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Open Access 01-12-2019 | Mood Disorders | Research

Contextual-relationship and stress-related factors of postpartum depression symptoms in nulliparas: a prospective study from Ljubljana, Slovenia

Authors: Polona Rus Prelog, Marijana Vidmar Šimic, Tanja Premru Sršen, Maja Rus Makovec

Published in: Reproductive Health | Issue 1/2019

Abstract

Background

For a significant proportion of women, postpartum depression (PPD) is the first mood episode in their lives, yet its aetiology still remains unclear. Insecure attachment in close adult relationships is considered to be a risk factor for depressive symptoms. This study aimed to gain further insight into the risk factors for postpartum depression symptoms (PPDS) of nulliparas in Slovenia and to examine vulnerability to developing depressive symptoms, with an emphasis on contextual and stress-related characteristics.

Methods

The sample consisted of 156 nulliparas in the third trimester of pregnancy enrolled in a childbirth preparation program. The following instruments were applied: Experiences in Close Relationships-Revised, the Edinburgh Postpartum Depression Scale (EPDS), the Zung Anxiety Scale and a question battery designed by the research team including questions about emotional support and work-related stress. Logistic regression was used to test the association between demographic, social, environmental, personality and attachment variables and PPD of nulliparas (EPDS ≥10), controlling for baseline (prepartum) depression score. A multivariable linear regression model was built with the postpartum EPDS continuous score as a dependent variable.

Results

28/156 (17,9%) were evaluated as being at risk for depression (EPDS≥10) in the last trimester and 25/156 (16%) at six weeks postpartum. The results of the logistic regression model controlled for prepartum depression score showed that increased risk for developing PPDS was associated with anxiety level postpartum, intimate-partner-attachment anxiety postpartum, and elevated stress due to loss of employment or an unsuccessful search for employment in the previous year. The results of the multivariable regression model, however, showed the association with education and postpartum anxiety with PPDS continuous score; EPDS after giving birth was higher for more educated and more anxious primiparas.

Conclusions

Our findings demonstrate the importance of anxiety symptoms and higher education level in assessments of nulliparas’ mental health. The results of our study show and confirm the results of previous research that anxiety symptoms in the immediate postpartum period are likely to be associated with depressive symptoms in nulliparas. The results also suggest that higher level of education of first-time mothers might not be a protective factor, especially for nulliparas with the university level of education. Further studies on larger samples should be considered.

Banti S, Mauri M, Oppo A, Borri C, Rambelli C, Ramacciotti D, et al. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset of depression. Results from the Perinatal Depression–Research & Screening Unit study. Compr Psychiatry. 2011;52(4):343–51. https://doi.org/10.1016/j.comppsych.2010.08.003.CrossRefPubMed

Glover V. Maternal depression, anxiety and stress during pregnancy and child outcome; what needs to be done. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):25–35. https://doi.org/10.1016/j.bpobgyn.2013.08.017.CrossRefPubMed

Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy. Curr Opin Psychiatry. 2012;25(2):141–8. https://doi.org/10.1097/yco.0b013e3283503680.CrossRefPubMedPubMedCentral

Hübner-Liebermann B, Hausner H, Wittmann M. Recognizing and treating Peripartum depression. Dtsch Arztbl Int. 2012;109(24):419–24. https://doi.org/10.3238/arztebl.2012.0419.CrossRef

Giardinelli L, Innocenti A, Benni L, Stefanini M, Lino G, Lunardi C, et al. Depression and anxiety in perinatal period: prevalence and risk factors in an Italian sample. Arch Wom Ment Health. 2011;15(1):21–30. https://doi.org/10.1007/s00737-011-0249-8.CrossRef

Robertson E, Grace S, Wallington T, Stewart D. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004;26(4):289–95. https://doi.org/10.1016/j.genhosppsych.2004.02.006.CrossRefPubMed

Goodman JH, Chenausky KL, Freeman MP. Anxiety disorders during pregnancy. J Clin Psychiatry. 2014;75(10):1153–84. https://doi.org/10.4088/jcp.14r09035.CrossRef

