DEPRESSION AND ANXIETY 32:120–128 (2015)
Research Article THE ASSOCIATION BETWEEN SOCIODEMOGRAPHIC CHARACTERISTICS AND POSTPARTUM DEPRESSION SYMPTOMS AMONG ARAB-BEDOUIN WOMEN IN SOUTHERN ISRAEL Samira Alfayumi-Zeadna, R.N., M.P.H.,1,2 ∗ Vered Kaufman-Shriqui, Ph.D., M.Sc., R.D.,3 Atif Zeadna, M.D.,4,5 Ari Lauden, M.D.,6 and Ilana Shoham-Vardi, Ph.D.1
Background: Prevalence rates of postpartum depression (PPD) are 10 to 20% among various populations. Little is known about the characteristics of PPD among populations experiencing cultural transition. This study aimed to assess PPD symptoms (PPDS) prevalence and to identify risk factors unique to ArabBedouin women in southern Israel. Methods: The sample included 564 women who visited maternal and child health clinics. Sociodemographic characteristics were obtained using in-person interviews. PPDS were assessed using a validated Arabic translation of the Edinburgh Postnatal Depression Scale (EPDS). Prevalence of PPDS was estimated using the cut-off score of EPDS ࣙ10; a more stringent cut-off score of EPDS ࣙ13 was used to define women with moderate to severe PPDS. Results: The prevalence of PPDS among women was 31%, of which 19.1% were assessed as having moderate to severe symptoms (EPDS ࣙ 13). In a multivariate logistic regression, the variables associated with EPDS ࣙ10 were having an ill-infant odds ratio (OR) = 3.9, lack of husband’s support (OR = 2.6), history of emotional problems (OR = 3.2), low income (OR = 1.6), low level of education (OR = 1.6), high marital conflicts (OR = 1.5), and an unplanned pregnancy (OR = 1.5). Conclusion: In the generally understudied population of Arab-Bedouin women living in southern Israel, we found a high prevalence of PPDS. The unique risk factors described in our research can inform health care professionals in designing interventions for early detection and C 2014 Wiley prevention of PPD. Depression and Anxiety 32:120–128, 2015. Periodicals, Inc.
Key words: postpartum depression; Edinburgh Postnatal Depression Scale; Arab-Bedouin women
6 Maccabi
Healthcare Services, Rahat Clinic, Southern Region,
Israel 1 Department of Public Health, Faculty of Health Sciences, Ben-
Gurion University of the Negev, Beer-Sheva, Israel Healthcare Services, Beer-Sheva, Israel 3 Centre for Research on Inner City Health, The Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada 4 Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, BeerSheva, Israel 5 Royal Victoria Hospital, Department of Obstetrics and Gynecology, McGill University, Montreal, Canada 2 Maccabi
C 2014 Wiley Periodicals, Inc.
∗ Correspondence to: Samira Alfayumi-Zeadna, Department of Pub-
lic Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O.B 653 Beer-Sheva, 8410501 Israel. E-mail: [email protected] Received for publication 18 October 2013; Revised 1 June 2014; Accepted 4 June 2014 DOI 10.1002/da.22290 Published online 10 July 2014 in Wiley Online Library (wileyonlinelibrary.com).
