Background

Around 10 to 15% of newly delivered women experience an episode of major depression; 3 to 5% of them have moderate to severe depression. Around 2 out of 1000 women are hospitalized for the postpartum nonpsychotic disorder. In the UK, 50% of the overall suicide reports are related to suicide due to postpartum mental illness either psychosis or severe depression mainly in the first-year postpartum [1]. Perinatal depression or “maternal depression” refers to a major or a minor episode of depression during pregnancy (termed antenatal) or within the first 12 months after delivery (termed postpartum or postnatal). Antenatal depression is now recognized as problematic (perhaps more) as postpartum depression [2].

Postpartum depression symptoms constitute tearfulness, emotional lability, guilt feeling, sense of hopelessness, loss of appetite, sleep disturbances, poor concentration, fatigue, irritability, and inability to cope with the infant [3]. It usually begins within 1–12 months after delivery [4]. The rate of depression is reported to be 7.4% during the first trimester, rising to 12.8% and remaining at 12% during the third trimester [5]. Among women with postpartum depression, over 50% are declared to have depression identified either before or during pregnancy [6]. The strongest predictor of perinatal depression is found to be past history of depression [7] and previous perinatal depression [6, 8].

The etiology of depression is generally accepted to be a combination of neurotransmitter disturbance, hormonal dysregulation, and genetic, and psychosocial factors can be the cause [9]; social risk factors include lack of a partner, marital difficulties (e.g., divorce), and low socioeconomic status (e.g., financial insecurity/hardship), and psychological factors include current depression or anxiety, history of depression, or other psychiatric illness [2].

Being a victim of violence increases the odds of perinatal depression sevenfold, while the older age of mothers decreases the odds by 20%. Exclusive breastfeeding and regular prenatal vitamin intake during pregnancy are associated with 80% and 0.17% decrease in perinatal depression occurrence, respectively [10].

Perinatal depression causes negative consequences for infants that range from immediate risks, such as preterm delivery [11] and neonatal complications [12], to longer term sequelae, such as impaired neurological, cognitive, emotional, and social development [13]. In addition, depressed mothers have more complex behavioral interactions with their children, becoming less responsive, more sensitive, and more intrusive in their care, and children develop an insecure attachment to mothers at age of 36 months [14].

Antenatal depression often goes unrecognized and untreated in part because of concerns about the safety issues of medicating pregnant women and because its symptoms mimic those associated with pregnancy such as changes in mood, cognitive affection, decreased energy level, and appetite change. Depressed women are more likely to have a poor quality of life [15], increased social stress [16], inadequate perinatal care, and persistent complications such as nausea, vomiting, and preeclampsia [17, 18].

Antenatal depression is noted as a strong predictor for postnatal depression [19]; therefore, early screening is mandatory [20], as it is difficult to predict who is having depression by non-detailed history taking [4].

Perinatal depression has been alarming due to the intertwined psychopathological causes and the harmful comorbidities [21]. Risk factors of postpartum depression are culturally determined especially in the developing world [22]. Moreover, culture-related factors are important determinants of occurrence or alleviation of postpartum depression. Thus, for the early detection of perinatal depression, it is mandatory to identify related risk factors in different communities [23].

The current study aimed to identify the rate and severity of major depressive disorder during pregnancy and postpartum period of Egyptian women and to compare women with and without perinatal depression regarding psychosocial factors, obstetric variables, and marital adjustment.

Methods

Participants

This is a comparative cross-sectional study that recruited 301 women by convenient random sampling coming for perinatal care in a primary healthcare unit from September 2014 until August 2015.

The study included women who were pregnant and women during the first 6 months postpartum, and their ages ranged between 18 and 45 years; women with either current psychiatric disorder other than depression or current major physical illness like renal/liver/cardiac diseases were excluded. The study protocol was approved by the Ethical Committee of the Faculty of Medicine. All women were briefed on the study, and a written informed consent was obtained.