Darcy JM, Grzywacz JG, Stephens RL, Leng I, Clinch CR, Arcury TA. Maternal depressive symptomatology: 16-month follow-up of infant and maternal health-related quality of life. J Am Board Fam Med. 2011;24(3):249–57. https://doi.org/10.3122/jabfm.2011.03.100201.CrossRefPubMedPubMedCentral

Xu H, Ding Y, Ma Y, Xin X, Zhang D. Cesarean section and risk of postpartum depression: a meta-analysis. J Psychosom Res. 2017;97:118–26. https://doi.org/10.1016/j.jpsychores.2017.04.016.CrossRefPubMed

10.

Rini C, Schetter C, Hobel C, Glynn L, Sandman C. Effective social support: antecedents and consequences of partner support during pregnancy. Pers Relatsh. 2006;13(2):207–29. https://doi.org/10.1111/j.1475-6811.2006.00114.x. CrossRef

11.

Pepping C, Halford W. Attachment and relationship satisfaction in expectant first-time parents: the mediating role of relationship enhancing behaviors. J Res Pers. 2012;46(6):770–4. https://doi.org/10.1016/j.jrp.2012.08.005.CrossRef

12.

Lee J, Koo H. The relationship between adult attachment and depression in Korean mothers during the first 2 years postpartum: a moderated mediation model of self-esteem and maternal efficacy. Pers Individ Dif. 2015;79:50–6. https://doi.org/10.1016/j.paid.2015.01.021. CrossRef

13.

Warfa N, Harper M, Nicolais G, Bhui K. Adult attachment style as a risk factor for maternal postnatal depression: a systematic review. BMC Psychol. 2014;2(1):56. https://doi.org/10.1186/s40359-014-0056-x.CrossRefPubMedPubMedCentral

14.

Bifulco A, Figueiredo B, Guedeney N, Gorman L, Hayes S, Muzik M, et al. Maternal attachment style and depression associated with childbirth: preliminary results from a European and US cross-cultural study. Br J Psychiatry. 2004;184(46):31–7. https://doi.org/10.1192/bjp.184.46.s31.CrossRef

15.

Ikeda M, Hayashi M, Kamibeppu K. The relationship between attachment style and postpartum depression. Attach Hum Dev. 2014;16(6):557–72. https://doi.org/10.1080/14616734.2014.941884. CrossRefPubMed

16.

Monk C, Leight K, Fang Y. The relationship between women’s attachment style and perinatal mood disturbance: implications for screening and treatment. Arch Womens Ment Health. 2008;11(2):117–29. https://doi.org/10.1007/s00737-008-0005-x.CrossRefPubMedPubMedCentral

17.

Robakis TK, Williams KE, Crowe S, Lin KW, Gannon J, Rasgon NL. Maternal attachment insecurity is a potent predictor of depressive symptoms in the early postnatal period. J Affect Disord. 2016;190:623–31. https://doi.org/10.1016/j.jad.2015.09.067.CrossRefPubMed

18.

Simard V, Moss E, Pascuzzo K. Early maladaptive schemas and child and adult attachment: a 15-year longitudinal study. Psychol Psychother. 2011;84(4):349–66. https://doi.org/10.1111/j.2044-8341.2010.02009.x. CrossRefPubMed

19.

Roisman G, Fraley R. A behavior-genetic study of parenting quality, infant attachment security, and their covariation in a nationally representative sample. Dev Psycho. 2008;44(3):831–9. https://doi.org/10.1037/0012-1649.44.3.831. CrossRef

20.

Fearon RM, Roisman GI. Attachment theory: progress and future directions. Curr Opin Psychol. 2017;15:131–6. https://doi.org/10.1016/j.copsyc.2017.03.002.CrossRefPubMed

21.

Selboe ST, Skogås AK. Working fulltime throughout pregnancy – the Norwegian women's perspectives. A qualitative approach. Midwifery. 2017;50:193–200. https://doi.org/10.1016/j.midw.2017.04.012.CrossRefPubMed

22.

