Faculty of Medicine

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Lithuanian University of Health Sciences

Faculty of Medicine

Department of Obstetrics and Gynecology

Title of Master’s Thesis:

The impact of paternal support and marital satisfaction on the development of maternal postpartum depression.

Author: Mohanad Bahro

Supervisor:

Lector Laura Malakauskienė

Consultant: PhD Gitana Ramoniene

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SUMMARY

Author name: Mohanad Bahro

Research title: The impact of paternal support and marital satisfaction on the development of

maternal postpartum depression (PPD).

Aim: To assess the impact of paternal support and marital satisfaction on the development of

maternal PPD.

Objectives: 1. To assess the incidence of PPD among women after delivery in LUHS Hospital,

Department of Obstetrics. 2. To evaluate the risk factors for PPD. 3. To determine the impact of different paternal support and marital satisfaction on the development of maternal PPD.

Methodology: The cross-sectional questionnaire-based study is carried out on a sample of 103

women after delivery in LUHS Hospital, Kaunas Clinics, Department of Obstetrics and Gynecology. The questionnaire focused on women’s perception of specific paternal support factors and marital satisfaction. Other predictor variables screened were socio-demographic and

psychological factors. Edinburgh Postnatal Depression Scale with a cutoff score>9 was used as

criteria to diagnose probable PPD. Variables were considered statistically significant when p<0.05.

Results: The prevalence of PPD in our study was 16.5% (n=17). Women who were in partnership

(p=0.02), who experienced depressing symptoms during pregnancy (p<0.001), who had the previous diagnosis of depression (p=0.02), and who experienced stressful life events (p=0.04) during pregnancy have shown to be significantly related to maternal PPD development. Women who reported that they did not experience or lacked physical help-seeking behavior during pregnancy (p<0.001), psychological help-seeking behavior during pregnancy (p<0.001), psychological help-seeking behavior during delivery (p<0.001) from their partners and who experienced a decrease in couple relationship quality during pregnancy (p<0.001) have shown a significant correlation with the development of maternal PPD.

Conclusion: 1. The incidence of PPD among women after delivery in our sample group was

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ACKNOWLEDGMENTS

I devote this thesis to my beloved mother, father, sister, and brother for their constant encouragement and unwavering faith in me. I want to thank my father Dr. Asem Bahro and mother Dr. Razan Said for their tremendous support, always inspiring me to follow my dreams. This journey would not have been possible without the help of my family, friends, professors and university staff.

Finally, I would like to thank my supervisor Dr. Laura Malakauskienė for her guidance throughout this research project.

CONFLICTS OF INTEREST

The author reports no conflicts of interest.

PERMISSION ISSUED BY THE ETHICS COMMITTEE

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LIST OF ABBREVIATIONS

PPD – Postpartum Depression

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TERMS

Postpartum – Following childbirth.

Paternal – of or appropriate to a father

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CHAPTER 1: INTRODUCTION

Depression is a disorder that affects the mood characterized by persistent feelings of sadness or/and anhedonia. Many women, especially those of childbearing age tend to experience depressive symptoms or mood disorders during the postpartum period. Postpartum depression (PPD) is a common mood disorder that tends to happen in 10-15% of pregnant women [1].

Postpartum depression has a significant negative impact, not only on the health of the mother but also on her child and partner [1-3]. Studies have shown that it accounts for 15-20% of the causes of postpartum mortality in the world. Therefore, the determination of maternal emotional distress during pregnancy and the identification of risk factors for this distress are considered clinical and public health importance. For this reason, numerous studies have been conducted to identify risk factors that have a significant impact on the development of maternal PPD. Among these risk factors were women with a history of depression, anxiety, stressful life events, risky pregnancy, the method of delivery, young age and hormonal changes [4].

From a prevention aspect, it is pivotal to explore possible causing and protective factors against emotional distress in pregnancy. To prevent PPD, these risk factors have been used for the development of screening programs and designing evidence-based prevention programs [4]. Despite the existence of all these studies, only a few have reported results on the parental support and marital satisfaction that possess a risk for developing PPD. Some studies have emphasized that paternal interest have a strong relation with PPD development; however, definite conclusions are lacking [5-9].