Research Article: Postpartum Depression in Arab-Bedouin Women
Abbreviations CI EPDS MCHC OR PPD PPDS
= = = = = =
confidence interval Edinburgh Postnatal Depression Scale maternal and child health clinics odds ratio postpartum depression postpartum depression symptoms
INTRODUCTION
Postpartum depression (PPD) is an adverse effect of
childbirth whose rates vary across countries and cultures with prevalence estimates of 10 to 20%.[1, 2] Most studies of PPD were conducted in Western societies. A meta-analysis of 59 studies reported that the average prevalence rate of nonpsychotic PPD was 13%.[3] A systematic review of studies conducted in economically developed countries, in which depression was diagnosed by a structured clinical interview, showed that the prevalence of major and minor PPD ranged from 6.5 to 12.9% through the first 6 postpartum months, peaking at 2 and 6 months postpartum.[4] Different rates and a wide range of PPD prevalence were shown in a review of studies from 40 non-Western countries, in which the prevalence of PPD varied from 0.5 to 60%.[5] The authors concluded that differences in prevalence rates across countries were associated mainly with cultural factors. The effects of PPD are both immediate and long-term, affecting both the newborn children and their subsequent childcare.[6] Maternal depression has been shown to affect infant neurodevelopment at ages as early as 1 month.[7] Significantly higher growth retardation was described at various time points.[8] Correlations found between maternal PPDS, low infant weight, impaired motor development,[9] developmental problems, and learning difficulties were significant.[10] Traditional risk-factors for PPD include delivery of an ill child,[11] maternal history of emotional problems,[12] having poor social support,[13] low maternal education,[10, 14] recent major stressful life events,[11] having more than three children,[12] and low income.[15] Additional risk factors include past and current interpersonal violence, which is associated with unique psychological and physical risk factors that include fear of childbirth, preterm labor, having a low birth weight infant, neonatal death, and difficulties with breastfeeding, all of which are factors related to PPD.[16] Among women with PPD, a history of their maltreatment as children can exacerbate depressive symptoms and may lead to impaired mother–infant interactions. Moreover, women who suffered from childhood abuse and neglect were at increased risk of developing prenatal depression.[17] A significant ethnic minority in southern Israel, the Arab-Bedouin society is in cultural transition and is attempting to preserve its traditional values and lifestyle. Most of the Arab-Bedouin living in southern Israel marry at a young age,[18] 57% live in consanguineous
121
marriages,[19] and an estimated 20% of all marriages are polygamous.[20] Macrosocial characteristics have been associated with adverse maternal mental health and may impose an additional emotional burden on women in the postpartum period. Indeed, minorities have been reported to suffer from a higher prevalence of PPD,[21] cultural transition has been identified as a risk factor for depression, and immigration was associated with increased risk (OR [odds ratio] = 2.16) for developing PPD.[22] Research conducted among Arab-Bedouin women in southern Israel reported a PPD symptoms (PPDS) prevalence rate of 44%.[23] Higher rates of PPD were reported among Arab women in the United Arab Emirates.[14] The purpose of this study was to assess the prevalence of and unique risk factors for PPDS among Israeli Arab-Bedouin women in the Negev desert of southern Israel. In conjunction with understanding the unique risk factors to which Arab-Bedouin are susceptible, studying PPDS among this population may provide essential information for the development of effective mental health and psychosocial interventions. Knowledge of the characteristics of PPDS unique to the Arab-Bedouin could inform interventions aimed at promoting positive outcomes in women or preventing adverse psychological symptoms for both child and mother.
METHODS STUDY DESIGN AND PARTICIPANTS This cross-sectional study examined the association between sociodemographic and cultural characteristics and PPDS among Israeli Arab-Bedouin women in southern Israel. The study was carried out in four urban locations. Women attending eight maternal and child health clinics (MCHC) were recruited from October 2008 to December 2009. Included in the study were Arab-Bedouin women who were 4 weeks to 7 months postpartum.
PRIMARY OUTCOME The primary outcome of interest was the prevalence of PPDS, which was assessed using the validated Arabic translation of the Edinburgh Postnatal Depression Scale (EPDS).[24] A self-rating questionnaire that evaluates the women’s feelings over the past week,[25] the EPDS has been found to be sensitive enough to identify even mild PPD.[26] The questionnaire used in this study included 10 items, and the total score ranged from 0 to 30. Prevalence of EPDS was estimated using the cut-off score of EPDS ࣙ10, whereas a more stringent cut-off score of EPDS ࣙ13 was used to define women with moderate to severe PPDS.[27] Women identified as being at high risk for PPDS according to the questionnaire score were referred to a family physician, a psychiatrist, and a social worker. Question 10 on the EPDS refers to thoughts of self-harm, and any positive score answer is considered a cause for concern. Women who replied positively to question 10, regardless of their EPDS score, were referred to the nearest hospital, Soroka University Medical Center. In addition, these women received referral letters to a family physician, a psychiatrist, and a social worker.
