|Year : 2015 | Volume
| Issue : 3 | Page : 657-662
Risk factors of maternal depression and anxiety in El-Fayum city
Taghreed M Farahat, Mohammad M Alkot, Kawthar A Emam
Department of Family Medicine, Menoufia Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||27-Mar-2014|
|Date of Acceptance||22-Jun-2014|
|Date of Web Publication||22-Oct-2015|
Kawthar A Emam
El-Fayum, 22 El Horryia Street, Baghous
Source of Support: None, Conflict of Interest: None
The aim of this study was to determine the risk factors of maternal depression and/or anxiety among women attending the primary health care facilities in El-Fayum city.
Women suffering from depression and/or anxiety during pregnancy are at an increased risk for postpartum depression throughout the perinatal period.
Patients and methods
This study was a nested case-control cross-sectional survey conducted among women attending primary health care centers in El-Fayum city.
The strongest risk factors of maternal depression and/or anxiety were presence of previous history of psychiatric illness (including antenatal and postnatal depression) to the woman or one of her family members, stressful life events or physical problems during pregnancy and early postpartum, and low levels of social support. History of abortion or miscarriage showed statistically significant results and was considered as an important risk factor (52% of the depressed cases had a previous history of abortion in comparison with controls). Logistic regression analysis was used to determine significant risk factors of maternal depression where the main risk factors for maternal depression and/or anxiety were history of abortion or miscarriage (odds ratio 4.1) and history of previous psychiatric illness (odds ratio 2.7) (including antenatal depression and postnatal depression).
Investigating perinatal stress and depression and identification of risk factors of these conditions may reduce the risk for postpartum chronic anxiety or undiagnosed depression.
Keywords: Anxiety, maternal depression, risk factors
|How to cite this article:|
Farahat TM, Alkot MM, Emam KA. Risk factors of maternal depression and anxiety in El-Fayum city. Menoufia Med J 2015;28:657-62
| Introduction|| |
Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration. Moreover, depression often comes with symptoms of anxiety. These problems can become chronic or recurrent and lead to substantial impairments in an individual's ability to take care of his or her everyday responsibilities. At its worst, depression can lead to suicide. Almost one million lives are lost yearly due to suicide, which translates to 3000 suicide deaths every day. For every person who completes a suicide, 20 or more may attempt to end his or her life. There are multiple variations of depression that a person can suffer from, with the most general distinction being depression in people who have or do not have a history of manic episodes ,.
About 10-15% of women in industrialized countries and between 20 and 40% of women in developing countries experience depression during pregnancy or after childbirth. Perinatal depression is one of the most prevalent and severe complications of pregnancy and childbirth. There is a new evidence suggesting that maternal depression in developing countries may contribute to infant risk of growth impairment and illness through inadvertent reduced attention to and care of children's needs .
There has been a widely held belief that anxiety in pregnancy is harmful to the fetus and contributes to adverse obstetric outcomes. The incidence of anxiety disorders is the same in pregnant women and in those who are not pregnant. Subclinical levels of anxiety vary normally through pregnancy, with peaks in the first and third trimester, and are specifically focused on infant health and well-being and childbirth. Anxiety in pregnancy is higher among younger, less well-educated women of low socioeconomic status. Firm estimates for prenatal anxiety do not exist, nor is there agreement about appropriate screening tools, but past studies suggest that a significant portion of women experience prenatal anxiety both in general and about their pregnancy .
Research in developing countries suggests that maternal depression may be a risk factor for poor growth in young children. This risk factor could mean that maternal mental health in low-income countries may have a substantial influence on growth during childhood, with the effects of depression affecting not only this generation, but also the next .
There is evidence that a number of risk factors are associated with maternal depression. Women experiencing these risk factors should be observed carefully by providers and screened regularly during pregnancy and postpartum. Risk factors include a history of mood disorders, substance abuse problems or history of alcohol dependence, maternal depression from a previous pregnancy, depression or family history of depression, life stress, poor marital relationships, low social status, lack of social support or absence of a community network, unplanned or unwanted pregnancy, and perinatal losses ,. Perinatal losses are traumatic events in the lives of families and can have serious long-term consequences for the psychological health of parents and any subsequent children . There is significant psychological/psychiatric morbidity associated with prenatal loss. Women exhibit significantly elevated levels of depression and anxiety in the weeks and months following the loss, compared with samples of pregnant, community, or postpartum women .Women with a history of miscarriage were found to experience more pregnancy-specific anxieties in the first trimester of a new pregnancy than pregnant women with no history of miscarriage. Patterns of 'depressive coping' and 'anxious grieving' after pregnancy loss are predictive of more marked anxiety and depression in the first trimester of a subsequent pregnancy .
