a Department of Public Health, Ataturk University, School of Medicine, Erzurum, Turkey.
b Department of Public Health, Dokuz Eylul University, School of Medicine, Izmir, Turkey.
c Current address: NIOSH, Division of Respiratory Diseases Studies, Morgantown, WV, USA.
d Department of Public Health, Erciyes University School of Medicine, Kayseri, Turkey.
e Department of Public Health, Inonu University School of Medicine, Malatya, Turkey.
f Department of Public Health, Elazig University School of Medicine, Elazig, Turkey.
g Department of Public Health, Selcuk University School of Medicine, Konya, Turkey.
Correspondence: Omur Cinar Elci, NIOSH, Division of Respiratory Diseases Studies, 1095 Willowdale Rd. MS 2800, Morgantown, WV 26505, USA. E-mail: oae3{at}cdc.gov
Abstract
Background There are few studies reporting depression in the postnatal period in developing countries. In this study our objective was to evaluate women from eastern Turkey in the postnatal one-year period in order to analyse the risk factors for depression.
Methods In this cross-sectional, multi-centre study, we selected a study sample from five eastern provinces. Among 2602 randomly selected women who gave birth within the last year, we included 2514 women in our analysis. The Edinburgh Postnatal Depression Scale was used for the evaluation of depression.
Results The percentage of women with high depression scores was 27.2%. Excess risk of depression was associated with several factors including unemployment, low education, poverty, poor family relations, low marital age, lack of medical services, and mental health problems.
Conclusions Depression in postnatal women is an important public health problem in the less developed eastern part of Turkey.
Keywords Maternal health, cross-sectional study, depression, postnatal, risk factors
Accepted 6 August 2002
One of the important public health problems affecting maternal and child health is postnatal depression (PND).13 Its prevalence varies between 3.5% and 40.0% depending on the definition, evaluation criteria, and geographical area.47 Various factors including obstetric, biological, psychological, and social variables may play a role in the aetiology of PND.810
Some authors have suggested that PND is a problem of industrialized countries; due to the socio-cultural pattern including traditional post-natal family support, non-industrialized populations do not often experience PND.1113 However, studies from non-industrialized countries provide limited information.1315 Although Danaci et al. reported a 14% prevalence; PND has received little attention in Turkey.16,17 To our knowledge this is the first study conducted in the eastern part of the country.
Since the beginning of the 20th century, Turkey has been in a socio-demographic, cultural, and economic transformation. In the last 70 years the population has increased from 13 million (10% urban) to 63 million (60% urban).18 This fast transformation and the complex social pattern of the country caused various cultural conflicts.19 Cultural conflicts as well as common features within less-developed countriespoverty, unemployment, lack of social services, and imbalance in income distributionhave provoked various psychosocial problems.1921 The consequences of these problems have been seen particularly in womens and childrens health. Women in particular have various risk factors in eastern Turkey, such as gender discrimination, status in the community, limited educational opportunities, and lack of health services. The majority of women have not fulfilled primary education (62.2%) and most of the women in eastern Turkey are housewives (75.4%).22 Limited educational and occupational opportunities increase the vulnerability of women to psychosocial problems.
We conducted this cross-sectional, multi-centre study to estimate the possible risk factors for depression in the postnatal one-year period in five eastern and central-eastern provinces of Turkey.
Materials and Methods
For this cross-sectional study, data were collected from the five eastern and central-eastern provinces of Turkey (Erzurum, Elazig, Malatya, Kayseri and Konya). These provinces are considered to be less developed compared to the western provinces.18,19 We selected the study population by a cluster-sampling method. First we divided each province into urban and rural areas. Each residential street in urban areas and each village in rural areas were considered to be one cluster. Registries of all married women who gave birth within the last year were obtained from the local health authorities. Using random numbers, we selected 20 women from each cluster for the study population of 2602 women. From these we accepted 2514 (96.6%) women for participation in the study. All women gave their informed consent. Due to methodological issues, such as questionnaire errors or missing data, 88 (3.4%) women were excluded.
Trained local health personnel collected data in scheduled home visits, by face-to-face interviews, from 5 January 2001 to 20 June 2001. In these interviews information on demographic features, possible risk factors of depression, including personal and family relationships, maternity and childhood data, and psychiatric history was collected by a partially structured questionnaire.
The Turkish version of the Edinburgh Postnatal Depression Scale (EPDS) designed for population-based screenings was used to investigate depression.23,24 On this scale a score of 0 to 30 is assigned to each respondent; the higher scores implying greater psychological distress. A cut-off point in the scale for the risk of PND is assigned as 13. Women with a score of 13 had higher possibility of PND. Validity of the Turkish version of EPDS was 84% for sensitivity and 88% for specificity; Chronbachs alpha-based agreement for this cut-off point was 0.79 and the correlation coefficient was 0.80 using the split half method.24
We compared women with high scores (13) to women with low scores in the study population using two-sided Student-t,
2, and linear trend tests with a 0.05 significance level. Unconditional logistic regression was also used to determine age- and province-adjusted odds ratios (OR) and 95% CI of depression in postnatal period for selected risk factors using SPSS version 10.1. Although there was no significant difference in demographic features or the prevalence of women with high scores among the five provinces, we included province as a control variable to prevent possible local and cultural variability. By using separate multivariate models, related variables such as economic status and occupation or family relations and family support during pregnancy, etc., were re-evaluated to eliminate possible confounding effects.
Results
The median age of the 2514 women in our study was 26.0 years (mean ± SD: 26.9 ± 5.3). Only 13.4% were living in rural areas and the overall illiteracy rate was 12.1%. A majority were housewives (88.6%), and the median marital age was 20.0 (mean ± SD: 20.0 ± 3.2). Among them the EPDS-based prevalence of depression in the 1-year postnatal period was 27.2% (n = 684).
