Background

Pregnancy is a complex process that can lead to dramatic changes in female’s physical, psychological, and social roles. Since pregnancy and birth-giving are both major life events and traumatic processes, postpartum is often considered to be the most risky stage for women to develop depression [1, 2]. Postpartum depression (PPD) is a cross-disciplinary disorder between obstetrics and psychology, which not only has a negative impact on the health of a lying-in woman and her marriage and family but also on breastfeeding, the mother-infant relationship, and the growth& development and emotional behavior of the infant. In more serious cases, infanticide and suicidal tendencies or behaviors may even occur, causing great harm to the mother’s family and society [3, 4].

Risk factors for PPD have been discussed more in previous studies. Pregnant women’s psychophysiological disorders can influence PPD. A meta-analysis by Liu et al. [5] concluded that PPD is relatively higher in developing countries and that gestational diabetes and a history of depression were considered risk factors. In addition, the influence of family on postnatal depression is equally essential. Xie et al. [6] concluded that postnatal family support, especially from the husband, is an essential protective factor for postnatal depression. Poreddi et al. [7] investigated family members in terms of both knowledge and attitudes and concluded that there is an urgent need to address misconceptions and negative stereotypes about postnatal depression among family members. Since there is still a COVID-19 pandemic and the prevalence and odds of PPD are significantly higher [8], there is a need for greater awareness and guidance on PPD.

A knowledge, attitude, and practice (KAP) survey is a structured survey method that can be used to investigate the current state of specific people (i.e., pregnant and lying-in women) toward a specific subject (i.e., PPD) [9]. The practice represents the various behaviors and actions taken by the surveyed people toward the specific subject. Previous studies examined the KAP toward related subjects in different populations. Temtanakitpaisan et al. [10] investigated pregnant women’s awareness of pelvic floor muscle training (PFMT) using a KAP questionnaire. A questionnaire revealed that women perceive that PFMT impacts their mental health and quality of life positively. Aiga et al. [11] used a KAP questionnaire to assess the effectiveness of maternal and child health manuals to intervene in maternal behavior change. Using this questionnaire allowed for greater effectiveness of maternal and child health manuals. KAP surveys are becoming increasingly important as they can enhance the views and perceptions of specific people about certain things. No data are available about the maternal awareness of PPD through the three KAP dimensions. In our study, a high-reliability and validity questionnaire was designed to investigate the three dimensions of maternal awareness. Furthermore, the practice dimension was used to guide maternal awareness to reduce the occurrence of PPD.

Methods

Study design and participants

This cross-sectional study was conducted between September 2022 and November 2022 at Binzhou Medical University Hospital and included pregnant (any gestational age) and lying-in women who volunteered to participate in this study as participants. Pregnant women were defined as reproductive-age women with a history of sexual activity, amenorrhea or menstrual abnormalities, positive blood or urine hCG test indicating pregnancy, and ultrasound findings of intrauterine gestational sac or embryo. The lying-in women were those with postpartum hospitalization or attending follow-up visits within 42 days after delivery. This study received ethical approval from the Ethics Committee of Binzhou Medical University Hospital (approval no. LW-37), and informed consent was obtained from the participants.

Procedures

Based on Expert Consensus on Guidelines for the Management of Postpartum Depression and previously published studies [12–14], the KAP questionnaire was self-designed and included four dimensions: (1) demographic data of the participants; (2) knowledge dimension, consisting of 10 questions (items K4 and K8 were incorrect statements), scored 1 point for correct answers and 0 points for wrong or unclear answers, with total scores ranging from 0 to 10 points; (3) attitude dimension, containing 10 questions scored using a 5-point Likert scale ranging from very positive (5 points) to very negative (1 point), with total scores ranging from 10 to 50 points; (4) practice dimension, including 11 items (item P1 included seven subitems) scored using 5-point Likert scale ranging from always (5 points) to never (1 point), with total scores ranging from 11 to 55 points. Higher scores indicated better KAP.

A small pre-test (50 copies) was conducted before the formal launch, and Cronbach’s α was 0.9266, suggesting a high internal consistency. The results of the confirmatory factor analysis are now shown in Supplementary Figure S1 ((CFI = 0.817 (> 0.800 is good); IFI = 0.818 (> 0.800 is good); RMSEA = 0.069 (< 0.080 is good); CMIN/DF = 3.859 (> 1; 1–3 is excellent, 3–5 is good)), indicating that the questionnaire has good reliability.

Online e-questionnaires are created through the Wen-Juan-Xing online platform in China (https://www.wjx.cn/app/survey.aspx), the questionnaires were distributed, and the data were collected from anonymous participants through Moments forwarding and WeChat group promotion. In order to ensure the quality and completeness of the questionnaire results, each IP address can only be used once for submission. Each question was compulsory. All questionnaires were checked for completeness, consistency, and validity by members of the research team.

