Factors influencing prenatal and postpartum depression in Korea: a prospective cohort study

Article information

Korean J Women Health Nurs. 2021;27(4):326-336

Publication date (electronic) : 2021 December 13

doi : https://doi.org/10.4069/kjwhn.2021.11.17

Hyeji Yoo¹, Sukhee Ahn^,1, Seyeon Park¹, Jisoon Kim², Jiwon Oh¹, Minseon Koh³

¹College of Nursing, Chungnam National University, Daejeon, Korea

²Department of Nursing, College of Health and Welfare, Woosong University, Daejeon, Korea

³Department of Nursing, Yeoju Institute of Technology, Yeoju, Korea

Corresponding author Sukhee Ahn College of Nursing, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea Tel: +82-42-580-8324 E-mail: sukheeahn@cnu.ac.kr

Received 2021 August 30; Revised 2021 November 17; Accepted 2021 November 17.

Abstract

Introduction

Depression is a common health concern among women during pregnancy and delivery, along with fatigue and anxiety [1], and it negatively affects all family members including the spouse and children [2-4]. Thus, there is a need for a longitudinal study exploring depression and associated factors across the prenatal and postnatal periods to prevent depression, identify intervention time points, and suggest intervention content.

Beck [5], who developed the theory of postpartum depression, identified 13 predictors of postpartum depression, including 10 predictors from the prenatal period and three predictors from the postnatal period, in a study of women with postpartum depression [6]. The prenatal predictors included marital status, socioeconomic status, self-esteem, prenatal depression, prenatal anxiety, pregnancy intention, history of depression, social support, marriage satisfaction, and stress, and the postnatal predictors were child care stress, infant temperament, and maternal blues [6]. According to a study that explored the effects of predictors of postnatal depression on postnatal depression [7], an experience of depression in the prenatal period and a history of depression were relevant factors at 6 weeks postpartum, an experience of depression in the prenatal period was relevant at 4 months postpartum, and low socioeconomic status, a history of depression, and an unintended pregnancy were relevant at 6 to 9 months postpartum. In a study from South Korea (hereafter Korea) that applied the above predictors of postnatal depression [8], prenatal depression, low social support, depressed mood postpartum, and child care stress were significant factors at 2 weeks postpartum, and prenatal depression, low social support, depressed mood postpartum, and unintended pregnancy were significant factors at 6 weeks postpartum [8]. In other studies, everyday stress and child care stress [3,9-11] or stress related to interpersonal relationships or finances during pregnancy [12] influenced postpartum depression. Overall, previous research has consistently shown that pregnancy and postpartum depression are related to different types of stress.

The 10 prenatal predictors suggested by Beck et al. [6] were found to be useful indicators to identify prenatal depression. Prenatal depression has been identified as an independent predictor of postnatal depression in multiple studies [4,7-9,13-15]. Compared to healthy women, women who experienced prenatal depression had lower self-esteem, social support, and marriage satisfaction, everyday life stress, unintended pregnancy, experience of prenatal pregnancy and anxiety, history of depression, and low socioeconomic status [16]. In another study, those with prenatal depression reported lower income and insufficient social support [17]. There were more single women, women with low quality of life, subjective health status, and marriage satisfaction, and women with high stress scores in the high-risk group for prenatal depression [15,18]. Therefore, prenatal and postnatal predictors are useful indicators to identify risk of prenatal and postnatal depression and measure its impact.

Parity was also identified as a significant factor in prenatal and postnatal depression [1,5,14,16,18,19], and its effect varied by time period. During pregnancy, depression among multiparous women was higher than that among nulliparous women [1,15,16,18], but in the postpartum period, depression among nulliparous women was higher than that among multiparous women [14,19]. Spousal depression also impacted women’s prenatal and postnatal depression. Spousal depression during the prenatal period had a continuing influence on the prenatal depression of pregnant women and on their postnatal depression at 1, 3, and 6 months postpartum. Spousal depression during the postnatal period had a lagged effect on women’s depression in the following time period [4].

A limitation in the existing literature is that most studies evaluated depression at specific time points during the prenatal or postnatal periods and explored predictors of depression cross-sectionally, making it difficult to understand the onset and trajectory of depression longitudinally. However, since women’s depression fluctuates and presents in various forms as they experience the transitions from the prenatal and postnatal periods to parenthood [4,20,21], it is necessary to assess the factors that influence the onset of depression from pregnancy to postpartum and to identify the time points for evaluation and intervention. Moreover, a prospective cohort study design provides the opportunity to explore predictors at different time points, as well as predictors that remain consistent or change during the study period, which can be helpful in establishing an effective health management strategy for pregnant women’s successful transition to parenthood.

