ORIGINAL RESEARCH – QUANTITATIVE
Prevalence and risk factors for postnatal depression in Sabah, Malaysia: A cohort study
Aza Sherin Mohamad Yusuff
a, Li Tang
b, Colin W. Binns
b, Andy H. Lee
b,*
aSchoolofMedicine,UniversityMalaysiaSabah,KotaKinabalu,Sabah,Malaysia
bSchoolofPublicHealth,CurtinUniversity,Perth,WA,Australia
1. Introduction
According totheWorldHealth Organization,depression has become the leading cause of disease burden for women of reproductiveage.1Postnataldepressionisdefinedas‘‘thepresence offiveofthefollowingsymptoms:depressedmood,diminished interest or pleasure in activities, appetite disturbance, sleep disturbance,physicalagitation,fatigue,feelingsofworthlessness or excessive or inappropriate guilt, decreased concentration or abilitytomakedecisionsorrecurrentthoughtsofdeathorsuicidal ideation.’’2Itisthemostcommoncomplicationofchildbearing,3 whichcanhavedeleteriouseffectsonthehealthofthemother,her
maritalrelationshipandinteractionwiththenewborn,aswellas infantgrowth.4Moreover,becauseofitspotentialadverseimpact on breastfeedingduration,5 boththedepressedmotherand her infantareunlikelytobenefitfromthenumeroushealthadvantages ofprolongedlactation.Inthelongterm,untreateddepressionmay leadtosubsequentemotional,behaviouralandcognitiveproblems for the child.6 In Malaysia, epidemiological data on postnatal depressionare stilllackingtoenableappropriatescreening and earlydetectionoftheproblem.
2. Literaturereview
Worldwide, the reported prevalence of postnatal depression varied widely between populations due to differentcriteria of assessment and period of time under consideration.7 A meta- analysisincorporating59studiesof12,810participantsreported anoverallprevalenceof13%,8withonsetoftheconditionoccurred ARTICLE INFO
Articlehistory:
Received16September2014
Receivedinrevisedform3November2014 Accepted4November2014
Keywords:
Postnataldepression EPDS
Prevalence Riskfactors Malaysia
ABSTRACT
Background: Postnatal depression canhave serious consequences for boththe mother and infant.
However,epidemiologicaldatarequiredtoimplementappropriateearlypreventionarestilllackingin Malaysia.
Aim: To investigate the prevalence of postnatal depression within six months postpartum and associatedriskfactorsamongwomeninSabah,Malaysia.
Methods:A prospectivecohortstudyof 2072womenwas conductedin Sabahduring 2009–2010.
Participants wererecruited at 36–38weeks of gestationand followed up at1, 3and 6 months postpartum.ThepresenceofdepressivesymptomswasassessedusingthevalidatedMalayversionofthe EdinburghPostnatalDepressionScale.Logisticregressionanalyseswereperformedtoascertainrisk factorsassociatedwithpostnataldepression.
Findings:Overall, 14.3% of mothers (95% confidence interval (CI) 12.5–16.2%) had experienced depressionwithinthefirstsixmonthspostpartum.Womendepressedduringpregnancy(oddsratio (OR)3.71,95%CI2.46–5.60)andthosewithconsistentworriesaboutthenewborn(OR1.68,95%CI1.16–
2.42)weremorelikelytosufferfromdepressionafterchildbirth.Womenwhosehusbandassistedwith infantcare(OR0.43,95%CI0.20–0.97)andmotherswhoweresatisfiedwiththeirmaritalrelationship (OR0.27,95%CI0.09–0.81)appearedtoincurareducedriskofpostnataldepression.
Conclusion:AsubstantialproportionofmotherssufferedfrompostnataldepressioninSabah,Malaysia.
Screeningandinterventionprogrammestargetingvulnerablesubgroupsofwomenduringantenataland earlypostpartumperiodsarerecommendedtodealwiththeproblem.
ß2014AustralianCollegeofMidwives.PublishedbyElsevierAustralia(adivisionofReedInternational BooksAustraliaPtyLtd).Allrightsreserved.
* Correspondingauthorat:SchoolofPublicHealth,CurtinUniversity,GPOBoxU 1987,Perth,WA6845,Australia.Tel.:+61892664180;fax:+61892662958.
E-mailaddress:[email protected](A.H.Lee).