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CHAPTER 2: AIMS AND OBJECTIVES

Aim: To assess the impact of paternal support and marital satisfaction on the development of

maternal postpartum depression.

Objectives:

1. To assess the incidence of postpartum depression for women after delivery in LUHS Hospital, Department of Obstetrics and Gynecology.

2. To evaluate risk factors for postpartum depression.

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CHAPTER 3: LITERATURE REVIEW

3.1 Definition, signs and symptoms, onset and prevalence of Postpartum Depression:

Postpartum depression (PPD) is a disabling mental disorder and is considered to be a significant health concern affecting the mother, partner and the baby [1-3].

Maternal PPD is defined as a non-psychoactive depressive episode, which is a mentally disabling disorder that occurs in mothers at a certain period [1].

Plenty of studies have been conducted to identify the onset of PPD signs and symptoms. The study involving 203 studies conducted between 2005 and 2014 showed that most symptoms occurred at the 4th _{week after delivery. The study showed that the prevalence of PPD varies from}

1.9% to 82.1% using (EPDS>9 as a diagnosis) with no significant difference between developed and developing countries. Assessment of PPD was made at different times ranging from a few days to 18 months after birth [10]. The prevalence of PPD in Asian countries is between 3.5% to 63.3% [11], based on research in 27 states of the United States of America, the average incidence of PPD is 11.5% [12]. G. Fellmeth has found that new mothers in both high and low-income countries had a 10-20% prevalence of PPD [13]. Additional studies have revealed that PPD can occur even antenatally. One example was a study conducted at Four Inner- City Mental Health Clinic in Dallas (N=802), which showed that 50% of PPD episodes began during the antenatal period [14]. Therefore, DSM-5 (Diagnostic and Statistical Manual-5) has diagnosed PPD as a depressive mental disorder with a prenatal onset that can occur anytime during pregnancy until four weeks after delivery [15].

PPD symptoms and signs generally manifest in emotional, behavioral and cognitive aspects. Mothers with PPD experience mood swings, anxiety, fatigue, agitation, feelings of hopelessness, and excessive worry about the baby’s health. Changes in behavior can be noticed by a lack of energy, social isolation, withdrawal, marital problems, insomnia or hypersomnia, and loss of interest in everyday activities. Cognitive changes include an inability to concentrate, forgetfulness, and slow decision making [2, 4, 6].

3.2 Etiologies, risk factors, and influence of importance:

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Evidence found that hormones such as testosterone, thyroid hormone, estrogen, progesterone, and cortisol may play a significant role in the development of PPD especially in pregnant women due to hormonal fluctuations, but the specific etiology of PPD is yet unclear [16].

Despite the unclear etiology, many risk factors have been found to increase the risk of PPD development. Classification of these risk factors can be into four fields [4]:

 Psychological factors. Anxiety, psychological distress, stressful life events, previous history of depression, and depressing symptoms during pregnancy are found to be the most potent factors in predicting PPD [4,17-22].

 Obstetrical factors. The number of porous has shown to be related to PPD. Mayberry LJ has reported that PPD is more prevalent in multiparous women [23]. While another study conducted showed that PPD has a higher incidence of nulliparous women [24]. Complications during labor and Emergency C-section have proven to increase the risk of PPD [4]. Hamdan A and Tamim H study have shown that PPD risk is reduced in breastfeeding women [25].

 Social factors. Reduced social support has been demonstrated to have a significant impact on PPD development. Unstable relationships, poor educational status, unemployment, and a low socio-economic level have also been found to affect PPD development [4,19-21].

 Lifestyle factors. A study conducted in Greece (n=529) has shown that a healthy diet during pregnancy including dairy products, vegetables, fruits, seafood and legumes in sufficient amounts is linked with reducing PPD risk up to 50% [26].

Many studies have shown that PPD can interfere with healthy maternal-infant bonding and negatively affect short and long-term child development [27]. Mothers with PPD were found to be more hostile and irritable, showing less engagement, warmth, love, emotions and physical touching with their child. These interactions are thought to be crucial to a child’s regulatory skill development and communication skills which usually develop through natural and warm interaction between the mother and their infants [27-29].

