Concept of postpartum depression
The World Health Organization (WHO) describes depressive disorders as conditions marked by persistent sadness, diminished interest or pleasure, feelings of guilt or low self-esteem, hopelessness, sleep disturbances, fatigue, poor concentration, and appetite changes These disorders can be chronic or recurrent, significantly hindering an individual's capacity to perform at work or school and manage daily activities In severe cases, depression may result in suicidal thoughts or actions (WHO, 2012).
Postpartum depression (PPD) is a significant mood disorder that can occur during pregnancy or within four weeks after childbirth, characterized as an episode of Major Depressive Disorder (MDD) Symptoms of PPD align with those of MDD, including feelings of sadness, hopelessness, worthlessness, fatigue, and difficulty concentrating Notably, the onset of PPD can extend into the first year postpartum Mothers suffering from PPD often experience profound sadness, anxiety, and exhaustion, which can hinder their ability to perform daily activities for themselves and their families.
Postpartum depressive symptoms can arise anytime within a year following childbirth, with a peak occurrence between 4 to 6 weeks postpartum Typically, these symptoms tend to resolve on their own within 2 to 6 months after delivery.
The American College of Obstetricians and Gynecologists (ACOG) advises that obstetrician-gynecologists and other providers of obstetric care should conduct a thorough screening for depression at least once during the perinatal period This includes a complete assessment of mood and emotional well-being, specifically screening for postpartum depression (PPD) using a validated instrument during the comprehensive postpartum visit.
Screening for postpartum depression enhances the early recognition of this disorder and facilitates care that leads to better clinical outcomes Various studies have employed different screening tools to assess depression in postpartum mothers.
The PHQ-9 is a widely used self-report questionnaire recommended by ACOG for assessing perinatal depression It demonstrates strong agreement with diagnoses made by mental health professionals, achieving 75% sensitivity and 90% specificity Scores range from 0 to 27, with higher scores indicating more severe depressive symptoms, categorized as minimal (0-4), mild (5-9), moderate (10-14), and severe (>15) Validated in obstetrics and gynecology settings, the PHQ-9 is commonly utilized in both research and clinical practice for evaluating depression symptoms, making preliminary diagnoses, and determining the severity of depression.
Beck Depression Inventory II (BDI-II)
The Beck Depression Inventory is among the most commonly employed screening devices, developed in 1961 and updated (BDI-II) in 1996 to reflect
The revised depression diagnostic criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) feature a self-report questionnaire with 21 items, demonstrating a sensitivity of 56-57% and a specificity of 97-100% Each item is scored from 0 to 3 based on severity, reflecting common feelings associated with depression, such as guilt, low self-worth, and suicidal ideation The questionnaire comprises 10 positive and 10 negative statements (Learman et al., 2018).
Edinburgh Postnatal Depression Scale (EPDS)
The Edinburgh Postnatal Depression Scale (EPDS) is widely utilized in both research and clinical settings due to its public domain status and availability in 50 languages, including Lao It boasts strong validation, with sensitivity and specificity that meet various clinical needs The original study indicated a sensitivity of 86% and a specificity of 78% at a threshold score of 12/13 Furthermore, data from the EPDS development team shows that using a cut-off score of 9/10 can reduce the failure to detect cases to under 10%, making it suitable for routine use by primary care providers.
10, used to increase the sensitivity of the instrument, demonstrated a sensitivity of 84-100% as well as a specificity of 82-88% (Cox et al., 1987).
Several validated screening instruments are available for identifying perinatal depression during pregnancy and the postpartum period Common tools include the EPDS, PHQ-9, and BDI-II, which measure depressive symptoms in postpartum mothers A meta-analysis by Shorey et al (2018) indicated that the prevalence of depression was consistent across different diagnostic tools Consequently, this study utilized the EPDS, as it is the most widely accepted and recommended tool in research.
HUPH the ACOG (ACOG, 2018) and the tool used in the previous study in northern Lao PDR.
Postpartum depression situation
In 2015, an estimated 322 million people globally, accounting for over 4% of the world's population, were affected by depression The Western Pacific Region alone had 66 million individuals living with this condition From 2005 to 2015, the prevalence of depression increased by more than 18% Notably, depressive symptoms were identified as the leading cause of mental illness, with 7.5% of the global population and 7% in the South-East Asia Region experiencing disability due to depression in 2015.
Every year, approximately 73 million adult women globally experience a major depressive episode, with mental disorders related to childbirth, such as postpartum depression, impacting around 13% of women within the first year after delivery (WHO, 2009).
Numerous studies have investigated the prevalence of postpartum depression (PPD), with a significant meta-analysis by Shorey et al in 2018 reviewing 58 studies of healthy mothers without a prior history of depression from 1988 to 2016 This analysis revealed an overall PPD prevalence of approximately 17%, with notable geographical variations: 16% in Asia, 11% in Africa, 19% in Australia, 8% in Europe, 26% in the Middle East, 19% in South America, and 16% in North America The prevalence rates at different assessment periods post-childbirth were 14% at 0–3 months, 16% at 4–6 months, 20% at 7–12 months, and 25% after 12 months Additionally, a study of 18 research projects across 12 Asian countries indicated a weighted prevalence of nearly 28%, with specific point prevalence rates at six weeks, three months, and six months postpartum.