No national guidelines exist regarding recommended screening intervals for depression during pregnancy and the year following delivery; however, the US Preventive Services Task Force recommends regular depression screening for all adults, and several professional organizations specifically recommend periodic screening during the perinatal and postpartum periods. Despite the lack of comprehensive recommendations, there is evidence that brief standardized depression screening instruments can accurately identify maternal depression. The Edinburgh postpartum depression scale is the most widely used tool, and numerous studies have found that it has moderate to good reliability in identifying women at high risk for postpartum depression . Health plans have a unique opportunity to educate pregnant women and new mothers on the importance of depression screening using programs already in place to ensure that members receive high-quality maternity care. Health plan maternity programs provide valuable educational materials developed specifically for pregnant women and new mothers. A study by Buist et al.  concluded that educational material has significant benefits for mental health literacy and health service use for perinatal women at risk for depression. Providing education about the risk factors for depression, health risks associated with undiagnosed and untreated depression, and ways to access screening and treatment would be invaluable to increase screening and treatment of maternal depression.
Routine contact with health care professionals (including general practitioners, health visitors, and midwives) during pregnancy and the postnatal period provides an opportunity to identify women who have, or are at risk of developing, a mental disorder. Health care professionals should be aware of the impact a woman's mental state can have on obstetric and maternity outcomes, the development of the fetus or child, and her partner and family. Simple and validated detection tools for mental disorders suitable for use in primary care exist only for depression, but health care professionals should also be alert to symptoms of other mental disorder .
Appropriate and timely treatment for maternal depression improves functioning not only for mothers, but also for children. Children whose mothers are successfully treated for depression show progressive and marked improvement in their own behaviors even a year after their mothers discontinue treatment .
| Patients and methods|| |
Type, setting, and time of the study
The current study is a nested case-control cross-sectional survey. It was conducted in all four family health centers (FHCs) of El-Fayum city, El-Fayum Governorate. The study was conducted during the period from 1 February 2013 to the end of December 2013.
Population of the study
Pregnant women attending the selected FHCs for antenatal care during the period of the study after their consent whose current pregnancy is the second or more (multigravida) were included.
Pregnant women whose current pregnancy is the first one (primigravida) were excluded.
The study was approved by the ethical committee of research in the Faculty of Medicine, Menoufia Governorate. Clear formal consent was taken from all participating women after complete clear explanation of the study objectives and methodology and nonobligation was offered.
It was online calculated at 85% power of study and 90% confidence interval. It was 180, which increased to 200 to avoid any dropout cases.
Tools of the study
- Edinburgh postnatal depression scale  and depression anxiety stress scale  for identification of patients who had depression or anxiety.
- Hamilton rating scale for depression  for assessing the level of depression and anxiety.
- Antenatal questionnaire was used to establish the representative nature of the sample; a range of background data were obtained. Participants provided contact details and information on age, completed educational level, and occupational status. The questionnaire contained close-ended and open-ended questions to collect data to determine the risk factors as follows: data related to current pregnancy and reproductive history and data related to the mental health of women during pregnancy to study the risk factors of depression and/or anxiety, such as presence of history of previous psychiatric illness to the woman or one of her family (including antenatal and postnatal depression), family dynamic events including lack of social support (such as relationships between their husbands, mothers, friends, and mother-in-law), and stressful life events (such as death of any relatives, financial problems, and change home) [Table 1] .
|Table 1: Distribution of the studied groups with respect to presence of any family dynamic events|
Click here to view
Procedure of the study
All participating women attending the FHCs of El-Fayum city during the period of the study were invited after their consent to participate in the study in which they were subjected to the following:
- Complete history taking.
- Complete clinical examination.
- Edinburgh postnatal depression scale and depression anxiety stress scale for identification of patients who had depression or anxiety and patients who had both depression and anxiety.
