|Year : 2021 | Volume
| Issue : 2 | Page : 103-109
Impact of pregnancy outcomes on postpartum depression among women attending primary health-care centers in Al-Madina Al-Munawarah, Saudi Arabia
Yasmeen Talal Aljehani1, Mariam Eid Alanzi2, Suzan Talal Aljehani3, Alrehaily Sami Saleem4, Salman Awadh Rasheed Alraddadi5, Rema mahmoud Alblowi6, Hanan Yousef Aly7, Salah Mohamed El Sayed8
1 Unit of Joint Post-Graduate Family Medicine Program; Academic Affairs for Training and Research, King Salman Bin Abdel-Aziz Medical City, Al-Madina, Saudi Arabia
2 Diabetic Center in King Fahd Hospital and Sayed Al Shohada Primary Health Care Center, Al-Madina, Saudi Arabia
3 Infection Control Department, Al-Amal Hospital, Directorate of Health, Al-Madina, Saudi Arabia
4 Department of Health Affairs for Planning and Organizational Transformation, Directorate of Health, Al-Madina, Saudi Arabia
5 Department of Health administration Directorate of Health, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawara, Saudi Arabia
6 Unit of Joint Post-Graduate Family Medicine Program, King Salman Bin Abdel-Aziz Medical City, Al-Madina, Saudi Arabia
7 Department of Neuropsychiatry, Sohag Faculty of Medicine, Sohag University, Egypt
8 Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawara, Saudi Arabia; Department of Medical Biochemistry, Sohag Faculty of Medicine, Sohag University, Egypt
|Date of Submission||18-Nov-2020|
|Date of Decision||18-May-2021|
|Date of Acceptance||09-Jun-2021|
|Date of Web Publication||16-Aug-2021|
Salah Mohamed El Sayed
Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah; Department of Medical Biochemistry, Sohag Faculty of Medicine, Sohag University, Egypt.
Source of Support: None, Conflict of Interest: None
Background: Postpartum depression (PPD) afflicts women and their families negatively. Unfortunately, PPD often goes undetected and untreated. We previously reported that PPD prevalence was 19.4% in Al-Madina region, Saudi Arabia. Objectives: The objective of the study was to identify significant risk factors of PPD among women in Al-Madina, Saudi Arabia. Methodology: A multistage random sampling technique recruited women visiting primary health-care centers in Al-Madina to immunize their babies. A cross-sectional descriptive study was done using Arabic translation of Edinburgh Postnatal Depression Scale for PPD screening using a cutoff score of ≥12. Our study also investigated demographic and other possible PPD risk factors. Results: This study enrolled 216 women out of 224 (response rate is 96.4%). PPD was not significantly associated with pregnancy planning, infant's gender, or infant's age. Primiparous women (n = 92, 42.7%) had a significant PPD risk (P < 0.05). More than half of mothers enrolled in our study (n = 124, 57.4%) were multiparous. Nearly 30.6% of participants (n = 66) used breastfeeding, while formula feeding was present in 40.7% (n = 88). PDD was reported more among women who breastfed their babies (27.3%) compared to those who artificially fed their babies (15.9%) and those using mixed feeding (16.1%). PPD was more significant among women who delivered by vaginal delivery (P < 0.05) compared to those delivered by cesarean section. Congenital abnormality of babies was reported by almost one-sixth of women (n = 36, 16.7%) but were not significantly associated with PPD. Conclusion: More than half of women having PPD (n = 124, 57.4%) were multiparous. PPD may negatively impair women's future pregnancy plans due to depression. PPD is significantly associated with primiparity and vaginal delivery and increases with breastfeeding. To the authors, PPD is a serious medical condition that should be taken into account with all deliveries. Primiparity is a risk factor, and PPD should be anticipated in primiparous women. Psychiatric evaluation and psychotherapy may be needed to help women and alleviate their fears in future pregnancies. Gynecologists should be aware of PPD and should receive a clinical experience in that. Psychiatric consultation is highly recommended whenever necessary.
