Keywords
depression - pregnancy - risk factors - prenatal care - postpartum period
Palavras-chave
depressão - gravidez - fatores de risco - pré-natal - perído pós-parto
Introduction
The pregnancy-puerperal cycle, either due to psychosocial factors or hormonal changes,
is a time of high risk for the development of depression.[1] A study of 1,558 women revealed that 17% of the pregnant women and 18% of women
in the immediate puerperium period screened had significant depressive symptoms in
late pregnancy.[2] Perinatal depression can lead to a range of consequences, such as the deterioration
of maternal care and the distress of the mother-infant relationship. It may also cause
adverse outcomes for the child's growth and development if it occurs during the puerperium
period.[3] It is vital, therefore, to pay special attention to the diagnosis and early treatment
of perinatal depression.
According to Martins,[4] the psychiatric disorders that predominantly affect women in the perinatal period
are divided into three categories: deep sadness syndrome, postpartum depression, and
postpartum psychosis. The deep sadness syndrome, also known as “baby blues,” begins
within the first 2 weeks postpartum, and symptoms may include crying, sadness, increased
anxiety, irritability, instability, mood swings, fatigue, and sleep disorders. Postpartum
psychosis develops within the first 3 weeks after delivery, a period in which the
symptoms are intense and severe, and may include delusions, conferring risk to both
mother and child.[5]
Perinatal psychiatric disorders usually occur within the first months postpartum,
but can happen earlier,[6] with the gradual development of depressive symptoms, which may be mistaken with
the deep sadness syndrome after childbirth.[7] Postpartum depression is a psychiatric disorder that causes emotional, behavioral,
and physical changes associated with the puerperium. It is estimated that 25 to 35%
of women develop depressive symptoms and ∼ 20% may experience depression, with an
intensification of symptoms in the 3rd trimester of pregnancy.[8]
Perinatal depression is multifactorial, involving psychosocial and sociodemographic
variables, physiological and biological factors, hereditary predispositions, and hormonal
changes. It relates to the body, mind, and lifestyle of the puerperal woman, and is
deemed difficult to prevent, as no single strategy has so far been capable of preventing
the disorder effectively.[9] Increased stress during pregnancy and delivery has been associated with the etiology
of postpartum depression. Consequently, both gestation and postpartum periods require
careful analysis to facilitate an early identification of the psychosocial, hormonal,
and physiological factors causing depression.[10]
As suggested by Salum e Morais et al.,[11] the major risk factors for postpartum depression include the lack of support from
the partner, family, and friends; low level of education; being a single mother with
a high parity; pregnancy at a young age; stress; and low family income. Other factors,
such as unwanted pregnancies, primiparous women, preterm births, marital conflicts,
and the death of family members or the last infant, also contribute to the adversity.[12]
We highlight, thus, the importance of the health professional for the early awareness
of the aforementioned factors in the effort to prevent depressive disorders and their
consequences in the perinatal period. Difficulties, however, such as lack of time,
the stigma related to mental illnesses during pregnancy and in the postpartum, and
insufficient or inadequate training in graduate school hinder the early detection
by obstetricians.[13] On that account, to reduce the impact of depression in pregnancy and the puerperium
on the mother, child, family, and community, it is necessary to discuss the different
aspects of the complication in the context of public health.
Developed by Cox et al.[14] in 1987 to assist primary care health professionals to detect postpartum depression
disorders, the Edinburgh postpartum depression scale (EPDS) is a screening questionnaire
that has been widely used to evaluate symptoms of depression during pregnancy and
the puerperium. The test can be completed by the patient in 5 minutes and consists
of a scale with 10 items, assessing symptoms related to depression over the preceding
7 days, with scores ranging from 0 to 3 for each item. The final result, therefore,
varies from 0 to 30.