Studies have also reported a reduction in breastfeeding continuity in mothers with PPD [27]. In this study, mothers with PPD have a significantly higher incidence to discontinue breastfeeding from 4 to 8 weeks after birth [30]. PPD can also interfere with the sleeping routines of infants and is found to be associated with a higher incidence of infant colic [31].

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12 Related Quality of Life (HRQoL). A Research conducted in Canada on 78 women with PPD during the first month till the tenth month postpartum, has shown worse functioning in all eight sections of The Short Form 36 Health Survey (SF-36) (vitality, physical functioning, bodily pain, general health perceptions, physical, social, emotional role functioning, and mental health) [32].

Studies have shown that PPD is associated with a reduction in marital relationship satisfaction, positive interactions and an increase in couple conflict. This relationship is of vital importance especially in early childhood, as it is related to the well-being between partners and children [33].

3.3 Criteria for diagnosis and screening

DSM-5 [15] recognizes PPD as a "depressive disorder with peripartum onset" which means anytime during pregnancy or within four weeks after delivery. Patients must fit the criteria for a major depressive disorder.

The DSM-5 criteria for the diagnosis of major depressive disorder are:

a) Five or more out of nine symptoms (along with at least one of depressed mood and anhedonia) in the same 2-week period. Each of these symptoms needs to be present nearly every day:

 Depressed mood;

 anhedonia, most of the day;

 Change in weight or appetite. Weight: 5 percent change over a month;

 sleeplessness or sleepiness;

 Psychological retardation or agitation;

 Lack of energy or continuous fatigue;

 Guilt or Worthlessness feelings;

 concentration problems; or

 Recurrent thoughts of suicide and death.

b) Symptoms cause significant distress or impairment.

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d) A psychotic disorder does not better explain the incident.

e) Manic and hypomanic episodes have never been experienced. Exclusion e) if mania or hypomania was induced by a substance usage or related to a medical condition.

Due to its significant impact on the individual and the family, the development of evidence- based screening programs has been made, all which play a crucial role in identifying and treating PPD. Many screening tools made for this purpose such as the Edinburgh Postnatal Depression Scale (EPDS), Postpartum Depression Screening Scale, Patient Health Questionnaire 9, Beck Depression Inventory I & II, Center of Epidemiologic Studies Depression Scale, Zung Self-Rating Depression Scale and others. From all of the screening tools; EPDS is most frequently used worldwide for clinical and research purposes. The scale is translated into more than 50 languages and is made up of ten validated questions, which takes less than 5 minutes to answer and follows a straightforward scoring system with the highest specificity and sensitivity (49-100% and 59- 100% in respect) compared to the other screening tools [34]. A study conducted in Denmark concluded that there is no notable difference in the validation of the EPDS against both DSM-5 and International Statistical Classification of Diseases (ICD-10) diagnostic criteria for depression[35].

In these terms, screening programs have been initiated periodically in many countries among prenatal and postnatal women. For example, in the United States, The American College of Obstetricians and Gynecologists recommend that all obstetricians and gynecologists should screen mothers for PPD with a validated screening tool at least once during pregnancy and every postpartum visit [34]. Besides, pediatricians can also aid in screening mothers for PPD during their routine pediatric visits as suggested by the American Academy of Pediatrics [36].

3.4 Impact of parental support, conflict and marital satisfaction on the development of PPD

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14 cohort study conducted in Valencia has demonstrated that a higher incidence of depression was among mothers with low marital satisfaction (14.7%) and poor quality in partner support (22.5%) [5]. A meta-analysis conducted in Australia that reviewed 120 publications, has displayed that antenatal and postnatal depression showed lower levels in those with higher relationship satisfaction. It also showed that paternal conflict and stress antenatally and postnatally were associated with higher depression and anxiety levels, while lower levels of antenatal and postnatal depression were associated with higher levels of paternal support [7]. Another study which also reported that mothers with PPD symptoms had expressed significantly lower perception of partner support and higher levels of partner conflict than mothers without PPD symptoms, found that three factors, partner provision of help, availability when needed and agreement with infant care explained the significant variance of EPDS scores and mental wellbeing [8]. To prove this, Misri S et al. divided mothers with diagnosed PPD into a control group and a support group, which consisted of patients and their partners. Both groups received psycho-educational classes. A significant decrease of depressive symptoms was noticed in mothers of the support group compared to those of the control group [9].

