Postpartum Depression in Primigravida Women In Rawalpindi, Northern Punjab, Pakistan

Naheed Raza
MScN Faculty in college of Nursing AFPGMI Rawalpindi razinaheed@gmail com

!o Author"
Ms #asmeen Saggu Director Clinical Nursing Shifa International Hospital H-8/4, Islamabad Ad unct Assistant !rofessor "Sc# Nursing !rogram $ni%ersit& of Health Sciences 'ahore ( !a)istan

A$S%RA!%
!ostpartum depression *!!D+, a ma or health concern, produces insidious effects on ne, mothers, their infant, and famil&# -his .uantitati%e descripti%e cross sectional stud& aimed to determine the pre%alence, and describe the associated ris) factors of postpartum depression among primipara/s ,omen in 0a,alpindi, Northern !un ab, !a)istan# -he Con%enient nonprobabilit& sample of 122 postnatal primipara/s ,omen and data ,as collected ,ithin 42 da&s of their postpartum period# 3ec) Depression In%entor& *3DI+ $rdu %ersion a %alidated research instrument to assess postpartum depression ,as used as stud& tool# Stud& ,as conducted in public, pri%ate and arm& hospitals of 0a,alpindi Northern !un ab, !a)istan# !articipants ,ere selected from 4ut !atient Department *4!D+ and postnatal ,ards of these Hospitals# -his stud& estimated the o%erall pre%alence for postpartum depression among primipara/s/ postnatal ,omen 567 of stud& participants ,ere falling in the categor& of ma or depression and 527 in mild depression# 0is) factors for postpartum depression among the target group has significant association ,ith education status of participants, !referred Se8 of 3ab&, emplo&ment statuses of ,omen, present bab& se8, mode of deli%er&# 9here as age, marital status, emplo&ment status of husband& monthl& income of famil& *in !a) 0upees+, and famil& S&stem ,ere not found contributing in de%eloping !!D among the participants# -his stud& informs a current situation of )no,ledge regarding ris) factors for postpartum depression and has implications for clinical practice# Health care professionals should be a,are of that the fact is as pre%alent in !a)istan# 9omen should be screened for potential ris) factors and depressi%e s&mptoms during pregnanc& and postpartum periods so that appropriate inter%entions, can be initiated at suitable time# -here is also a need to create a,areness in public order to minimi:e depressi%e s&mptoms in postnatal ,omen through nursing practice, nursing administration and other health care professionals/ education# 'eywords" postpartum depression& ris( factors& primigra)ida

IN%R*+,!%I*N -he earl& postpartum period is recogni:ed as the first fe, ,ee)s after the child birth, a time of reflecti%e change and one of the most demanding and stimulating transitions for ,omen and their families *Affonso, and "a&berr&, ;<<2+# -his transition is smooth in most of the ,omen ho,e%er due to certain ris) factors and co-morbids# Some ,omen go in to a depressi%e state during this period# Depression is a disabling disorder affecting appro8imatel& ;5; million people ,orld,ide *9H4 Health 4rgani:ation, 5225+# It has been recogni:ed b& the ,orld Health 4rgani:ation *9H4+ as one of the greatest burdens of illnesses for indi%iduals, families and societies *9H4, 5221+, and it is e8pected to sho, a rising trend in the ne8t 52 &ears *9H4, 5228+# Depression ,ill be ran)ed as the second ma or cause of disease burden b& 5252 *'ope:, "athers, =::ati, >amson, and "urr&, 5226? "athers and 'oncar, 5226+# American !s&chiatric Association *522@+ and Aoodman *522@+ belie%e that ,omen are more %ulnerable to ma or depressi%e episodes as compared to men# As ,omen/s reproducti%e e%ents, such as pregnanc& pose a significant ris) to the mental health of the ,omen *3a)er, 5226+# In the literature, three categories of postpartum mental disturbances are described in order of climbing se%erit&B maternit& blues, postpartum depression *!!D+ and postpartum ps&chosis *3roc)ington, and mental health 48ford ;<<6+# "aternit& blues is a common, benign, transitor& condition occurring in the first da& after deli%er&# Its incidence ranges from 12 ( 82 7# "aternit& blues usuall& begins 1-4 da&s after deli%er& and pea)s on 4-@ da&s# S&mptoms are cr&ing, an8iet&, mood liabilit&, insomnia, confusion and d&sphoria# -he s&mptoms last from a fe, hours to a couple of da&s ha%e fe, negati%e se.uels and do not re.uire treatment *3ec), ;<<;, 4/Hara, ;<<4, 3roc)ington, ;<<6+# !ostpartum ps&chosis is a se%ere and rare disorder ,ith an acute onset after a s&mptom-free phase# "ost postpartum ps&choses begin ,ithin the first 1 ,ee)s after deli%er&# Its incidence is 2#; ( 2#5 7# !rodromal s&mptoms are often seen as sleep disturbances, h&pomania and irritabilit&, delusions, hallucinations and gross impairment in functioning# =motional s&mptoms are most prominent# -he pre%ailing %ie, is that this disorder is biologicall& mediated *3o&ce, ;<<4? 3roc)ington, ;<<6+# !ostpartum depression refers to a non-ps&chotic depressi%e episode that begins in or e8tends into the postpartum period *Co8, "urra& C Chapman ;<<1+# It is a disorder lasting more than 5 ,ee)s, the se%erit& of ,hich meets criteria for a ma or depression categor&# Clinical s&mptoms of !!D ma& enlist depressed mood, mar)edl& diminished pleasure in appro8imatel& all acti%ities ,insomnia or h&per insomnia, ,ps&chomotor agitation or