Depression and Anxiety
122
Alfayumi-Zeadna et al.
STUDY PROCEDURE After obtaining ethical approvals from the Helsinki committees of Maccabi Health Services (number 2008074) and Soroka University Medical Center (number 10288) and a permit from the Israeli Ministry of Health, Arab women who were treated at the MCHC were solicited by a nurse for their participation in the study. Those who agreed to participate and who met the inclusion criteria signed an informed consent form. Women were interviewed 4 weeks to 7 months postpartum and screened for PPDS using the EPDS. Complete data were obtained for 564 women.
DATA COLLECTION Data were collected by a nurse and a research assistant who were trained in administering the required questionnaires. Interviewers underwent structured training in administering the EPDS and about the referral procedures for at-risk women. In-person interviews were conducted with women in the MCHC. Five hundred forty-nine (97.3%) women agreed to participate, versus 15 women (2.7%) who agreed to participate left before the interview was conducted due to time constraints. All interviewers were Arab women from the participants’ culture, and interviews, which took an average of about a half an hour, were conducted in Arabic. Interviews were conducted 5 days a week. In addition to the EPDS, sociodemographic and cultural characteristics were collected in structured interviews. The socio-demographic and cultural section of the questionnaire included 24 questions on maternal age, marital status, educational level, employment, income level, extent of husband’s support, stressful event of the last year, infant health, place of residence, number of children, pregnancy planning, and characteristics of the marriage (e.g., consanguinity and polygamy).
DEFINITIONS OF SOCIODEMOGRAPHIC AND CULTURAL CHARACTERISTICS Level of Education. Maternal education was divided into three categories: 9, 10–12, and ࣙ13 years. Income. Household income level is the level of income as subjectively perceived by the study participants, who were presented with the definitions on a scale ranging from 1 = “good to very good” to 4 = “not so good to not good at all.” The variable was later dichotomized into two categories of (1) average and above and (2) lower than average. Breastfeeding. Breastfeeding at the time of interview was divided into two categories: breastfeeding to any extent or no breastfeeding at all. Living Next to Extended Family. Living next to the extended family and maintaining a traditional lifestyle were collectively defined as living close to the woman’s and/or the husband’s family. Residence. Women’s residence was divided into two categories: (1) a village that is not legally recognized by the Israeli government, and therefore it does not have running water, electricity, or plumbing, and houses are subject to demolition; and (2) a regular settlement (urban or rural) that has all the above-mentioned facilities. Husband’s Support. The extent of the husband’s involvement and assistance in household chores and childcare was evaluated using a 1-item question. Each woman was asked whether her husband provided financial support and assistance with childcare and household chores. The answers ranged originally on a scale from 1 to 4 (1 [always], 2 [sometimes], 3 [seldom], 4 [never]), and this variable was later grouped in two categories: husbands who assist in household chores and childcare, and provide financially for their wife and children (always and sometimes = yes, and never and seldom = no). Stressful Life Event during the Last Year. A stressful event was defined as any tragic or adverse emotional event that happened in the year prior to the pregnancy and birth. Women were asked whether there was a stressful event (e.g., death in the family, divorce, loss of job, Depression and Anxiety
accident, disease, or any event the women defined as stressful) during the last year. Responses were categorized as yes or no. Ill Infant. Medical records were used to determine whether the child had a chronic illness. In the event that this information was obtained via maternal report data, it was verified against the medical records. History of Emotional Problems. Whether there was a maternal history of emotional problems (yes/no) was obtained from medical records and defined as anxiety, depression, and PPD based on a diagnosis by the family physician. Marital Conflicts. Marital conflicts were defined as the frequency and severity of conflicts or problems between the woman and her spouse and were evaluated using the question “Are there any conflicts or problems in your marital relationship?” The answers ranged on a scale from 1 (seldom) to 4 (frequent conflicts and severe problems). The variable was then dichotomized into the two categories of high marital conflicts (for categories 3 and 4) and low marital conflicts (for categories 1 and 2).