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CHAPTER 4: RESEARCH METHODOLOGY AND METHODS

This study is a cross-sectional questionnaire-based study carried out on a sample of postpartum women in LUHS Hospital Kaunas Clinics, Department of Obstetrics & Gynecology between the 3rd _{of December 2018 to 10}th _{of January 2019.}

One hundred thirty anonymous questionnaires were distributed to women after delivery during their inpatient stay. A total of 103 postpartum women had responded and participated in this study. The questionnaire created by us was written in Lithuanian language and set-up in 4 sections:

1. Socio-demographics

The following variables were assessed: age, educational level, marital status. 2. Factors that may be a risk for PPD

The number of pregnancies and deliveries, presence or absence of depressing symptoms, previous diagnosis of depression and stressful life events. Planned pregnancy, agreed pregnancy, the method of delivery and the type of anesthesia used during labor were also assessed.

3. Assessment of parental support and conflict

Questions about women’s opinion regarding presence or absence of her partner’s: help-seeking behavior, psychological behavior, involvement, active engagement, empathy and understanding, his company during routine doctor visits and her opinion on how their relationship quality changed. The factors mentioned above were all assessed in the questionnaire during pregnancy, delivery and after delivery.

4. Depression Questionnaire

Ten validated questions of the Edinburgh Postnatal Depression Scale (EPDS) were used. The EPDS is an instrument most commonly used worldwide to identify depression in postpartum women. It was validated in Lithuania in 2006 by prof. Danileviciute V. Each item was scored (from 0 to 3) on a four-point scale and a straightforward scoring system with the highest specificity and sensitivity (49-100% and 59-100% in respect) compared to other screening tools (23). For this study, a cutoff score of 10 or more is used to diagnose PPD in women.

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CHAPTER 5: RESULTS

5.1 Sample characteristics

The study group was made of 103 women. The screening for PPD in these patients was between the first day after delivery until the second week of birth with a median of 5 days. Most of the participants were of the 31-35 years old group (67%, n=69).

Less of the women were on their first pregnancy (36.9%, n=38), while the majority had two or more pregnancies (63.1%, n=65).

The majority of women were married (78.6%, n=81), 21.4% were in partnership (n=22), and none of these participants were single or divorced.

In the entire group of 103 participants who were screened for PPD, the prevalence of PPD was (16.5%, n=17).

The maternal characteristics are detailed in Table1.

Table 1. Maternal characteristics

Characteristics n ( %) Age Group 18-25 years 1(0.9) 26-30 years 21 (20.4) 31-35 years 69 (67) 36-45 years 12 (11.7) Number of pregnancies First pregnancy

Second and more pregnancies

38(36.9) 65(63.1) Number of deliveries

First delivery

Second and more deliveries

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18 Primary Secondary High school College University 0 (0) 5 (4.9) 29 (28.2) 11 (10.7) 58 (56.3) Postpartum Depression (EPDS>9)

Yes No

17 (16.5) 86 (83.5)

5.2 Risk factors for PPD

The factors, screened to determine their relationship with PPD, are listed in Table 2. Four factors had shown to be significantly related to PPD occurrence. Women in the partnership were substantially more likely to develop PPD compared to those who were married (p=0.02). Those who experienced depressing symptoms during pregnancy were significantly more likely to develop PPD (p<0.001), as well as those who had the previous diagnosis of depression (p=0.02). The presence of stressful life events during pregnancy also has shown to be significantly related

to PPD development (p=0.04).

Never less, the results have shown that women in the age group of 26-30 years developed PPD the most often (33%, n=7). Women who had lower than a bachelor's degree were found to have a higher prevalence of PPD (24.4%, n=11) compared to those with a university degree (10.3%, n=6).