The authors evaluated its psychometric properties in the United Kingdom, obtaining
a sensitivity of 86% and a specificity of 78%. Different scores (between 9–13 points)
were compared in the EPDS, with a good correlation.[14] The scores often used for diagnosis were ≥ 10 or ≥ 12 points. Decreasing the score,
the sensitivity increases, but the specificity decreases, causing the occurrence of
an elevated false-positive rate.[14] In Brazil, the scale was validated by Santos et al. in 1999.[15] The authors suggest a cutoff point of 11 to 12, with a sensitivity of 72% and a
specificity of 88%. The main objective of the present research was to identify patients
experiencing depression during pregnancy and the immediate postpartum period using
a score ≥ 12 in the EPDS as a cutoff point indicating depression, so as to establish
a line of care for the vulnerable group.
Methods
The cross sectional study included 315 women, aged between 14 and 44 years, who received
perinatal care at the Maternity Hospital Leonor Mendes de Barros (HMLMB), in São Paulo,
between July 1, 2019 and October 30, 2020. The interview was conducted with 136 pregnant
women with more than 28 weeks of gestation, and 176 postpartum women within the first
postpartum week. The research protocol was approved by the local research ethics committee
before the study began, and all of the women provided written informed consent prior
to participating in the interview. After signing the consent form, the patient was
enrolled in the study and replied to the interview conducted by one of the authors
of study (T. A. O./G. G. C. M. L.). In the interview, the women first answered a questionnaire
to identify the major risk factors associated with depression. Afterward, the patient
herself filled out the EPDS. The scale was completed in ∼ 5 minutes. The interviewers
had been trained in the use of the EPDS, and any doubts that eventually came up were
jointly discussed. All such interviews took place in ambulatory or maternity ward
settings. The interviewer remained blind to the score or the answers because after
EPDS to be completed by the mother then it was placed together with the questionnaire
in an envelope.
The cutoff was ≥ 12 to indicate whether the patient had depression. The exclusion
criteria were: absence of prenatal care, women pregnant with fetuses with congenital
malformations and/or diseases incompatible with life, assisted fertilization, stillbirth,
and neo-mortality. The collected data was assessed on Microsoft Office Excel 10 spreadsheets
(Microsoft Corp., Redmond, WA, USA), the Epi Info 7 program was used to analyze the
frequency distribution of categorical variables, and the Mann-Whitney test was used
to analyze the continuous variables. The independent variables were categorized to
analyze the association between each independent and outcome variable using a bivariate
analysis to calculate the crude odds ratio with 95% confidence interval. Those variables
that were associated with a p-value < 0.1 in the bivariate analysis were entered into a multivariate logistic regression
model to calculate the adjusted Odds Ratio and to eliminate the effects of confounding.
Analyses by means of logistic regression were performed using the BioStat version
5.3 software.The statistical significance level was set to p < 0.05 for all analyses.
Results
Among 315 patients, 62 (19.7%) patients scored ≥ 12 in the EPDS screening, experiencing
probable perinatal depression. The demographic characteristics of the patients are
shown in [Table 1]. The age ranged from 14 to 44 years, with the average age of 28.3 ± 6.1 in the group
signaling perinatal depression (group 1) and 28.9 ± 6.8 years in the group of women
without depression (group 2). There were no significant differences in relation to
skin color, marital status, use of contraceptive methods by the couple, occupation
of the partner or the pregnant woman, and level of education. There were significant
differences related to the average family income, which was lower in the group with
depression (group 1).
Table 1
Sociodemographic characteristics of the group screened with the Edinburgh postpartum
depression scale
|
Variables
|
Group 1
(n = 62)
|
Group 2
(n = 253)
|
P-value
|
|
Age average (years)
|
28.3 ± 6.1
|
28.9 ± 6.8
|
0.65
|
|
White (%)
|
26 (41.9)
|
125 (49.4)
|
0.29
|
|
Married/cohabitation
|
50 (80.6)
|
220 (86.9)
|
0.20
|
|
Do not use contraceptives
|
15 (24.2)
|
60 (23.7)
|
0.93
|
|
Partner with occupation
|
48 (77.4)
|
202 (79.8)
|
0.67
|
|
Mothers with occupation
|
28 (45.2)
|
138 (54.5)
|
0.18
|
|
Monthly income average
|
1,954 ± 1,320
|
2,393 ± 1,488
|
0.02
|
|
Education ≤ 8 years
|
10 (16.1)
|
41 (16.2)
|
0.98
|
As seen in [Table 2], depressive symptoms were more frequent in multiparous than in nulliparous women,
and the average of prenatal appointments was lower. Group 1 also had a higher incidence
of previous depression or emotional disorders. Contrarily, complications associated
with the pregnancy and the type of delivery did not present significant differences
between the two groups ([Table 2]).