ContentslistsavailableatScienceDirect
Women and Birth
j our na l ho me pa g e : ww w . e l se v i e r . com / l oca t e / w om bi
http://dx.doi.org/10.1016/j.wombi.2014.11.002
1871-5192/ß2014AustralianCollegeofMidwives.PublishedbyElsevierAustralia(adivisionofReed InternationalBooksAustraliaPtyLtd).Allrightsreserved.
mostlyduringthefirstthreemonthsafterdelivery.9Recentstudies have concluded that the prevalence of depressive symptoms withinthreemonthspostpartumwashighat19%.10Statisticsfrom Asiaindicateawiderangeof3.5%to63.3%ofmotherssuffering frompostnataldepression.4
In Malaysia,thelimitedresultsavailablesuggesteda ranged between3.9%and22.8%.11–14Among377mothersinthestateof Kelantan,theprevalenceofpostnataldepressionwas22.8% and 20.7%at1and4–6weekspostpartum,respectively.13Yetasurvey of 154women attending the 6 weeks postpartum check-upat a general hospital in Kuala Lumpur reported a prevalence of depression at 3.9%.11 Of the four published studies conducted amongMalaysian mothers,three usedthe EdinburghPostnatal Depression Scale (EPDS) for the assessment of depressive symptoms.11,13,14
Risk factors for postnatal depression also differ between developing and developed countries. A literature review of 65studiesfromAsiashowedthathistoryofdepression,stressful life events, low social support, antenatal anxiety, unplanned pregnancy,preferenceof infant’s gender,and low income were pertinentriskfactors.4For Malaysianwomen,depressivesymp- toms during late pregnancy, emergency delivery, traditional postpartum practice, marital problems, as well as low income wereassociated withanincreasedrisk of developing postnatal depression.11–14Theaimofthisprospectivecohortstudywasto investigatetheprevalenceandriskfactorsofpostnataldepression duringthefirstsixmonthspostpartuminSabah,EasternMalaysia.
3. Participantsandmethods 3.1. Studydesignandparticipants
A prospectivelongitudinalstudyofmaternaldepression was conducted at five maternal and child health clinics in Kota Kinabaluand PenampangDistrictsof Sabah,Malaysia, between 2009and2010.Sabah,withapopulationof3.5million,issituated on the island of Borneo in East Malaysia. According to the DepartmentofStatisticsMalaysia,theGrossDomesticProductper capitainSabahwasapproximately17,100Ringgit(5400USD)in 2010,belowthenationallevelof27,900Ringgit(8850USD).
Women who attendedtheclinics fortheir routineantenatal careat 36–38 weekswere invited to participate in this study.
Exclusioncriteriaweremultiplepregnancy,illiteracyordeemed unwell to participate as advised by health professionals. No incentives wereprovidedfor participation. Aminimum sample size of 900 mothers at six months postpartum was required, calculated by assuming a prevalence of postnatal depression between7%and12%.
During 36–38 weeks of gestation, 2072 eligible women consentedtoparticipate(responserate92.2%).Theywereasked tocompleteaself-administeredquestionnaireinaprivatespace.
Trained nurses were available for clarification if required.
Information collected fromthe baseline questionnaireincluded demographic,socioeconomic,andhealthcharacteristicsaswellas depressivesymptomsduringpregnancy.Thecontentvalidityof thebaselinequestionnairewasverifiedinapilotstudyinvolving 50pregnantwomeninthestudypopulation.Motherswerethen followedupat1,3,and6monthspostpartumwhentheyreturned totheclinicsfor immunisationandroutine examinationof the infants.Atotalof979participants(47.2%)remainedinthecohort attheendof6monthspostpartum.
3.2. Measurementofpostnataldepression
The EPDS is a 10-item self-administered questionnaire designedspecificallytomeasurepostnataldepression.Eachitem
wasratedon a4-pointscale(0–3),withthetotalscoreranging from0to30.ThereliabilityandvalidityoftheMalayversionofthe EPDShavebeenverified,wherebyascoreof11.5representedthe optimum cut-offpoint for72.7% sensitivity,95% specificityand positivepredictivevalueof80%.15Therefore,womenwithanEPDS score12werecategorisedashavingdepressivesymptomsinthis study.
3.3. Ethicalconsiderations
Thestudyprotocol wasapprovedbytheSabahStateHealth Department and theHuman Research Ethics Committeeof the researcher’s institution (approval number HR 169/2008), and conformed tothe provisions of theDeclaration of Helsinki. An informationletter explainingtheprojectwasgivenandread to eachwomanbeforeobtainingherwrittenconsent.Allparticipants wereassuredofconfidentiality oftheinformationprovidedand theirrighttowithdrawatanytimewithoutprejudice.