STATISTICAL ANALYSIS The χ 2 test or Fisher’s exact test was used, as appropriate, to compare categorical variables. One-way analysis of variance (ANOVA) was used to compare continuous variables between the groups (EPDS scores of 0–9, 10–12, and ࣙ13) with a post hoc Scheffe test and a Bonferroni correction for multiple comparisons. Multivariate logistic regression analyses were performed to identify independent risk factors for PPDS. All covariates with P ࣘ .10 in univariate models were considered for inclusion in multivariable models. The best model was chosen using the -2LL goodness of fit test. The OR and 95% confidence interval (95% CI) were computed. All statistical analysis was performed using the SPSS 16.0 for windows package (PASW Inc., Chicago, IL). P-values 10 years 0–9 years Employment status Employed Not employed Residence Town/village Unrecognized village Number of children 1 ࣙ2 Consanguineous marriage Yes No Polygamous marriage Yes No Marital conflicts Yes No Last pregnancy planned Yes No Infant’s health status Ill Healthy Breastfeeding at time of interview Yes No Contraceptive use at time of interview Yes no Pregnant at time of interview Yes No Husband’s support Yes No Living close to family Yes No Stressful event in last year Yes No
Depression and Anxiety
EPDS scores 0–9 10–12 N = 390 (%) N = 66 (%)
ࣙ13 N = 108 (%)
P-valuea 0.49
29 (5.3) 423 (77.5) 94 (17.2)
20 (69.0) 287 (67.8) 72 (76.6)
4 (13.8) 52 (12.3) 8 (8.5)
5 (17.2) 84 (19.9) 14 (4.9)
246 (46.1) 288 (53.9)
179 (72.8) 190 (66.0)
24 (9.8) 38 (13.2)
43 (17.4) 60 (20.8)
0.22
Research Article THE ASSOCIATION BETWEEN SOCIODEMOGRAPHIC CHARACTERISTICS AND POSTPARTUM DEPRESSION SYMPTOMS AMONG ARAB-BEDOUIN WOMEN IN SOUTHERN ISRAEL Samira Alfayumi-Zeadna, R.N., M.P.H.,1,2 ∗ Vered Kaufman-Shriqui, Ph.D., M.Sc., R.D.,3 Atif Zeadna, M.D.,4,5 Ari Lauden, M.D.,6 and Ilana Shoham-Vardi, Ph.D.1
Background: Prevalence rates of postpartum depression (PPD) are 10 to 20% among various populations. Little is known about the characteristics of PPD among populations experiencing cultural transition. This study aimed to assess PPD symptoms (PPDS) prevalence and to identify risk factors unique to ArabBedouin women in southern Israel. Methods: The sample included 564 women who visited maternal and child health clinics. Sociodemographic characteristics were obtained using in-person interviews. PPDS were assessed using a validated Arabic translation of the Edinburgh Postnatal Depression Scale (EPDS). Prevalence of PPDS was estimated using the cut-off score of EPDS ࣙ10; a more stringent cut-off score of EPDS ࣙ13 was used to define women with moderate to severe PPDS. Results: The prevalence of PPDS among women was 31%, of which 19.1% were assessed as having moderate to severe symptoms (EPDS ࣙ 13). In a multivariate logistic regression, the variables associated with EPDS ࣙ10 were having an ill-infant odds ratio (OR) = 3.9, lack of husband’s support (OR = 2.6), history of emotional problems (OR = 3.2), low income (OR = 1.6), low level of education (OR = 1.6), high marital conflicts (OR = 1.5), and an unplanned pregnancy (OR = 1.5). Conclusion: In the generally understudied population of Arab-Bedouin women living in southern Israel, we found a high prevalence of PPDS. The unique risk factors described in our research can inform health care professionals in designing interventions for early detection and C 2014 Wiley prevention of PPD. Depression and Anxiety 32:120–128, 2015. Periodicals, Inc.