Table 2
Clinical and obstetric variables of the group screened with the Edinburgh postpartum
depression scale
|
Variables
|
Group 1
(n = 62)
|
Group 2
(n = 253)
|
P-value
|
|
Nulliparous (%)
|
8 (12.9)
|
76 (30)
|
0.01
|
|
Average perinatal appointments
|
7.8 ± 3.2
|
9.2 ± 3.6
|
0.01
|
|
Pregnancy adversities
|
26 (43)
|
78 (30.8)
|
0.09
|
|
Antecedents of depression or psychiatric disorders
|
26 (41.9)
|
33 (13)
|
< 0.01
|
|
Vaginal birth
|
18/27 (66.7)
|
92/149 (61.7)
|
0.62
|
The behavioral aspects of the couple during the third trimester and the first postpartum
week were analyzed in [Table 3]. Dissatisfaction with the pregnancy was more evident in group 1, in which some patients
even acknowledged the wish for abortion in early pregnancy. The lack of a good relationship
with the partner was another aspect more frequent in group 1. Contrarily, the support
of the partner, both during pregnancy and after childbirth, was not contrasting statistically.
Psychological aggression (mistreatment) was also more frequent in group 1, while physical
aggression was situated on the threshold of statistical significance. The delivery
experience, however, was considered positive for most patients in both groups.
Table 3
Behavioral variables of the group screened with the Edinburgh postpartum depression
scale
|
Behavioral variables
|
Group 1
(n = 62)
|
Group 2
(n = 253)
|
P-value
|
|
Satisfaction with pregnancy
|
55 (88.7)
|
244 (96.4)
|
0.03
|
|
Desire to abort in the beginning of the pregnancy
|
10 (16.1)
|
13 (5.1)
|
< 0.01
|
|
Bad relationship with the partner
|
18 (29)
|
18 (7.1)
|
< 0.01
|
|
Partner's support during pregnancy
|
52 (83.9)
|
227 (89.7)
|
0.19
|
|
Partner's support after childbirth
|
24/27 (88.9)
|
138/149 (92.6)
|
0.45
|
|
Physical aggression
|
3 (4.8)
|
2 (0.8)
|
0.05
|
|
Psychological aggression
|
14 (22.6)
|
14 (5.5)
|
< 0.01
|
|
Negative experience during delivery
|
5/27 (18.5)
|
13/149 (8.7)
|
0.16
|
Standard multiple regressions were performed to differentiate the independent effects
of predictor variables on the occurrence of perinatal depression ([Table 4]). Antecedents of depression or psychiatric disorders and psychology aggression during
pregnancy showed to be predictive of perinatal depression development on a multivariable
analysis.
Table 4
Multivariable analysis showing the risk factors associated with the perinatal depression
of the pregnant women (n = 315) screened with the Edinburgh postpartum depression scale
|
Variables
|
Coefficient
|
OR
|
IC95%
|
P-value
|
|
Nuliparous
|
-0.2312
|
0.7936
|
0.33 a 1.93
|
0.6103
|
|
Montly income ≤ R$ 1,800[**]
|
0.5200
|
1.6820
|
0.91 a 3.11
|
0.0972
|
|
Satisfaction with pregnancy
|
0.0482
|
1.0504
|
0.25 a 4.43
|
0.9459
|
|
Desire to abort in the beginning of the pregnancy
|
0.8886
|
2.4316
|
0.87 a 6.77
|
0.0890
|
|
Bad relationship with the partner
|
0.0954
|
1.1001
|
0.14 a 8.92
|
0.9288
|
|
Physical aggression
|
-0.3464
|
0.7020
|
0.08 a 6.65
|
0.7619
|
|
Psychological aggression
|
1.2900
|
3.6329
|
1.49 a 8.88
|
0.0047[*]
|
|
< 10 appointments [**]
|
-0.0204
|
0.9798
|
0.53 a 1.82
|
0.9486
|
|
Antecedents of depression or psychiatric disorders
|
1.1362
|
3.1149
|
1.52 a 6.39
|
0.0019[*]
|
* Statistically significant
** Best cutoff point for analysis
Discussion
The lower income in group 1 demonstrates the lack of social support for the exercise
of motherhood, as concerns, doubts, and domestic conflicts can be triggered due to
the lack of economic resources to support the newborn or even the family, also considering
that multiparous women are associated with an increased risk of depression. Our study
shows that psychosocial risk factors are strongly related with the onset of depression
in the sample group, whether due to dissatisfaction with the pregnancy or poor relationship
with the partner, even when the experience of childbirth was positive.