We calculated the age- and province-adjusted OR of depression with selected risk factors. In Table 1, we present the risk of depression in postnatal period by socio-demographic characteristics. Although the EPDS score was significantly higher among women from rural areas (t = 3.460, P = 0.001), risk of depression in the postnatal period was similar in urban and rural areas. There was a significantly declining trend of depression risk by education among both women and their husbands (
2trend = 17.838, P < 0.001 for women, and
2trend = 11.194, P < 0.001 for husbands). Risk of depression in women without education was twice that of college graduates (OR = 2.08, 95% CI: 1.393.11). There was an excess risk of depression among housewives (OR = 1.41, 95% CI: 1.051.90) and women whose husbands were unemployed (OR = 2.22, 95% CI: 1.553.19); both differences were statistically significant. We also found a highly significant declining trend by economic status (
2trend = 47.858, P < 0.001). Women with very poor economic status had more than a six times higher risk of depression than those with very good economic status (OR = 6.15, 95% CI: 2.0419.03).
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Discussion
We evaluated depression and risk factors in women from the eastern part of Turkey during the 12-month postnatal period. The study population was typical of eastern Turkey, with a majority of early-married, young housewives with limited education. In this study, we observed that more than 25% of women had a high risk of depression in their postnatal first year and there was no significant difference based on the time elapsed from the date of the last delivery. Postnatal depression likely starts in the first couple of postpartum weeks; however, it is not uncommon to observe psychological problems one or even two years after delivery.25 Our study supported a possible risk of depression in the postpartum year. The observed depression rate in this study was higher than in many industrialized countries; OHara and Swain reported that the prevalence of PND varied between 1020% in 12 separate studies using the EPDS.26 Some authors have suggested that PND is less common in non-industrialized countries;1113 however, in our study, PND was an important public health problem in a non-industrialized country.
We observed a significantly increased risk of depression among women with poor family relationships as reported in previous studies.2630 A study from Israel reported that lack of social support and marital disharmony are strong predictive risk factors of PND.31 A similar study from South Africa showed a link between the risk of PND and family relationships, social support, and preparation for motherhood.32 A positive pattern of family relationships might be counted as one of the most important protective factors in the aetiology of PND. It is believed that traditional family relationships in the eastern part of Turkey are very close and strong; however, we observed that almost 40% of women complained of insufficient family support during pregnancy. These results supported our suggestion that family-related social variables may be important in the aetiology of depression.
In our analysis we found a significantly increased risk of depression with various socioeconomic variables including education, occupation, and economic status. In Santiago, Chile, mothers with lower incomes had a threefold increase in the prevalence of PND in comparison to mothers with higher incomes.33 Previous studies also reported low socioeconomic status as a risk factor for PND.3438 Zelkowitz et al. reported that there was no relationship between education and PND,39 whereas others observed a negative correlation between years of education and PND.30,40 We believe that improving the social status of women would be an important step in a preventive approach against PND.
In this study we found a significant excess risk of depression among women with maternal risk factors including early-age pregnancy, unplanned pregnancy, premenstrual syndrome, miscarriage, and lack of antenatal care. Most of these factors have been previously reported as risk factors for PND.27,37,38,40,4145 To our knowledge, this is the first study reporting early-age pregnancy, delivery at home, and number of daughters as additional factors. It is noteworthy that we observed a significant trend of depression with the number of daughters, but not with the number of sons. Controlling for the gender of previous children showed that mothers of female babies had higher risk of depression, which may be important indicators of gender discrimination and the social status of women. In the population of eastern Turkey, boys are more desirable than are girls. Zhang similarly showed that a husbands desire for a boy child was significantly associated with PND in China.30 In our analysis, depression was also associated with two childhood characteristics, health problems in infants and insufficient infant care as reported previously.10,27,46,47 We observed an excess risk of PND with emotional stress and mental disorders; these have been previously determined as risk factors.26,27,39,40,45,46,4851 These results showed that effective community-based public health services, including maternity and childhood care, are vital factors for mental health as well as physical well-being. More than 10 years of regional conflict and social instability might also influence public health in the eastern part of Turkey.
As a historical bridge between Europe and Asia, Turkey during the last century has been undergoing a social and cultural transformation. Traditional eastern values and social structures are becoming less important, but a western social infrastructure has not yet been established to support women. In other words, the household responsibilities of women have not decreased but they have been also carrying outside responsibilities. Beside these, there are various other chronic social problems impacting womens health including, high birth rate, low education level, poverty, insufficient health care, and an inadequate social security system in the country.18,19,22
In this study, limitations should be considered. Since EPDS is a screening test, it is not easy to determine the prevalence of PND accurately without a diagnostic confirmation. However, the broad, multi-centre design increased the power of our study to observe the possible risk factors of PND. The cross-sectional study design has limited capability to evaluate PND risk factors. We could not assess pre-birth mood state and other risk factors prospectively. The important strength of our study is that we observed a significant relationship between EPDS-based depression evaluation and possible risk factors. The long term consequences of this health problem in less developed populations should be evaluated in further prospective studies.
In conclusion, we observed that in eastern Turkey, depression in the postnatal first year is an important public health problem and significantly related to many social, economic, and psychological factors. Informing health professionals and social workers about these issues is important in improving the maternal and child health in developing countries.
Acknowledgments
Authors would like to thank mothers who participated in this study, the health workers of the regional health centres who worked on data collection, and Molly Pickett-Harner who reviewed the language of this report.
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