In Korea, the level of interest in prenatal depression is relatively low; instead, most studies have explored postnatal depression and its predictors among postpartum women [3,9,13,14,22]. One study investigated the prevalence of prenatal and postnatal depression and associated factors from early pregnancy to 4 weeks postpartum in a cohort of pregnant women [15]. However, prospective cohort studies analyzing prenatal and postnatal depression in women have not generally included their husbands’ depression as a factor. In a previous Korean study exploring time points in a cohort, the prevalence of depression slightly decreased from 19.3% at 12 weeks of pregnancy and 13.8% at 24 weeks of pregnancy to 14.0% at 36 weeks of pregnancy, although it then increased to 16.8% at 4 weeks postpartum [15]. In a study on postpartum depression [8], the prevalence was higher, 36.3% at 2 weeks postpartum and 36.7% at 6 weeks postpartum. International studies measured prenatal depression at 14, 24, and 34 weeks of pregnancy [1]; depression of pregnant women in the third trimester of pregnancy and at 1, 3, and 6 months postpartum [4]; and postpartum depression at 6 weeks, 4 months, and 6 to 9 months postpartum with the second trimester of pregnancy as the baseline [6]. As women adjust to pregnancy over the course of the gestational period, this study aimed to explore levels of prenatal depression at 8-week intervals beginning at 20 weeks of pregnancy (with follow-ups at 28 weeks and 36 weeks of pregnancy) and levels of postnatal depression at 2, 6, and 12 weeks postpartum.

This study aimed to identify levels of depression longitudinally at six time points from 20 weeks of pregnancy to 12 weeks postpartum among Korean women who experienced pregnancy and delivery and to identify the factors that affected depression at each time point. The specific goals were as follows.

1) To identify the prevalence of prenatal depression at 20, 28, and 36 weeks of pregnancy and the prevalence of postnatal depression at 2, 6, and 12 weeks postpartum.

2) To explore the factors that influence the prevalence of prenatal depression at 20, 28, and 36 weeks of pregnancy and the prevalence of postnatal depression at 2, 6, and 12 weeks postpartum.

Methods

Results

General and delivery-related characteristics of women

The average age of the pregnant women who participated in the prenatal survey was 32.9 (±3.41). Most women (91.3%) had graduated college or higher, and majority (55.3%) were employed. All participants were married (100%), and a majority (53.0%) reported a monthly household income of greater than 4,000,000 Korean won. Among the pregnant women who participated in the postnatal survey, 68.3% were nulliparous, and the majority (60.1%) had a vaginal delivery (Table 1).

Table 1.

Demographic and obstetric characteristics of the female participants

Prevalence of depression and distribution of factors associated with depression among women

The prevalence of depression among women was 21.5% at 20 weeks, 20.5% at 28 weeks, and 10.5% at 36 weeks of pregnancy, and it was 32.8% at 2 weeks, 24.6% at 6 weeks, and 22.4% at 12 weeks postpartum. Nine prenatal factors, three postnatal factors, parity, and spousal depression were identified as factors associated with depression.

Among the nine prenatal factors, 6.4% to 8.7% of women in the prenatal period and 8.2% to 10.4% of women in the postnatal period were classified as low socioeconomic status. The score for a lack of self-esteem was 0.37 to 0.44 points in the prenatal period and 0.38 to 0.48 in the postnatal period. Experiences of prenatal depression were reported by 66.2% to 68.9%, experiences of postnatal depression by 52.5% to 53.6%, experiences of prenatal anxiety by 66.2% to 68.9%, and experiences of postnatal anxiety by 44.8% to 48.1%. The score for unintended pregnancy was 0.75 to 0.80 points in the prenatal period and 0.73 to 0.77 points in the postnatal period, while a history of depression was present in 12.3% to 14.2% of participants in the prenatal period and 12.6% to 15.3% in the postnatal period. The scores for a lack of social support were 2.05 to 2.24 and 2.33 to 2.96 points, those for marriage dissatisfaction were 0.17 to 0.24 and 0.25 to 0.37 points, and those for everyday life stress were 0.51 to 0.82 and 0.37 to 0.42 points in the prenatal period and in the postnatal period, respectively. Among the three postnatal factors, the scores for child care stress ranged from 0.46 to 0.94 points, those for infant temperament ranged from 0.62 to 0.95 points, and 41.5% to 48.1% of participants reported maternal blues. Among the pregnant participants, 68.0% were nulliparous, while 69.3% of the postpartum participants were nulliparous. The prevalence of depression among spouses was 10.5% at 20 weeks, 10.5% at 28 weeks, and 12.7% at 36 weeks of pregnancy and 6.2% at 2 weeks, 10.0% at 6 weeks, and 6.9% at 12 weeks postpartum (Table 2).