Keywords: Al-Madinah. primiparous women, breast feeding, congenital abnormality, multiparous women, postpartum depression, risk factors
|How to cite this article:|
Aljehani YT, Alanzi ME, Aljehani ST, Saleem AS, Alraddadi SA, Alblowi Rm, Aly HY, El Sayed SM. Impact of pregnancy outcomes on postpartum depression among women attending primary health-care centers in Al-Madina Al-Munawarah, Saudi Arabia. Saudi J Health Sci 2021;10:103-9
|How to cite this URL:|
Aljehani YT, Alanzi ME, Aljehani ST, Saleem AS, Alraddadi SA, Alblowi Rm, Aly HY, El Sayed SM. Impact of pregnancy outcomes on postpartum depression among women attending primary health-care centers in Al-Madina Al-Munawarah, Saudi Arabia. Saudi J Health Sci [serial online] 2021 [cited 2021 Dec 6];10:103-9. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/2/103/323875
| Introduction|| |
The term postpartum depression (PPD) is widely used but varies considerably in its definition. PPD is defined in different ways depending on depression source and the duration between onset of depression and delivery. Onset of PPD and criteria of PPD diagnosis and severity of the depression are other important factors. PPD prevails in 5%–7% of pregnancies and is easily overlooked by many gynecologists. PPD is a mood disorder that begins after childbirth and usually lasts beyond 6 weeks.
According to the American College of Obstetricians and Gynecologists, screening for antepartum or PPD should be strongly considered. Patients with identified risk factors of PPD may be selected for screening. Preparation for postpartum care and consideration of prophylactic treatment have been recommended in women having PPD. PPD has many criteria: lasts more than 2 weeks, occurs within 1st month; may last up to 1 year, causes moderate-to-severe dysfunction and suicidal ideation may be present. Primary health-care centers may play important roles in early detection and management of PPD.
Because of the negative consequences of PPD, not only for women but also for their infants and families as a whole, it is important to detect and treat this disabling disorder. However, in spite of increased evidence that PPD can be effectively treated and prevented, it often goes undetected and untreated in many women. A study of primary health-care units in Bolton, England, found that health-care personnel detected PPD in fewer than half of those women seen in the clinic. Improving mental health is closely linked to the fifth Millennium Development Goal to improve maternal health.
The prevalence of PPD in Al-Madina (Al-Madinah) is not known at least to the best knowledge of the authors. Traditionally, after a child is born in Saudi Arabia, grandmothers and family entertain both baby and mother for about 40 days to allow better mother's care of the baby. That is a characteristic of the Saudi community and reflects family ties. However, such custom declined nowadays. Saudi Arabia may be in a transitional stage, and this issue may be a one of the risk factors of PPD among women in Al-Madinah.
In Arabic societies, depression is a commonly missed diagnosis in medical practice, and PPD may be overlooked. In Morocco, PPD prevalence was 20% where PPD was related to a lack of parental support, bad marital relationships, sick babies, and reported husband's violence. Moreover, in Bahrain kingdom, PPD prevailed among 37% of investigated women where a history of depression and lack of family and husband's encouragement were vital predictors of PPD development. In Jordan, PPD prevailed in 27% in a sample that included 278 Jordanian primiparous mothers. PPD symptomatology was closely associated with and decreased maternal education and low socioeconomic standards. In another Jordanian study that enrolled 300 mothers, PPD prevalence was 42% and was exaggerated by bad marital relationships. In developed countries, PPD occurs in about 12% to 13% of postpartum women. More recently, PPD rates in the United States have been reported as 10% to 20%. In our previous study enrolling 216 mothers in Al-Madinah, Saudi Arabia, PPD prevalence in this sample was 19.4% that is higher than PPD prevalence in developed countries but is still better than some Arabic countries.
Published studies on PPD highlighted some risk factors and triggers beyond PPD.,,,,,,, Our current study was designed to shed light on possible PPD triggers among women attending primary health-care centers in Al-Madina. Our study aims also at calculating the prevalence of PPD among women in Al Madinah, Saudi Arabia and and identify some of the risk factors associated with PPD.
| Materials and Methods|| |
Study area and study population
Medina, Al Madinah Al Munawwarah, “The Enlightened City” in Arabic, is the second holiest city in Islam and the capital of the Medina Province of Saudi Arabia. The 2020 estimated population of the city is 1,488,782, making it the fourth-most populous city in the country. Located at the core of the Medina Province in the western reaches of the country, the city is distributed over 589 square kilometers (227 square miles), 293 km2 (117 sq. mi.) of which constitutes the city's urban area, while the rest is occupied by the Hejaz mountain range, empty valleys, agricultural spaces and older dormant volcanoes.
There are 48 primary health-care centers in Al-Madinah, which provide mother and child health-care services. Women who regularly visited the health-care centers for immunizing their newborn babies (1 year or younger) were enrolled in this study.
Sampling technique and sampling method
A multiple-stage sampling technique was used in this study:
Stage 1: Stratifying the city of Al-Madina into two sectors (high social class district and low social class district).
Stage 2: Simple random sampling to select two primary health care centers from each sector.