Key words: postpartum depression; Edinburgh Postnatal Depression Scale; Arab-Bedouin women
6 Maccabi
Healthcare Services, Rahat Clinic, Southern Region,
Israel 1 Department of Public Health, Faculty of Health Sciences, Ben-
Gurion University of the Negev, Beer-Sheva, Israel Healthcare Services, Beer-Sheva, Israel 3 Centre for Research on Inner City Health, The Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada 4 Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, BeerSheva, Israel 5 Royal Victoria Hospital, Department of Obstetrics and Gynecology, McGill University, Montreal, Canada 2 Maccabi
C 2014 Wiley Periodicals, Inc.
∗ Correspondence to: Samira Alfayumi-Zeadna, Department of Pub-
lic Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O.B 653 Beer-Sheva, 8410501 Israel. E-mail: [email protected] Received for publication 18 October 2013; Revised 1 June 2014; Accepted 4 June 2014 DOI 10.1002/da.22290 Published online 10 July 2014 in Wiley Online Library (wileyonlinelibrary.com).
Research Article: Postpartum Depression in Arab-Bedouin Women
Abbreviations CI EPDS MCHC OR PPD PPDS
= = = = = =
confidence interval Edinburgh Postnatal Depression Scale maternal and child health clinics odds ratio postpartum depression postpartum depression symptoms
INTRODUCTION
Postpartum depression (PPD) is an adverse effect of
childbirth whose rates vary across countries and cultures with prevalence estimates of 10 to 20%.[1, 2] Most studies of PPD were conducted in Western societies. A meta-analysis of 59 studies reported that the average prevalence rate of nonpsychotic PPD was 13%.[3] A systematic review of studies conducted in economically developed countries, in which depression was diagnosed by a structured clinical interview, showed that the prevalence of major and minor PPD ranged from 6.5 to 12.9% through the first 6 postpartum months, peaking at 2 and 6 months postpartum.[4] Different rates and a wide range of PPD prevalence were shown in a review of studies from 40 non-Western countries, in which the prevalence of PPD varied from 0.5 to 60%.[5] The authors concluded that differences in prevalence rates across countries were associated mainly with cultural factors. The effects of PPD are both immediate and long-term, affecting both the newborn children and their subsequent childcare.[6] Maternal depression has been shown to affect infant neurodevelopment at ages as early as 1 month.[7] Significantly higher growth retardation was described at various time points.[8] Correlations found between maternal PPDS, low infant weight, impaired motor development,[9] developmental problems, and learning difficulties were significant.[10] Traditional risk-factors for PPD include delivery of an ill child,[11] maternal history of emotional problems,[12] having poor social support,[13] low maternal education,[10, 14] recent major stressful life events,[11] having more than three children,[12] and low income.[15] Additional risk factors include past and current interpersonal violence, which is associated with unique psychological and physical risk factors that include fear of childbirth, preterm labor, having a low birth weight infant, neonatal death, and difficulties with breastfeeding, all of which are factors related to PPD.[16] Among women with PPD, a history of their maltreatment as children can exacerbate depressive symptoms and may lead to impaired mother–infant interactions. Moreover, women who suffered from childhood abuse and neglect were at increased risk of developing prenatal depression.[17] A significant ethnic minority in southern Israel, the Arab-Bedouin society is in cultural transition and is attempting to preserve its traditional values and lifestyle. Most of the Arab-Bedouin living in southern Israel marry at a young age,[18] 57% live in consanguineous
121
marriages,[19] and an estimated 20% of all marriages are polygamous.[20] Macrosocial characteristics have been associated with adverse maternal mental health and may impose an additional emotional burden on women in the postpartum period. Indeed, minorities have been reported to suffer from a higher prevalence of PPD,[21] cultural transition has been identified as a risk factor for depression, and immigration was associated with increased risk (OR [odds ratio] = 2.16) for developing PPD.[22] Research conducted among Arab-Bedouin women in southern Israel reported a PPD symptoms (PPDS) prevalence rate of 44%.[23] Higher rates of PPD were reported among Arab women in the United Arab Emirates.[14] The purpose of this study was to assess the prevalence of and unique risk factors for PPDS among Israeli Arab-Bedouin women in the Negev desert of southern Israel. In conjunction with understanding the unique risk factors to which Arab-Bedouin are susceptible, studying PPDS among this population may provide essential information for the development of effective mental health and psychosocial interventions. Knowledge of the characteristics of PPDS unique to the Arab-Bedouin could inform interventions aimed at promoting positive outcomes in women or preventing adverse psychological symptoms for both child and mother.