A systematic review indicated a higher prevalence of postpartum depression (PPD) in low- and lower-middle-income countries, reaching nearly 20% (Fisher et al., 2012) In Thailand, the National Survey reported a PPD prevalence of 8.4% using the EPDS tool (Panyayong, 2013), while a provincial study revealed a significantly higher rate of 25% (Petpornprapas & Lotrakul, 2009) Research among Vietnamese women in Danang and Hanoi showed postnatal depressive symptoms at 19.3% and 27.6%, respectively (Do et al., 2018; Van Vo et al., 2017) Additionally, a study of Chinese mothers found that approximately 30% reported PPD 1-3 years postpartum, with rates of 28% in the first year, 30.8% in the second year, and 31.8% in the third year, as measured by the Center for Epidemiologic Studies Depression Scale (CESD) (Chi et al., 2016).
Postpartum depressive symptoms can arise anytime within a year following childbirth, with their prevalence peaking at eight weeks postpartum before gradually declining Research indicates that these symptoms are less common immediately after delivery, likely due to the absence of complete physiological changes and the initial lack of childcare stress (Norhayati et al., 2015).
1.2.2 Postpartum depression situation in Lao PDR
In 2015, the World Health Organization reported that 3.2% of the population in Lao PDR, equating to 209,326 individuals, experienced depression By 2018, the Ministry of Health Lao PDR documented approximately 2,421 patients with mental health conditions, with around 10% (240 cases) specifically diagnosed with depression, predominantly affecting women (64%) Despite these figures, there is a lack of statistics on postpartum depression (PPD) due to the focus of routine postpartum care in Lao PDR.
Health facilities in Lao PDR do not acknowledge postpartum depression (PPD), leading to insufficient services for routine screening during prenatal and postnatal care As a result, PPD is not considered a significant issue in the region, which hinders physical recovery, breastfeeding, and family planning efforts.
A recent study on PPD, conducted in 2017 among women in Oudomxay Province found a prevalence of PPD at 15.2% by using the EPDS tool with cut-off point above
A significant study indicates that approximately 93% of women in Vientiane Capital adhere to a restricted diet known as “yu kum” following childbirth (Barennes et al., 2009) Traditional beliefs suggest that feelings of unhappiness or poor health, referred to as “pit kum” or cultural brow syndrome, signal underlying issues Therefore, further research is essential to better understand postpartum depression (PPD) among Lao women (Bertrand et al., 2002).
The Government has prioritized Reproductive, Maternal, Newborn, and Child Health (RMNCH) through the National Assembly (MoH Lao PDR, 2018) It is crucial to highlight the significance of maternal mental health alongside physical health, urging healthcare professionals, particularly obstetricians and gynecologists, as well as policymakers, to recognize the importance of routine screening for postpartum depression (Musau, 2012).
Table 1.1 Summary of previous studies of prevalence and incidence of postpartum depression worldwide, in neighboring countries and in Lao PDR
Region or country Prevalence of PPD Year Source of data
A meta-analysis of 58 studies worldwide 17% 2018 Shorey et al
Low and lower middle income countries 20% 2012 Fisher et al
The 18 studies in 12 Asian countries 28% 2011 Roomruangwong et al
19.3% 2018 Do 27.6% 2017 Van Vo Lao PDR, Oudomxay Province 15.2% 2017 Inphouvieng
Consequences of depression during postpartum period
Globally, maternal mental health issues are a major public health concern which lead to maternal morbidity and mortality, impacts on physical health and even suicide (WHO, 2019)
A study in Vietnam revealed that 39.7% of depressed mothers experienced suicidal ideation within the past week (Van Vo et al., 2017) Research by Howard et al indicates that women with heightened depressive symptoms are more susceptible to suicidal thoughts and self-harm during the postpartum period, with rates ranging from 3% to 14% (Howard et al., 2011; Orsolini et al., 2016) This finding aligns with Wisner's study, which found that 19.3% of depressed mothers with an EPDS score of 10 or higher reported self-harm.
HUPH ideation, and 30% with EPDS score ≥13 also had self-harm ideation (Wisner et al.,
Maternal depression significantly impacts children, leading to both short-term and long-term consequences Short-term effects include disrupted maternal-infant interactions and a decrease in positive activities such as reading and singing (Paulson et al., 2006) Depressed mothers are also more likely to adopt poor sleep practices and unhealthy feeding habits Research indicates that non-depressed mothers are 6.14 times more likely to practice exclusive breastfeeding, while depressed mothers have 4.40 times higher odds of having underweight infants (Madeghe et al., 2016) Long-term consequences include a strong correlation between maternal depressive disorder and issues such as delayed child growth, early childhood underweight, and stunting, particularly in developing countries (Patel et al., 2003; Surkan et al., 2008; Surkan et al., 2011).
Prevention of postpartum depression
Postpartum depression (PPD) can be prevented by identifying clear markers following childbirth, particularly within the first three months when the risk is highest Screening can effectively identify high-risk mothers during their frequent postnatal visits with healthcare professionals, allowing for the detection of risk factors and the implementation of preventive measures (Dennis, 2004) Consequently, three levels of prevention have been established based on these factors.
- Primary prevention that involves educating mothers on the nature and
HUPH health professionals especially midwives, to be able to screen for risk factors It helps in decreasing the incidence of the disorder
- Secondary prevention that reduces the prevalence of this disorder by early identification and interventions that minimize the frequency, duration and severity It involves well-timed screening and appropriate interventions
- Tertiary prevention that involves early identification and treatment to limit disability This is possible by regular follow-ups, prophylactic medication and individual, couple or group therapy.
