BDI Self- Esteem Self- Efficacy Maternal Confidence Social Support EPDS - 0.738** -0.679** NS NS -0.434** BDI 0.738** - -0.619** NS NS -0.308* Self- Esteem Self- Efficacy Maternal Confidence -0.679** -0.619** - 0.404** NS 0.532** NS NS 0.404** - NS 0.299* NS NS NS NS - NS Social Support *p <.05, ** p <.01, -0.434** -0.308* 0.532** 0.299* NS - NS = Not Significant
Qualitative study A qualitative approach, using an interpretive Heideggerian perspective in a focus group format, elicited the perinatal client s perception of risk factors, how that perception affected the pregnancy experience, and to what degree self efficacy plays a role in their perceived ability to make healthy choices.
Mode of Inquiry Based upon an interpretive framework Purpose is to explicate shared concerns, and create new understandings of how pregnant women perceive risk factors in their lives Three focus groups composed of 3-5 participants were the primary means of generating data. With participant permission, focus group conversations were audio- taped and transcribed by a transcriptionist
Method The setting for all three focus groups was the heath department. Semi-structured questions included: 1) What do you see as important in helping you get through this pregnancy? 2) What kinds of things make it harder for you to feel positive about this pregnancy? 3) In this pregnancy, what do you identify as negative things happening in your life that make you feel sad or depressed? 4) Do you feel you have the capability to find the help that you need when you are going through a difficult time? The co facilitators guided the discussion through the use of probes All identifying information was removed from the transcribed text and replaced with pseudonyms
Analysis A modified version of the Heideggerian hermeneutic approach developed by Diekelmann, Allen and Tanner (1989) guided analysis Transcribed text from the focus group was used as supportive verification of initial interpretations. Themes were identified and examined in a continual, circular process of refining and reinterpreting. Implicit and explicit meanings were extracted Interpretations, patterns and themes were identified and compared with the text. Constitutive patterns were justified and interpretive findings finalized in the final report.
Themes Theme 1: Feeling joy in the moment Theme 2: Depression is...something you think about Theme 3: Rearranging your thinking- Not what I expected Theme 4: Gathering support
Theme 1-Feeling joy in the moment The expectation for these women is that joy is part of the pregnancy process. you try to envision it...it s just cool stuff. It s a joyful experience and a lot of work...i don t suggest it for anyone...that s for sure
Theme 2- Depression is something you think about Participants related that depression was something they thought about. For several depression was a phenomenon familiar to them. Several participants related past experiences of mood swings, apathy and periods of isolation. It made me more nervous that I might be more prone to depression.
Theme 3-Rearranging your thinking: Not what I expected Participants spoke of a future that was different...they didn t know what to expect. It s weird, you see people having babies on movies...but you really didn t know what to expect. For others, the bonding they expected to happen, didn t... I felt like maybe I should be bonding with her like that too...when I wasn't, I felt like something was wrong.
Theme 4-Garnering support Almost all participants voiced that support ( gathering support ) was critical to their well being, and ultimately, the well being of their child. They've never been negative towards us or anything..they ve always been supportive The support was definitely a big help with mental aspect.
Acknowledgments Grant funding by Dr. J. Richard Corbett Research Trust Award. Special thanks to New Hanover County Health Department staff and participants.