The current study identified the clinical factors associated with postpartum depression and anxiety among a sample of Lebanese women. Postpartum depression is a debilitating health disorder that mandates greater efforts to raise the awareness among pregnant females about its natural occurrence and the counseling strategies that can be employed to cope with this situation. In this study, several factors both related to the mother and the child contributed to postpartum depression. Specifically, if the mother was illiterate, had delivered more than 3 babies, had complications both during pregnancy and post-partum, encountered hypotension, anemia, or abortion had higher depression scores. Even factors related to the child as wakening more than 5 times per night, did not consume food regularly compared to normal neonate feeding habits, or had health problems all had a risk to have higher depression score. As for anxiety, there were some factors which were related in depression as well increase the score of anxiety as being illiterate, had complications both during pregnancy, encountered hypotension, and had unhappy marriage. Even factors related to the child as wakening more than 5 times per night, did not consume food regularly compared to normal neonate feeding habits, or had health problems all had a risk to have higher anxiety score in the post-partum period.
Validation of both scales
In our study, the EPDS scale items converged over a three-factors solution outlining a total of 64.73% of the variance, with an internal consistency of 0.826. Several validation studies in different countries have confirmed the clinical and epidemiological value of the scale; in Chile, the items of the EPDS converged over one factor with a Cronbach alpha of 0.914 25. In France, the EPDS items converged over a solution of two factors, with a Cronbach alpha of 0.76 28. Our results confirm that the Arabic version of the instrument has good psychometric properties, which explains the variability (64.73%).
As for the PASS scale items, in our study it joined over a total of 7 factors, explaining a total of 65.12% of the variance, and leading to an internal consistency of alpha Cronbach alpha = 0.920. These findings are different from those with the original developers (four factors) but similar in terms of internal consistency (Cronbach alpha = 0.96) 35. The validation of this scale in Turkey 30 revealed that the Cronbach's Alpha value for the scale is = 0.95, and the sub-dimensions obtained by explanatory factor analysis are: (1) general anxiety and specific fear, (2) perfectionism and control, (3) social anxiety and adjustment disorder, (4) acute anxiety and trauma. This test was also validated in Bangladesh 29 and the exploratory factor analysis showed 4 factor solution of the Bangla PASS (1. Acute anxiety 2. General worry and specific fears 3. Perfectionism control and trauma 4. Social anxiety); whereas the temporal stability and internal consistency was also satisfactory (Cronbach’s Alpha .970). The Australian validation in its turn, suggested a four-factor structure addressing symptoms of (1) acute anxiety and adjustment, (2) general worry and specific fears, (3) perfectionism, control and trauma and (4) social anxiety, with an excellent reliability (Cronbach’s α = 0.96) 35. As seen above, alpha Cronbach values show a very small variation between different countries, which means that these populations share very close anxiety and depression postpartum symptoms.
Factors associated with depression
This study revealed that the rate of depression and anxiety in the post-partum Lebanese population was 61.8% and 67.7% respectively where this finding is higher than a study done by Pan-Yen Lin, et al and meta-analysis which stated that the occurrence of depression was 5.1% at the fourth week of postpartum and 5.7% at 2 months postpartum 36,37. In addition, it has been reported that the prevalence of post-partum depression affects about 10–15% of adult mothers annually with depressive symptoms lasting more than 6 months 38. The rate of depression in this study is similar to another study conducted by Halbreich et al. that reported around 60% prevalence rate of depression 39.
In this study, the factors that were associated with post-partum depression are higher post-partum anxiety, insomnia, and complications development during pregnancy. In this study insomnia was highly associated with the development of post-partum depression since sleep deprivation might be a trigger factor for the onset of certain psychological problems encountered post-delivery as the onset of mania and unbalanced sleep pattern is more prevalent in new mothers 40. Maintenance of balanced sleeping hours aids in the relaxation and minimizes the risk of depression.
In this study, secondary level of education compared to illiterate was associated with lower PPD that could be potentially explained by the increased levels of maturity, greater exposure to certain life experiences, and to more education that enables mothers to deal with the emotions allied with motherhood more than less educated females 41.
Additional research is required to elucidate the relation between the level of education and postpartum depression as the results from studies are contradictory since some studies reported no association between the level of education and PPD and others noted that education is a predictor of PPD 42,43.