Risk factors related to postpartum depression
Postpartum depressive disorder is a significant mental health issue influenced by various genetic, demographic, psychosocial, and environmental factors Following childbirth, mothers experience substantial physiological changes that can impact their mental well-being This critical period requires focused attention on both maternal and newborn health, particularly regarding psychological aspects This research investigates the risk factors associated with postpartum depressive symptoms among mothers in Vientiane Capital, Lao PDR, within 4 to 24 weeks after delivery, considering socio-demographic, economic, obstetric, pregnancy, pediatric health, and family relationship factors.
Younger mothers, particularly those aged 13 to 19, face the highest levels of depression, with studies indicating that mothers aged 15 to 24 and those under 24 are at a twofold increased risk of postpartum depression (PPD) compared to women over 30.
Research indicates that women aged 31 to 35 are commonly affected by postpartum depression (PPD) (Milgrom et al., 2008) Conversely, a study in Qatar revealed that mothers over 35 years old face the highest risk of PPD (Bener et al., 2012) Interestingly, another study involving 1,950 women conducted 2 to 12 weeks postpartum found that older maternal age and higher maternal self-efficacy are linked to a decreased risk of experiencing postpartum depression (Abdollahi et al., 2014).
Research indicates that the level of education is a crucial factor in predicting postpartum depression (PPD) among new mothers in Hanoi, Vietnam, particularly during the first year after delivery (Do et al., 2018) A study conducted by Chi et al in China revealed that having an education of 9 years or less is significantly linked to an increased risk of PPD (Chi et al., 2016) This finding aligns with other research that demonstrates a strong association between low educational attainment and PPD (Ghaedrahmati et al., 2017) Additionally, a study in Qatar identified that education levels below intermediate were correlated with higher instances of PPD (Bener et al., 2012) In Vietnam, it was found that women with primary, secondary, and high school education faced risks of PPD at rates of 2, 1, and 3.5 times higher, respectively (Tho Tran et al.).
2018) However, the study of Fisher showed that having more education was a protective factor of PPD (Fisher et al., 2012)
Employment status plays a crucial role in postpartum depression (PPD), as evidenced by a study indicating that unemployment is a significant risk factor for PPD among women three months after childbirth (Sampson et al., 2017) Similarly, research conducted in Qatar and Iran revealed a strong association between being a housewife and experiencing depression six to eight weeks postpartum (Bener et al., 2012; Kheirabadi et al., 2009) In contrast, a study of Vietnamese women found that government employees and private sector workers, as well as farmers, faced a significantly higher risk of PPD, with odds increasing fourfold and threefold, respectively.
Research indicates that employment status, particularly in professional roles, is linked to a lower risk of postpartum depression (PPD) Studies show that having a permanent job serves as a protective factor against PPD, especially in low- and lower-middle-income countries.
Ethnicity plays a significant role in the prevalence of postpartum depression (PPD) A systematic review conducted in low- and lower-middle-income countries indicates that belonging to the ethnic majority serves as a protective factor against PPD (Fisher et al.).
2012) The Lao PDR consists of four major ethnic groups that differ in language and culture, so it is interesting to study this factor
Religion plays a significant role in understanding social demographics, particularly in relation to depressive moods A cohort study indicated that religion is linked to postpartum depression (PPD) among Thai women (Limlomwongse et al., 2006) Additionally, research conducted in urban Thailand revealed that Buddhist individuals experience notably lower depressive symptoms compared to those who do not identify as Buddhist (Xu et al., 2020).
Severe marital conflict is strongly linked to depression, while having a supportive and trustworthy partner can mitigate this risk A study conducted at a tertiary hospital in Kolkata revealed that single mothers are significantly more likely to experience postpartum depression within four to seven days after giving birth.
Financial status is a common risk factor of PPD Studies in Asian countries have found that financial difficulties were a main predictor of depressive
Research indicates a strong correlation between low family income and an increased risk of postpartum depression (PPD) among mothers (Bener et al., 2012; Roomruangwong et al., 2011; Chi et al., 2016) A national study in Thailand also highlighted that economic insufficiency is linked to PPD (Panyayong, 2013) Multiple studies have consistently shown that low income significantly contributes to the prevalence of postpartum depression (Ghaedrahmati et al., 2017; Ghosh & Goswami, 2011; Inphouvieng).
Research indicates that low-income households significantly increase the risk of postpartum depression (PPD) among women A study conducted in Malaysia revealed that women from low-income backgrounds faced nearly three times the risk of developing PPD Similarly, findings from Qatar highlighted a strong correlation between low monthly income and heightened postpartum depressive symptoms.
1.5.2 Obstetric, pregnancy and pediatric factors
Number of living children, delivery and pregnancy
Research indicates a complex relationship between the number of deliveries and postpartum depression (PPD), with studies showing that multiparous women are at a higher risk In the U.S., Mathisen et al (2013) and Mayberry et al (2007) found that postpartum depression is more common among women with multiple children compared to those with none Similarly, a study in India revealed that mothers with several children face over five times the risk of developing PPD compared to first-time mothers (Desai et al., 2012) Additionally, Kheirabadi et al (2009) reported a significant association between having three or more children and PPD during the six to eight weeks postpartum in Iran Furthermore, research from Pakistan highlighted a notable link between postpartum depression and having five or more children (Rahman et al., 2007).
