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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 35  |  Issue : 1  |  Page : 64-68

A community-based study of postpartum depression in rural Southern India


Department of Community Medicine, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Date of Submission14-Mar-2018
Date of Decision30-Jul-2018
Date of Acceptance04-Sep-2018
Date of Web Publication27-Mar-2019

Correspondence Address:
Dr. Vanishree Shriraam
Department of Community Medicine, Sri Ramachandra Medical College and Research Institute, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_13_18

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  Abstract 


Background: Depression is the most common complication postpartum affecting 10%–15% of women, contributing greatly to maternal mortality and morbidity, but the care availed is very low among the women who suffer. Objective: The aim is to study the prevalence of postpartum depression among recently delivered women in a rural population and the health care utilization pattern for the condition among women. Methodology: This was conducted as a population-based cross-sectional study in a rural population served by primary health center. All women in the study area who had a pregnancy outcome during the past 6 months and have completed 42 days since their last delivery were included in the study. The data on postpartum depression were collected using the Edinburgh Postnatal Depression Scale (EPDS). Results: There were 365 postpartum women in the study area who participated in the study. Mean age of the study participants was 24.5 years. The deliveries were Institutional in 97.8% of women. The prevalence of depression among the study women (an EPDS score of 10 and above) was 11%. Among women with depression, a history of depression before the last delivery was given by 42.5% of women. Only 7.5% of women had sought some form of health care for their problem. Conclusion: The study shows that the prevalence of depression among postpartum women is quite high and the health seeking for depression is very low. Health professionals and workers have to be trained to raise awareness, detect, and treat depression among postpartum women promptly.

Keywords: Cross-sectional study, depression, Edinburgh postnatal depression scale score, health seeking, postpartum


How to cite this article:
Shriraam V, Shah PB, Rani M A, Sathiyasekaran B. A community-based study of postpartum depression in rural Southern India. Indian J Soc Psychiatry 2019;35:64-8

How to cite this URL:
Shriraam V, Shah PB, Rani M A, Sathiyasekaran B. A community-based study of postpartum depression in rural Southern India. Indian J Soc Psychiatry [serial online] 2019 [cited 2019 Apr 24];35:64-8. Available from: http://www.indjsp.org/text.asp?2019/35/1/64/254994




  Introduction Top


Women are between 2 and 3 times more likely to experience depression and anxiety than men. Women in the postpartum period are even more vulnerable.[1] Postpartum depression is a unique, frequently unrecognized, yet devastating disorder. It is the most common complication postpartum affecting 10%–15% of women. The prevalence is even higher in developing countries. This contributes substantially to maternal mortality and morbidity and represents a considerable public health problem affecting women and their families.[2]

In addition, maternal depression affects the children's physical and psychological health. Maternal depression results in lower birth weight of infants, higher rates of underweight at 6 months of age, poor long-term cognitive development, higher rates of antisocial behavior and more frequent emotional problems among their children.[1]

In a prospective hospital based study in Goa in 2000, among 270 mothers, depressive disorder was detected in 23% of women at 6–8 weeks of delivery using the Edinburgh Postnatal Depression Scale (EPDS).[3] In a cross-sectional community-based study conducted in rural Jharkhand and Orissa among 5801 mothers around 6 weeks after delivery using Kessler 10-item scale, 11.5% of mothers had symptoms of distress.[4] In another community-based prospective study done in Vellore, the prevalence of postpartum depression was found to be 19.8%.[5]

The factors that contribute to maternal depression include: marital status of the mother, unplanned/unwanted pregnancy, unwanted gender of the baby, poor relationship with a partner, lack of emotional support in family, insufficient social support, poverty and social adversity, previous personal history of depression, prenatal depression or anxiety, childcare stress, poor physical health of the woman or the baby, and coincidental adverse life events.[3],[6]

The majority of patients suffer from depression for >6 months and when untreated, a quarter of them are depressed for more than a year. Postpartum onset is the index depression episode in >50% of cases, again underscoring the unique triggering effect of childbirth.[7] Signs and symptoms are clinically indistinguishable from major depression that occurs in women at other times.[8] Most cases require treatment by a health professional.[9] The keys to successful treatment are early identification and intervention. Even though effective psychological and pharmacological treatment strategies are existing for depression, even in industrialized countries, less than half of the women who suffer benefit from them. The situation is much worse in the developing countries where <5% of women tend to avail care.[1]

The current study aims to study the prevalence of postpartum depression among recently delivered women in a rural population in Mugalivakkam Primary Health Centre area of Kanchipuram district in Tamil Nadu and the health care utilization for postpartum depression among women.