The study did not relate physical or hormonal factors as some authors have done,[9]
[16] searching for a biological cause for depression. It was considered that the antecedent
of depression or emotional disorders, more frequent in group 1, makes it unlikely
that hormonal changes, typical of pregnancy, will have a preponderant role in depression
during the period since all pregnant women had similar hormonal changes, yet only
20% developed depression.
Gauthreaux et al.[17] examined the relationship between the desire to be pregnant and postpartum depression
by assessing depressive symptoms. The authors concluded that women who did not wish
to become pregnant had a higher risk of developing postpartum depression than women
who desired pregnancy. Turkcapar et al.[18] noticed the same correlation, detecting a percentage of women with postpartum depression
who were dissatisfied with their pregnancies. Similar to our case study, the authors
also concluded that episodes of domestic violence were associated with the group experiencing
depression. Among the main risk factors, antecedents of depression and psychological
aggression were highlighted. In fact, women who experienced previous history of depression
have strong association with depressive symptoms in pregnancy, regardless of ethnicity.[19] In the present study, antecedents of depression or psychiatric disorders along with
psychological aggression were found to be independently associated with perinatal
depression.
The occurrence of perinatal depression may lead to the discontinuation of breastfeeding,
family conflicts, and the neglect of the infant's physical and psychological needs.
By compromising the ability to create healthy and stable bonds, the disorder can negatively
influence the relationship between mother and child, in addition to cause damage to
the psychomotor and language development and, as a result, lead to relevant cognitive
and social impairments.[20] Adolescents and children whose mothers had postpartum depression showed an elevated
risk of multiple adverse outcomes.[21]
This study emphasizes the importance of identifying risk factors based on an individual's
subjective experience. The scales for diagnosing depression are tools that facilitate
tracking and diagnosing the disorder during prenatal care and the immediate puerperium.
The use of validated scales can contribute to the production of new evidence concerning
the correlation of risk factors and protective measures during pregnancy. Evidence
is necessary to support health professionals in the preventive implementation of an
adequate approach to coping with the problem.
Antecedents of depression, physical and emotional stress, either caused by socioeconomic
factors such as income or by the lack of support from the partner, are risk factors
for perinatal depression. The creation of prenatal programs based on a psychological
approach, as stated by some authors,[22]
[23]
[24] can contribute to the definition of a preventive line of care focused on perinatal
depression. During prenatal care, it is necessary to verify the need for support by
assessing the quality of the pregnant women's relationships, contributing to the establishment
of positive social relations during the period. Since depression is the most common
complication of the perinatal period currently, health professionals, particularly
doctors and nurses, play a fundamental role in its early detection as well as intervention.
Thus, avoiding the occurrence or worsening of the depressive process and its consequences.
This study suggests that all pregnant women should undergo screening in the third
trimester of pregnancy or the postpartum period. The EPDS is a simple and useful instrument
for screening, as it presents an easy method for diagnosis. To treat the vulnerable
group, alongside screenings, professional references and therapeutic resources are
also needed.
Conclusion
In conclusion, there is a significant association between the occurrence of depression
and certain psychosocial factors, notably antecedents of depression and psychological
abuse, which were predictive factors in a multivariate analysis. To face this challenge,
prenatal care must provide a comprehensive psychological approach to identify and
treat the disorder. Offering an appropriate line of care to the vulnerable group will
contribute to the improvement of the wellbeing of the mother and the future of the
infant.