History of abortion, still birth and child death
Research indicates that a history of abortion significantly increases the risk of postpartum depression (PPD), with a study in India revealing nearly a fivefold increase among postpartum women within the first year (Desai et al., 2012) Similarly, a study conducted in the urban slums of Dhaka, Bangladesh, found that experiences of miscarriage, stillbirth, or child death were associated with heightened postpartum depressive symptoms within one year after childbirth (Azad et al., 2019) Furthermore, a community-based cohort study from a rural sub-district in Bangladesh identified perinatal death as a risk factor for developing postnatal depression, with affected mothers being 14 times more likely to experience depression compared to their non-depressed counterparts (Gausia et al., 2009).
Planned pregnancy significantly influences mental health outcomes, as evidenced by studies in Bangladesh, China, and Iran, which reveal a strong correlation between unplanned pregnancies and an increased risk of postpartum depression (PPD) (Azad et al., 2019; Chi et al., 2016; Kheirabadi et al., 2009) Similarly, research among Malaysian women indicates that those experiencing unplanned pregnancies face 3.3 times higher odds of developing PPD compared to their counterparts with planned pregnancies (Ahmad et al.).
2018) In contrast, the study in Karachi has found that planned pregnancy was a protective factor against postnatal depression (Kalar et al., 2012)
Antenatal care services play a crucial role in enhancing maternal and child health in developing countries Research indicates that effective antenatal care can significantly reduce the risk of postpartum depression (PPD) For instance, a study in Syria demonstrated a protective effect of antenatal care against PPD (Roumieh et al., 2019) Similarly, findings from Eastern Turkey highlighted that insufficient medical attention during pregnancy increases the risk of PPD (Inandi et al., 2002) Additionally, Abdollahi's research revealed that delayed prenatal care is linked to a higher susceptibility to postpartum depression (Abdollahi et al., 2014) Furthermore, a study conducted in rural Nepal identified poor or nonexistent antenatal care as a contributing factor to predicted distress (Clarke et al., 2014).
HUPH that a high number of visits to the antenatal care clinic was a strong risk factor for postpartum depressive symptoms (Josefsson et al., 2002)
Complications during pregnancy/delivery and postpartum periods
Introduction of the study site
As of the 2015 Census, Vientiane capital covers an area of 3,920 km² and has a population of 820,940, making it the second most populous city in Lao PDR The capital is divided into nine districts, with only three being fully urbanized, and 77.9% of its area is urban.
The study focused on two districts in Vientiane Capital, Sisattanak and Hadsayfong, which exhibit distinct demographic characteristics Sisattanak, classified as an urban area by national statistical offices and based on World Bank estimates, comprises 37 villages with a population of 116,920 In contrast, Hadsayfong is identified as a peri-urban area, characterized by a blend of rural and urban features, reflecting its ongoing urbanization process.
2018) It consists of 60 villages with a population of 97,609 inhabitants (Lao Statistics Bureau, 2015).
Conceptual framework
A conceptual framework was developed based on a review of empirical studies and the demographics of the study population to guide research on postpartum depressive symptoms among women in Vientiane Capital in 2019 This study identified three key components influencing these symptoms: socio-demographic-economic factors, pregnancy and obstetric health factors, and family relationships.
Figure 1.1 Conceptual framework of the study entitled “Prevalence and factors associated with postpartum depressive symptoms among women in Vientiane Capital, Lao PDR, 2019”
Maternal age, level of education, occupation, ethnicity, religion, marital status, and financial status
+ Obstetric, pregnancy, and pediatric health factors:
The article discusses key factors related to maternal and infant health, including the number of pregnancies, deliveries, and abortions, as well as the count of living children and any history of stillbirths It emphasizes the importance of last pregnancy planning, the frequency of antenatal care visits, and any complications or illnesses experienced during pregnancy and the postpartum period Additionally, it addresses mental health issues during pregnancy, the mode of delivery, postpartum age, gestational age at birth, infant feeding practices, and the health status of newborns.
Living arrangement, conflicts with family members, intimate partner violence, social support (family support, friend support, and partner support)
Research Subjects
Shorey et al conducted a systematic review revealing no significant differences in the prevalence of postpartum depression (PPD) across various screening time points within the first year postpartum However, they noted an increase in PPD prevalence among subjects beyond six months postpartum In contrast, Inpouvieng's study reported a PPD prevalence rate of 15.2% among women who gave birth between four to six weeks postpartum To build on these findings, the current study focused on postpartum mothers between four to 24 weeks (one to six months), with participant recruitment assessed through specific criteria.
- Postpartum women at 04 to 24 weeks
- Living baby at the time of study
- Postpartum women willing to participate in this study
- Postpartum women who could speak the Lao language
- Lao women living in Vientiane Capital for at least 6 months
- Known cases of mental illness or mental medication
- Mothers of twins or triplets
Study sites and duration
This research was carried out across 48 communities in the Sisattanak and Hadsayfong districts of Vientiane Capital, Lao PDR The study spanned a duration of one year and two months, beginning with the concept note development in January 2019 and culminating in the final thesis submission to HUPH in April 2020 Data collection occurred over a one-month period in September 2019, following the receipt of ethical approval from both the HUPH and UHS ethics committees.
