Predictors of maternal and paternal depressive symptoms at postpartum
Introduction
For most parents, the birth of a child brings joy and a sense of fulfillment and satisfaction to family life [1]. However, a substantial proportion of couples struggle to adapt to new parenthood, feel stressed in caring for their infants, and become depressed in the perinatal period [2], [3]. A recent meta-analysis published in the Journal of the American Medical Association reports that both women (23.8%) and men (10.4%) suffer from depression between the first trimester and 1 year postpartum [2]. In a survey of 376 new parents in the Fujian Province of China, postpartum depression was reported to affect 14.9% of mothers and 12.5% of fathers, and partner's depression was found to be a major predictor of depression for both mothers and fathers [3]. In another study of 130 first-time Chinese parents in a southeastern city in China, Gao et al. (2009) found a similar prevalence of depression in mothers (13.8%) and fathers (10.8%) at 6-8 weeks postpartum, and a significant relationship between maternal and paternal depression. Postnatal depression has negative impacts for both the parents and their children [4], [5]. Women with a history of postpartum depressive symptoms are six times more likely to have recurrent depressive symptoms [4]. Postnatal depression has been linked to attachment insecurity and delay in emotional, developmental, social, and interaction difficulties in children [6], [7], [8], [9]. In a population-based cohort of 10,975 fathers and their children, depression in fathers in the postnatal period was found to be associated with later psychiatric disorders in their children [5]. Given the increasing evidence of postnatal depression in mothers and fathers, and the adverse effects on their children's psychosocial health, the investigation of predictors of postnatal depression in both women and men during the transition to parenthood is warranted.
There was a considerable amount of literature on risk factors associated with postnatal depression among women. Two major reviews conducted across Asian countries reported prenatal depression, stressful life events, poor marital relationship, and low social support as major predictors of postnatal depression among women [10], [11]. In recent years, increasing effort has been focused on predictors of postnatal depression among men. Wee et al. [12] conducted a systematic review of 26 studies and found that having a partner with depression, poor relationship satisfaction, and low social support were strong correlates of postnatal depression in fathers. The evidence indicates the need for understanding postnatal depression in the family as a social system in which the parents experience stressors and engage in coping during the critical time of parental transition.
The conceptual framework of the present study was based on Antonovsky's Salutogenic Model, which focuses on individual strength and capacity for successful adjustment to life stressors [13]. During the transition to parenthood, new parents are faced with profound changes in roles, relationships, and lifestyles, which have been found to heighten their level of stress [14], [15]. Ngai and Chan [14] conducted a longitudinal study of 78 Chinese mothers in Hong Kong and found that women exhibited an increased level of stress from pregnancy to early postpartum, and disruption in daily life, family relationship, finances, and working conditions were identified as the major stressors. According to Antonovsky [13], stressor life events produce tension, which may result in emotional arousal and threaten the individual's sense of well-being. In a longitudinal study of 367 women in Australia, concurrent parenting stress was found to be a strong predictor of postnatal depression, accounting for 6% of the variance [16]. In Kalainin and Arthur's [10] review of 64 studies across 17 Asian countries, stressful life events and child care stress were found to be strong risk factors for postnatal depression among Asian women. In a survey study of 130 first-time Chinese parents, perceived level of stress was found to be significantly associated with depression for both mothers and fathers during the postpartum period [15], suggesting that stress may have a deteriorating effect on parents' mental health and increase the risk of postnatal depression.
In the face of life stressors, Antonovsky [13] postulated that family sense of coherence can be a protective factor against poor mental health. Family sense of coherence is defined as a global family orientation in which the environment is comprehensible (structured, rational, and predictable), meaningful (challenging and worthwhile), and manageable (adequate resources to cope with challenge) [17]. During the transition to parenthood, parents with a strong family sense of coherence perceive themselves as having both internal and external resources sufficient to deal with the demands of new parenthood; thus, they are less likely to feel threatened by the stressors and less vulnerable to develop depressive symptoms [17]. Family sense of coherence has been found to play a significant role in family well-being and diminish the negative impact of stressful life events and transitions. In a study of 116 American families taking care of mentally retarded children, Lustig and Akey [18] found that parents with a higher sense of family coherence reported better family adaptation. In another study of 78 American families caring for a family member with an illness, Anderson [19] found that family sense of coherence was a strong predictor of the quality of family life, accounting for over 30% of the variance, and a mediator in reducing the impact of stress on the family. In a local study of 128 Chinese childbearing couples, couples with a greater family sense of coherence were found to report a lower level of anxiety and better family functioning [20], suggesting that family sense of coherence has a potential influence on the family's adaptation and well-being during parental transition.