- Hamilton rating scale for depression for assessing the level of depression, where 46% had mild depression, 28% had moderate depression, and 26% had severe depression.
According to presence or absence of depression and/or anxiety, all participants were divided into two groups:
Group A included women having any type of prenatal depression and/or anxiety (n=50) considered as the case group. Group B included women having no psychological problems (n=150) considered as the control group. Both groups were subjected to antenatal questionnaire, which took about 20 min to be completed, to study the risk factors of depression and anxiety among the participating women [Table 2].
|Table 2: Distribution of the studied groups with respect to previous bad obstetric history|
Click here to view
Qualitative data were presented as numbers and percent, and the c2 -test was used to compare two or more qualitative groups. Logistic regression test was used to test the association between variables and to detect the risk factors. The P-value of 0.05 or less was considered the cutoff value for significance.
| Results|| |
Sociodemographic characteristics were statistically nonsignificant in the development of antenatal depression. The study showed that the main risk factors for maternal depression and/or anxiety were history of abortion or miscarriage [odds ratio (OR) 4.1] and past history of psychiatric illness (OR 2.7) (including antenatal and postnatal depression), and presence of any family dynamic events (OR 5.2) was more likely to report symptoms of antenatal depression [Table 3].
|Table 3: Comparisons between the case and control groups regarding their past history of psychiatric disorders|
Click here to view
Results of study of family dynamic events as a risk factor showed that lack of social support that presented from changing the relationships between woman and her family members was significantly associated with increased risk for depressive symptoms during pregnancy; in addition, the study showed that 84% of depressed cases had a history of stressful life events in the last year compared with 44% of the controls. Assessment of the level of depression showed that 46% had mild depression, 28% had moderate depression, and 26% had severe depression.
Study of risk factors among depressed patients represented that, in women who had history of abortion or miscarriage, 65.4% had mild depression, 15.4% had moderate, and 19.2% had severe depression. In addition, 50% of depressed cases reporting a history of previous psychiatric illness scored severe depression, 22.2% scored moderate depression, and 28.8% scored mild depression. In addition, the importance of family dynamic events as a significant risk factor in scoring the level of depression was shown, as 67% of cases reporting a history of changing relationships scored severe depression, whereas 29.4% scored moderate depression and 5.9% scored mild degree of depression.
| Discussion|| |
Regarding comparisons of previous bad obstetric history among different study groups as a risk factor of maternal depression, the current study showed that women who have previous bad obstetric history were more likely to develop antenatal or postnatal depression. This result was consistent with other studies, which reported that women who had a traumatic delivery (including all types of delivery) have an increased risk for postpartum depression and increased risk of developing post-traumatic stress disorder, which may mimic postpartum depression ,,,.
In the current study, comparisons between the studied groups showed highly significant association between depression and miscarriage (OR 4.1). The logistic regression found that pregnant women with a history of miscarriage had a significantly high risk for anxiety and depression; this result was in agreement with the study by Gong et al.  who reported that women with a history of miscarriage experienced significant anxiety and depression during their next pregnancy [Table 4]. Bergner and colleagues found that maladaptive or less useful coping strategies and psychological factors predicted increased depression at 7-month postmiscarriage, and this continued in a new pregnancy. Blackmore et al.  documented that women who had experienced miscarriage or stillbirth had significantly higher levels of anxiety and depression in a subsequent pregnancy, and the impact persists, despite the birth of a healthy child. The current study showed that presence of previous history of psychiatric illness was associated with depression (OR 2.7). Similarly, Muhajarine  found that past as well as family history of previous psychiatric illness were significantly associated with development of antenatal depression. Regarding family dynamic events, the current study showed that women who had changes in the family inter-relationships (such as relationships between their husbands, mothers, friends, and mother-in-law) were more likely to develop antenatal or postnatal depression (OR 5.2). Lancaster et al.  reported that, in total, more than 20 articles addressed the relationship between social support and depressive symptoms during pregnancy. Seventeen studies assessed total social support from any source. On average, these studies demonstrated a medium correlation between a lack of social support and depressive symptoms [Figure 1],[Figure 2] and [Figure 3].