Research design
A cross-sectional study utilizing quantitative methods was conducted to evaluate the prevalence of postpartum depressive symptoms among women in Vientiane Capital, Lao PDR, and to identify the factors associated with these symptoms.
Sample size
The sample size was determined using a single population proportion formula with the following assumptions:
- n as the minimum sample size required
- p as the expected proportion of postpartum women who have depressive symptoms (Following Inphouvieng’s study (2017) p of 0.152, (15.2%) was used.)
- z confidence level (With 95% confidence, then z = 1.96)
- d as absolute precision (d=0.04 was used)
The study determined a sample size of 520 postpartum women by applying a design effect (DEFF) of 1.7 To account for potential dropouts, the sample size was increased by 5%, resulting in a requirement of 540 eligible mothers Ultimately, 530 participants were recruited from 48 communities across two districts in Vientiane Capital, with 521 participants completing the screening questionnaires and face-to-face interviews.
Sampling method
Multistage sampling was employed to derive the study sample from the nine districts of Vientiane Capital – three urban and six peri-urban (Lao Statistics Bureau, 2018) in the following steps:
- Step 1: Two districts within Vientiane Capital were selected by simple random sampling: Sisattanak from the urban ones and Hadsayfong from the peri-urban
In Step 2, simple random sampling was employed to select villages within each district, ensuring a diverse representation of socio-demographic backgrounds and facilitating the recruitment of sufficient postpartum mothers for the study.
HUPH month to collect the data, 50% of the villages in each district were selected, 18 from Sisattanak and 30 from Hadsayfong
In Step 3, postpartum mothers aged 04 to 24 weeks were identified through records from the health offices in two districts, resulting in the enrollment of 260 mothers from Sisattanak District and 261 mothers from Hadsayfong District for the survey The interviews with all 521 respondents were successfully completed within one month, as illustrated in Figure 2, which outlines the sampling procedure.
Step 1: Simple random selection of districts
Step 2: Simple random selection of 50% of villages in each district
Step 3: Recruiting of target population living in the selected villages
Figure 2.1 Diagram of sampling method
03 urban districts 06 peri-urban districts
18 villages selected from 37 villages in
30 villages selected from 60 villages in Hadsayfong District
Total 261 postpartum mothers (One month)
Data collection
Five female students from UHS were selected as interviewers for a research project They underwent a one-day training session to standardize data collection procedures, which covered the study's purpose, research ethics, interviewing techniques, and questionnaire details to prepare them for conducting interviews.
- Before finalizing the questionnaire, a pilot study was conducted on 25 July 2019 in Saysettha District with 48 respondents in face-to-face interviews to check the reliability of the research instruments
- Letters were submitted to the directors of the two study sites to obtain permission for the data collection and discussion about sample and sampling
In September 2019, data collection commenced following ethical approvals from the Hanoi University of Public Health (HUPH) and the University of Health Sciences (UHS) Ethical Research Committee Interviewers, accompanied by health workers or village health volunteers, approached postpartum mothers at their homes to seek permission for interviews Upon consent, mothers signed informed consent forms, and face-to-face interviews were conducted using a structured questionnaire, each lasting approximately 30 minutes If a mother was unavailable during the initial visit, the team made follow-up visits on another day.
Research variables
Socio-demographic-economic, pregnancy, obstetrics and pediatric health, and family relationship profiles all combine to influence PDS Hence, there were three groups of
- Socio-demographic-economic variables (maternal age, level of education, occupation, ethnicity, religion, marital status and financial status);
Obstetric, pregnancy, and pediatric health factors play a crucial role in maternal and infant well-being Key elements include the number of pregnancies, deliveries, and abortions, as well as the count of living children and any history of stillbirth Effective pregnancy planning and the frequency of antenatal care visits are essential for monitoring complications during pregnancy and the postpartum period Additionally, addressing mental health issues during pregnancy, understanding the mode of delivery, and considering the gestational age at birth are vital Infant feeding practices and the overall health status of newborns further influence outcomes in maternal and child health.
The study examines how family relationship factors, including living arrangements, conflicts with family members, intimate partner violence, and social support, influence postpartum depressive symptoms, which are assessed using the Edinburgh Postnatal Depression Scale (EPDS) Detailed definitions and measurements of the variables utilized in this research are provided in Annex 1.
Research instruments and measurements
The questionnaire contained six parts (Parts 1-6), with 54 items, covering the independent variables (see 2.7) and including the MSPSS, WAST set questionnaire and the EPDS
- Part 1: Socio-demographic and economic characteristics of participant Part 1 contained 07 items, to obtain information on maternal age, educational level, occupation, ethnicity, religion, marital status and financial status of family
- Part 2: Obstetric, pregnancy and pediatric health factors
Part 2 had 15 items regarding history of obstetric, pregnancy and pediatric health factors, namely, number of pregnancies, number of deliveries, number of abortions, number of living children, history of
HUPH focuses on critical aspects of maternal and infant health, including stillbirths, effective pregnancy planning, and the importance of multiple antenatal care visits It addresses complications that may arise during pregnancy and the postpartum period, as well as mental health challenges faced by mothers Additionally, the article highlights the significance of the mode of delivery, gestational age at birth, and the impact of infant feeding practices on newborn health status.