METHODS STUDY DESIGN AND PARTICIPANTS This cross-sectional study examined the association between sociodemographic and cultural characteristics and PPDS among Israeli Arab-Bedouin women in southern Israel. The study was carried out in four urban locations. Women attending eight maternal and child health clinics (MCHC) were recruited from October 2008 to December 2009. Included in the study were Arab-Bedouin women who were 4 weeks to 7 months postpartum.
PRIMARY OUTCOME The primary outcome of interest was the prevalence of PPDS, which was assessed using the validated Arabic translation of the Edinburgh Postnatal Depression Scale (EPDS).[24] A self-rating questionnaire that evaluates the women’s feelings over the past week,[25] the EPDS has been found to be sensitive enough to identify even mild PPD.[26] The questionnaire used in this study included 10 items, and the total score ranged from 0 to 30. Prevalence of EPDS was estimated using the cut-off score of EPDS ࣙ10, whereas a more stringent cut-off score of EPDS ࣙ13 was used to define women with moderate to severe PPDS.[27] Women identified as being at high risk for PPDS according to the questionnaire score were referred to a family physician, a psychiatrist, and a social worker. Question 10 on the EPDS refers to thoughts of self-harm, and any positive score answer is considered a cause for concern. Women who replied positively to question 10, regardless of their EPDS score, were referred to the nearest hospital, Soroka University Medical Center. In addition, these women received referral letters to a family physician, a psychiatrist, and a social worker.
Depression and Anxiety
122
Alfayumi-Zeadna et al.
STUDY PROCEDURE After obtaining ethical approvals from the Helsinki committees of Maccabi Health Services (number 2008074) and Soroka University Medical Center (number 10288) and a permit from the Israeli Ministry of Health, Arab women who were treated at the MCHC were solicited by a nurse for their participation in the study. Those who agreed to participate and who met the inclusion criteria signed an informed consent form. Women were interviewed 4 weeks to 7 months postpartum and screened for PPDS using the EPDS. Complete data were obtained for 564 women.
DATA COLLECTION Data were collected by a nurse and a research assistant who were trained in administering the required questionnaires. Interviewers underwent structured training in administering the EPDS and about the referral procedures for at-risk women. In-person interviews were conducted with women in the MCHC. Five hundred forty-nine (97.3%) women agreed to participate, versus 15 women (2.7%) who agreed to participate left before the interview was conducted due to time constraints. All interviewers were Arab women from the participants’ culture, and interviews, which took an average of about a half an hour, were conducted in Arabic. Interviews were conducted 5 days a week. In addition to the EPDS, sociodemographic and cultural characteristics were collected in structured interviews. The socio-demographic and cultural section of the questionnaire included 24 questions on maternal age, marital status, educational level, employment, income level, extent of husband’s support, stressful event of the last year, infant health, place of residence, number of children, pregnancy planning, and characteristics of the marriage (e.g., consanguinity and polygamy).