Statistical analysis

Stata 17.0 (Stata Corporation, College Station, TX, USA) was used for statistical analysis. The Kolmogorov-Smirnov test was used to examine the distribution of the continuous variables, and most of them were not conforming to a normal distribution. They were presented as median (P25, P75) and analyzed using the Wilcoxon test. Age was presented as means ± standard deviations (SD). Categorical data were expressed as n (%). Pearson’s correlation was used to analyze the correlation between knowledge scores, attitude scores, and practice scores. Univariable and multivariable logistic regression analyses were used to analyze the factors influencing practice. Sufficient knowledge, positive attitude, and proactive practice were defined as scores exceeding 70% of the total score for each respective dimension [15]. All statistical tests were performed using two-sided tests, and P < 0.05 were considered statistically significant.

In the absence of relevant literature on pelvic floor dysfunction and pelvic floor ultrasound in our population, the sample size for the study was calculated with an anticipated proportion of mask-wearing practice as 50%, at a 95% confidence level and 5% error margin the required sample size of 384 was calculated. Considering a 70% response rate, at least 549 participants were needed to be included [16].

Results

Baseline and KAP scores in pregnant and lying-in women

Five hundred ninety-four pregnant women completed the questionnaire, with most participants aged 25–35 years (78.5%), nearly two-thirds of whom were urban residents, and more than two-thirds had a bachelor’s degree or higher. The total score of the knowledge dimension for all participants was 6.27 ± 2.45, with statistical differences (p < 0.05) for different age, places of residence, education, work status, and para; the total score of the attitude dimension was 36.37 ± 4.16, with statistical differences for different age, residence, education, work status, gravida, para, and current gestational age (p < 0.05), the total score of the practice dimension was 38.54 ± 7.93, and there were statistical differences in the scores of different age, education, and work status (p < 0.05) (Table 1).

Table 1 Baseline characteristics and KAP scores
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Knowledge, attitude, and practice scores

The total scores for the three dimensions of knowledge, attitude, and practice were 6.24 ± 2.43, 36.67 ± 3.82 and 38.31 ± 7.27 for pregnant women and 6.30 ± 2.49, 36.00 ± 4.53 and 38.83 ± 8.69 for lying-in women, respectively, and there was no statistical difference between the total scores of pregnant women and mothers in the three dimensions (P > 0.05). However, on the attitude dimension, pregnant women had scores of 4.16 ± 1.13 for item A1, 4.41 ± 0.78 for A2, and 2.75 ± 1.05 for A6, and lying-in women had scores of 3.75 ± 1.36, 4.22 ± 0.98 and 2.94 ± 1.09 for items A1, A2, and A6, respectively, with statistical differences in the scores of the three subscales (p < 0.001; 0.014; 0.038) The remaining detailed scores are shown in Table 2. In terms of knowledge dimension, 363 (61.11%) participants were correct that PPD is a common puerperal psychiatric syndrome that occurs within four weeks, 475 (79.97%) participants were correct that the occurrence of PPD is related to genetic, neuroendocrine disorders and psychosocial factors, 522 (87.88%) participants believed that PPD needs to be treated, and 417 (70.20%) participants were correct that medication should be avoided during breastfeeding, and overall, the majority of participants had a relatively correct understanding of PPD (Table 3). For Supplementary Table 1, the percentages of each sub-item score in the attitude dimension; for Supplementary Table 2, the percentages of each item score in the practice dimension.

Table 2 Group comparison
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Table 3 Knowledge Dimension
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Correlation analysis between the scores of the three different dimensions

By analyzing the two-by-two Pearson coefficients between the total scores of the three dimensions, the results showed that the Pearson coefficient between the practice score and attitude score was 0.162 (p < 0.001), the Pearson coefficient between practice score and knowledge score was 0.318 (p < 0.001), the Pearson coefficient between attitude score and knowledge score was 0.165 (p < 0.001), and all dimensions were positively correlated with each other (Table 4).

Table 4 Pearson correlation analysis
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Factors associated with the practice scores

Univariate logistic regression analysis revealed that knowledge dimension scores, attitude dimension scores, age, education, work status, and current stage were the factors that influenced the practice dimension scores. When incorporating these factors into a multivariate logistic regression model, the results showed that knowledge scores (OR = 1.235, 95%CI: 1.128–1.353, P < 0.001 per 1 point), attitude scores (OR = 1.052, 95%CI: 1.005–1.102, P = 0.030 per 1 point), work status‘s others (OR = 0.431, 95%CI: 0.193–0.961, P = 0.040 vs. employed) and Current stage‘s postpartum period (OR = 1.509, 95%CI: 1.043–2.182, P = 0.029 vs. pregnancy period) were significantly associated with a higher practice score (Table 5).

Table 5 Univariate logistic regression analysis
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Discussion

This preliminary cross-sectional study explores pregnant and lying-in women’s perceptions of PPD. We surveyed participants in three dimensions by creating a KAP questionnaire. The study results showed that maternal scores in the three dimensions differed across states, pregnant and maternal women had good knowledge of PPD in more than half of the participants, and that practice dimension scores correlated with knowledge and attitude scores. However, disregard for PPD remained prevalent among a minority of participants. Therefore, the KAP survey allows for a preliminary understanding of the different dimensions of PPD in the maternal population. Based on the results, education and coping measures for PPD can be developed and implemented to address these biases and negative stereotypes associated with PPD.