3.4. Statisticalanalysis
Descriptive statistics were first performed to profile the characteristics of participants, taking into account the missing data for some variables. In addition to univariate statistics, stepwise logistic regression analysis was applied to ascertain theriskfactorsassociatedwithpostnataldepression.Independent variables considered in the logistic regression model included socio-demographic variables(maternalage,ethnicity,education level,occupation, monthlyhouseholdincome),biomedical vari- ables(genderofinfant,methodofdelivery),psychosocialvariables (plannedpregnancy, antenataldepression,maternalsatisfaction withinfant’sgender,practical/emotionalsupportduringconfine- ment,whetherhusbandhelpedtakecareoftheinfant,satisfaction withmaritalrelationship,consistentworriesabouttheinfant)and traditional postpartum practicerelated variables (adherence to foodtaboosduringconfinement,confinementwithinthehouse).
Informationontheindependentvariableswasobtainedviaself- reportfrom thequestionnaires. These plausiblefactors, chosen fromtheliterature,wererelevantintheMalaysiancontext.Both crude and adjusted odds ratios (OR) and corresponding 95%
confidenceintervals(CI)wereusedtoassessthemagnitudeofthe associations. All analyses were conducted using the IBM SPSS StatisticalPackageversion21(IBM,Armonk,NY,USA).
4. Results
The average ageof the2072 participantswas26.7 (SD 5.6) years. The majority of the women were Muslims (64.2%) and housewives (70.2%), who came from families with a monthly incomelessthan1000Ringgit(68.3%).Intermsofethnicgroup, 78% of the participants wereindigenous people comprising all Sabahethnicminoritygroups.Theremainingparticipantswereof Indonesian(10.5%),Filipino(4.2%),Chinese(4.0%),Malay(3.4%),or Indian(0.3%)origin.About76%ofthepartnersattainedsecondary school education or above and 70% of them had full-time employment.Comparedtowomenremaininginthecohort,those whowerelosttofollow-uphaveobtainedatertiarydegree,and employedwithahigherhouseholdincome,butnodifferencesin maternalage,religionorethnicitywereapparentbetweenthetwo groups.
Inthisstudy,theprevalence(95%CI)ofpostnataldepression wasfoundtobe7.1%(5.8–8.5%)at1month(n=1362),6.9%(5.5–
8.5%)at 3 months(n=1153), and 7.6% (6.1–9.4%)at 6 months (n=979).Overall,195outof1362mothers(14.3%,95%CI12.5–
16.2%)hadeverexperienceddepressionduringthefirstsixmonths postpartum.
Table1comparesmotherswithandwithoutdepressionafter childbirth.Basedontheunivariateanalyses,fivefactorsappeared tobepotentially associated withthedevelopment of postnatal depression within six months postpartum, namely, maternal occupation,antenataldepression,whetherhusbandassistedwith infantcare,satisfactionwithmaritalrelationship,andconsistent worriesabouttheinfant.
Table2presentstheresultsfrombackwardstepwiselogistic regression, which confirm the apparent association between antenataldepressionand depressivesymptoms afterchildbirth.
Women who suffereddepression during pregnancy weremore likely todevelop postnatal depression afterwards(adjusted OR 3.71,95%CI2.46–5.60),whencomparedtotheircounterpartswho werefreeof depressivesymptoms beforechildbirth.Consistent worriesabouttheinfant(adjustedOR1.68,95%CI1.16–2.42)also tended to be positively associated with the risk of postnatal depression.Ontheotherhand,womenwhoreceived helpfrom
theirhusbandtowardsinfantcare(adjustedOR0.43,95%CI0.20–
0.97)andthosewhoweresatisfiedwiththeirmaritalrelationship (adjustedOR0.27,95%CI0.09–0.81)werelesslikelytobecome depressedafterdelivery.Furthersubgroupanalysisbyfollow-up timepoint(1,3and6monthspostpartum)showedthatantenatal depressionwasconsistentlyassociatedwiththeriskofdepressive symptomsafterchildbirth.
5. Discussion
Thisprospectivecohortstudyprovidesthefirstreportonthe prevalence and risk factors for postnatal depression among mothersinSabah,Malaysia.Theobservedprevalenceofpostnatal depression duringthefirst sixmonthspostpartum (14.3%)was lowerthanthosereportedformothersresidinginKualaLumpur (16.7%,6weekspostpartum)14andinKotaBharuDistrict,north- east of Peninsular Malaysia (20.7%, 4–6 weeks postpartum).13
Table 1
Characteristicsofparticipantsbydepressionstatusafterchildbirth(n=1362).
