Postpartum depression and its correlates: a cross-sectional study in southeast Iran | BMC Women’s Health

Study design and participants

This cross-sectional correlational study was performed to investigate the relationship between prenatal care, depression, anxiety, stress, and postpartum depression in women who have recently given birth to a baby. The research samples are women who gave birth (via vaginal delivery or cesarean section) 3 days ago. The sample size included 186 women who gave birth to a baby in the Nik-nafs maternity ward of Rafsanjan. The inclusion criteria were: (1) mothers aged 18 or above; (2) mothers without known psychological problems and disorders; (3) mothers without visual and auditory processing disorders. The exclusion criteria were: (1) existence of gynecologic diseases affecting the status of pregnancy, pregnancy results, and maternal and infant health, (2) termination of pregnancy due to preterm premature rupture of the membranes.

Sample size and sampling

Based on studies by Izadirad et al. [21] to determine the relationship between health literacy and prenatal care adequacy index (r = 0.244) with 99% confidence and 90% test power, the sample size was considered to be 140 people according to the following formula. Concerning the conditions of mothers and the possibility of non-response, 200 questionnaires were distributed.

Finally, 186 mothers completed the questionnaires.

Measurement

Demographic information

Demographic information of the participants included age, Body Mass Index (BMI) of the mother, sex of the baby, type of delivery, previous delivery, number of deliveries, number of pregnancies, history of abortion, number of children, employment status, level of education, and income.

Edinburgh postnatal depression scale (EPDS)

This 10-item self-reported measure is designed to screen women for depressive symptoms during pregnancy and the postnatal period with scores from 0 to 3 (the maximum EPDS score is 30). The cut-off point remains at 13 or more, suggesting antenatal depressive symptoms. This questionnaire was developed by Cox et al. [22], and has been used in different countries to study postpartum depression [23]. Montazeri et al. [24] have used it in Iran and the internal correlation coefficient has been 0.80 [24]. In the present study, the reliability of the EPDS scale using Cronbach’s alpha coefficient was 0.79 and 0.76 3 days and 6 months after delivery, respectively.

Depression, anxiety, stress scale (DASS-21)

The Depression, Anxiety, and Stress Scale (DASS-21), developed by Lovibond and Lovibond in 1995, was designed to assess the psychological constructs of depression, anxiety, and stress [25]. The scale consists of 21 items, including seven items for each of the three subscales of depression (7 items), anxiety (7 items) and stress (7 items) on a four-point Likert scale (never/low/medium/high). The lowest score is zero, and the highest score is three. The total score of each is obtained through the sum of the scores of the related items. The total score of the subscales should be doubled. Zakeri et al. [26] In Iran, Cronbach’s alpha coefficient was reported to be 0.81, 0.74, and 0.78, for depression, anxiety, and stress, respectively, for Iranian version of DASS-21 [26]. In the present study, the reliability of the DASS-21 scale using Cronbach’s alpha coefficient respectively was 0.75 and 0.80 for anxiety and stress 3 days after delivery. In addition, the reliability of the DASS-21 scale was 0.93 and 0.79 for anxiety and stress, respectively, 6 months after delivery. In the present study, we used two subscales of anxiety and stress.

Quality of prenatal care questionnaire (QPCQ)

This questionnaire was developed and validated by Sword et al. [27] in an Australian context to measure prenatal care quality. QPCQ includes 46 items with six subscales, including (1) Information sharing: focus on how prenatal care providers answer questions, keep information confidential, and ensure women understand reasons for tests (9 items), (2) Anticipatory Guidance: women should get enough information to make decisions (11 items), (3) Sufficient Time: the time prenatal care providers spend (5 items), (4) Approachability: the health care provider’s approachability (4 items), (5) Availability: the availability of the clinic/office staff or prenatal care provider in 5 items, and (6) Support and Respect: respect and support by prenatal care providers in 12 items. The items are on a five-point Likert scale (from strongly disagree = 1 to strongly agree = 5). Items 8, 15, 23, 28, and 40 are scored reversely. The total score of QPCQ (46 questions) ranges from 46 to 230, with a higher score reflecting a higher quality of prenatal care. The QPCQ is a valid and reliable measure of the overall quality of prenatal care [27]. In the present study, the validity of this questionnaire was obtained by using face and content validities. We used internal consistency and test–retest for the QPCQ to assess reliability. The internal consistency was good (α = 0.94) and the Intraclass correlation coefficient was 0.47 [28].

Data collection and statistical analysis

The researcher referred to the research settings and started sampling in Niknafs maternity ward after obtaining the necessary permission. Thus, the demographic information form, QPCQ, EPDS, and DASS-21 questionnaire (subscales of anxiety and stress) were distributed among the eligible samples, who answered the questionnaires in the presence of the researcher (face-to-face). In addition, The EPDS and DASS-21 were completed and evaluated 6 months after delivery. EPDS and DASS-21 were assessed with a telephone interview 6 months after delivery. Two hundred questionnaires were distributed over 5 months (October 2019 to February 2020), and 186 copies were returned (response rate: 93%). Finally, 186 samples were included in the study. No questionnaires were excluded from the study. The data were then analyzed by SPSS 22 and significance level of 0.05 was considered. Descriptive statistics (frequency, percentage, mean and standard deviation) were used to describe the information. Pearson correlation coefficients were used to determine the relationship between the quantitative variables of the study. The independent t-test, Mann–Whitney U, ANOVA, and Kruskal–Wallis tests (considering the normality of the data) were used to determine PPD according to the qualitative variables of the study. If the variable was normally distributed, an independent t-test was used to compare PPD according to two groups, and an ANOVA test was used to compare PPD according three or more groups. If the variable was not normally distributed, the Mann–Whitney U test was used to compare PPD according to two groups, and the Kruskal–Wallis test was used to compare PPD according to three or more groups. Multivariate linear regression was used to identify the PPD determinants. We used multiple linear regression to estimate the relationship between the independent variables of the present study and the dependent variable of PPD (after delivery and 6 months after delivery). A significance level of 0.05 was considered.