Table 2.

Changes in factors influencing women’s depression from the prenatal to postpartum period

Factors that influenced prenatal and postpartum depression among women

The impact of nine prenatal factors, parity, and spousal depression on prenatal depression was evaluated at 20 weeks, 28 weeks, and 36 weeks of pregnancy. Eight factors consistently had a significant effect on prenatal depression at the three time points. These were low socioeconomic status, lack of self-esteem, experience of prenatal depression, experience of prenatal anxiety, history of depression, lack of social support, marriage dissatisfaction, and everyday life stress. Unintended pregnancy was significantly associated with prenatal depression at 28 weeks and 36 weeks of pregnancy. However, at every time point, parity and prenatal depression among spouses were not associated with prenatal depression among

At 20 weeks of pregnancy, a history of depression (OR, 5.40), low socioeconomic status (OR, 4.89), low marriage satisfaction (OR, 2.90), experience of prenatal anxiety (OR, 2.60), experience of prenatal depression (OR, 2.48), lower self-esteem (OR, 2.48), higher everyday life stress (OR, 1.60), and lower social support (OR, 1.30) were associated with prenatal depression. At 28 weeks of pregnancy, low socioeconomic status (OR, 3.38), experience of prenatal anxiety (OR, 3.02), history of depression (OR, 2.99), lower self-esteem (OR, 2.69), lower marriage satisfaction (OR, 2.54), experience of prenatal depression (OR, 2.12), higher everyday life stress (OR, 1.88), lower social support (OR, 1.39), and lower intention for pregnancy (OR, 1.34) were associated with prenatal depression. At 36 weeks of pregnancy, low socioeconomic status (OR, 11.81), experience of prenatal anxiety (OR, 9.88), experience of prenatal depression (OR, 4.58), history of depression (OR, 4.97), lower self-esteem (OR, 3.12), lower marriage satisfaction (OR, 2.51), lower intention for pregnancy (OR, 1.73), higher everyday life stress (OR, 1.69), and lower social support (OR, 1.32) were associated with prenatal depression (Table 3).

Table 3.

Factors influencing women’s prenatal depression during pregnancy (N=219)

As for the factors that influenced postnatal depression, the impact of nine prenatal factors, three postnatal factors, parity, and spousal depression on women’s depression was evaluated at 2 weeks, 6 weeks, and 12 weeks postpartum. Among the prenatal factors, experience of prenatal depression, experience of prenatal anxiety, low self-esteem, social support, marriage satisfaction, and high everyday life stress were associated with postnatal depression at the three time points. Among the postnatal factors, infant’s temperament and maternal blues were continuously significant. At 2 weeks postpartum, unintended pregnancy and, at 12 weeks postpartum, low socioeconomic status were additional factors that were associated with depression among women at each time point. At all time points, history of depression, parity, and spousal depression were not associated with postpartum depression among women.