Gjerdingen D, McGovern P, Attanasio L, Johnson P, Kozhimannil KB. Maternal depressive symptoms, employment and social support. J Am Board Fam Med. 2014;27(1):87–96. https://doi.org/10.3122/jabfm.2014.01.130126.CrossRefPubMed

23.

Miyake Y, Tanaka K, Sasaki S, Hirota Y. Employment, income, and education and risk of postpartum depression: the Osaka maternal and child health study. J Affect Disord. 2011;130(1–2):133–7. https://doi.org/10.1016/j.jad.2010.10.024.CrossRefPubMed

24.

Gender statistics - Statistics Explained [Internet]. [place unknown]. Ec.europa.eu. 2018. [updated 2018 Feb 2018; cited 2018 Sep 24]. Available from: https://ec.europa.eu/eurostat/statistics-explained/index.php/Gender_statistics

25.

Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland. BMJ Open. 2013;3(11):e004047. https://doi.org/10.1136/bmjopen-2013-004047.CrossRefPubMedPubMedCentral

26.

Iwata H, Mori E, Sakajo A, Aoki K, Maehara K, Tamakoshi K. Prevalence of postpartum depressive symptoms during the first 6 months postpartum: association with maternal age and parity. J Affect Disord. 2016;203:227–32.CrossRefPubMed

27.

O'Connell MA. Preventing, recognising, and responding to fear of childbirth and birth trauma. BMJ. 2019;365:l2279.CrossRefPubMed

28.

Koprivnik P, Plemenitaš A. Pojavnost depresij v poporodnem obdobju v slovenskem vzorcu. Med Razgl. 2005;44:139–45.

29.

Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev. 2013;(2). https://doi.org/10.1002/14651858.CD001134.pub3.

30.

Sylvén SM, Thomopoulos TP, Kollia N, Jonsson M, Skalkidou A. Correlates of postpartum depression in first time mothers without previous psychiatric contact. Eur Psychiatry. 2017;40:4–12. https://doi.org/10.1016/j.eurpsy.2016.07.003.CrossRefPubMed

31.

Yim IS, Tanner Stapleton LR, Guardino CM, Hahn-Holbrook J, Dunkel Schetter C. Biological and psychosocial predictors of postpartum depression: systematic review and call for integration. Annu Rev Clin Psychol. 2015;11(1):99–137. https://doi.org/10.1146/annurev-clinpsy-101414-020426.CrossRefPubMedPubMedCentral

32.

O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.CrossRefPubMed

33.

Fraley RC, Waller NG, Brennan KA. An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol. 2000;78(2):350–65. https://doi.org/10.1037//0022-3514.78.2.350.CrossRefPubMed

34.

Cox JL, Holden J, Henshaw C. Perinatal mental health: the EPDS manual. 2nd ed. London: RCPsych Publications; 2014.

35.

Cox JL, Chapman G, Murray D, Jones P. Validation of the Edinburgh postnatal depression scale (EPDS) in non-postnatal women. J Affect Disord. 1996;39:185–9. https://doi.org/10.1016/0165-0327(96)00008-0.CrossRefPubMed

36.

Koprivnik P, Plemenitaš, A. Screening for postpartum depression – why is it not implemented in Slovenia? Zdrav Vestn. [Internet]. 2009 [cited 2018 Sep 24]. 78(5): 261–264. Available from: http://www.dlib.si/?URN=URN:NBN:SI:DOC-NHG94LAA

37.

Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12(6):371–9. https://doi.org/10.1016/S0033-3182(71)71479-0.CrossRefPubMed

38.

Peduzzi P, Concato J, Kemper E, Holford TR, Fein-stein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49:1373–9.CrossRefPubMed

39.

Agresti A. In: Hoboken NJ, editor. An introduction to categorical data analysis: Wiley; 2007.

40.