retardation, signiDcant 9eight loss or ,eight gain, loss of energ&, feelings of ,orthlessness and e8cessi%e guilt, lo, self-esteem and self- confidence, difficult& in concentration, and suicidal ideation *A!A, 5222? and 9H4, 522E+# -he "arcF Societ&, an international organi:ation for the stud& of ps&chiatric illness related to childbearing, recogni:es the time of %ulnerabilit& for postpartum depression as one &ear after deli%er& *!arr&, and Ha&nes 5222+# In Anglo-American literature the definition for postpartum depression is often used in a ,ider concept including both ma or and minor depressions? as a minor depression ma& be a potentiall& se%ere disorder ,hen occur in the postpartum period# "ental disturbance follo,ing childbirth ,as first mentioned b& Hippocrates *appro8# 422 3C+ but the first good description of postpartum mental illness ,as ,ritten b& a Grench ps&chiatrist, 'ouis "arcF, in ;8@8 *-illhagen, ;<81+# In !a)istan the pre%alence of depression in ,omen ranges 127 to 667 *"ir:a and >en)ins, 5224+, ,hereas studies ha%e sho,n higher pre%alence in rural population *Donani and Huberi, 5222+# Gurthermore, ,omen reproducti%e e%ents such as pregnanc&, labour and role change posses ris) to the mental health of ,omen *3a)er, 5226+# It is also documented that about ;1 percent of pregnant ,omen and ne, mothers ha%e !ostpartum Depression *!!D+ *4/Hara C S,ain, ;<<6+# 0esearchers belie%e that %ariation in the le%el of hormones such as estrogen, progesterone and cortisol ,hich increase greatl& during pregnanc& but in the first 54 hours after childbirth, hormone le%els .uic)l& return to normal# -his big change in hormone le%els ma& lead to depression *3a)er, 5226+# Gurthermore, reproducti%e e%ents, ph&sical changes, and other ps&chosocial stressors during pregnanc& and after child birth ma& precipitate the occurrence of depressi%e s&mptoms *3ennett, =inarson, -addio, Ioren, C =inarson, 5224+# -here is significant e%idence representing that the status in societ&, illiterac&, po%ert&, and poor social support, and unemplo&ment, lac) of autonom&, marital conflicts and stressful life e%ents predisposes !!D *0ehman, I.bal, and Harrington, *5221+#, -hara, and patal, 5226+# -here are a fe, hospital and communit& based studies that ha%e estimated pre%alence of !!D and its ris) factors in postpartum ,omen in !a)istan# Similarl& a communit& based stud& in Iahuta, !a)istan supports that the pre%alence of postpartum depression and its associated factors is more in the postnatal period than during the antenatal period *Ilainin, 522<+# -he purpose of this stud& ,as to determine the pre%alence of postpartum depression, and to describe the associated ris) factors of postpartum depression among !rimpara ,omen in 0a,alpindi, Northern !un ab, -his stud& ,as based on consecuti%e sample postpartum

!rimpara ,omen in their postpartum period ,ithin 42 da&s, attending selected stud& setting four public and militar& hospitals, outpatient clinics and postnatal ,ards# -his stud& attempted to determine the pre%alence of postpartum depression and to describe the associated ris) factors of postpartum depression among !rimipara ,omen# -he findings of this stud& ma& pro%ide as a baseline data for health care planning and strengthen the importance of care of the pregnant ,omen during and after deli%er&# It ,ill also help to prepare nurses and other health care professionals/ in their practice# Gurthermore effect on future and ongoing research on this issue# -I%.RA%,R. R./I.0 Depression has been recogni:ed b& the ,orld Health 4rgani:ation *9H4+ as one of the greatest burdens of illnesses for indi%iduals, families and communities# Depression is becoming a significant public health issue, ,ith a continuous rise in its pre%alence it ,ill be ran)ed as the second ma or cause of disease burden b& 5252 *'ope:, "athers, =::ati, >amison, and "urra&, 5226+# -he rate of postnatal depression in de%eloping countries ranges from ;67 to 1@7 *!atel, 0odrigues, DeSou:a, 5225? A&din et al#, 522@? Cooper et al#, ;<<<? "ir:a, and >en)ins# 5224+ and is a ma or contributor to the Jburden of disease/ in these countries, especiall& in !a)istan *'eung, Arthur, "arin son, 522@a+# =8isting literature is on the pre%alence, etiolog&, treatment, pre%ention of an8iet& and depressi%e disorders in !a)istan# 4%er 52 studies, both .uantitati%e and .ualitati%e, including smaller studies ,ith methodological problems, ,ere included in the anal&ses ,hich ,ere conducted ,ithin !a)istan# -he result sho,ed that the rate of depression for men ranges from ;27 to 117 and for ,omen 5<7 to 667 *"ir:a, and >en)ins#5224+# In this anal&sis fort&-t,o studies in%estigated the lin)s bet,een socio-demographic factors and !!D ,ith economic difficulties, socioeconomic status, unemplo&ment, domestic %iolence, a lac) of emotional social support, lo, le%el of education of self, cultural factors *e#g# child gender+, relationship conflict ,ith their husbands and mothers-in-'a, tended to suffer from !!D# Hong Iong phenomenological stud&, depressed ,omen *n K ;;+ identified stressful situations that might contribute to their !!D including feelings of incompetence regarding child care, difficulties in identif&ing a trust ,orth& bab&-minder ,ith reasonable ser%ice charges, conflicts bet,een the realit& of e8periences and e8pectation, and conflicts ,ith Chinese traditional rituals *'eung, "arin son, and Arthur, 522@b, Affonso, Anind&a, Horro,it:, and "a&berr&, 5222+# -he combined period pre%alence of postnatal depression and minor depressi%e disorders is estimated to be bet,een @7 and 5@7 *Affonso, Anind&a, Horro,it:, and "a&berr&# 5222+# A number of studies ha%e been conducted in de%eloped countries focusing