|Figure 1: Distribution of the studied cases according to the effect of significant risk factors on the level of depression.|
Click here to view
|Figure 2: Distribution of cases and controls showing the effect of previous obstetric history especially stillbirth and abortion as risk factors of maternal depression related to current pregnancy.|
Click here to view
|Figure 3: Distribution of the Hamilton depression scale among depressed patients.|
Click here to view
|Table 4: Logistic regression analysis used to determine significant risk factors of maternal depression|
Click here to view
| Conclusion|| |
These findings indicate the need for understanding of perinatal stress and depression. Earlier identification of prenatal risk factors can lead to more effective treatment before the traditional diagnosis of postpartum depression. In addition, investigating perinatal stress and depression and identification of risk factors of these conditions may reduce the risk for chronic anxiety or undiagnosed depression and improve the health and function of the mother and newborn, with positive impact on the family welfare in general.
| Acknowledgements|| |
Conflicts of interest
| References|| |
World Health Organization. Mental health aspects of women′s reproductive health: a global review of the literature. Pregnancy, childbirth and the postpartum period 2009; 2
Dunkel Schetter C. Psychological science on pregnancy: stress processes, biopsychosocial models, and emerging research issues. Annu Rev Psychol 2010; 62
Rahman A, Patel V, Maselko J, Kirkwood B. The neglected ′m′ in MCH programs - why mental health of mothers is important for child nutrition. Trop Med Int Health 2008; 13
National Association of County and City Health Officials (NACCHO). Women′s mental health: Local Health Department strategies in addressing depression among pregnant and parenting women. Issue Brief. [Last accessed on 2007 Aug].
National Business Group on Health (NBGH). Preventing, identifying and treating maternal depression: tools for employers. Issue Brief, March 2005.
Armstrong DS. Perinatal loss and parental distress after the birth of a healthy infant. Adv Neonatal Care 2007; 7
Lok IH, Yip AS, Lee DT, Sahota D, Chung TK. A 1-year longitudinal study of psychological morbidity after miscarriage. Fertil Steril 2010; 93
Bergner A, Beyer R, Klapp BF, Rauchfuss M. Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping. J Psychosom Obstet Gynecol 2008; 29
National Research Council and Institute of Medicine. Depression in parents, parenting, and children: opportunities to improve the identification, treatment, and prevention. committee on depression, parenting practices, and the healthy development of children. board on children, youth, and families. Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press; 2009.
Buist AE, Austin MP, Hayes BA, Speelman C, Bilszta JLC, Gemmill AW, et al.
Postnatal mental health of women giving birth in Australia 2002-2004: findings from the beyond blue National Postnatal Depression Program. Aust N Z J Psychiatry 2008; 42
National Institute of Health and Clinical Excellence.Antenatal and postnatal mental health: clinical management and service guidance, (NICE, guidelines 45) 2007National Collaborating Centre for Mental Health, UK. Available at: http://[email protected]
Wickramaratne P. Children of depressed mothers 1 year after remission of maternal depression: findings from the STARFNx01D Child study. Am J Psychiatry 2011; 168
Murray D, Cox J. Screening for depression during pregnancy with the Edinburgh depression scale (EPDS). J Reprod Infant Psychol 1990; 8
Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd ed. Sydney: Psychology Foundation; 1995.
Hamilton M. A rating scale for depression. J Neurol Neurosur Psychiatry 1960; 23
Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27
White T, Matthey S, Boyed K, Barnett B. Postnatal depression and post-traumatic stress after child birth: prevalence, course and co-occurrence. J Reprod Infant Psychology 2006; 24
Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Womens Ment Health 2005; 8
Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Womens Ment Health 2006; 9
Creedy DK, Gamble J. Implications of poor care on trauma symptom development following childbirth. J Psychosom Obstet Gynecol 2007; 28
X Gong, J Hao, F Tao, J Zhang, H Wanga, R Xu. Pregnancy loss and anxiety and depression during subsequent pregnancies: data from the C-ABC study. Eur J Obstet Gynecol Reprod Biol 2013; 166
ER Blackmore, D Côté-Arsenault, W Tang, V Glover, J Evans, J Golding, TG O′Connor. Previous prenatal loss as a predictor of perinatal depression and anxiety. Br J Psychiatry 2011; 1-6. doi: 10.1192/bjp.bp.110.083105.
Bowen A, Muhajarine N. Antenatal depression. Can Nurse 2006; 102
Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol 2010; 202:
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]