Measures

A predesigned sheet

It included the demographic data (age, educational level, occupation, and number of children), psychiatric history (past history of perinatal depression, other psychiatric illnesses, family psychiatric history), subjective feeling of stress (mother-in-law disputes, child responsibility, stigma of being the second wife, financial burdens), and obstetric data (natal period either pregnancy or postpartum, history of infertility/induction of labor/abortion/stillbirth, if pregnancy, the baby or its gender was wanted or not, and attitude toward the gender of the baby).

Fahmy and El Sherbini social classification

It includes items on the age, sex, level of education and occupation of the parents, family size, estimated economic level, and sanitation in the house. The total score is 30; 25 or higher scores indicate high social class, 20–24 middle class, 16–19 low social class, and 15 or less very low social class [24].

The Dyadic Adjustment Scale (DAS)

It is a 32-item self-administered questionnaire to assess marital adjustment, composed of four subscales: dyadic consensus, dyadic satisfaction, dyadic cohesion, and affection expression. The total score ranges from 0 to 151. The Arabic version of the scale was used [25].

Edinburgh Postnatal Depression Scale (EPDS)

It is validated to be used in the antenatal and postnatal periods. It is a 10-item self-rating instrument, whereas each item has a 4-point scale. The minimum and maximum total scores are 0 and 30, respectively. It focuses on the cognitive and affective features of depression [26]. The study used the Arabic version of EPDS [27].

The Structured Clinical Interview for DSM-IV (SCID-I)

It is a semi-structured diagnostic interview updated for the DSM-IV. The study used the Arabic version [28].

Hamilton Rating Scale for Depression (HAM-D)

It is 21-item questionnaire used to rate the severity of major depression. Scores between (0–6), (7–17), (18–4), and > 24 indicate no depression, mild, moderate, and severe depression, respectively [29].

Procedure

The study was performed by a stratified random sampling of 301 women who were initially assessed using the predesigned sheet for assessing the demographic, psychiatric, and obstetric items hypothesized to be risk factors for maternal depression. All subjects were asked to complete the EPDS for the possibility of perinatal depression. Among the 301 women, 33 women (22 pregnant women and 11 in postpartum period) scored > 9 on the EDPS, so they were further interviewed by the structured clinical interview (SCID-I) for diagnosis of major depressive disorder. Only 14 (9 pregnant women and 5 in the postpartum period) women warranted a current major depressive episode diagnosis, so they answered the HAM-D to detect the severity of depression.

Statistical analysis

All data were recorded and entered in a statistical package on a compatible computer. Analysis was done using the statistical package for the social sciences (SPSS, 17th version). Comparison between two independent populations was done using an independent t-test. Fisher’s exact and χ2 tests were used to compare qualitative data. The results were tabulated, grouped, and statistically analyzed. The level of significance was p < 0.05 (significant) and p < 0.01 (highly significant).

Results

Sociodemographic and subjective feeling of stress among pregnant and postpartum women

The sample consists of 301 women: 166 (55.1%) in pregnancy and 135 (44.9%) in postpartum periods. Their mean age was 23.7 ± 4.9 and 24.7 ± 5.3 years, respectively. Finishing secondary and high education was the most prevailing educational levels. Most of participants were housewives (77.7%), and more than two-thirds had very low socioeconomic level (75.2%). Most of the pregnant women (44.6%) were having their first child, while a greater portion of postpartum women (69.6%) had two or more previous children (Table 1).

Table 1 Comparison between pregnant and postpartum women regarding the sociodemographic data and subjective feeling of stress scores
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There were statistically significant differences regarding number of children (p < 0.001), occupation (p < 0.031), and educational level (p < 0.001) between pregnant and postpartum women. Considering the subjective feeling of stress items, disputes with mother-in-law and financial burdens were the highest stressful situations recorded by both groups (Table 1).