DEFINITIONS OF SOCIODEMOGRAPHIC AND CULTURAL CHARACTERISTICS Level of Education. Maternal education was divided into three categories: 9, 10–12, and ࣙ13 years. Income. Household income level is the level of income as subjectively perceived by the study participants, who were presented with the definitions on a scale ranging from 1 = “good to very good” to 4 = “not so good to not good at all.” The variable was later dichotomized into two categories of (1) average and above and (2) lower than average. Breastfeeding. Breastfeeding at the time of interview was divided into two categories: breastfeeding to any extent or no breastfeeding at all. Living Next to Extended Family. Living next to the extended family and maintaining a traditional lifestyle were collectively defined as living close to the woman’s and/or the husband’s family. Residence. Women’s residence was divided into two categories: (1) a village that is not legally recognized by the Israeli government, and therefore it does not have running water, electricity, or plumbing, and houses are subject to demolition; and (2) a regular settlement (urban or rural) that has all the above-mentioned facilities. Husband’s Support. The extent of the husband’s involvement and assistance in household chores and childcare was evaluated using a 1-item question. Each woman was asked whether her husband provided financial support and assistance with childcare and household chores. The answers ranged originally on a scale from 1 to 4 (1 [always], 2 [sometimes], 3 [seldom], 4 [never]), and this variable was later grouped in two categories: husbands who assist in household chores and childcare, and provide financially for their wife and children (always and sometimes = yes, and never and seldom = no). Stressful Life Event during the Last Year. A stressful event was defined as any tragic or adverse emotional event that happened in the year prior to the pregnancy and birth. Women were asked whether there was a stressful event (e.g., death in the family, divorce, loss of job, Depression and Anxiety
accident, disease, or any event the women defined as stressful) during the last year. Responses were categorized as yes or no. Ill Infant. Medical records were used to determine whether the child had a chronic illness. In the event that this information was obtained via maternal report data, it was verified against the medical records. History of Emotional Problems. Whether there was a maternal history of emotional problems (yes/no) was obtained from medical records and defined as anxiety, depression, and PPD based on a diagnosis by the family physician. Marital Conflicts. Marital conflicts were defined as the frequency and severity of conflicts or problems between the woman and her spouse and were evaluated using the question “Are there any conflicts or problems in your marital relationship?” The answers ranged on a scale from 1 (seldom) to 4 (frequent conflicts and severe problems). The variable was then dichotomized into the two categories of high marital conflicts (for categories 3 and 4) and low marital conflicts (for categories 1 and 2).
STATISTICAL ANALYSIS The χ 2 test or Fisher’s exact test was used, as appropriate, to compare categorical variables. One-way analysis of variance (ANOVA) was used to compare continuous variables between the groups (EPDS scores of 0–9, 10–12, and ࣙ13) with a post hoc Scheffe test and a Bonferroni correction for multiple comparisons. Multivariate logistic regression analyses were performed to identify independent risk factors for PPDS. All covariates with P ࣘ .10 in univariate models were considered for inclusion in multivariable models. The best model was chosen using the -2LL goodness of fit test. The OR and 95% confidence interval (95% CI) were computed. All statistical analysis was performed using the SPSS 16.0 for windows package (PASW Inc., Chicago, IL). P-values 10 years 0–9 years Employment status Employed Not employed Residence Town/village Unrecognized village Number of children 1 ࣙ2 Consanguineous marriage Yes No Polygamous marriage Yes No Marital conflicts Yes No Last pregnancy planned Yes No Infant’s health status Ill Healthy Breastfeeding at time of interview Yes No Contraceptive use at time of interview Yes no Pregnant at time of interview Yes No Husband’s support Yes No Living close to family Yes No Stressful event in last year Yes No
Depression and Anxiety
EPDS scores 0–9 10–12 N = 390 (%) N = 66 (%)
ࣙ13 N = 108 (%)
P-valuea 0.49
29 (5.3) 423 (77.5) 94 (17.2)
20 (69.0) 287 (67.8) 72 (76.6)
4 (13.8) 52 (12.3) 8 (8.5)
5 (17.2) 84 (19.9) 14 (4.9)
246 (46.1) 288 (53.9)
179 (72.8) 190 (66.0)
24 (9.8) 38 (13.2)
43 (17.4) 60 (20.8)
0.22