Factorsa Notdepressed(n=1167) Depressed(n=195) CrudeOR(95%CI) p
Maternalage(years) 0.915
<30 866(74.2%) 144(73.8%) 1.00
30 301(25.8%) 51(26.2%) 1.02(0.72,1.44)
Ethnicity 0.681
Indigenous 894(76.6%) 152(77.9%) 1.00
Non-indigenous 273(23.4%) 43(22.1%) 0.93(0.64,1.33)
Maternaleducationlevel 0.285
Primary 379(33.5%) 74(39.4%) 1.00
Secondary 627(55.4%) 94(50.0%) 0.77(0.55,1.07)
Tertiary 126(11.1%) 20(10.6%) 0.81(0.48,1.39)
Maternaloccupation 0.042
Notemployed 793(69.6%) 146(76.8%) 1.00
Employed 347(30.4%) 44(23.2%) 0.69(0.48,0.99)
Monthlyhouseholdincome(Ringgit) 0.264
<1000 768(66.9%) 137(72.9%) 1.00
1000–3000 308(26.8%) 42(22.3%) 0.76(0.53,1.11)
>3000 72(6.3%) 9(4.8%) 0.70(0.34,1.43)
Genderofinfant 0.647
Male 616(53.1%) 107(54.9%) 1.00
Female 544(46.9%) 88(45.1%) 0.93(0.69,1.26)
Methodofdelivery 0.200
Vaginaldelivery 1055(91.5%) 172(88.7%) 1.00
Caesareansection 98(8.5%) 22(11.3%) 1.38(0.84,2.25)
Plannedpregnancy 0.085
No 482(42.1%) 94(48.7%) 1.00
Yes 664(57.9%) 99(51.3%) 0.77(0.56,1.04)
Antenataldepression <0.001
No 1038(88.9%) 137(70.3%) 1.00
Yes 129(11.1%) 58(29.7%) 3.41(2.38,4.88)
Maternalsatisfactionwithinfant’sgender 0.659
No 138(12.0%) 21(10.9%) 1.00
Yes/don’tmind 1013(88.0%) 172(89.1%) 1.12(0.69,1.82)
Practical/emotionalsupportduringconfinement 0.248
Always 887(79.4%) 135(74.2%) 1.00
Sometimes 197(17.6%) 39(21.4%) 1.30(0.88,1.92)
Seldom 33(3.0%) 8(4.4%) 1.59(0.72,3.52)
Husbandassistedwithinfantcare <0.001
No 35(3.0%) 39(21.4%) 1.00
Yes 1123(97.0%) 170(88.5%) 0.24(0.14,0.42)
Satisfactionwithmaritalrelationship <0.001
No 14(1.2%) 14(7.3%) 1.00
Yes 1142(98.8%) 179(92.7%) 0.16(0.07,0.33)
Consistentworriesaboutinfant 0.015
No 538(47.4%) 72(37.9%) 1.00
Yes 596(52.6%) 118(62.1%) 1.48(1.08,2.03)
Adherencetofoodtaboosduringconfinement 0.414
No 794(69.1%) 127(66.1%) 1.00
Yes 355(30.9%) 65(33.9%) 1.15(0.83,1.58)
Confinementwithinthehouse 0.118
No 719(62.9%) 110(57.0%) 1.00
Yes 424(37.1%) 83(43.0%) 1.28(0.94,1.74)
OR,oddsratio;CI,confidenceinterval.
a Missingdatapresentforsomevariables.
Nevertheless,theprevalenceofdepressivesymptomsat1month postpartum(6.9%)wasclosetotheestimateof9.8%at6–8weeks postpartumfromanothersurveyconductedinBachokDistrictof Kelantan.12
A significant association was found between antenatal and postnataldepression.Althoughresearchindifferentcultureshas similarlysuggesteddepressivesymptomsinpregnancyasastrong predictor of postnatal depression,16–18 screening of depression duringpregnancyisseldomprovidedaspartoftheantenatalcare services in Asian countries such as Malaysia. In our cohort, 285women(13.8%)weredepressedduringtheantenatalperiod.
Routine screening for depression and referral of depressed pregnantwomenfortreatmentshouldbeincludedinthematernal healthpolicyinordertopreventpostnataldepression.
Asexpected,motherswhoweredissatisfiedwiththeirmarital relationship tended to suffer from depression after delivery.
Low marital satisfaction has been consistently shown to be a determinant of postnatal depression among Asian mothers.4 Indeed, a previous study of 174 Malaysian mothers found a significantlyhigherproportionofwomenwithmaritalproblemsin thepostnatal depressiongroupcompared tothenon-depressed group.12AnotherstudyreportedthatHongKongwomenwhohad maritaldissatisfactionwereatleasttwicemorelikelytodevelop postnataldepressionthanthosewithoutmaritalproblems.19The qualityofmaritalrelationshipwasidentifiedtobeapertinentrisk factorinthepresentstudy,whichmaybeattributedtothecustoms and beliefs of thesociety. For most Malaysian women,marital conflictshouldberesolvedprivatelyandnotsharedwithothers.
