Abstract

Clinical picture and triggering factors for postpartum depression (PPD, postnatal depression) may vary across culturally diverse women with different causes e.g. lack of breast-feeding and consanguinity. The reported incidence of PPD among samples of Arabic women ranges from 10% to 37%. In this study, we investigated a sample of mothers (n=216) attending the primary health care centers in Al-Madina, Saudi Arabia. Data acquisition was done via a cross-sectional design. Ethical committee approval was taken and participation in the study was optional. Herein, we report that PPD prevalence in this sample was 19.4% using the Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) with a cut-off score of ≥ 12. Our study included mothers of different age groups: <20 years, 20-30 years, 30-40 years and >40 years. Majority of investigated women were in the age group 20-30 years (60.2%, n= 130). Predictors of PPD were related to parity and gravidity. Primiparous women were at almost double-folded risk of getting PPD compared to multiparous women (adjusted OR=1.91; 95% CI: 1.01-3.38). Women who delivered by normal vaginal method were more likely to have PPD compared to those delivered by cesarean section (Adjusted OR=3.11; 95% CI: 1.35-7.16). However, PPD was not significantly associated with the presence of mothers of delivering women during their confinement. Vast majority of investigated women had a regular marital life (90.6%, n=196) i.e. not widows or divorced and were house wives (79.6, n = 172). There was no significant association between PPD and women`s age or women`s family income. Compared to non-working women, those working were at slightly higher risk for PPD. However, this was also not statistically significant. Likewise, mothers’ history of depression was not associated with having postnatal depression. Moreover, PPD was not associated with regular marital status or the level of education. The relatively low number of investigated cases in our study may be limitation. More future research studies are warranted.

1. Introduction

The term postpartum depression (PPD) is extensively utilized in recent years although its definition is still variable. PPD is defined in different ways depending on the source, and the diagnosis of PPD. PPD is related to the degree of the depression and the time duration between the start of depression and labour ¹. PPD is a mood disorder that begins after and usually lasts beyond six weeks. It is also termed postnatal depression ². The onset of PPD tends to be gradual and may persist for many months, or develop into a second bout following the next pregnancy ¹. PPD symptoms generally begin within 48 hours of delivery, peak at about 3 to 5 days ³, and lasts around 2 weeks. It may last up to several months or even a year ⁴. Depression constitutes a big load among psychiatric illnesses needing psychiatric care. Depression may be the second highest health problems in the near future ⁵.

Postnatal depression is an important category of depression. Currently, there is a large body of evidence proving that postnatal depression has a substantial impact on the mother, husband ⁶, family ⁷, and mother-baby interactions ⁸. Furthermore, postnatal depression affects the future cognitive and emotional development of newborns ⁹, especially when PPD occurs early ¹⁰. Published studies provides strong evidences that PPD is strongly related to long-term emotional, cognitive and intellectual problems in children ^{11, 12}. Studies from South East Asia and Africa proved that mothers’ depression is associated with impaired infant’s health and nutrition ^{13, 14, 15, 16}. Mothers’ fears regarding child protective services and separation from the baby may increase their anxiety regarding harming themselves or their babies ¹⁷.

The etiology of PPD is still obscure although several factors may play a role e.g. social, psychological and biological factors may involved. Psychosocial risk factors include lack of social support, recent negative life events, and a history of depression ^{18, 19} have been strongly associated with PPD. Women who suffered from depression during pregnancy were found to have a five times higher risk of developing PPD ¹⁹. Likewise, women with anxiety during pregnancy were found to have a three times higher risk for PPD ²⁰. In addition, PPD is postulated to be due to sudden hormonal withdrawal after delivery or poor response to circulating oxytocin hormone that usually enhances mother-infant attachment ²¹. Less than 50% of cases of PPD are detected by primary healthcare professionals in routine clinical practice ²².