Part 3 had 02 items or questions regarding the family matters of living arrangement and conflicts with family members
Part 4 focuses on measuring perceived social support through the Multidimensional Scale of Perceived Social Support (MSPSS), created by Zimet in 1988 The scale has been translated into Lao and reviewed by thesis advisors The MSPSS consists of 12 self-administered questions rated on a 7-point Likert scale, making it user-friendly for both administration and scoring.
- Part 5: Women Abuse Screening Tool (WAST)
Part 5 was to measure the exposure of participants to possible violence using the WAST The tool was translated into Lao again with help from the thesis advisors The full WAST has eight items, each with three choices or a three-point scale of never or none, sometimes, a lot or often
- Part 6: Edinburgh Postnatal Depression Scale (EPDS)
Part 6 administered the EPDS, which was developed in 1987 by John Cox, a consultant psychiatrist in the United Kingdom (Cox et al., 1987) The EPDS is a self-report questionnaire with 10-items The scale asks the respondent about their feelings over the previous seven days Each item has four choices or responses, scoring 0, 1, 2 or 3 according to increasing severity of the symptom In this study, face-to-face interviews, rather than self-reporting, was used to obtain the EPDS responses
Before data collection commenced, the English questionnaire was translated into Lao with assistance from two qualified Lao advisors holding PhDs and experienced in public health and psychiatry research The Lao version of the questionnaire underwent pre-testing for reliability A pilot study involving 48 participants across three villages in Saysettha District was conducted to assess the content reliability of the research instruments, utilizing Cronbach’s alpha analysis.
The questionnaire demonstrated an acceptable reliability score of 0.75 based on 48 samples Following the pilot phase, the wording and phrasing were refined according to feedback from local participants during the reliability test, enhancing the clarity of the questions.
- Measurement of postpartum depressive symptoms
The Edinburgh Postnatal Depression Scale (EPDS) was utilized to measure the dependent variable, recognized as the leading instrument for assessing postnatal depression It is the primary tool endorsed by the American College of Obstetricians and Gynecologists (ACOG) and is widely accepted in both research environments and clinical studies.
The Edinburgh Postnatal Depression Scale (EPDS) is utilized globally to screen for postnatal depression and has recently been adapted to assess antenatal depression in women and depression in men during both antenatal and postnatal periods Its widespread application in clinical and research environments makes it a key tool for identifying postpartum depression.
- The EPDS is a self-reporting questionnaire
A cut-off score of 9/10 may be suitable for routine use by primary care workers, as evidence indicates that this threshold can reduce the failure to detect cases to under 10% In contrast, the original assessment consists of 10 questions with a cut-off point of 12/13 (Cox et al., 1987).
The scoring system for the questionnaire assigns values of 0 to 3 for responses a, b, c, and d for questions E1, E2, and E4, while questions E3, E5, E7, E9, and E10 are scored in reverse, with values of 3 to 0 for the same responses The total EPDS score can range from 0 to 30, where a score of 9 or less indicates no presence of PDS, and a score of 10 or more suggests the presence of PDS For further details, refer to Part 6 in Annex 2.
The perceived social support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS), which is a self-administered tool featuring 12 questions rated on a 7-point Likert scale, ranging from "very strongly disagree" (1) to "very strongly agree" (7) This scale includes three subscales, each containing four questions, designed to evaluate support from family, friends, and significant others.
Significant other subscale: Sum across items 1, 2, 5, & 10, and then divide by 4
Family subscale: Sum across items 3, 4, 8, & 11, and then divide by 4 Friends subscale: Sum across items 6, 7, 9, & 12, and then divide by 4 Total Scale: Sum across all 12 items, then divide by 12
A high score represents high perceived social support (Gregory D Zimet, 1988)
(The details of the questionnaire are in Part 4 in Annex 2)
The MSPSS is a reliable tool for the overall and sub-scales measured
It avoids social desirability bias influencing subjects' responses Social support is thus related to depression only for those subjects
HUPH experiencing high levels of life stress, which lends support to the buffering hypothesis (Dahlem et al., 1991)
- Measurement of intimate partner violence
The exposure of participants to violence was assessed using the WAST, a widely used IPV screening tool among healthcare professionals, which has a sensitivity of 47% and a specificity of 96% This tool evaluates various forms of violence, including physical, emotional, and sexual abuse.
A systematic review of IPV screening tools confirmed that the WAST had internal reliability and discriminant validity (Rabin et al., 2009)
The full WAST includes eight items, scoring 1 for Never, 2 for Sometimes and 3 for Often Total scores thus range from 8 to 24, with
12 points or less indicating no abuse and 13 points or more indicating the presence of abuse (Brown et al., 2000)
(The details of the questionnaire are in Part in Annex 2).
Data analysis methods
Data was coded and entered into Epidata software before being transferred to STATA version 14 for cleansing and analysis Descriptive statistics were analyzed for various data categories, including socio-demographic, obstetric, pregnancy, pediatric health, and family relationships, presenting results as percentages, frequencies, means, standard deviations, and minimum and maximum values Prevalence was calculated as the percentage of participants who screened positive from the total sample A univariate analysis assessed the association between postpartum depression (PPD) and participant characteristics, while multiple logistic regression analysis measured the relationships between risk factors and postpartum depressive symptoms Bivariate analysis was also conducted.