Psychiatric and obstetric history among pregnant and postpartum women

Regarding the psychiatric history, perinatal depression was reported in 6.6% and 4.4% of pregnant and postpartum women, respectively (Table 2). Around 80.7% and 84.4% of pregnant and postpartum women had planned pregnancies, respectively. All their babies were wanted. There was a statistically significant difference among the two groups regarding the attitude of parents toward the gender of the baby (p < 0.001), with negative attitude in 22.9% of pregnant women.

Table 2 Comparison between pregnant and postpartum women regarding the psychiatric and obstetric variables
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There were statistically significant differences among the two groups regarding history of induction of labor (p = 0.009) and history of abortion/stillbirth (p = 0.012) with higher rates shown in pregnant women (4.8% had history of induction and 13.9% had history of abortion) than women in postpartum period. There was no statistically significant difference considering the history of infertility (Table 2).

Depression and marital satisfaction among pregnant and postpartum women

The rate of depressive symptoms during pregnancy and postpartum period was 13.2% and 8.1%, respectively, using the EPDS. Subjects who had a cutoff score > 9 answered the SCID-I questionnaire showing major depressive disorder with mild to moderate severity measured by the Hamilton Depression Scale in 5.4% and 3.7% of pregnant and postpartum subjects, respectively.

Using the Dyadic Adjustment Scale, the rate of marital satisfaction was 93.4% during pregnancy and 97% in postpartum period. There were no statistically significant differences regarding marital satisfaction, EPDS, SCID-I, and HAM scores between the two groups (Table 3).

Table 3 Comparison between pregnant and postpartum females using EPDS, SCID-I, HAM-D, and DAS
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The sociodemographic differences among depressed and nondepressed women

There was a statistically significant difference between major depressive disorder and occupation; depression was higher in employed females than in housewives (p = 0.031). There were no statistically significant differences between depression and variables like age, number of children, social status, and educational level (Table 4).

Table 4 Demographic data, psychiatric and obstetric history in relation to depression by SCID-I among the total sample
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The psychiatric and obstetric variables among depressed and nondepressed women

There were no statistically significant differences regarding the psychiatric and obstetric history and depression. There was a statistically significant difference in depression occurrence and marital satisfaction (p < 0.001). The most common causes of stress reported in depressed women were disputes with the mother-in-law, stigma being the 2nd wife, and financial strains with statistically significant relation with depression (p = 0.002, 0.047, and 0.001, respectively) (Table 5).

Table 5 Psychiatric, obstetric, and subjective feeling of stress and marital satisfaction variables in relation to depression by SCID-I among the total sample
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Discussion

This study provides considerable evidence that women experience deterioration in their psychological adjustment during the perinatal period where they should be taught coping strategies to reduce stress and depression. In the current study, the rate of perinatal depression during pregnancy was 13.2% by the EPDS, comparable to previous studies [30, 31]. Previous studies showed higher prevalence of depression during pregnancy in developing countries (19–25%) compared to developed countries (7–15%) [32].

The rate of major depressive disorder during pregnancy based on the SCID-1 scale was 5.4%. Consistently, previous studies reported a point prevalence of depression at the first trimester to be 1.0–5.6% [33] and with similar results in Japan (6%) [34].

The rate of depressive symptoms in postpartum period was 8.1% by using the EPDS. This can affect the mother’s ability to care for her baby and can limit her capacity to engage positively in social interactions [35]. Higher rates of depression were also reported in other areas in Egypt like El-Minia city (49.5%) [36], Sohag (39%) [37], and in Mansoura (17.9%) [30].

The rate of major depression in the postpartum period in our results was 3.7% by the SCID-I. It has been noted that the prevalence of postpartum depression varied from 1.9 to 82.1% in developing countries and from 5.2 to 74.0% in developed countries [38]. These differences might be due to differences in the type of the screening instrument used, cutoff scores, cultural variables, and differences in socioeconomic environments. The current study showed higher rate of depression in pregnant women (13.3%) than the postpartum (8.1%). This was consistent with findings by other studies [39,40,41], referring to the high levels of depression in pregnant women compared to postpartum.

The mean age of our sample was early 20s, and there was no significant difference between depressed and nondepressed mothers. This was consistent with the previous studies [42,43,44].