on the pre%alence of depression among postpartum ,omen# It has been documented that the rate of depression in ,omen is higher during their childbearing &ears *Co8, "urra&, and Chapman, ;<<1? Cooper, and "urra&, ;<<8+# ;41 studies ,ere identified reporting pre%alence in 42 countries as mostl& measured b& the =dinburgh !ostpartum Depression *Co8 et al#, ;<8E+# In Asian countries it is ranged from ;;#27 to 62#87 *Halbreich and Iar)un, 5226+# Sur%e&s and epidemiological studies ha%e reported progressi%el& high rates of postpartum depression in di%erse cultures across the ,orld *Crott&, and Sheehan# 5224+# Ho,e%er, epidemiological studies sho, that mothers/ heightened susceptibilit& to depression continues for at least the first 6 months or longer after childbirth *Cooper C "urra&, ;<<8? =%ans, Heron, Grancomb, 4)e, C Aolding, 522;? Aoodman, 5224? Huang C "athers, 522;? Iumar C 0obson, ;<84+# !ea) in the phase immediatel& after child birth *Co8, "urra&, C Chapman, ;<<1? 0eece, ;<<1+# 'ong-lasting up to;5 ,ee)s post deli%er& *Cooper, Campbell, Da&, Iennerle&, C 3ond, ;<88+# Internationall& and ,ithin countries, %ar&ing pre%alence rates ha%e been reported# In Ireland, pre%alence rates of postnatal depression %ar& from ;;#47 to 58#6 7 *Crott& C Sheehan, 5224? Cr&an et al#, 522;? Areene, Nugent, 9eiec:ore) Deering, 4/"ahon&, C Araham, ;<<;? 'ane et al#, ;<<E? "artin, ;<EE? 4/Neill, "urph&, C Areene, ;<<2+# -he ma orit& of studies used the =dinburgh !ostnatal Depression Scale *=!DS+? *Co8, Holden, C Sago%s)&, ;<8E+ ,ith %ar&ing cut off scores *;;(;1+ and %ar&ing timescales *6-;5+ ,ee)s post deli%er&# In the $nited States, rates of postnatal depression %ar& bet,een ;2#47 *4/Hara, He)os)i, !hillips, C 9right, ;<<2+ at < ,ee)s post deli%er& *3ec), 9ard, "endelson, C =rbaugh, ;<6;+ to 51#17 at ;4 ,ee)s post deli%er& *Stuart, Couser, Schilder, 4/Hara, C Aorman, ;<<8+, using the 3ec) Depression In%entor& *3DI+# Affonso, et al *5222+ conducted a stud& to e8plored differences in the !re%alence rates of postnatal depression among a sample of first-time mothers *nK8<5+# -he e%idence sho,n, nine Countries representing fi%e continents %alidated translated %ersions of the =dinburgh !ostnatal Depression Scale *=!DS+ *Co8 et al#, ;<8E+and the 3ec) Depression In%entor& *3DI++ *3ec) et al#, ;<6;+ ,ere used -he result demonstrated ,ide %ariations in pre%alence rates using the =!DS, ,ith scores ranging from E1#E7 at 4(6 ,ee)s postpartum to 62#87 at ;2(;5 ,ee)s postpartum in -ai,an #-his is compared ,ith a significantl& lo,er pre%alence rate of ;1#27 at 4-6 ,ee)s postpartum and of ;@#57 at ;2(;5 ,ee)s postpartum in S,eden# -he lo,er le%els of depression found in 9estern =uropean countries ma& ha%e been contributed b& buffering factors# 0ecentl& in -ai,an and the $I Huang and "athers *522;+ found pre%alence rates of ;8 7 in the $I and ;< 7 in -ai,an b& using the =!DS and a cut off score of ;5, sho,ing more similarit& than differences in these rates ,as found a rate of