  Methodology Top


This study was conducted as a population based cross sectional study in a rural population served by Primary Health Centre, Mugalivakkam in Kundrathur block of Kancheepuram district in Tamil Nadu, India. The primary health center has five health sub-centers and 35 villages with a total population of 49,005 as of March 31, 2008.

According to the World Health organization, the post-partum period or Puerperium is the period which begins with 1 h of the delivery of the placenta and continues until 6 weeks (42 days).[10] In this study, all women in the study area irrespective of whether they are a resident of the village or a visitor who had a pregnancy outcome during May 2008 to January 2009 and have completed 42 days since their last delivery but are <6 months of delivery were included irrespective of outcome of birth. They were interviewed in their homes. Written informed consent in the native language (Tamil) was obtained from the study participants. The standard of living of study participants was assessed using the SLI index.[11]

The data on postpartum depression were collected using the EPDS. The EPDS is easy to administer and has proven to be an effective screening tool. The EPDS was translated in the native language (Tamil) and was used to identify depression in the postpartum period after evaluating for content and face validity. The EPDS has questions about symptoms of depression. There are ten questions in the scale each scoring from 0 to 3 with a maximum score of 30. A score of 10–12 indicates moderate depressive symptoms and 13 or more a clinically relevant depressive symptomatology.[8],[12],[13]

The study women were asked whether they had those symptoms during the postpartum period for 7 or more consecutive days. Women who scored ten or above were further enquired about the factors contributing to their depression and whether they had sought care for their problem. Any woman who has availed health care services for postpartum depression under any approved system of medical care was considered to have sought health care. If they had not sought care for their health problem, the reason for not seeking care was asked.

Ethical approval

The study was approved by the Institutional Ethics Committee of Sri Ramachandra Medical College and Research Institute.

Data analysis

Data entry and analysis of the variables were done using the Statistical Package for Social Sciences (SPSS for Windows, Version 16.0. SPSS Inc., Chicago). Descriptive statistics were calculated for background variables, postpartum depression, and its health-seeking behavior. Association between postpartum depression and the related factors were analyzed using the Chi-square test.


  Results Top


There were 365 eligible postpartum women available at the time of interview, and all of them gave informed consent to participate in the study. The mean age of the study participants was 24.5 years, and the standard deviation was 3.3 years. Most of the women were literates (92.3%) and housewives (95.6%).

The deliveries were Institutional in 97.8% of women. The place of delivery was Health sub-center/primary health center in 112 (30.7%) women, secondary level Government hospital in 50 (13.7%), private nursing home in 61 (16.7%) and medical college hospital in 134 (36.7%). Only eight women (2.2%) delivered at home/during transit. Doctors conducted the delivery in 238 (65.2%) and nurses in 120 (32.9%) women. Five of the women had twin delivery, and there were two stillbirths.

[Table 1] gives the EDPS score of the study women.
Table 1: Edinburgh postnatal depression scale score of the study women (n=365)

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The prevalence of depression among the study women (an EPDS score of 10 and above) was found to be 11% (40/365). The prevalence of major depression (a score 13 and above) was found to be 7.4% (27/365). Among the women with score 10 and above history of depression before the last delivery was given by 17 (42.5%). More than 90% (21/23) of the remaining women had the onset of depression since the 1st to the 3rd day of delivery. Nearly three-fourths of the women continued to have the symptoms until the date of interview (up to 6 months postpartum). Women who scored 10 and above on EPDS were referred for medical help.

The demographic characteristics of age, educational status, the standard of life, and type of family were found not to be associated with the prevalence of postpartum depression [Table 2].
Table 2: Prevalence of postpartum depression based on demographic characteristics

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Although the prevalence of postpartum depression was higher among women who had antenatal anemia and those who had given birth to a girl baby, the differences were not statistically significant. A higher proportion of women with multiple births had depression postpartum compared to women who had single births and women who had delivered by vaginal route had a higher prevalence of depression compared to women delivered by cesarean section (P < 0.05) [Table 3].
Table 3: Prevalence of postpartum depression based on delivery characteristics

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[Figure 1] shows the factors that were attributed by the women for their depression.
Figure 1: Factors attributed by women for depression (n = 40)

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The mothers who were depressed quoted family problems such as poverty, death of a close relative, nuclear family, and lack of social support. Among 11 women who quoted the unwanted gender of the infant as a reason, 6 women (54.5%) had previous girl child/children. Other four women preferred to have a male child (36.4%) and only one woman wanted a girl child (9.1%). Marital disharmony was because of domestic violence by the husband under the influence of alcohol and marital separation.