Itispossiblethatmaritalconflicteventuallybecomesasourceof stressleading todepression, particularlyfor first-time mothers whoarevulnerableemotionally.
The literaturehasdemonstratedthelinkbetween postnatal depressionandwomenwhoseinfanthadseriousorprolonged healthproblems.20,21Thisstudysimilarlyfoundthatconsistent worry about the infant was significantly associated with an elevatedriskofpostnataldepression.Somedepressedmothers might have neglected their infant’s illness and not seek professional help until the problem became severe, whereas others might get excessively nervous as a result of the newborn’sminorhealthproblemsandvisittheirphysiciansmore frequently.4
Consistentwiththeliterature,22,23motherswhodidnotreceive helpfromtheirhusbandincaringfortheinfantwereexposedtoa higherrisk ofdeveloping postnataldepression. After childbirth, womenusuallyrequireadditionalsupportbecauseofthefatigue andmoodswingscausedbyphysicalchanges,suchasadropin hormones, andthe demandsof caring for thebaby.Asnuclear families are now common in Malaysia, it is important for the
husband to provide both practical assistance and emotional supportduringthepostnatalperiod.
Thebirthofafemaleinfantislikelytohaveasignificantimpact onpostnataldepressioninseveralAsiancountriessuchasIndia, China, and Japan.16,24,25 However, our findings suggested no association between the infant gender and depression after delivery, and consistent with previous studies of Malaysian mothers.12,13TheIslamicreligiousideologythatdiscouragesany discriminationmightbetheunderlyingfactorfortheobservedlack ofassociation.12
Severallimitationsshouldbeconsideredwheninterpretingthe findings.Firstly, theresultsmaynot begeneralisedbeyond the state of Sabah becauseof variations in culture between ethnic minoritygroups.Inaddition,similartootherobservationalstudies, self-selectionbiascannotbeavoided.Anotherlimitationconcerns therelatively highrate ofloss tofollow-up. Only 47.2% of the participants remained in the cohort at the end of 6 months postpartum.Nevertheless,thefinalsamplewasstill sufficiently largetoallowmultivariateanalysisofpostnataldepressionforthe populationofSabah.In-depthinvestigationsarerecommendedto enableacomprehensiveunderstandingoftheunderlyingissuesof postnatal depression among mothers in Sabah. Lastly, further research is still required to provide information on postnatal depressioninotherpartsofMalaysia.
6. Conclusion
A substantial proportion (14%) of mothers had experienced depression during the first six months postpartum in Sabah, Malaysia, based on our prospective cohort study. Antenatal depression,lackofassistancewithinfantcarefromthehusband, dissatisfactionwithmaritalrelationship,andconsistentworries about theinfant, were allassociated withan increasedrisk of postnataldepression,accordingtothelogisticregressionanalysis.
Screeningandinterventionprogrammestargetingthesevulnera- blesubgroupsofwomenduringantenatalandearlypostpartum periodsarerecommendedtodealwiththeproblem.
Conflictofinterest
Theauthorsdeclarethattheyhavenoconflictofinterest.
Acknowledgements
Theauthorsgratefullyacknowledgethetimeandeffortgiven bythemothersandhealthworkerstoourstudy.Nofundingwas receivedtoconductthisresearch.
Table 2
Factorsassociatedwithpostnataldepressionfromstepwiselogisticregressionanalysis(n=1112).
Factors n(%) AdjustedOR(95%CI)a p
Antenataldepression <0.001
No 965(86.8%) 1.00
Yes 147(13.2%) 3.71(2.46,5.60)
Husbandassistedwithinfantcare 0.041
No 38(3.4%) 1.00
Yes 1074(96.6%) 0.43(0.20,0.97)
Satisfactionwithmaritalrelationship 0.019
No 17(1.5%) 1.00
Yes 1095(98.5%) 0.27(0.09,0.81)
Consistentworriesaboutinfant 0.006
No 528(47.5%) 1.00
Yes 584(52.5%) 1.68(1.16,2.42)
OR,oddsratio;CI,confidenceinterval.
a Non-significantvariableswerematernalage,ethnicity,maternaleducationlevel,maternaloccupation,monthlyhouseholdincome,genderof infant,methodofdelivery, plannedpregnancy,maternalsatisfaction withinfant’sgender, practical/emotionalsupportduring confinement, adherencetofoodtaboosduringconfinementandconfinementwithinthehouse.
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