At 2 weeks postpartum, maternal blues (OR, 7.82), higher child care stress (OR, 2.89), and more difficult infant temperament (OR, 1.95) were associated with postnatal depression among postnatal factors, and experience of prenatal anxiety (OR, 3.13), lower marriage satisfaction (OR, 2.51), experience of prenatal depression (OR, 2.39), higher everyday life stress (OR, 2.30), lower self-esteem (OR, 1.53), lower intention for pregnancy (OR, 1.40), and lower social support (OR, 1.29) were associated with postpartum depression among prenatal factors. At 6 weeks postpartum, higher child care stress (OR, 2.66), maternal blues (OR, 2.43), and more difficult infant temperament (OR, 1.83) were associated with postpartum depression among postnatal factors. Among prenatal factors, lower marriage satisfaction (OR, 3.14), higher everyday life stress (OR, 2.34), experience of prenatal depression (OR, 2.06), experience of prenatal anxiety (OR, 2.00), lower self-esteem (OR, 1.86), and lower social support (OR, 1.22) were associated with postpartum depression. At 12 weeks postpartum, maternal blues (OR, 3.21), higher child care stress (OR, 1.73), and more difficult infant temperament (OR, 1.58) were associated with postpartum depression among postnatal factors, and among prenatal factors, low socioeconomic status (OR, 6.14), experience of prenatal depression (OR, 4.21), lower self-esteem and marriage satisfaction (OR, 3.34), experience of prenatal anxiety (OR, 2.71), higher everyday life stress (OR, 2.34), and lower social support (OR, 1.23) were associated with postpartum depression (Table 4).

Table 4.

Factors influencing women’s postpartum depression during the postpartum period (N=183)

Discussion

Depression among women constantly fluctuated in different patterns during the prenatal and postnatal time periods. The prevalence of depression among women decreased to 10.5% at 36 weeks of pregnancy from 20.5% to 21.5% at 20 weeks and 28 weeks of pregnancy. This result is similar to a previous report that prevalence of prenatal depression decreased slightly from 16 weeks of pregnancy to 25 weeks and 36 weeks using the same instrument, but with a cutoff of 12 [26]. The reason could be that toward the end of pregnancy, women adapt to the physical and psychological changes from pregnancy and have increased anticipation of meeting the baby.

During the postpartum period, the prevalence of depression was highest at 32.8% at 2 weeks postpartum, which decreased to 22.4%–24.6% with time. The reasons for high prevalence in the early postpartum period at 2 weeks seem to be that as women’s main task becomes performing the role of a mother to care for the infant, they experience child care stress, lack of confidence in their role [22], or maternal blues. Compared to previous longitudinal studies that followed depression prevalence from pregnancy to postpartum [1,4-6,15,30], this study showed a significant difference in depression prevalence. In a previous cohort with pregnant women [15] that evaluated depression using the same tool and cutoff [15], prenatal depression was reported at a similar level as in the current study at 13.9% to 19.4%, but the prevalence at 4 weeks postpartum was 16.7%, which is lower than the prevalence of depression at 2 weeks and 6 weeks postpartum in this study. Among pregnant women in Finland [30], the prevalence of depression measured using Center for Epidemiologic Studies Depression Scale (C-ESD) was 11.0% at the third trimester of pregnancy and 10.5% at 3 months postpartum, showing a similar trend across prenatal and postnatal periods. A study that evaluated depression using the EPDS (cutoff score of 12) or C-ESD among pregnant women in the United States [4] reported a slightly higher prevalence of 38.5% in the third trimester of pregnancy, but a consistently lower prevalence of 23.1% at 1 month postpartum and 19.2% at 3 months postpartum. These differences could be due to the sociocultural characteristics related to pregnancy, delivery, and postpartum in the countries where participants live or the use of varying measurement time points and tool cutoffs.

Low socioeconomic status, low self-esteem, experience of prenatal depression, experience of prenatal anxiety, history of depression, low social support, low marriage satisfaction, and high everyday life stress among pregnant women were factors associated with prenatal depression at all three time points. Pregnancy intention was an additional factor at 28 weeks and 36 weeks of pregnancy. This result is similar to previous studies that found prenatal depression to be associated with income level [15,17,18, 21], history of depression, plans to become pregnant, stress levels [15,18], marriage satisfaction [18], social support [17], prenatal anxiety, self-esteem, and unemployment [16]. Various psychosocial stresses in the lives of women and their families accumulate during pregnancy and constantly influence prenatal depression along with the stress from pregnancy [12]. Therefore, it is necessary to inform women about effective coping strategies for stress during pregnancy. A previous study reported that depression was decreased among pregnant women by providing prenatal education intervention about physical and psychological adaptation, delivery preparation, infant care, and spousal relationships [31], which suggests directions for interventions for perinatal women and their families. Nurses can evaluate the factors associated with prenatal depression before and after pregnant women’s prenatal health checks and satisfy women’s and family members’ psychosocial needs through education and counseling. Moreover, in order to reduce the stress about delivery and burden related to child care, it would be possible to provide education on delivery preparation including understanding the delivery process, practicing breathing methods, and visiting the delivery room, along with education and role exercise opportunities about breastfeeding and infant care.