Table 2. Socio-demographic and psychological variables and its relation with PPD.

Socio-demographic and psychological variables Total Positive PPD N (%) P Value OR (95% CI) Number of pregnancies 1st _Pregnancy ₃₈ _7(18.4) _0.68 _{1.19 (0.3-} 2.0)

More than one 65 10(15.4)

Number of deliveries

1st _Delivery ₄₅ _8(17.8) _0.75 _{1.14 (0.3-}

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More than one deliveries 58 9(15.5) Marital status Single Married Divorced Partnership 0 81 0 22 0(0) 10(12.3) 0(0) 7(31.8) 0.02 2.57(1.1-5.9)

Previous diagnosis of depression

Yes No 6 97 3(50) 14(14.4) 0.02 3.46(1.3-8.8)

Depression symptoms during pregnancy Yes No 18 85 11(61.1) 6(7.1) <0.001 8.62(3.6- 20.4)

Stressful life events

Yes No 33 70 9(27.3) 8(11.4) 0.04 2.38 (1.0- 5.6) Planned pregnancy Yes No 79 24 14(17.7) 3(12.5) 0.54 1.41 (0.4- 4.5)

P-values are calculated by chi square test OR= odds ratio

CI= confidence interval

5.3 Relationship-specific paternal support, relationship quality and its relation with Maternal PPD

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20 occurrence. Women who reported that they did not experience or lacked physical help-seeking behavior during pregnancy (p<0.001), psychological help-seeking behavior during pregnancy (p<0.001), psychological help-seeking behavior during delivery (p<0.001) from their partners and who experienced a decrease in couple relationship quality during pregnancy (p<0.001) has shown a significant relationship with the development of maternal PPD.

Other two variables like negative psychological help-seeking behavior after delivery (p=0.004) and a decrease in relationship quality after delivery (p<0.001) also had shown to be statistically significant but cannot be taken into consideration due to our small study sample. Factors that have demonstrated significant statistical relation are present in Table 3. Other factors that were screened but did not show significant relation are present in Table 4.

Table 3. Relationship-specific paternal support and relationship quality, concerning maternal PPD. Relationship-specific paternal support factors Total Positive PPD n (%) P Value OR (95% CI)

Physical help-seeking Behavior during pregnancy No Yes 12 91 9(75) 8(8.8) <0.001 8.53 (4.0-17.8) Psychological help-seeking Behavior during delivery

No Yes 15 87 9(60) 8(9.2) <0.001 6.52 (2.9-14.2) Psychological help-seeking Behavior during pregnancy

No Yes 9 93 7(77.8) 10(10.8) <0.001 7.23 (3.6-14.3) Psychological help-seeking Behavior after delivery

No Yes 3 200 3(100) 14(14) 0.004 7.14 (4.3-11.6)

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Increase Decrease No change 35 12 56 0(0) 10(83.3) 7(12.5) <0.001

Relationship quality after pregnancy Increase Decrease No change 47 2 54 6(12.8) 2(100) 9(16.7) 0.005

CI= confidence interval

Table 4. Relationship-specific paternal support and relationship quality, concerning maternal PPD Relationship-specific paternal support factors Total Positive PPD n (%) P Value OR (95% CI)

Is his Engagement efficient during pregnancy No Yes 2 101 1(50) 16(15.8) 0.30 3.1 (0.7-13.5)

Physical help-seeking behavior after delivery No Yes 5 97 2(40) 15(15.5) 0.19 2.58 (0.8-8.3)

Efficient involvement and task fulfilling after delivery

No Yes 1 102 0(0) 17(16.7) 1.0

Accompany to routine doctor visits during pregnancy

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22

Always accessible and available during pregnancy No Yes 3 100 1(33.3) 16(16) 0.42 2.08 (0.39- 10.9)

Accessible and available during delivery No Yes 8 95 2(25) 15(15.7) 0.50 1.5 (0.43-5.7)

Always accessible and available after delivery. No Yes 2 101 1(50) 16(16) 0.30 3.1 (0.7-13.5)

Empathize and show adequate understanding during pregnancy

No Yes 2 101 1(50) 16(16) 0.30 3.1 (0.7-13.5)

Empathize and show adequate understanding after delivery

No Yes 3 100 2(66.7) 15(15) 0.07 4.4(1.7-11.2)

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CHAPTER 6: DISCUSSION OF RESULTS

Despite several studies conducted regarding PPD and its factors of influence, very few studies focused on and investigated paternal support's influence on maternal PPD. In our study, we focused on the paternal support and marital satisfaction to investigate any relation or

influence on maternal PPD.