;<#87 *'eung, "artinson, et al#, 522@+ in Hong Iong Chinese ne, mothers, more than half of ,hich ,ere !rimipara *n K56<+,using the =!DS ,ith a cut off score of L ;1 at 6 ,ee)s post deli%er&# 0ahman et al# *5221+ e8plored antenatal and postnatal depression in a rural communit& sample of 615 pregnant ,omen in a rural sub-district of 0a,alpindi, !a)istan# "aternal depression ,as assessed using the Schedule for Clinical Assessment in Neurops&chiatr& *SCAN+ de%eloped b& 9H4 *;<<1+, ,hich uses the ICD-;2 criterion for diagnosing depression# -he ,omen ,ho met the eligibilit& criteria ,ere inter%ie,ed using SCAN# -he inter%ie,s ,ere administered b& e8perienced clinicians at t,o occasions that is 6 ,ee)s before the e8pected date of deli%er& and ;2-;5 ,ee)s after deli%er&# -he findings sho,ed a 5@7 point pre%alence of depression disorder during the third trimester of pregnanc& and 587 during the postnatal period *;2-;5 ,ee)s after deli%er&+# -his stud& also clearl& indicated the same trend of rising pre%alence of depression from the antenatal to the postnatal period as sho,n b& the Chandran et al# *5225+, but ,ith a relati%el& higher rate of depression among pregnant and postnatal !a)istani ,omen 51, 15# 3ro,n and 'umle& *5222+ conducted a stud& in "elbourne, Australia, in.uired maternal depression in a large cohort of ne, mothers *n K;,11;+ as part of 'ife as a "other !ro ect# 0esults indicated the 5@ *;6#<7+ mothers ,ere postnatal depressed at 6-E months post deli%er&, using Cut off score of L ;1on the =!DS *Co8 et al#, ;<8E+# Also using a cut off of ;1 month =!DS and Smaller sample of first-time mothers onl& *nK ;41+ "orse, Dur)in, 3uist, and "ilgrom *5224+, Identified a pre%alence rate of ;;7 at 6 ,ee)s an of ;2#67 at 1 months, indicating a little drops in rates in this period *'eung, "artinson,et al# 522@ *b++# -he difference in pre%alence rates ma& be ;; attributed to sampling methodologies ,ith lo,er rates, ,hich ,ere identified ,ith first time mothers onl&# A sample of first time mothers ,as used in S&dne&, but in a longer stud& period *"atthe&, 3arnett, >ud&, and 9aters, 5222+# 0eported an e%en lo,er pre%alence rate of 6#47 4 months postpartum, using a cut off score of L ;5 the =!DS *Co8 et al#, ;<8E+# M.%1*+*-*G# Study +esign A descripti%e cross sectional stud& ,as used to determine the pre%alence of postpartum depression and describe the associated ris) factors of postpartum depression among !rimipara ,omen# -he data ,as gathered from 4 public and militar& hospitals 0a,alpindi Northern !un ab #!a)istan# Sample Size

-o achie%e the primar& ob ecti%e, ,hich ,as to determine the pre%alence of post partum depression, calculated sample si:e ,as a minimum 122 postpartum !rimipara ,omen# +ata !ollection Instruments Gor detecting depression during postpartum period the %alidated $rdu %ersion of the 3ec) Depression In%entor& *3DI+ ,as used to screen and label stud& participants ha%ing depression# +ata Analysis All the anal&sis ,as done using the Statistical !ac)age for Social Sciences *S!SS+ %ersion ;E#Data entr& ,as through codes, and ,as prepared for statistical anal&sis b& using descripti%e statistics mean, percentages, and fre.uenc& tables# "oreo%er, the multiple logistic regression techni.ue ,as applied to e8amine ,hether socio-demographic and ps&cho-social factors ,ere significant predictors of depression during postpartum period# Inclusion criteria" !articipants from 4!D / postnatal ,ards in stud& settings# !rimipara ,omen ,ithin postpartum period ,ithin 42 da&s# !rimipara ,omen not ha%ing an& )no,n medical illness *ante partum ps&chotic illness# 3et,een the age of ;6 to 42 &ears# !ostnatal ,omen ,ho are able to understand and spea) $rdu and local language# !ostnatal ,omen ,ho gi%e their consent to participate in the stud&# hemorrhage,

chronic or pregnanc& induced h&pertension, diabetes, gestational diabetes and )no,n

.2clusion criteriaB "ultipara !ostnatal primigra%ida ,omen ha%ing pre%ious histor& of depression or other )no,n ps&chiatric illness# !ostnatal primigra%ida ,omen ha%ing an& medical or pregnanc& related complications# !ostnatal primigra%ida ,omen ,ho ,ill not consent to participate in the stud& ,ere e8cluded from the stud&# FIN+INGS AN+ +IS!,SSI*N *F R.S,-%S -hree hundred !rimigra%ida ,omen ,ere approached for the recruitment in the stud&# -he o%erall pre%alence of depression in !rimigra%ida ,omen ranged from 527 to 56 7# Data