PPD occurs during the first postpartum year and is manifested by helplessness, loss of energy, prolonged guilty sensation, lack of joy, decreased concentration, depressed mood, social withdrawal and lack of interest in self-care. PPD symptoms also include a low sense of self-worth, changes in appetite, sleep pattern disturbances, and suicidal ideation. Physical symptoms also include exhaustion, fatigue, changes in appetite, and sleep disorders ^{23, 24, 25}. Women suffering from PPD exhibit decreased interest in health promotion behaviors with suppressed emotional, physical, and psychological status ²⁶. The present study aims at investigating the prevalence and impact of personal factors upon PPD in women attending primary health care centers in Al-Madina (Al-Madinah), Saudi Arabia.

2. Methodology

Our study was performed in Al-Madinah, Saudi Arabia ²⁷. Al-Madinah is the second most important Islamic pilgrimage destination after Makkah. There are 48 primary health care centers in Al-Madina that introduce many health services to mothers and their children. Women attending the primary health care centers for immunizing their babies (aged one year or less) were considered in this study.

The population size (total number of mothers attending four primary health care clinics in one month) was 2510 mothers. The calculated sample size (using Epi info) was 224 mothers. This is a cross-sectional study that included women attending primary health care centers in Al-Madina. The study was performed over two successive years 2019-2020.

All woman were directly met by the first author during her visit for vaccinating her baby. The researcher used a questionnaire obtained from a previously published study. The tool consists of two sections: The first part is the Edinburgh Postnatal Depression Scale (EPDS) that was used to investigate PPD symptoms. EPDS included 10 points that were put to scan PPD criteria in community samples ²⁸. EPDS scale validates the intensity of depressive clinical picture. Each item is scored on a 4-point rate (from 0 to 3 reflecting increased intensity of symptoms) ²⁸. The minimum and maximum total scores are 0 and 30, respectively, in which 0 is the minimum depression score and 30 is the maximaum depression score ²⁸. EPDS was translated into many languages as Arabic, mother tongue of participants) and validated for use in scanning depression symptoms. This assists health workers to detect postnatal depression ²⁸.

The Arabic version of the EPDS was utilized in this study. Using a cut-off score of 12 out of 30, the specificity and the sensitivity of EPDS scale were 93% an 73%, respectively ²⁸. In this study, a cut-off score of ≥ 12 was used.

Ÿ All females in their postnatal period (one year or less were included)

Ÿ From all nationalities.

There were no exclusion criteria.

Statistical analysis was performed using SPSS software version 20.0. Categorical variables were used using a suitable frequency format. Crude and adjusted odds ratios were calculated. Results were presented in the form of crude and adjusted odd ratios (ORs) and their 95% confidence interval (CI) where 95% CI that does not include 1 were considered statistically significant.

A prior ethical committee approval was gained from the general supervisor of the postgraduate family medicine training program in Al-Madinah. Approval by the regional ethical committee was also gained. Participation in the study was optional and verbal consent was obtained from all women participating in this study. Participants’ confidentiality was guaranteed.

Investigated variables observed in the study included:

Ÿ Maternal age

Ÿ Marital status

Ÿ Educational level

Ÿ Working

Ÿ History of depression

Ÿ Presence of her own mother (grandmother) during puerperium

Ÿ Monthly income

Their socio-demographic characteristics are presented in Table 1. The age of 130 women (60.2% of investigated mothers) ranged from 20 to 30 years while that of 62 mothers (28.7%) ranged between 31 and 40 years. Majority of them (n= 196, 90.6%) were married. The remainder of women were either divorced (n=10, 4.6%) and widows (n=10, 4.6%). Slightly less than a third of them (n=66, 30.2%) were graduated from university whereas 10.2% (n=22) were illiterate. Most of them (79.6%, n=172) were house wives whereas the remaining 44 women (20.4%) were workers.

As indicated by Figure 1, PPD was present among 19.4% (n=42) of the investigated women who attended primary health care centers during the whole period of the study conduction.