In this prospective questionnaire-based study carried out on a sample of postpartum women during first two weeks of post-partum with a cut-off score (>9) on EPDS, the prevalence of PPD for women 16.5% was lower than that reported in United States 11.5% [12], but similar to those reported in Germany 17% and Norway 16.5% [6] using the same cut-off score.

From the potential socio-demographic and psychological risk factors examined in this study, and consistent with other studies, previous diagnosis of depression [4,17,19-21], depressing symptoms during pregnancy [5,25,19,21], stressful life events during pregnancy [5,36] and unmarried marital status [5,19,21,22] were factors that mostly predicted PPD development and are essential clinical indicators of increased risk of maternal PPD.

However, the other potential risk factors screened as: maternal age [22], number of pregnancies [23,24], number of deliveries [23,24], education level [22], planned pregnancy [19], method of delivery[21], type of analgesics or anesthesia used during labor and presence of company during labor did not show a potent significant effect on the development of PPD in the direction expected from previous studies.

Nevertheless, in our study, there was an increase in the incidence of PPD in those in the age group of 26-30 years and those who had lower than a bachelor’s degree, but the association is not within the limit of statistical significance.

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24 behavior said as "Helps me with the household chores" was also one of three partner‐specific support factors that were proven by Dennis CL et al. [8] to show a significant variance of EPDS scores.

Findings from our study also revealed that women experiencing a low perception of psychological help-seeking behavior from their partners during pregnancy and delivery had significantly reported depressive symptoms. Perceived lack of psychological support can be interpreted as a lack of love, emotions, cognitions, listening, speaking or encouragement to seek help when needed. Both Pilkington PD et al. [7] and Dennis CL et al. [8] have proven that emotional support and effective communication are significantly related to higher depressing symptoms and worst mental well-being.

The decrease in couple relationship quality during pregnancy, as reported by women, best predicted women at risk of postpartum depression in our study. While the incidence of PPD was found significantly higher in mothers with low marital satisfaction by Escriba-Aguir Vet al. [5], Malus A et al. [6] have reported that PPD symptoms were more severe in women who expressed lesser satisfaction in their relationship compared to those who expressed deeper appreciation in their relationship.

Nevertheless, psychological help-seeking behavior and relationship quality after delivery were both found to be statistically significant, but these results cannot be taken into account due to the small sample size. Probably, with a larger sample, statistical significant differences could be found.

Contrary to another author [8], partner accessibility and availability during pregnancy, delivery and after, did not show a statistically significant effect on the EPDS score. This could also

be due to the small sample size in our study. In other terms, this could be explained that partner

availability alone without showing physical or psychological help is useless.

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CHAPTER 7: CONCLUSIONS

1. The incidence of PPD among women after delivery in our sample group was 16.5%. 2. The socio-demographic and psychological factors that mostly predicted PPD development

are the previous diagnosis of depression, depressing symptoms during pregnancy, stressful life events during pregnancy and unmarried marital status.

3. Paternal support factors, such as decrease relationship quality of couple during pregnancy,

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CHAPTER 8: PRACTICAL RECOMMENDATIONS

As there is found the strong influence of paternal support and marital satisfaction on the development of maternal PPD, it should be recommended to doctors and midwives in maternity care homes:

1. to encourage couples to attend the maternity care lectures instead of the mothers alone. 2. to include seminars about the paternal support and it’s beneficial effects.