,as collected from target population i#e# primigra%ida ,omen on the basis of predetermined selection criteria#

+.S!RIP%I*N

Age "arital status

=ducation status of participants

=ducation status of husband =mplo&ment status of ,omen

RANG. ;6-52 5;-5@ 56-12 1;-1@ 16-42 "arried 9ido, Illiterate "udrassa !rimar& education "iddle education Secondar& education Intermediate Araduate degree !ostgraduate Illiterate !rimar& education "iddle education Secondar& education Intermediate education Araduate degree !ostgraduate House ,i%es =mplo&ed outside the home self emplo&ed in door 'aborers 3usiness Ao%ernment obs !ri%ate obs 4thers 'ess than @, 222 rupees

FR.3,.N!# @; ;@1 84 ;2 5 5<8 5 ;; ; @@ 5E ;;1 @4 5< ;2 ;; ;1 ;< ;@< @2 42 8 5EE ;; ;5 51 ;1 ;52 ;5< ;@ ;6

P.R!.N%AG. ;E#27 @;#27 58#27 1#17 2#E7 <<#17 2#E7 1#E7 2#17 ;8#17 <#27 1E#E7 ;8#2 7 <#E7 1#1 7 1#E 7 4#17 6#1 7 @17 ;6#E 7 ;1#1 7 5#E 7 <5#17 1#E7 47 E#E 7 4#1 7 42#27 41#2 7 @#27 @#17

=mplo&ment status of Husband "onthl& Income of

Gamil& *!a) 0upees+

Gamil& S&stem +.S!RIP%I*N 'ength of "arriage !resent !regnanc& Status !referred Se8 of 3ab&

@,222 to ;2,222 rupees "ore than ;2,222 rupees Nuclear famil& >oint famil& =8tended famil& RANG. Mears "onths !lanned $nplanned 3ab& bo& 3ab& girl 3ab& did not matter 3o&s Airls -,in bo& and girl -,in girls -,in bo&s -riplet t,o bo&s and one girl -riplet 1 girls Spontaneous %aginal deli%eries Instrumental deli%eries Caesarean sections 3reast feeding Gormula feeding 3oth

;;< ;64 @8 54; ; FR.3,.N!# 518 65 564 18 <2 ;4 ;<6 ;1< ;48 E 5 5 ; ; ;5< 8 ;61 ;<4 ; ;2@

1<#E7 @4#E7 ;<#17 82#17 2#17 P.R!.N%AG. E<#17 52#E7 8E#17 ;5#E7 12#2 7 4#E7 6@#17 46#17 4<#1 7 5#17 2#E 7 2#E7 2#17 2#17 41#27 5#E7 @4#17 64#E7 2#17 1@#27

!resent Se8 of 3ab&

"ode of Deli%er&

"ethod of Geeding 3ab&

Association 4etween +epression and ;6-52 5;-5@ 56-12 1;-1@ 16-42 %otal "arital status "arried 9ido, %otal Association 4etween +epression and =ducation status of participants Range Illiterate "udrassa !rimar& education "iddle education Range

Mild +epression <*;E#6 7+ @<*16#67+ 15*18#;7+ 4*42#;7+ 2*#27+ ;24*14#E7 + ;25*14#57 + 5*;22#27+ ;24*14#E7 + Mild +epression 8*E5#E7+ 2*#27+ <*;6#47+ E*5@#<7+

Moderate +epression ;8*1@#17+ 4@*5<#47+ 5<*14#@7+ 5*52#27+ 2*#27+ <4*1;#17+ <4*1;#@7+ 2*#27+ <4*1;#17+ Moderate +epression ;*<#;7+ 2*#27+ 51*4;#87+ 8*5<#67+

Se)ere +epression 54*4E#;7+ 4<*15#27+ 51*5E#47+ 4*42#27+ 5*;22#27+ ;25*14#27 + ;21*14#57 + 2*#27+ ;25*14#27 + Se)ere +epression 5*;8#57+ ;*;22#27+ 51*4;#87+ ;5*44#47+

Fisher %otal @;7 ;@17 847 ;27 57 122 5<87 57 122 Fisher %otal ;;7 ;7 @@7 5E7 .2act %est p5)alue 5#@22 #115 .2act %est p5)alue

Age of !articipants

;1#458

2#264

=mplo&ment status of ,omen =mplo&ment status of husbands "onthl& income of famil& *!a) 0upees+ Gamil& s&stem

"atric Intermediate Araduate degree !ostgraduate %otal House ,ife =mplo&ed outside the home Self emplo&ed in door %otal 'aborers 3usiness Ao%ernment obs !ri%ate obs 4thers %otal 'ess than @, 222 rupees @,222 to ;2,222 rupees "ore than ;2,222 rupees Don/t )no, %otal Nuclear families >oint families =8tended families %otal 3o&s Airls -,in bo& and girl -,in girls -,in bo&s -riplet t,o bo&s and one girl -riplet 1 girls %otal Spontaneous %aginal deli%eries Instrumental deli%eries Caesarean sections %otal 'ess than ;2 Da&s ;2-;< Da&s 52-5< Da&s Areater than =.ual to 12 Da&s %otal