Health seeking for postpartum depression

Only three of the 40 women with depression (7.5%) had sought some form of health care for their problem. All the three of them had sought care from the obstetrician who delivered their child, two in a private nursing home and the third woman at a medical college hospital.

Most women with depression (92.5%) did not seek any form of health care. Many women uttered sentences like-“Parents told that I would be alright soon,” “Thought will recover on its own,” “Just waiting for better days to come” which was considered as “Non-perception of depression as a health problem,” although few women quoted reasons like “baby was unwell– so couldn't go,” “I was too busy with household chores,” “No one to take me to hospital,” etc.


  Discussion Top


In this cross-sectional study done among 365 women in a rural area in Tamil Nadu, the prevalence of depression during postpartum period was found to be 11%, and among them, two-thirds had major depression.

This study finding was similar to the community-based study conducted in rural Jharkhand and Orissa in which, 11.5% of mothers had symptoms of distress.[4] Furthermore, the prevalence of major depression in this study (7.4%) is similar to that in Gadchiroli where, severe anxiety, or depression during the postpartum period was present in 7.4% of the women.[14] The prevalence of depression in this study was different from that found in the studies done in South Karnataka (2.3%), Delhi (6%), Vellore (19.8%), Goa (23%) and also in other countries such as Aberdeen (21%), Australia (16.9%), and Lisa Segre (15.7%).[3],[5],[15],[16],[17],[18],[19] This could have been due to the difference in methodology, time of data collection with reference to delivery and also difference in socio-cultural environment of the study women.

In the study done in Goa, out of the women who were detected with a depressive disorder, 78% of the patients had clinically substantial psychological morbidity during the antenatal period. Only 22% had depression that arose in the puerperal period.[3] However in our study, history of such symptoms before last delivery was given by 42.5% of women only. This might be because of the current study design being cross-sectional and the point of contact being after 42 days since delivery. As such, depression is not perceived as a health problem by most women. Hence, its status before the last delivery might have been underreported by the women.

Depression was more commonly present in women with multiple births (P < 0.01). Although multiple births as a risk factor for postpartum depression is less explored in other studies, it is understandable as the demand for care from the mother is very high and stressful. The finding that a significantly higher proportion of women who had vaginal delivery suffered depression as compared to those who had cesarean section is different from other studies. Certain studies report caesarean section as a risk factor for depression and others report no difference in prevalence of depression between vaginal delivery and cesarean section.[4],[9] The finding in this study could be explained that women who had vaginal delivery had to return to household chores earlier and had less rest and so were more prone.

In this study, among two women who had still birth, one woman was depressed. The other woman delivered twins and one baby was alive. She quoted receiving strong emotional support from her mother-in-law because of which she could overcome the death of her child without going into depression. This reinforces the importance of family support for the postpartum women in combating depression.

Factors such as family problems of poverty, lack of support, etc., unwanted gender of the infant, especially a female child, marital disharmony, domestic violence, and poor health of the mother or the baby were quoted as reasons for their depression by the women. These factors were similar to that reported as risk factors for depression in the study by Patel et al., Chandran et al. and in the meta-analysis done by Beck and Tatano.[3],[4],[5],[6],[9]

There was a strong son preference among the depressed women. The only woman who preferred a girl child quoted “My mother in law has threatened to send me out of the house and was planning to get my husband married again. She may keep this baby boy with herself when I am thrown out. Had it been a girl baby, at least I will have some one for me in life.” This again reveals the male preference in the family and the society as a whole.

Only 7.5% of women with depression sought some form of health care. Mothers who had not sought health care quoted that they did not perceive it as a health problem. This is because of the low awareness of the symptoms of depression among postpartum women. According to a study by Bowen et al., depressive symptoms improve over the course of the pregnancy into the postpartum period, particularly when women receive counseling or psychotropic treatment.[20] Thus visualizing the harmful effects of postpartum depression on both mother and the infant, it becomes really important that all antenatal women be screened for depression early in pregnancy as well as in the postpartum period and those who have depression receive prompt intervention.

The strength of the study is that it is a community-based study which included all the postpartum women in the study area. This is one of the few studies that have sought information on the health care utilization pattern of study women. The limitations are, being a cross-sectional study, number of women with depression was small and so, association between depression and various factors were not significant.