Our study found that complications during delivery is strongly associated with PPD which can be explained by the emergence of physical and mental troubles encountered by the mother due to the fear from the consequences of complications development, where this outcome is consistent with the outcomes of other studies 17,44. Our study found that delivery periods of less than 14 hours had a more protective effect compared to duration more than 14 hours which can be demonstrated by the pain associated with giving birth that increases the risk of PPD development as the duration of labor is prolonged.
Factors associated with anxiety
As for anxiety prevalence, the range was reported to be from 13 to 40% which is lower than the findings in this study 45. This wide variation in the anxiety prevalence rates is highly reliant on the type of anxiety assessment, the scale depicted in the assessment, the cut-off score for anxiety, the severity of anxiety, the timing and the frequency of the assessment, and the country of origin 45,46.
In this study, the high rates of anxiety in the post-partum period may relate to the fact that the anxiety scale scores were based on interviews where denying symptoms may be hindered through face-to-face contact.
The factors associated with postpartum anxiety in this study include higher postpartum depression, premature birth and the use of technology during delivery. The results of this study supporting the relation between preterm infants and post-partum anxiety is encountered in previous studies concluding that in preterm infant mothers, the risk of anxiety was 2.7 times higher than in full-term infant mothers 33,47.
A multitude of studies have observed the combined relationship between symptoms of anxiety and PPD, which is consistent with the findings in this study 48. Onset of anxiety can range from few days to few weeks after delivery and usually peaks in the first 2–3 months following childbirth. Postpartum anxiety appears mainly in mothers who have the fear from cot death. One plausible explanation that might elaborate on the reason why this accumulation of fear over time leads to postpartum anxiety is that: nocturnal vigilance deprives mothers from the normal sleeping pattern, since this causes them to remain awake listening to the breathing of the infant. Therefore, the irregular sleeping pattern and anxiety (through constant worrying) seem to be related. This recurrent checking for the safety and health of their children predisposes to anxiety and depression 49,50.
In our study, anxiety was associated with planned pregnancy and an indifferent attitude to pregnancy. An unwanted pregnancy may significantly change life, be a stressful experience with different impacts on quality of life and may trigger certain psychological problems as anxiety 51. In our study, the delivery of premature baby is associated with PPA which concluded the same in other studies 52,53. The underlying reasons for this relation can be depicted by the isolation that the parents are exposed to after the delivery of premature babies that mandate hospitalization due to the difficulty in discharging premature infants without being admitted to neonatal intensive care units. The isolation of infants and a lengthy hospital stay pose sudden changes on the bonding of the parents with their offspring 54.
The normal bonding process starts before birth and develops after it where neonatal intensive care units is a contributing stressful factor as demonstrated 55. The early relationship between parents and newborn infants encountered in the first moments immediately post-delivery is fundamental and plays a crucial role in this intimate bonding 56.
During hospital admission to premature babies, mothers often experience negative thoughts and ideas and contradictory emotional reactions that is usually diagnosed as grief, sorrow, guilt, fear, anger, loss of self-esteem, and sense of failure 57. This situation and feelings predispose mothers to anxiety.
Limitations
There are some limitations to this study. Prevalence rates of perinatal depression were assessed in this study using self-reported instruments such as EPDS, which is not considered solid evidence in the clinical depression diagnosis and typically overestimate incidence rates 58,59. The EPDS is a screening test requiring further diagnostic confirmation through a structured or semi-structured interview. Consequently, accurate conclusions cannot be drawn. The utilization of a comprehensive tool as Patient Health Questionnaire that aids in screening, diagnosing, monitoring, and measuring the intensity of depression is a more useful instrument. In addition, there might an information bias where participants might either over- or underestimate their symptoms. Also, a selection bias might be present since the sample was taken from doctor’s clinics and is not representative of the whole population.
Clinical Implications
This highly prevalent problem of postpartum depression and anxiety among Lebanese women has several risk factors. An interplay of these factors is likely to play a role in causing postpartum depression and anxiety. Taking care of these highly modifiable risk factors can prevent PPD and PPA development. Thus, early recognition of risk factors for PPD/ PPA may aid clinicians in early intervention and management. A collaborative-care approach (for example, a mental-health professional and an obstetrician collaboration) would be appropriate to identify high-risk mothers for PPD and PPA development. Resolving marital and family conflicts before conception, helping the mothers to draw a support plan, having realistic expectations of birth and parenting, addressing issues of self-esteem and encouraging them to quit smoking and waterpipe might be some of the ways to prevent postpartum disorders. We also recommend that a psychiatrist and a psychologist attend a postnatal care unit to advise mothers at risk of developing PPD or PPA as well as other psychiatric disorders.