As shown in Figure 1, more than one third of the investigated women (n= 82, 38%) had a monthly income of more than 10000 SR/month whereas 15.7% of them (n=34) had a monthly income less than 2000 SR/month.

Women`s family income was not significantly associated with PPD.

Then we studied other risk factors associated with PPD to delineate any possible significance or important association.

As illustrated in Table 2, women in the age group 20-30 years were at almost double risk for PPD compared to those aged less than 20 years. However, this difference was not statistically significant (crude OR=2.4; 95% CI: 0.52-11.03).

As shown in Table 3, mother`s marital status was not significantly related to the development of PPD.

Table 4 demonstrates that women`s educational level was not significantly related to the development of PPD.

Compared to non-working women, working mothers were at slightly higher risk for PPD. However, this was also not statistically significant as seen in Table 5 (crude OR=1.78; 95% CI: 0.82-3.84).

As shown in Table 6, mother`s past history of depression was not related to the development of PPD.

As seen in Figure 3, more than half of the women (53.7%) reported presence of their own mothers during confinement. That was not statistically significant in relation to PPD.

Results of logistic regression analysis revealed that primiparous women were at almost double-folded risk of getting PPD compared to multiparous women (adjusted OR=1.91; 95% CI: 1.01-3.38). Women who delivered by normal vaginal method were more likely to have PPD compared to those delivered by cesarean section (Adjusted OR=3.11; 95% CI: 1.35-7.16).

3. Discussion

Clinical picture and risk factors for development of PPD are variable in women from different cultures. Further future research is needed for evaluating these differences ²⁹ e.g. consanguinity (marriage to first or second cousins) and lack of breast-feeding were reported as potential risk factors for PPD ³⁰. Reported PPD incidence among Arabic women was from 10% to 37% ³¹. In a sample of 125 women living in the United Arab Emirates, 20% of investigated mothers exhibited moderate to high levels of PPD symptoms. Participating mothers having increased symptoms of PPD had lack of breastfeeding, poor relationships with their mother-in-law and negative body image ³².

In the present study, we report a prevalence of 19.4% of PPD (n= 42) (Figure 1) using the Arabic translation EPDS with a cut-off score of ≥ 12. In another Arabic study conducted in Bahrain kingdom using the same tool and cut-off point, a higher PPD prevalence was reported (37.1%) ³³. This difference could be partially attributed to the difference of the point of time applied in our study versus their study as they recruited women who were in the postnatal period and regularly visiting the 8-week child and mother clinic at primary health care centers. Our study included women who attended the primary health care centers for immunization of their babies aged one year or less.

Comparing our data with different published studies investigating PPD in other countries was difficult due to differently used tools (standardized diagnostic tools, screening tools, different cut-off points of the same tools, different time points and the cultural issues) ^{14, 34, 35, 36}. In spite of difficult PPD assessment tools, PPD prevalence and symptoms in our study were comparable to many reported studies in nearby countries. In a study In Emirates enrolling 95 mothers in Dubai and using the Present State Examination (PSE) assessment, PPD prevalence was 15.8% ³⁷. In Morocco, the PPD prevalence was 18.7% (at 2 weeks postpartum) using the Mini International Neuropsychiatric Interview (MINI). Moreover, PPD prevalence was 20.1%, using a cut-off score of 12 with the EPDS ³⁸. Moreover, Chaaya et al. in Lebanon reported a PPD prevalence rate of 21% (using an EPDS score of 12/13 at 4-5 months postpartum). Interestingly, PPD had resolved spontaneously after 4 months ³⁹. In turkey, PPD prevalence was 31.4% among all the mothers at six weeks postpartum (with a cut-off value of ≥13 using EPDS) ⁴⁰.