  Conclusion Top


The present study shows that the prevalence of depression among postpartum women is quite high and the health seeking for depression is very low. It is high time that health policymakers take necessary steps to include the component of mental health in reproductive and child health program. Health professionals and workers have to be trained to raise awareness and treat depression among postpartum women promptly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
The World Health Report 2005. Make Every Mother and Child Count. Chapter. 4. Attending to 136 Million Births, Every Year. p. 61-77. Available from: http://www.who.int/whr/2005/chap4-en.pdf. [Last accessed on 2008 Jul 05].  Back to cited text no. 1
    
2.
Warner R, Appleby L, Whitton A, Faragher B. Demographic and obstetric risk factors for postnatal psychiatric morbidity. Br J Psychiatry 1996;168:607-11.  Back to cited text no. 2
    
3.
Patel V, Rodrigues M, DeSouza N. Gender, poverty, and postnatal depression: A study of mothers in Goa, India. Am J Psychiatry 2002;159:43-7.  Back to cited text no. 3
    
4.
Prost A, Lakshminarayana R, Nair N, Tripathy P, Copas A, Mahapatra R, et al. Predictors of maternal psychological distress in rural India: A cross-sectional community-based study. J Affect Disord 2012;138:277-86.  Back to cited text no. 4
    
5.
Chandran M, Tharyan P, Muliyil J, Abraham S. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India. Incidence and risk factors. Br J Psychiatry 2002;181:499-504.  Back to cited text no. 5
    
6.
Beck CT. Predictors of postpartum depression: An update. Nurs Res 2001;50:275-85.  Back to cited text no. 6
    
7.
Johnson TR, Apgar B. Women's Primary Health Grand Rounds at the University of Michigan. Postpartum Depression.  Back to cited text no. 7
    
8.
Wisner KL, Parry BL, Piontek CM. Clinical practice. Postpartum depression. N Engl J Med 2002;347:194-9.  Back to cited text no. 8
    
9.
Stewart DE, Robertson E, Dennis CL, Grace SL, Wallington T. Postpartum depression: Literature review of risk factors and interventions. Tornato Public Health 2003. Available from: http://www.who.int/mental_health/prevention/suicide/lit_review_postpartum_depression.pdf. [Last accessed on 2011 Oct 18].  Back to cited text no. 9
    
10.
World Health Organization. Postpartum Care of Mother and Newborn: A Practical Guide. WHO/RHT/MSM/98.3. Geneva: WHO; 1998.  Back to cited text no. 10
    
11.
National Family Health Survey (NFHS)–India NFHS – 2: Main Report – Health Education to Villages. Chapter – 2. Background Characteristics of Households. p. 41.  Back to cited text no. 11
    
12.
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry 1987;150:782-6.  Back to cited text no. 12
    
13.
Sidor A, Kunz E, Schweyer D, Eickhorst A, Cierpka M. Links between maternal postpartum depressive symptoms, maternal distress, infant gender and sensitivity in a high-risk population. Child Adolesc Psychiatry Ment Health 2011;5:7.  Back to cited text no. 13
    
14.
Bang RA, Bang AT, Reddy MH, Deshmukh MD, Baitule SB, Filippi V, et al. Maternal morbidity during labour and the puerperium in rural homes and the need for medical attention: A prospective observational study in Gadchiroli, India. BJOG 2004;111:231-8.  Back to cited text no. 14
    
15.
Bhatia JC, Cleland J. Obstetric morbidity in South India: Results from a community survey. Soc Sci Med 1996;43:1507-16.  Back to cited text no. 15
    
16.
Dubey C, Gupta N, Bhasin S, Muthal RA, Arora R. Prevalence and associated risk factors for postpartum depression in women attending a tertiary hospital, Delhi, India. Int J Soc Psychiatry 2012;58:577-80.  Back to cited text no. 16
    
17.
Glazener CM, Abdalla M, Stroud P, Naji S, Templeton A, Russell IT, et al. Postnatal maternal morbidity: Extent, causes, prevention and treatment. Br J Obstet Gynaecol 1995;102:282-7.  Back to cited text no. 17
    
18.
Brown S, Lumley J. Physical health problems after childbirth and maternal depression at six to seven months postpartum. BJOG 2000;107:1194-201.  Back to cited text no. 18
    
19.
Segre LS, O'Hara MW, Losch, ME. Race/ethnicity and perinatal depressed mood. J Reprod Infant Psychol 2006;24:99-106.  Back to cited text no. 19
    
20.
Bowen A, Bowen R, Butt P, Rahman K, Muhajarine N. Patterns of depression and treatment in pregnant and postpartum women. Can J Psychiatry 2012;57:161-7.  Back to cited text no. 20
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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