Elsevier

Journal of Affective Disorders

Volume 227, February 2018, Pages 731-738
Journal of Affective Disorders

Research paper
Factors associated with postpartum depression in women from low socioeconomic level in Argentina: A hierarchical model approach

https://doi.org/10.1016/j.jad.2017.11.091Get rights and content

Highlights

  • 167 (31.0%) mothers screened positive in the Edinburgh Postpartum Depression Scale (score ≥10).

  • 23 (4.3%) women that responded as having thoughts of self‑harm were included.

  • Lower education, higher parity, prior depression and lack of support were risk factors.

  • There is a need for improved screening and diagnosis for postpartum depression in Argentina.

Abstract

Purpose

to estimate the prevalence of depression at 4-week postpartum using the Edinburgh postpartum Depression Scale (EPDS) in women who delivered in a public maternity hospital in Argentina.

Methods

This prospective cohort study was carried out from March to August 2016 in northwest Argentina. Eligibility included delivering a singleton live birth 28 weeks of gestational age or over, 18 years or older and resided within 1 h from the maternity hospital. Women were excluded if they or their newborn were in the intensive care unit. We defined a positive screening as an EPDS score of 10 or higher or a positive response to item 10, which indicates thoughts of self-harm.

Results

A total of 587 women were enrolled and 539 women completed the home visit interview and the EPDS. A total of 167 (31.0%, 95% CI 27.1–35.1) mothers screened positive in the EPDS using a score ≥ 10 and 99 (18.4%, 95% CI 15.1–21.6%) using a score ≥ 13, which indicate increased severity of depressive symptoms. In both cases, the 23 (4.3%) women that responded as having thoughts of self-harm were included.

Conclusion

Nearly a third of women who participated had depressive symptoms at four weeks postpartum in a public hospital in Tucumán, Argentina. Socio-demographic, particularly personal psychiatric history, factors and social and cultural influences can impact results.

Our results highlight the need for improved screening and better diagnostic tool for women with postpartum depression in Argentina and to investigate the impact of postpartum depressive symptoms on women's health and their families.

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

References (61)

  • R. Alvarado et al.

    First validation of aSpanish-translated version of the Edinburgh postnatal depression scale (EPDS) for use in pregnant women. A Chilean study

    Arch. Womens Ment. Health

    (2015)
  • R. Alvarado et al.

    First validation of aSpanish-translated version of the Edinburgh postnatal depression scale (EPDS) for use in pregnant women. A Chilean study

    Arch. Womens Ment. Health

    (2015)
  • C. Alvarado-Esquivel et al.

    Validation of the Edinburgh postpartum depression scale in a population of puerperal women in Mexico

    Clin. Pract. Epidemiol. Ment. Health

    (2006)
  • Argentina, 2010. Instituto Nacional de Estadística y Censos. Censo nacional de población, hogares y viviendas: censo...
  • J.A. Barr et al.

    Infanticide secrets: qualitative study on postpartum depression

    Can. Fam. Physician

    (2008)
  • C.T. Beck

    Predictors of postpartum depression: an update

    Nurs. Res.

    (2001)
  • H.A. Bennett et al.

    Prevalence of depression during pregnancy: systematic review

    Obstet. Gynecol.

    (2004)
  • M. Bloch et al.

    Effects of gonadal steroids in women with a history of postpartum depression

    Am. J. Psychiatry

    (2000)
  • X.1 Chi et al.

    Screening for postpartum depression and associated factors Among women in China: a cross-sectional study

    Front. Psychol.

    (2016)
  • T.M. Cook et al.

    Descriptive epidemiology of stigma against depression in a general population sample in Alberta

    BMC Psychiatry

    (2010)
  • G. Cormick et al.

    Text message interventions for follow up of infants born to mothers positive for Chagas disease in Tucumán, Argentina: a feasibility study

    BMC Res. Notes

    (2015)
  • J.L. Cox et al.

    A controlled study of the onset, duration and prevalence of postnatal depression

    Br. J. Psychiatry

    (1993)
  • J.L. Cox et al.

    Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale

    Br. J. Psychiatry

    (1987)
  • J. Dayan et al.

    Prenatal depression, prenatal anxiety, and spontaneous preterm birth: a prospective cohort study among women with early and regular care

    Psychosom. Med.

    (2006)
  • C.L. Dennis et al.

    Identifying women at-risk for postpartum depression in the immediate postpartum period

    Acta Psychiatr. Scand.

    (2004)
  • Depressive Disorders

    Diagnostic and Statistical Manual of Mental Disorders

    (2013)
  • Y. Dibaba et al.

    The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia

    BMC Pregnancy Childbirth

    (2013)
  • T. Field et al.

    Prenatal depression effects on the fetus and newborn: a review

    Infant Behav. Dev.

    (2006)
  • J. Fisher et al.

    Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review

    Bull. World Health Organ.

    (2012)
  • N.I. Gavin et al.

    Perinatal depression: a systematic review of prevalence and incidence

    Obstet. Gynecol.

    (2005)
  • Cited by (25)

    • The peripartum period involvement in the development of post-partum depression. A prospective cohort study

      2022, Journal of Psychosomatic Research
      Citation Excerpt :

      The MINI interview was carried out the same day the EPDS was completed or within the following week. All questionnaires used were adapted from our previous studies in those maternal hospitals [9,11]. The study used the RedCap mobile app, an offline electronic data capture installed on tablets [11].

    • Triggering of postpartum depression and insomnia with cognitive impairment in Argentinian women during the pandemic COVID-19 social isolation in relation to reproductive and health factors

      2021, Midwifery
      Citation Excerpt :

      Another local research studied 86 women between 4 to 12 postpartum weeks in a private healthcare center, who achieved different EPDS scores: ≥10-12 (19%) and ≥13 (19%) (Mathisen et al., 2013). Pham et al. (2018), studied a cohort of 539 women in northwestern Argentina and found prevalences of 31% and 18% using the score cut-off ≥10 and ≥13 (EPDS), respectively. In another study, 45 puerperal women hospitalised in a public maternal hospital were interviewed during the first three postpartum days to find 37% with EPDS scores above 9 (Paolini et al., 2012).

    • Factors associated with depression during pregnancy in women from a low socioeconomic level: A hierarchical model approach

      2021, Psychiatry Research
      Citation Excerpt :

      We conducted a multivariate analysis using hierarchical modeling following the recommendations about the design. ( Pham et al., 2017) This conceptual hierarchical framework was constructed using knowledge of the demographic and biological determinants of depression during pregnancy looking for an explanatory or causal model. The relationship between depression during pregnancy and the study variables was conceptually based on a theoretical hierarchical model designed by the study investigators.

    • Depression after pregnancy

      2021, The Neuroscience of Depression: Features, Diagnosis, and Treatment
    • Risk factors for postpartum depression in Chinese women: A cross-sectional study at 6 weeks postpartum

      2021, Journal of Psychosomatic Research
      Citation 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.

    View all citing articles on Scopus
    View full text