Our study included mothers of different age groups: <20 years, 20-30 years, 30-40 years and >40 years. Majority of investigated women were in the age group 20-30 years (60.2%, n= 130) (Table 1). Vast majority of investigated women are currently married (90.6%, n=196) (Table 1) i.e. not widows or divorced. Also, majority of investigated women are house wives (79.6, n = 172) (Table 1).

Our data revealed also that there was no association between PPD and women`s age (Table 2) and so was women`s family income that was not significantly associated with PPD (Figure 2).

Compared to non-working women, those working were at slightly higher risk for depression. However, this was also not statistically significant (Table 5). Likewise, mothers’ history of depression was not associated with having postnatal depression (Table 6). This is quite similar to what Al Dallal and Grant had reported in Bahrain kingdom ³³. Likewise, Ohara and Swain reported no association between a history of depression and postnatal depression ³⁴. Our study did not report any significant relationship between history of depression and PPD symptoms on the contrary of other studies ^{39, 40, 41, 42}.

In this study, PPD was not related to regular marital status (Table 3) or educational level (Table 4), which contradicts other reports from Canada and Lebanon that reported a relationship between decreased educational level and risks of developing PPD ^{39, 42, 43}. However, the number of investigated cases in our study may be a limitation that encourages increasing the sample in the future to show that more clearly. Educational levels may be directly associated with household income (Figure 2), which in turn may affect the women’s concerns about the costs of taking care of the infants. However, in Saudi Arabia, the primary care provider of the family is considered to be the husband and level of education is not necessarily related to household income. Additionally, this study found no significant relationship between PPD and family income which also conflicts with the results of Lanes et al. ⁴³ and Tannous et al. ⁴⁴.

Importantly in this study, primiparous women were at almost double-folded risk of getting PPD compared to multiparous women (adjusted OR=1.91; 95% CI: 1.01-3.38). Women who delivered by normal vaginal method were more likely to have PPD compared to those delivered by cesarean section (Adjusted OR=3.11; 95% CI: 1.35-7.16) (Table 7). In the current study, the support offered by participants’ `mothers (grandmothers) was examined. No significant association with EPDS score≥12 was found when grandmothers identified as a provider of support were present. Whether this perception was a reflection of reality or a manifestation of depressive symptoms could not be determined in this study. However, this study did not confirm such finding. However, PPD was not significantly associated with the presence of mothers of delivering women during their confinement (Figure 3).

Despite many limitations, our study findings may carry some importance in confirming the presence and prevalence of PPD in Al-Madina, Saudi Arabia. We declare herein that there were some limitations that faced our study. Data acquisition was done via a cross-sectional design. The EPDS screening test needs diagnostic confirmation through structured or semi-structured interviews ⁴⁵. Thus, accurate conclusions may not be got smoothly. The net PPD prevalence was limited to women visiting the primary health care centers. Hence, generalizing these results should be taken carefully. Finally, our study investigated mothers during the first postpartum year where antenatal depression was assessed by self-report without prior formal assessments done during pregnancy.

4. Conclusion

In conclusion, our data confirms that PPD is a relatively common psychiatric disorder that afflicts about one fifth of women in Al-Madina. This rate is comparable to those reported in other regional studies. Spontaneous vaginal delivery and primiparous status were predictors and triggers of PPD.

5. Recommendations

Our study recommends the following:

1. More effort and resources should be provided for better prevention and treatment programs of PPD in Al-Madina.

2. More research should be done for better enrollment of women during the antenatal period.

3. Saudi health authorities and physicians should be aware of the high prevalence rate and risk factors of PPD to protect mothers.

4. More prevalence studies should be performed in Saudi Arabia and should include larger samples of women. Future studies are better to be performed even in resource-poor settings.

5. Future studies should also be performed to validate EPDS and determine the appropriate cut off values.

6. Screening for depression in late pregnancy is strongly recommended to detect women at risk of PPD.

7. More qualified and skilled medical professionals should be ready to deal with PPD in cooperation with the psychiatry physicians.

Conflict of interest

The authors declare that there is no conflict of interest.

References