!resent bab& se8

5<*5@#E7+ 5@*46#17+ ;E*@8#67+ <*<2#27+ ;247 <5*11#57+ ;2*<2#<7+ 5*;6#E7+ ;247 E*12#47+ 6*46#57+ 1@*5<#57+ @;*1<#@7+ @*11#17+ ;247 1*;8#87+ 1E*1;#;7+ 64*1<#27+ 2*#27+ ;247 ;<*15#87+ 8@*1@#17+ 2*#27+ ;247 16*5@#<7+ 62*42#@7+ @*E;#47+ ;*@2#27+ 2*#27+ ;*;22#27+ ;*;22#27+ ;247 1;*54#27+ 5*5@#27+ E;*41#67+ ;247 @;*4<#<7+ 51*4;#87+ 55*5@#<7+ 8*;6#17+ ;24*14#E7 +

18*11#67+ ;@*5E#87+ 8*5E#67+ ;*;2#27+ <47 <2*15#@7+ ;*<#;7+ 1*5@#27+ <47 8*14#87+ 1*51#;7+ 18*1;#E7+ 4;*1;#87+ 4*56#E7+ <47 <*@6#17+ 4*58#67+ @;*1;#;7+ 2*#27+ <47 52*14#@7+ E4*12#E7+ 2*#27+ <47 4E*11#87+ 41*5<#;7+ 5*58#67+ 2*#27+ 5*;22#27+ 2*#27+ 2*#27+ <47 44*14#;7+ ;*;5#@7+ 4<*12#;7+ <47 1@*1@#@7+ 51*4;#87+ 54*58#57+ ;5*54#@7+ <4*1;#17+

46*42#E7+ ;4*5@#<7+ 4*;1#87+ 2*#27+ ;257 <@*14#17+ 2*#27+ E*@8#17+ ;257 8*14#87+ 4*12#87+ 4E*1<#57+ 1E*58#E7+ 6*42#27+ ;257 4*5@#27+ 48*42#17+ 4<*5<#<7+ ;*;22#27+ ;257 ;<*15#87+ 85*14#27+ ;*;22#27+ ;257 @6*42#17+ 4@*12#47+ 2*#27+ ;*@2#27+ 2*#27+ 2*#27+ 2*#27+ ;257 @4*4;#<7+ @*65#@7+ 41*56#47+ ;257 5@*55#@7+ <*;6#47+ 1<*4@#<7+ ;5*54#@7+ ;25*14#27 +

;;17 @47 5<7 ;27 122 5EE7 ;57 ;;7 122 517 ;17 ;527 ;5<7 ;@7 122 ;67 ;;<7 ;647 ;7 122 @87 54;7 ;7 122 ;1<7 ;487 E7 57 57 ;7 ;7 122 ;5<7 87 ;617 122 ;;; @@ 8@ 4< 122

;6#84;

#22;

@#14<

#E58

<#6<<

#2<5

5#;56

#884

;<#E28

#22<

"ode of deli%er&

;6#;8E

#22;

Duration of !ostpartum !eriod

+iscussion
-his .uantitati%e descripti%e cross sectional stud& ,as conducted among 122 !rimipara ,omen in 0a,alpindi, Northern !un ab, !a)istan ,ho met the defined criteria #-he stud& aimed the pre%alence of postpartum depression in !rimipara ,omen and highlighted the associated e8plore ris) factors contributing to postpartum depression in these ,omen# Stud& also loo)ed at association bet,een the !rimipara ,omen socio-demographic profile and depression#

-he uni%ariate of this sample sho,ed that age is not significant *pK 2#264+ association for depression during postpartum period# Ho,e%er, the current stud& indicated the teenage and older age of ,omen had contributed in se%ere depression ,hich is contrar& to the studies conducted in de%eloping countries# -he age of the mother ,as found as one of se%eral independent %ariables associated ,ith !!D *"an:ano, Aarcia, and "oreno, 5225+# Gurthermore, researches carried out in other regions of !a)istan ha%e found older age to be one of the ris) factors for depression in the general population and for depression during pregnanc& *Ali, 0ahbar, Naeem, -areen,C Samad, 5225? Hamirani et al#,5226? Hussain,Aater, -omenson, C Creed, 5224? 0abbani C 0a a, 5222+# -he uni%ariate anal&sis of stud& sho,ed no significant association bet,een depression and marital status of participants/ *pK #115+#,omen ,ho ,ere ,ido, the& had no depression because their children ,ere source of hope for them and also the& had social support from their parents and parents in- la,s# Ho,e%er, a stud& conducted b& 4/Hara, *;<86+? indicated in his stud& that ,omen e8periencing postpartum depression reported significantl& more dissatisfaction ,ith lac) of support from significant relations Irfan, 3adar 5225# It has been ac)no,ledged that education pro%ides different means of coping mechanism to deal ,ith stressors#N It raises the self- efficac& and therefore, the self esteem of the ,omen# It also ma)es ,omen feel less helpless in difficult situations and gi%e a greater sense of control o%er their en%ironmentN*Harpham, ;<<4, as cited in Ali et al#, 5225, p#@;6+#-he current stud& findings are in agreement ,ith the ,omen ,ith elementar& and secondar& education had higher rate for de%eloping !!D# A stud& conducted in a tertiar& care hospital in Iarachi ,hich concluded that age and lo, le%el of education of mother as significant predictors of !!D *"an:ano, Aarcia, and "oreno, 5225+#-he importance of education is e%ident from the abo%e statistics that the pre%alence of depression is in%ersel& proportional to the le%el and status of education# Similarl&, this stud& finding is congruent ,ith the pre%ious stud& that higher the education lo,er the depression is obser%ed among !rimigra%ida ,omen in postpartum period# Higher education opens ne, %istas to,ards a,areness and understanding as a result education pro%es to be an obstacle for depression as it is an effecti%e tool to combat against negati%e thoughts ,hich lead to depression# As e8treme depression ,as obser%ed among participant ,ith "adrassa education# It appears that lac) of formal education is one of ma or ris) factors for de%eloping depression during postnatal period# Illiterac& is the root cause of all e%ils so the reason for high depression is