The study examined the relationship between various independent variables, including socio-demographic, economic, pregnancy, obstetric, pediatric, and family relationship factors, and the dependent variable of postpartum depressive symptoms In the bivariate analysis, variables with a p-value less than 0.2 were included in the multivariable logistic regression model The multivariate analysis employed standard entry techniques, identifying variables with a p-value less than 0.05 as significant predictors The results, including crude and adjusted odds ratios along with their 95% confidence intervals, were presented in both text and tables.
Ethical issues
The study posed minimal risk to participants, having received formal ethics approval from the Research Ethics Committee of the University of Health Sciences in Lao PDR and the ethical review board for biomedical research at Hanoi University of Public Health in Vietnam Face-to-face interviews were conducted in respondents' homes, where mothers were asked about their social, demographic, and economic situations, pregnancy history, health, family relationships, social support, experiences of intimate partner violence, and postpartum feelings Participants were compensated with a small gift and had the right to withdraw from the study at any time To ensure privacy, respondents' names were not recorded, and all information was kept confidential The research objectives, methodology, and potential risks were clearly explained to each participant prior to the interviews.
General information of respondents
3.1.1 Socio-demographic-economic profile distribution of the participants
Table 3.1 reveals that the population is nearly evenly split, with 49.9% (260 individuals) residing in the urban Sisattanak district and 50.1% (261 individuals) in the peri-urban Hadsayfong district The majority of participants, 53.7% (280 individuals), are aged between 21 and 30 years, with a mean age of 27.5 years (SD=5.8), and ages ranging from 16 to 42 years Regarding education, 41.7% (217 respondents) completed lower or upper secondary school, while 58.8% are unemployed The predominant ethnicity among the population is Lao-Tai, comprising 85.2% (443 individuals), and 84.4% (440 individuals) identify as Buddhists Additionally, 97.7% (509 interviewees) are currently married, and about 20.7% (108 participants) report insufficient funds for their daily needs.
Table 3.1 Socio-demographic-economic profile distribution of the participants
Socio-demographic-economic factors (n: 521) Frequency Percentage District
49.9 50.1 Maternal age (mean 27.5 years, SD 5.8 years, Min:16, Max:42)
Never been in school/Primary school
Certificate/Bachelor’s degree or higher
Other (single/divorced/separated/widowed)
3.1.2 Obstetric, pregnancy and pediatric health factors
Table 3.2 Obstetric profile distribution of sample
Table 3.2 above shows that more than half of the participants (277; 53.2%) had been pregnant 2-3 times, half of the population (265; 50.9%) had given birth 2-3 times,
342 (65.6%) had never had an abortion, more than half (268; 51.4%) of them had 2-
3 living children, only 6 (1.2%) had a history of still births, and 293 (56.3%) were 13-24 weeks after childbirth
Table 3.3 Pregnancy profile distribution of sample
54.1 45.9 Number of antenatal care visits in recent pregnancy
5 Complication during last pregnancy period
95.6 4.4 Mental health problem during pregnancy
If so, type of mental health issue (n1)
3.1 96.9 Receiving of mental health treatment (n1)
18.7 81.3 Place where mental health treatment received (n=6)
Assisted instrumental vaginal delivery (ventrose, forceps)
Table 3.3 reveals that over half of the participants (54.1%) planned their last pregnancy, with a significant majority (91.4%) attending between 4 to 10 antenatal care visits Complications were rare, affecting only 4.4% during pregnancy and 4.4% during the postpartum period Additionally, 6% experienced mental health issues during their last pregnancy, with 78.1% of those (30 out of 31) reporting anxiety or other mental health concerns.
6 (18.6% of n: 31) were receiving mental health treatment, 4 (66.7% of n: 06) received that treatment from a traditional healer, and 419 (80.4%) had normal vaginal deliveries for their last pregnancy
Table 3.4 Pediatric health profile distribution of sample
Pediatric health factors Frequency Percentage
Gestational age of birth for last delivery
Mix of breastfeeding and formula milk
20 New born health status (from birth until now)
If newborn unhealthy, new born admitted at NICU (n1)
Table 3.4 reveals that 8.5% of respondents experienced preterm births (≤ 36 weeks), while 55% provided exclusive breastfeeding Additionally, 94% reported having healthy babies, with only 6% having unhealthy ones Notably, 38.7% of the unhealthy babies (12 out of 31) required admission to the NICU.
Family relationship factors Frequency Percentage
Living without family of birth/in-laws
Living with family of birth
Living with family in-law
According to Table 3.5, 42% of respondents, totaling 219 individuals, reported living separately from their birth families or in-laws Additionally, 3.5% of respondents, or 18 individuals, frequently experienced conflicts with family members, while 39.9%, equating to 208 individuals, reported occasional conflicts with their families.
3.1.4 Measuring social support of postpartum mothers
Table 3.6 Measuring social support of postpartum mothers using MSPSS
There is a special person who is around when she is in need 215(41.2) Strongly disagree There is a special person with whom she can share her joys and sorrows
Her family really tries to help her 228(43.7%) Strongly disagree
She gets the emotional help and support that she needs from her family
She has a special person who is a real source of comfort to her 197(37.8%) Strongly disagree
Her friends really try to help her 142(27.2%) Neutral
She can count on her friends when things go wrong 153(29.4%) Neutral
She feels that she cannot openly discuss her family issues, as indicated by 34.7% strongly disagreeing with the statement While she maintains a neutral stance regarding friendships, with 23% feeling indifferent, she acknowledges the presence of a special person in her life who genuinely cares about her emotional well-being.