3. Seminars should be oriented towards educating both parents as opposed to focusing solely on the mothers.

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CHAPTER 9: REFERENCES

(1) Seyfried LS, Marcus SM. Postpartum mood disorders. Int Rev Psychiatry 2003 Aug;15(3):231- 242.

(2) Moore Simas TA, Huang MY, Patton C, Reinhart M, Chawla AJ, Clemson C, et al. The humanistic burden of postpartum depression: a systematic literature review. Curr Med Res Opin 2018 Nov 23:1-31.

(3) Letourneau NL, Dennis CL, Benzies K, Duffett-Leger L, Stewart M, Tryphonopoulos PD, et al. Postpartum depression is a family affair: addressing the impact on mothers, fathers, and children. Issues Ment Health Nurs 2012 Jul;33(7):445-457.

(4) Ghaedrahmati M, Kazemi A, Kheirabadi G, Ebrahimi A, Bahrami M. Postpartum depression risk factors: A narrative review. J Educ Health Promot 2017 Aug 9;6:60.

5) Escriba-Aguir V, Artazcoz L. Gender differences in postpartum depression: a longitudinal cohort study. J Epidemiol Community Health 2011 Apr;65(4):320-326.

(6) Malus A, Szyluk J, Galinska-Skok B, Konarzewska B. Incidence of postpartum depression and couple relationship quality. Psychiatr Pol 2016 Dec 23;50(6):1135-1146.

(7) Pilkington PD, Milne LC, Cairns KE, Lewis J, Whelan TA. Modifiable partner factors associated with perinatal depression and anxiety: a systematic review and meta-analysis. J Affect Disord 2015 Jun 1;178:165-180.

(8) Dennis CL, Ross L. Women's perceptions of partner support and conflict in the development of postpartum depressive symptoms. J Adv Nurs 2006 Dec;56(6):588-599.

(9) Misri S, Kostaras X, Fox D, Kostaras D. The Impact of Partner Support in the Treatment of Postpartum Depression. Can J Psychiatry 2000 08/01; 2019/01;45(6):554-558.

(10) Norhayati MN, Hazlina NH, Asrenee AR, Emilin WM. Magnitude and risk factors for postpartum symptoms: a literature review. J Affect Disord 2015 Apr 1;175:34-52.

(11) Klainin P, Arthur DG. Postpartum depression in Asian cultures: a literature review. Int J Nurs Stud 2009 Oct;46(10):1355-1373.

(12) Ko JY, Rockhill KM, Tong VT, Morrow B, Farr SL. Trends in Postpartum Depressive Symptoms - 27 States, 2004, 2008, and 2012. MMWR Morb Mortal Wkly Rep 2017 Feb 17;66(6):153-158.

(28)

28 Journal of Obstetrics &Gynaecology. 2016;124(5):742-752.

(14) Yonkers KA, Ramin SM, Rush AJ, Navarrete CA, Carmody T, March D, et al. Onset and persistence of postpartum depression in an inner-city maternal health clinic system. Am J Psychiatry 2001 Nov;158(11):1856-1863.

(15) Postpartum depression Diagnostic Criteria - Epocrates Online [Internet]. Online.epocrates.com. 2019 [cited 27 February 2019]. Available from:

https://online.epocrates.com/diseases/51236/Postpartum-depression/Diagnostic-Criteria

(16) Soares CN, Zitek B. Reproductive hormone sensitivity and risk for depression across the female life cycle: a continuum of vulnerability? J Psychiatry Neurosci 2008 Jul;33(4):331-343. (17) 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 Jan;202(1):5-14. (18) Nielsen D, Videbech P, Hedegaard M, Dalby J, Secher N. Postpartum depression: identification of women at risk. BJOG: An International Journal of Obstetrics and Gynaecology. 2005; 107(10):1210-1217.

(19) Davey HL, Tough SC, Adair CE, Benzies KM. Risk factors for sub-clinical and major postpartum depression among a community cohort of Canadian women. Matern Child Health J 2011 Oct;15(7):866-875.

(20) Lee DT, Yip AS, Leung TY, Chung TK. Identifying women at risk of postnatal depression: a prospective longitudinal study. Hong Kong Med J 2000 Dec;6(4):349-354.