Studies on the link between KAP and PPD are rare, especially during the COVID-19 pandemic in recent years, which may have had a direct psychological and social impact on pregnant women and women who have just given birth due to the relative restriction of social activities. In this study, we found statistically significant differences in their scores on the three dimensions of KAP across age groups, education, and work status. This is more consistent with the findings of previous studies. Silva et al. [17] found statistical differences in anxiety-depression scores by maternal age through a questionnaire survey of pregnant women. At the same time, PPD was associated with age and a high rate of PPD among lying-in women, which is associated with maternal anxiety and should further enhance mental health during pregnancy and puerperium. A meta-analysis of a Chinese study by Nisar et al. [18] found that the prevalence of perinatal depression showed an increasing trend in the last decade. At the same time, a higher educational level was a protective factor. Our study showed that as educational background increased, higher education was associated with higher KAP scores. Using a sample analysis of 15,000 mothers in a nationwide French cohort, Nakamura et al. [19] found occupational rank. Employment and higher socioeconomic status made possible by education reduced the occurrence of PPD, with higher scores for those who were employed than for those who were not employed and those who worked part-time in the three dimensions. Overall, we should pay further attention to pregnant women and lying-in women with low scores on the three dimensions.

Although our results showed no statistically significant differences in the scores of women during pregnancy and lying-in on the three dimensions, there were differences in the scores obtained by women at different periods on some subitems. Analysis of the subitems with differences showed that women during pregnancy took PPD more seriously in their mindset and actions and were more willing to be proactive in being screened for PPD. A woman in labor is likely to worry about how to care for her child, which can cause them anxiety. Also, the hormonal changes and frequent mood swings from pregnant women to mothers may affect their perception of PPD. Pięta et al. [20] argue that special attention should be paid to women who experience negative mental states during pregnancy. They argue that mood changes during pregnancy, labor, and lying in are often extreme and can change significantly in short periods. For their part, researchers such as Andrzej [21] suggest practical actions in the field of public health, which would raise awareness among young women and pregnant women and make them aware of the importance of physical activity for their pregnancy and childbirth process. We also believe we should provide psychological support to pregnant women to enhance their awareness of PPD.

Our results show a positive correlation between maternal scores on the three dimensions, with the three dimensions influencing each other. Previous studies generally agree that there is a correlation between knowledge, attitudes, and practices. Alsabi [22] surveyed social support networks during the COVID-19 pandemic in Malaysia, and they found that public perceptions of PPD were correlated with their knowledge and attitudes. Highet et al. [23] investigated three aspects of perinatal depression awareness, attitudes, and knowledge among Australians, and they concluded that people without mental health training had lower awareness and attitudes towards the etiology of PPD, and when awareness increased, the attitudes towards PPD also changed. Jones et al. [24] conducted a national survey of midwives and found that when midwives are professionally educated, and their knowledge is improved, it also leads to better cognitive and practical skills in assessing and caring for women with PPD. Likewise, Elshatarat [25] believes that educating healthcare professionals and improving their understanding of PPD will improve their knowledge, practice, and self-confidence. We also believe daily information should be provided to pregnant women to understand PPD and prevent it by increasing knowledge and positive attitudes towards PPD.

For maternal practice aspects, we concluded through multivariate logistic regression analysis that the knowledge and attitude dimensions influence practice. At the same time, the postpartum period will have a higher practice score than the pregnancy period (OR = 1.509 [1.043–2.182]). It is essential for maternity to put into practice both psychological and behavioral aspects of the intervention. Earls et al. [26] argued that payment should be advocated for increased training in the screening and treatment of PPD, with significant support for the mother-infant relationship, and for the identification of perinatal depression to be incorporated into pediatric practice. A randomized controlled trial by Meng et al. [27] concluded that a circulatory care intervention positively affected postpartum anxiety and depression and significantly reduced the incidence of PPD. We believe that pregnant and lying-in women should be motivated to act and seek interventions to prevent PPD. A meta-analysis by Zhou et al. [28] also concluded that pregnant women should actively use portable electronic devices to address depressive symptoms in postpartum women, increase knowledge of PPD through electronic devices to change their attitudes and use mHealth interventions to complement routine clinical care for PPD. Therefore, maternal practice is crucial to reducing the incidence of PPD by providing maternal guidance through knowledge and attitudes so that they can be more proactive in seeking professional help. It may be that hormonal changes and the impact of the newborn and the family on the mother make postpartum women more aggressive in seeking help. However, better results are obtained with behavioral interventions early in pregnancy.

This study has some limitations; firstly, this sample is from a single center. At the same time, there is also an insufficient sample size; future multi-center studies are needed to expand the sample size. Secondly, despite the high Cronbach’s alpha coefficient, the KAP survey may need to be validated by more institutions as it is artificially designed.

Conclusions and recommendations

This KAP study revealed that pregnant and lying-in women had relatively good knowledge and positive attitudes toward PPD. Better knowledge and positive attitudes can also improve practice toward PPD. Therefore, it is essential to develop appropriate policies to educate mothers about PPD and improve their attitudes and practices toward PPD. Such improvements could have public health implications, considering that PPD is associated with serious morbidity.