Her family is willing to help her make decisions 129(24.8%) Strongly disagree
She can talk about her problems with her friends 115(22%) Neutral
Table 3.6 presents the responses to the MSPSS items, revealing that 41.2% of participants strongly agreed they had a special person available in times of need, while 41% felt they could share their joys and sorrows with someone special Additionally, 43.7% strongly agreed that their family made genuine efforts to assist them, and 41.3% felt they received the emotional support they needed from family However, 37.8% identified a special person as a source of comfort, with 27.2% remaining neutral about friends' willingness to help Furthermore, 34.7% strongly agreed they could discuss problems with family, while 39% acknowledged having a caring special person in their life Lastly, 24.8% strongly agreed that their family was willing to help with decision-making, and 22% were neutral regarding their ability to talk about issues with friends.
Table 3.7 Level of social support (using MSPSS)
Family relationship factors Frequency Percentage
0 Partner or special person support (Min: 1.75; Max: 7)
Table 3.7 presents the social support levels received by postpartum mothers, assessed using the Multidimensional Scale of Perceived Social Support (MSPSS) The support is classified into three categories based on average scores: low (2.9), moderate (3.0 to 5.0), and high (greater than 5.0) Notably, 229 participants, accounting for 43.9%, fall within these categories.
A significant portion of participants, 292 (56.1%), reported receiving high to moderate levels of social support Notably, 347 mothers (66.6%) received strong support from their partners, while 302 (58%) benefited from high levels of family support Additionally, only 84 participants (16.2%) experienced high levels of support from their friends.
3.1.6 Measuring intimate partner violence using WAST
Table 3.8 Measuring intimate partner violence (using WAST)
A significant majority of respondents, 72.5%, reported having a stress-free relationship with their intimate partner Additionally, 51.2% found that resolving arguments with their partner is not difficult Notably, 54.3% of participants indicated that they never feel put down or bad about themselves as a result of these arguments Furthermore, an overwhelming 86.2% stated that they never experience physical aggression, such as hitting, kicking, or pushing, during conflicts However, some respondents expressed feelings of fear regarding their partner's words or actions.
The survey results indicate that a significant majority of respondents reported never experiencing physical abuse from their partners, with 91.2% (475 individuals) stating they were never physically abused In contrast, emotional abuse was reported by 67.9% (354 individuals) as occurring sometimes Additionally, 94.2% (419 individuals) indicated that they never faced sexual abuse from their partners For further details on the responses to the WAST items, please refer to Annex 4.
Table 3.8 presents data on intimate partner violence measured by the WAST, revealing that 72.5% of participants reported no stress in their home relationships Additionally, 51.3% found it easy to resolve arguments with their partner, while 54.3% had never felt belittled during conflicts A significant 86.2% had never experienced physical aggression, and 72.7% felt safe from their partner's actions or words Despite this, 67.9% acknowledged experiencing emotional abuse at times, although 94.3% reported never facing sexual abuse.
Table 3.9 Exposure to intimate partner violence (IPV)
Family relationship factor Frequency Percentage
Intimate partner violence WAST score (Min: 12, Max: 24)
Table 3.9 illustrates the assessment of intimate partner violence (IPV) through the WAST, establishing a score cut-off point of ≥ 13 Among the participants, 44 mothers, representing 8.5%, reported experiencing IPV, with WAST scores ranging from a minimum of 12 to a maximum of 24.
Postpartum depressive symptoms
Table 3.10 Edinburgh Postpartum Depression Scale
The respondent has consistently anticipated events with pleasure, with 56% expressing enjoyment as much as they always could, and 73.5% feeling the same as they ever did Additionally, the respondent has experienced unnecessary self-blame when faced with difficulties.
234(44.9%) Yes, some of the time
The respondent has been anxious or worried for no good reason 270(51.8%) No, not at all
The respondent has felt scared or panicky for no good reason 295(56.6%) No, not at all
Things have been getting on top of the respondent 254(48.7%) No, have been coping as well as ever The respondent has been so unhappy that she has had difficulty sleeping
The respondent has felt sad or miserable 308(59.1%) No, not at all
The respondent has been so unhappy that she has been crying 312(59.8%) No, never
The thought of harming herself has occurred to her 4(0.8%) Sometimes
(Details of the answers to the EPDS items are shown in Annex 6)
Table 3.10 reveals the emotional responses of postpartum mothers as measured by the EPDS A significant majority, 56% (292), reported they could always laugh and find humor, while 73.5% (383) looked forward to activities with enjoyment Additionally, 44.9% (234) occasionally blamed themselves for issues, and 51.8% (270) felt no anxiety without reason Furthermore, 56.6% (295) did not experience fear or panic, and 48.7% (254) felt they coped as well as ever Notably, 57.7% (300) reported no unhappiness affecting their sleep, 59.1% (308) did not feel sad or miserable, and 59.8% (312) had never been unhappy to the point of crying Only 0.8% (4) indicated that thoughts of self-harm had occasionally crossed their minds.
3.2.2 Prevalence of postpartum depressive symptoms
Table 3.11 Prevalence of postpartum depressive symptoms
EPDS score