In this study, there was a significant difference between pregnant and postpartum women with the majority having modest educational level (secondary and high education) with no significant correlation with depression in consistent with previous studies [42, 45, 46]. Previous studies reported that education is a predictor of postpartum depression [47], and that mothers who had a higher level of education were more at risk of postpartum depression [48, 49], being sensitive and embarrassed to admit depressive symptoms [50]. Yet, other studies found that educated mothers have supportive social networking and high self-esteem [51].

Furthermore, the rate of depression was higher among employed Egyptian mothers. These data were similar to previous studies which detected higher depression in working females than housewives [46, 52]. This could be explained by the increasing workload on women to meet the economic needs of their household besides the negative attitude of relatives towards their work in lower and middle social classes [53]. However, investigating other confounders related to employment is warranted. On the contrary, employment was related to a lower prevalence of depressive symptoms mainly during pregnancy [54, 55].

Most of the pregnant women in the current study (44.6%) were having the first child, while a greater portion of postpartum women (69.6%) had two or more previous children with significant difference, but with no significant association with depression, which can be explained by the meshwork of social support received in that specific culture, similar to the previous studies [42, 56]. The number of children was not a significant factor for developing depression in this study. However, a study in UAE reported a significant association between depression and the number of children [57].

Disputes with the mother-in-law were one of the risk factors of depression among our cohort. This was in line with findings of previous studies on eastern women, due to having to live with the husband’s family and be responsible to take care of them [58,59,60]. The woman is supposed to follow the advice of her mother-in-law in different aspects of her life, and this consequently makes women struggle in silence to control their life lacking self-autonomy. Depressive symptoms become prominent if women gain no support from their husbands.

Another determinant factor of depression was the financial burdens, which reflects the lack of self-sufficiency in face of one self’s and home needs, as financial security protects against depression [61]. This agrees with studies reflecting the high perinatal depression triggered in low-income women [62, 63]. Furthermore, there was a significant relation between depression and being a second wife due to the social stigma and stress women continuously get that may lead to a sense of alienation, anxiety, and depression.

In consistent with prior studies, marital satisfaction was reached in almost all the pregnant and postpartum women, as guidance and affection given by husbands help women manage their stress positively [64, 65]. On the other hand, women who did not receive sufficient support from their husbands were vulnerable to depression [30, 36, 51, 66].

The previous history of depression is considered a strong predictor of postpartum depression [7, 39]. In contrast, the current study showed no correlation between the history of mental illness and perinatal depression. In rural areas, mental problems are still considered “family secrets” that should not be disclosed to outsiders. The stigma associated with mental disorders is considered a shame for the entire family [67]. Some women who took part in our study did not recognize depression as a psychological issue but considered the problems a result of the “evil eye.”

Moreover, the satisfaction by the baby gender was one of the culturally related determinant factors of depression. This could be attributed to the religious beliefs of giving compassion, acceptance, and contentment with God’s providence that overrides the engrained cultural stereotype of male gender preference for financial benefits and heritage concepts. In the current study, a low incidence of previous abortion was reported from recruited women that were not associated with perinatal depression in consistent with previous studies [68].

Limitations

The current study is limited by its cross-sectional design which cannot provide reliable causal correlations. The small sample size recruiting mothers attending a single public primary health service can affect the ability of reliable generalization to the whole Egyptian population. Also, the small number of depressed women and reported psychosocial factors such as the second wife. Another limitation is the lack of medical records that can give more detailed data on the psychiatric and family histories of patients.

Conclusions

Perinatal depression with mild to moderate intensity was reported in 5.4% and 3.7% of Egyptian women during pregnancy and the postpartum period, respectively. Moreover, it was strongly linked to cultural factors including marital women’s employment, mother-in-law disputes, being the second wife, and socioeconomic burdens. Assessment of marital dynamics and thorough psychiatric history taking can identify high-risk mothers for early diagnoses and management of perinatal depression.