,ell understood, but no depression ,hich is noticed among illiterates is another area to be e8plored in future research# -he findings of this stud& also e8plored association bet,een depression and emplo&ment status of ,omen# -he ma orit& of the ,omen *<5#117+ in the present stud& ,ere house,i%es, 47 self emplo&ed ,ere doing small business in the home, and 1#6E7 ,ere emplo&ed outside the home# 9omen ,ho are emplo&ed outside home ,ere not li)el& to be depressed as these ,omen are in%ol%ed in health& acti%ities ,hich open ne, %istas, challenges and inno%ations in their li%es# In general, the lo, rate of ,omen/s emplo&ment status ,as not significantl& associated ,ith depression, as had been reported b& other authors *4/Hara, ;<86+# -he stud& found that association bet,een depression and estimated monthl& house hold income *in !a) rupees+# -he high le%el of depression in participants ,ho had lo, famil& income can be due to certain socioeconomic factors that it is difficult to ma)e both ends meet and to fulfill their desires# -hough, other authors ha%e reported an association bet,een lo, monthl& income and depression among ,omen *Ouraish&, Sultana, 0ia:, 522@+# -he researcher has e8plored and found that monthl& income relation to depression and in this region the ma orit& of the ,omen *417+ ,ere dependent on pri%ate ob and *427+ on go%ernment ob# 4n the other hand, a hospital based !rospecti%e, Comparati%e stud&, in Indonesia sho,ed 55#1@7 a relati%el& high pre%alence of post partum depression among ,omen ,ith lo, income# -he current stud& has also found significant association bet,een oint/nuclear famil& s&stem and depression, ,hich is consistent ,ith pre%iousl& reported studies *0ahman et al#, 5221? 0&an et al#, 522@+# It is generall& held belief that oint famil& s&stem pro%ides great social support and to pre%ent de%elopment of depression# 9hich is supported b& -a.ui, Itrat, Oid,ai, and Oadri, *522E+ ,ho concluded in his stud& that li%ing in a nuclear famil& ,as strong independent predictor of depression *Gi)ree, and 3hatti, ;<<<+# 9here as the high le%el of depression is found in ,omen ,ho compromise ,ith the suggestions gi%en b& members *e#g#, mother-in-la,s+ of famil&# -hese findings might be surprising, as !rimipara in this stud& ,ere more depressed because of lac) of e8perience of the ne, role of motherhood and lac) of social support from their famil& members# Some aspects of postpartum rituals *superstitious held beliefs li)e )eeping )nife under pillo, ma& pre%ent e%il spirits+, especiall& restricted acti%ities, unh&gienic condition of ,omen ma& generate stress, tension, and frustration# 4ther traditional practices carried out in different regions also impelled ,omen/s mental health to,ards depression as cultural issues *such as gender preference+ ser%es as dri%ing force in this regard# As compared to oint families lesser depression ,as found among