Abajobir AA, Maravilla JC, Alati R, Najman JM. A systematic review and meta-analysis of the association between unintended pregnancy and perinatal depression. J Affect Disord. 2016;192:56–63. https://doi.org/10.1016/j.jad.2015.12.008.CrossRefPubMed

41.

Mercier RJ, Garrett J, Thorp J, Siega-Riz AM. Pregnancy intention and postpartum depression: secondary data analysis from a prospective cohort. BJOG. 2013;120(9):1116–22. https://doi.org/10.1111/1471-0528.12255.CrossRefPubMedPubMedCentral

42.

Christensen AL, Stuart EA, Perry DF, Le HN. Unintended pregnancy and perinatal depression trajectories in low-income, high-risk Hispanic immigrants. Prev Sci. 2011;12(3):289–99. https://doi.org/10.1007/s11121-011-0213-x.CrossRefPubMedPubMedCentral

43.

Xie RH, He G, Koszycki D, Walker M, Wen SW. Fetal sex, social support, and postpartum depression. Can J Psychiatr. 2009;54(11):750–6. https://doi.org/10.1177/070674370905401105. CrossRef

44.

Shapiro GD, Fraser WD. Review: psychosocial and psychological interventions reduce postpartum depression. Ann Intern Med. 2013;159(4):JC8. https://doi.org/10.7326/0003-4819-159-4-201308200-02008.CrossRefPubMed

45.

Della Vedova AM, Ducceschi B, Cesana BM, Imbasciati A. Maternal bonding and risk of depression in late pregnancy: a survey of Italian nulliparous women. J Reprod Infant Psychol. 2011;29:208–22. https://doi.org/10.1080/02646838.2011.592973. CrossRef

46.

Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY. Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol. 2007;110(5):1102–12. https://doi.org/10.1097/01.AOG.0000287065.59491.70.CrossRefPubMed

47.

Ross LE, Evans SE, Sellers EM, Romach MK. Measurement issues in postpartum depression part 1: anxiety as a feature of postpartum depression. Arch Womens Ment Health. 2003;6(1):51–7. https://doi.org/10.1007/s00737-002-0155-1.CrossRefPubMed

48.

Falah-Hassani K, Shiri R, Dennis CL. Prevalence and risk factors for comorbid postpartum depressive symptomatology and anxiety. J Affect Disord. 2016;198:142–7. https://doi.org/10.1016/j.jad.2016.03.010.CrossRefPubMed

49.

Kirchmann H, Steyer R, Mayer A, Joraschky P, Schreiber-Willnow K, Strauss B. Effects of adult inpatient group psychotherapy on attachment characteristics: an observational study comparing routine care to an untreated comparison group. Psychother Res. 2012;22(1):95–114. https://doi.org/10.1080/10503307.2011.626807.CrossRefPubMed

50.

Pham D, Cormick G, Amyx MM, Gibbons L, Doty M, Brown A, Norwood A, Daray FM, Althabe F, Belizán JM. Factors associated with postpartum depression in women from low socioeconomic level in Argentina: a hierarchical model approach. J Affect Disord. 2018;227:731–8.CrossRefPubMed

51.

Bad HE, Alhamdan N, Ajaj A, Alali F. Postpartum depression and health related quality of life: a necessary assessment. Int J Fam Commun Med. 2017;1(1):00005.

Title: Contextual-relationship and stress-related factors of postpartum depression symptoms in nulliparas: a prospective study from Ljubljana, Slovenia
Authors: Polona Rus Prelog
Marijana Vidmar Šimic
Tanja Premru Sršen
Maja Rus Makovec
Publication date: 01-12-2019
Publisher: BioMed Central
Keywords: Mood Disorders
Postpartum Depression
Postpartum Depression
Affective Disorder
Anxiety
Published in: Reproductive Health / Issue 1/2019
Electronic ISSN: 1742-4755
DOI: https://doi.org/10.1186/s12978-019-0810-x

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Springer Medicine

Contextual-relationship and stress-related factors of postpartum depression symptoms in nulliparas: a prospective study from Ljubljana, Slovenia

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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