Research paperFactors associated with postpartum depression in women from low socioeconomic level in Argentina: A hierarchical model approach
Introduction
Perinatal maternal depression, defined as the onset of a nonpsychotic depressive episode of mild to major severity during pregnancy or the first 12 months postpartum (Gavin et al., 2005, Depressive Disorders, 2013), can in turn result in impaired mother-to-child bonding (Beck, 1998, Stein et al., 1991), adverse child development (Beck, 1998), and even suicide (Tabb et al., 2013) or infanticide (Barr and Beck, 2008). Unfortunately, despite its negative impact on maternal and child health, perinatal maternal depression is often under-diagnosed and under-treated (Gelaye et al., 2016a).
Postpartum depression (PPD) is considered one of the most frequent maternal morbidities after delivery, yet the published prevalence rates of PPD are difficult to compare across studies and countries. Initial reports of the World Health Organization described a prevalence of PPD of 10% for high-income countries (HICs) and 15% for low and middle-income countries (LMICs) (Fisher et al., 2012). A more recent a systematic review of PPD in 23 LMICs showed a pooled prevalence of 19.0% (15.5–23.0) (Gelaye et al., 2016a). However, studies from low to high-income countries show a wide variability that can be attributed to multiple factors such as the time of evaluation, the method of assessment, and the different assessment tools with various cutoff points (Halbreich and Karkun, 2006, O'Hara and Swain, 1996). Several literature reviews regarding PPD have shown that socioeconomic and cultural factors, such as dialects, perception and stigma of mental health and the utilization of a “Western” screening tool in a non-Western community, can also be driving forces for the wide range of PPD prevalence rates (Gelaye et al., 2016a, Zubaran et al., 2010, Bashiri and Spielvogel, 1999).
Argentina's healthcare system is comprised of 3 distinct sectors: the labor union, the private, and the public. There are two reported studies estimating PPD, which were conducted in the labor union and private sectors. Mathisen et al. found that 37.2% (27.7–47.7) of the 86 middle-class women interviewed from the labor union sector had depressive symptoms at 6-week postpartum, and the risk factors associated were cesarean section, pregnancy complications, labor complications, multiparity, and incomplete breast feeding (Mathisen et al., 2013). Rozic et al. estimated a prevalence of 17.8% (14.4–21.9) of the 398 women from the private sector at 5 days postpartum, and the risk factors included personal history of PPD or depression, maternal age less than 25 years old, tobacco consumption and complications in the newborn (Rozic et al., 2012).
It is relevant to provide information regarding the prevalence of PPD in the public sector. The public sector serves about 50% of the population, including those who lack formal work or cannot afford private insurance and are not eligible to receive labor union insurance funds. Women who receive care from the public hospitals are more likely to belong to a lower-middle socioeconomic level and prevalence of PPD in the public sector is expected to be higher due to the increased prevalence of risk factors (lower maternal age, multiparty, lower socioeconomic status (SES), and lesser access to health care) (Argentina, 2010, Schwarcz et al., 2008).
Our primary objective is to estimate the prevalence of PPD using the Edinburgh Postpartum Depression Scale (EPDS) at 4-week postpartum in women who delivered in a public maternity hospital in Tucumán, Argentina and to examine the association between PPD and sociodemographic, medical and obstetric factors.
Section snippets
Study design and participants
This observational prospective cohort study was carried out from March to August 2016 in San Miguel de Tucumán at the Instituto Maternidad Provincial Nuestra Señora de las Mercedes, a public maternity hospital that serves as the referral ward for northwest Argentina with approximately 7000 deliveries per year (Cormick et al., 2015).
Eligible women were those that had delivered a singleton live birth 28 weeks of gestational age or over, were 18 years or older, could provide at least 2 sources of
Results
1042 women were screened consecutively from the Labor and Delivery book and 706 were classified as potentially eligible (see Fig. 1). However, 119 were further excluded as they could not provide two sources of contact information (n = 1), lived more than 1 h from the maternity hospital (n = 42), were discharged from the maternity before study personnel could invite them (n = 5), refused (n = 10), were unable to be located (n = 53), or were not invited because the desired sampled size had been
Discussion
We found that the prevalence of PPD was 31.0% (95% CI 27.1–35.1) and 18.4% (95% CI 15.1–21.6%), using the cutoff score ≥ 10 and ≥ 13, respectively. The analysis from the hierarchical model showed that lower education level, higher parity, personal history of depression, perceived negative interaction with health care professionals, or feelings of vulnerability or insecurity at delivering, having a female newborn, or lacking childcare help were risk factors for screening positive for PPD.
Conclusion
Our prospective cohort study shows that nearly a third of women had depressive symptoms at four weeks postpartum in a public hospital in Tucumán, Argentina and further revealed that socio-demographic factors, particularly personal psychiatric history, and social and cultural influences can impact results. Due to the limited evidence in Argentina, our results highlight the need for improved screening and a better diagnostic tool for women with PPD. In addition, it would be prudent to further
Acknowledgements
The authors wish to thank the contribution of the Instituto de Ginecología y Obstetricia Nuestra Señora de las Mercedes in Tucumán, the research assistants, Sebastian Diaz and Valeria Bosio, El Centro de Educación Médica e Investigaciones Clínicas, and Instituto de Efectividad Clinica y Sanitaria. We would also like to express personal gratitude to the Tucuman community, especially the social workers including Adriana Diaz, Belén Villarreal, Luciana Villareal, Ana Silvia Naharro, Ayelén
Funding source
This work was supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Institute, National Heart, Blood, and Lung Institute, and the NIH Office of Research for Women’s Health through the Fogarty Global Health Fellows Program Consortium comprised of the University of North Carolina, John Hopkins University, Morehouse School of Medicine, and Tulane University (R25TW009340); also funded by the National Institutes
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2021, Journal of Psychosomatic ResearchCitation Excerpt :This hospital-based cross-sectional study revealed the incidence of PPDS among Chinese women to be 14.6%, consistent with previous studies performed in China [38]. The relative lower incidence compared to that in Pham et al. ‘s study may be the result of exclusion of cases of antenatal depression and history of depression [5]. It also revealed a statistically significant association between ABO blood groups and PPDS risk in Chinese women: women with blood group A had a significantly higher risk of PPDS, compared to those with other blood groups.