nuclear families# -he reasons might be the factors related to self dependence at home, less emotional disturbance, lo, interruption, lo, ,or) load of famil& and less preference to,ards cultural, tradional, and regional customs# -his is the combination of people and their beha%ior that is affecting this factor# -he preference for male child is deepl& rooted in South Asia ,here ,omen are often blamed for the birth of girls# !reference for bo&s o%er girls is common in China, especiall& in rural China, India as ,ell as in !a)istan and other Asian countries# -here are se%eral possible e8planations for this occurrence# "ostl& parents rel& on sons economicall& ,hen the& become old# Gurthermore, famil& names are considered an important representation of the famil& and are accepted through the male line# -he stud& has also found significant association bet,een depressions and preferred se8 of the bab& among 11#17 -!rimipara ,omen# Ho,e%er, this stud& suggests that the effects of ha%ing a female child on the motherPs mood ma& onl& be temporar&# -his stud& also supported pre%ious findings from China that deli%ering a female ,as significantl& associated ,ith postpartum depression ,ith a t,o-fold greater than before ris) compared to ,omen ,ho deli%ered a male bab& *Co8, Connor, Iendell, ;<85? Iarmaliani, Asad et al, 5228+# ## -he stud& has also found that 6@#117 parents do not bother the gender of the fetus before deli%er&# Ho,e%er the negati%e reaction of famil& members to,ards the birth of a female bab& ma& be dominant in creating or e8acerbating depression# -he preference for male children ma& be communicated to the mother and those ,ho deli%er females ma& recei%e less support and less positi%e criticism# 'ac) of social support has ,idel& been found as a ris) factor for postpartum depression *Co8, Connor, Iendell, ;<85? "an:ano, Aarcia, and "oreno, 5225? -a.ui, Itrat, Oid,ai, and Oadri, 522E? Hhang, ;<<@? Alasser, 3arell, 3o&)o, Hi%, and 'us)&, 5222+# Although, the magnitude of the effect of social support on postpartum depression is %aried among different studies *"ir:a, and >en)ins 5224+# 3ergant et al# *;<<8+ reported that cesarean section ,as one of se%eral %ariables considered to be a significant ris) factor for patients ,ith Qearl& postnatal depressi%e disorderQ at @ da&s after childbirth# Gisher et al# *;<<E+ reported that cesarean section ,as associated ,ith increased ris) to patients of !!D at @-,ee)s postpartum in !rimipara ,omen# !articipant ,ho ha%e caesarean sections the& feel e8pectations for the perfect household but lac) of energ&, high an8iet& le%el, inabilit& to mo%e from bed, sleeping and eating difficulties and inabilit& to ta)e care their infant and famil& members, not fit for doing household chores are the factors of grief for famil& members# "ostl& the negati%e role pla&ed b& in-la,s is the cause of inducing more tension and stress in postnatal ,omen# -hese conditions are more

pre%alent in families ,ith lo, socio-economic status# -he result of this stud& is congruent ,ith earlier stud& and found the significant association ,as obser%ed bet,een depression and mode of deli%er&# -he percentage of births among participants deli%ered b& cesarean section ,as @4#117 the highest le%el in researcher/s stud& ,hich pla&s a great role in de%eloping depression in postpartum period# *utcome 6 ,tilization of Study" -he stud& finding can be e.uall& implemented in nursing practice, nursing administration and other health care professionals# -here are distinct feature ,hich ha%e come up during research ,hich ,ere not under the scope of this stud&# Ho,e%er, it has gi%en an insight that future research stud& can e8tend the scope of those perspecti%es# -he findings needs to be shared at larger forum ,ith all the sta)eholders concerned so as to plan care modalities for pregnant ,omen in general and !rimipara in particular to support them in their ne, role of motherhood# Implication for nursing .ducation and practice It is of great importance that health care professionals should be a,are of this phenomenon and its related concepts# -he finding of stud& ,ill bring a scientific and e%idence based truth to the health care planners, nursing/ mid,ifer& and medical educationist to pro%ide )een emphasis on the postpartum care of ,omen into the curricula of all health care pro%iders# As earl& identification of ris) factors, priorities and cost-effecti%e pre%enti%e health measures at primar&, secondar& and tertiar& le%el could be applied# Girst of all, famil& planning and counseling ser%ice ma& reduce un,anted /unplanned pregnanc&# Secondl&, secondar& pre%ention inter%entions encompass earl& detection and treatment of disabling depressi%e s&mptoms# 0outine screening for !!D b& using self reported .uestionnaire during postpartum period are strongl& encouraged# Ginall&, tertiar& pre%ention inter%entions need pre%enting relapses of depressi%e s&mptoms# 0outine follo, up and home health %isits during the pregnanc& and post partum period are strongl& recommended# Implications for Research -he ad%ancement that has been made in an& field is based on e%idence and data gathered from research, and sharing of the findings ,ith sta)eholders# Similarl&, there is a need to

conduct the stud& countr& ,ide and to e8plore other cultural, religious aspects ,hich ma& trigger the de%elopment of !!D in !rimipara so as to plan health facilities and communit& access to at primar&, secondar& and tertiar& le%el of care# Guture studies ,ill assist in de%eloping interdisciplinar& and intra-sectoral collaborations to impro%e planning de%elopmental programs for the communit& to address illiterac& and access to health care pro%ider# Conse.uentl&, ,omen ma& ha%e better economic opportunities to get social and economic empo,erment# -imitation of the study" -here ,ere number of limitations in this stud&B -he use of con%enience sampling limits to 0a,alpindi and the results can not be generali:ed to other parts of the countr&# 'imited sample si:e ,as not enough to %alidate the finding# 'imited time of the stud& is a big limitation# 3udgetar& constraint#

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fromhttpB//,,,#searo#,ho#int/en/section;;E4/section;;<</section;@6EV6E4;#htm Hhang, S# 9# *;<<@+# Getal gender and maternal ph&sical and ps&chological health# "aternal and Child Health in China, ;2*4+, ;2;