Maternal blues, difficult infant temperament, and child care stress were identified as factors associated with postnatal depression, consistent with previous studies [8]. It seems that the risk of postpartum depression is increased difficulties in adjusting during the transition to parenthood including mood changes in the early postpartum period, lack of understanding of infant temperaments, and decreased maternal confidence due to difficulties in child care. Therefore, in order to reduce the rate of postpartum depression, practical education and information resources related to infant care should be provided during mothers’ stay in the postnatal ward or recovery centers. Most prenatal factors that influenced prenatal depression were significantly associated with postnatal depression. This result is similar to factors identified in previous studies, such as prenatal depression [7,8,13], prenatal anxiety [7], everyday life stress [7,28], socioeconomic status [7], lack of social support [7,8,28], and financial stress [12]. When stressors during pregnancy are not resolved and continue postpartum, these factors become long-term and consistent stressors [7,30]. Unlike a study that found pregnancy intention to be a significant factor associated with depression among pregnant women measured 6 weeks and 6 to 9 months postpartum [7], intention for pregnancy influenced depression in women at 28 weeks and 36 weeks of pregnancy and at 2 weeks postpartum in this study. Intention for pregnancy is related to the acceptance of pregnancy; therefore, women who do not accept their pregnancy may negatively receive the physical and psychological discomfort of pregnancy [32]. Moreover, the compounded effect of unintended pregnancy and socioeconomic burden could have resulted in the significant relationships between unintended pregnancy and prenatal depression and between low socioeconomic status and postpartum depression. However, the finding that everyday life stress, social support, marriage satisfaction, and child care stress were common factors associated with prenatal and postpartum depression could suggest the possibility of family-centered prevention interventions for postpartum depression that aid the adjustment of women and their family members, including their spouses. Education about the recovery of mothers and the parental role for mothers who visit for their regular postnatal checkups, online or phone education and counseling for mothers and family members who cannot travel, and service linkage to local mental health welfare centers can provide opportunities to participate in postpartum depression prevention programs.

Parity was not significantly associated with depression among women. This finding is consistent with studies that found the number of children not to be associated with prenatal depression [15,18], suggesting the importance of nursing practices that assess and intervene for women’s depression regardless of their parity. However, this result diverges from studies that reported that prenatal depression was higher among multiparous mothers [1,15,16,18], postpartum depression was higher among nulliparous mothers [14,19], and the severity of postpartum depression was twice as high when mothers with consistently high levels of depression had children [30]. Further exploration of the association between prenatal and postpartum depression and parity is necessary. Depression among spouses also was not associated with prenatal or postpartum depression. This result is not consistent with a previous study that found early postpartum depression among spouses impacted women’s depression up until 6 months postpartum [4]. A reason for this could be the gap between expectations about gender roles and parenting roles as husband and wife and the actual execution of those roles, as well as differences in the characteristics of spousal relationships by country.

This study has a few limitations. Caution is required in generalizing the results of this study since the sample was constructed using convenience sampling of pregnant women who visited a women’s hospital in one location. Moreover, during the 10-month data collection from 20 weeks of pregnancy to 12 weeks postpartum, the dropout rates were 20% at 36 weeks of pregnancy and 27% at 2 weeks postpartum due to various reasons such as change in participants’ residence, health issues of the child, and loss to follow-up. Effective strategies to minimize dropout, such as frequent contact during the transition from the prenatal to postnatal period and postcards to congratulate women on their new baby, are thus necessary.

In summary, the prevalence of depression among women tracked from 20 weeks of pregnancy to 12 weeks postpartum was higher during postpartum (22.4%–32.8%) than during pregnancy (10.5%–21.5%). Common factors associated with prenatal depression were low socioeconomic status, experience of prenatal depression, experience of prenatal anxiety, history of depression, low self-esteem, low social support, low marriage satisfaction, and high everyday life stress. Common factors associated with postpartum depression were high child care stress, difficult temperament of infant, and maternal blues, in addition to the prenatal factors. Therefore, nurses should regularly assess the level of depression and factors associated with depression from the prenatal period to postpartum, provide interventions to address depression that are in line with pregnant women’s and their families’ needs, and support healthy pregnancy, delivery, and postpartum adaptation.

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Notes