(21) McCoy SJ, Beal JM, Shipman SB, Payton ME, Watson GH. Risk factors for postpartum depression: a retrospective investigation at 4-weeks postnatal and a review of the literature. J Am Osteopath Assoc 2006 Apr;106(4):193-198.

(22) Qobadi M, Collier C, Zhang L. The Effect of Stressful Life Events on Postpartum Depression: Findings from the 2009-2011 Mississippi Pregnancy Risk Assessment Monitoring System. Matern Child Health J 2016 Nov;20(Suppl 1):164-172.

(23) Mayberry LJ, Horowitz JA, Declercq E. Depression symptom prevalence and demographic risk factors among U.S. women during the first two years postpartum. J Obstet Gynecol Neonatal Nurs 2007 Nov-Dec;36(6):542-549.

(24) Kheirabadi GR, Maracy MR, Barekatain M, Salehi M, Sadri GH, Kelishadi M, et al. Risk factors of postpartum depression in rural areas of Isfahan Province, Iran. Arch Iran Med 2009 Sep;12(5):461-467.

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the United Arab Emirates. Arch WomensMent Health 2011 Apr;14(2):125-133.

(26) Chatzi L, Melaki V, Sarri K, Apostolaki I, Roumeliotaki T, Georgiou V, et al. Dietary patterns during pregnancy and the risk of postpartum depression: the mother-child 'Rhea' cohort in Crete, Greece. Public Health Nutr 2011 Sep;14(9):1663-1670.

(27) Field T. Postpartum depression effects on early interactions, parenting, and safety practices: a review. Infant Behav Dev 2010 Feb;33(1):1-6.

(28) Lovejoy MC, Graczyk PA, O'Hare E, Neuman G. Maternal depression and parenting behavior: a meta-analytic review. Clin Psychol Rev 2000 Aug;20(5):561-592.

(29) Jean AD, Stack DM, Fogel A. A longitudinal investigation of maternal touching across the first six months of life: age and context effects. Infant Behav Dev 2009 Jun;32(3):344-349.

(30) Dennis CL, McQueen K. Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Acta Paediatr 2007 Apr;96(4):590-594.

(31) Dennis CL, Ross L. Relationships among infant sleep patterns, maternal fatigue, and development of depressive symptomatology. Birth 2005 Sep;32(3):187-193.

(32) Da Costa D, Dritsa M, Rippen N, Lowensteyn I, Khalife S. Health-related quality of life in postpartum depressed women. Arch WomensMent Health 2006 Mar;9(2):95-102.

(33) Garthus-Niegel S, Horsch A, Handtke E, von Soest T, Ayers S, Weidner K, et al. The Impact of Postpartum Posttraumatic Stress and Depression Symptoms on Couples' Relationship Satisfaction: A Population-Based Prospective Study. Front Psychol 2018 Sep 19;9:1728.

(34) Screening for Perinatal Depression - ACOG [Internet]. Acog.org. 2019 [cited 23 February 2019]. Available from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-

Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression?IsMobileSet=false

(35) Smith-Nielsen J, Matthey S, Lange T, Vaever MS. Validation of the Edinburgh Postnatal Depression Scale against both DSM-5 and ICD-10 diagnostic criteria for depression. BMC Psychiatry 2018 Dec 20;18(1):393-018-1965-7.

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Faculty of Medicine

Table of Contents

SUMMARY

ACKNOWLEDGMENTS

CONFLICTS OF INTEREST

PERMISSION ISSUED BY THE ETHICS COMMITTEE

LIST OF ABBREVIATIONS

TERMS

CHAPTER 1: INTRODUCTION

CHAPTER 2: AIMS AND OBJECTIVES

CHAPTER 3: LITERATURE REVIEW

CHAPTER 4: RESEARCH METHODOLOGY AND METHODS

CHAPTER 5: RESULTS

CHAPTER 6: DISCUSSION OF RESULTS

CHAPTER 7: CONCLUSIONS

CHAPTER 8: PRACTICAL RECOMMENDATIONS

CHAPTER 9: REFERENCES