In addition to internal resources, external resources such as social support from family members and friends have consistently been found to be associated with postnatal depression [10], [21]. Antonovsky [13] proposed that ties to significant others could make a valuable contribution to successful coping with stressors, thus reducing the risk of postnatal depression. In a large prospective study of 22,968 women in Australia, a low level of partner support was found to be a significant predictor of postnatal depression [22]. In another longitudinal study of 534 pregnant women in China, women with low prenatal and postnatal social support were found to have a higher rate of postnatal depression [23]. Low levels of social support and poor marital relationship have also been found to be associated with postnatal depression among the men. In Roubinov et al.'s [24] study of 92 Mexican American fathers, poor marital relationship quality was found to predict paternal depression at postpartum. In a longitudinal study of 622 fathers in Hong Kong, poor marital relationship and poor social network were identified as risk factors for paternal depression across the perinatal period [25]. Wee et al. [12] conducted a systematic review of 26 studies among the men and concluded that the most common correlates of paternal depressive symptoms pre- and post-birth were having a partner with depression, poor relationship satisfaction, and low social support.
Despite the strong link between maternal and paternal depression [2], most previous research has examined risk factors associated with postnatal depression among women only [10], [11], and few studies have compared predictors of maternal and paternal depression during the perinatal period [3]. There also appears to be a paucity of research examining family sense of coherence and its role in postnatal depression among the women and men during the transition to parenthood. Given that the social and personal costs of postnatal depression are far reaching [4], [6], improved understanding of the predictors of parental depression at postpartum is important for the development of effective clinical and public health interventions. The aim of this study was thus to investigate the risk factors associated with postnatal depression in mothers and fathers, in particular the predictive role of family sense of coherence, stress, social support, and family and marital functioning during pregnancy; the effect that any changes in these factors from pregnancy to postpartum; and partner's depressive symptoms may have on postnatal depression at 6 months postpartum.
Section snippets
Participants
The present study was part of a longitudinal study that explored the influence of psychosocial variables on family adaptation during the transition to parenthood. A convenience sample of 256 childbearing couples attending the antenatal clinic of a regional hospital in Hong Kong was recruited in January–May 2011. Inclusion criteria were childbearing couples aged 18 or above, able to read Chinese and having no previous history of psychiatric illness. A subset of data collected at pregnancy and 6
Sample characteristics
Of the 270 childbearing couples that were eligible, 256 couples (97.8%) gave consent for the study and complete the assessment during pregnancy, and 200 couples (78%) completed both assessments during pregnancy and at 6 months postpartum. Table 1 shows the demographic and obstetric characteristics of the subgroups of mothers and fathers. The mean age of the couples was 33.4 years (SD 4.6), and most had attained at least a secondary level of education (99.8%). Most of the women (82%) and all of
Discussion
The prevalence of depressive symptoms for the fathers in the present study ranged from 7% (during pregnancy) to 10.5% (at 6 months postpartum), which is in accordance with the prevalence of depressive symptoms reported in a meta-analysis of 26 studies on paternal depression during the perinatal period (10.4%) [2]. The prevalence of depressive symptoms for the mothers in the present study (15.5% during pregnancy and 11.5% at 6 months postpartum) is slightly lower than the results of a major review
Conflict of interests
The authors declare that they have no conflict of interest.
Acknowledgements
This study was supported by the Research Grant of the University of Hong Kong. We would also like to thank the parents for their contributions and participation in this study.
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