Stage 3: Systematic random sampling to include the sample size from the patients attending each primary health-care centers. The number was proportional to the total number of mothers attending each primary health-care center for immunizing their babies. The researcher enrolled every third woman who came to the primary health-care centers. The number of subjects enrolled in the study was proportional to the total number of mothers who regularly visited each primary health-care center in the last month for immunizing their baby.
The population size (total number of mothers attending the four clinics in 1 month) was 2510 mothers. Expected frequency was 20%. Worst acceptable percentage was 46.4% with a confidence interval of 95%. The calculated sample size (using Epi info) was 224 mothers. Our study enrolled 216 women.
Type of study
Our study is cross-sectional and descriptive that enrolled women regularly visiting primary health-care centers in Al-Madinah. The study period took two successive years 2019–2020.
Data collection tools
Each woman was interviewed by the first author during her visits to vaccinate her infant. The researchers used a questionnaire obtained from a previously published study. The questionnaire tools consisted of two sections:
The 1st part is the Edinburgh Postnatal Depression Scale (EPDS) widely utilzed to screen PPD. The EPDS included ten items for screening PPD in mothers' samples based on rating the severity of PPD depressive symptoms. Each item takes a 4-point scale (from 0 to 3 reflecting increased severity of symptoms). The minimum and maximum total scores are 0 and 30, respectively, where 0 is the minimum in depression and 30 is the most severely depressed. EPDS is currently used in many countries with different languages, for example, in Arabic countries. EPDS is rated for use in screening to validate PPD. The Arabic translation of EPDS is a reliable and valid screening tool. Using a cutoff score of 12 out of 30, the sensitivity and the specificity of EPDS scale were 73% and 93%, respectively. In this study, a cutoff score of ≥12 was utilized to compare it with other regional studies.
The 2nd part of data acquisition through this questionnaire entailed past psychiatric history, checking physical illness, demographic factors, and other possible risk factors for PPD in addition to obstetric history, socioeconomic status, marital relationship, and others. The questionnaires were administrated by interviewing mothers at the time of attendance.
A pilot study
The questionnaire had been given to ten cases in one primary health center to test for its applicability and feasibility, time taken to finish the interview, and the process of conducting the study. The questionnaire was clear and understood by the patients and took approximately 10 min to be completed. Data collected from those subjects were not included in the main study.
- All females in their postnatal period (1 year or less were included)
- From all nationalities.
- Females diagnosed with any psychiatric illness.
- Women living outside Al-Madina, Saudi Arabia
- Women having any health conditions affecting psychiatry, for example, advanced liver diseases.
- Unplanned Pregnancy
- Mode of birth
- Infant's gender
- Infant's feeding
- Age of the infant at the time of data collection
- Congenital abnormality of the baby.
- Presence of her own mother during puerperium.
Data entry and analysis
Statistical measurements and analysis were performed using IBM (CA, USA). Categorical variables analysis was performed through a simple frequency Crude, and adjusted odds ratios (ORs) were done to evaluate possible associations between explanatory variables (independent variables) and dependent variable. Bivariate analysis was done to validate PPD risk factors. Final outcomes included independent variables that maintained a significant association with the outcome after adjustment, according to the likelihood ratio test. Results were presented as crude and adjusted ORs and their 95% confidence interval (CI) where 95% CI that does not include 1 were considered statistically significant.
- Approval letter was obtained from the head manager of postgraduate family medicine training program in Al-Madinah, Saudi Arabia
- Approval by the regional ethical committee was also obtained
- Verbal consent was obtained from all women who participated in the study
- All data of the study were absolutely confidential.
| Results|| |
The study aimed at interviewing 224 women, but the investigator could interview only 216 women for investigating possible risk factors for PPD.
Almost half of the babies of women participating in the study were males and the other half were females (n = 106, 50.9%) versus (n = 110, 49.1%), respectively. This is indicated in [Figure 1].
|Figure 1: Infant's gender of women regularly visiting primary health-care centers in Al-Madina, Saudi Arabia|
Click here to view
Infant's age at time of study conduction
The ages of participating women's infants ranged between 9 and 12 months among almost half of women (49.1%, n = 106), whereas it was <4 months among 25% of them (n = 54) as demonstrated in [Figure 2].
|Figure 2: Infant's ages at the time of performing our study during mothers' visits to vaccinate their babies at the primary health-care centers in Al-Madinah|
Click here to view
As seen in [Figure 3], breastfeeding was reported by slightly less than a third of the women (30.6%, n = 66), while formula feeding was reported by 40.7% (n = 88) of them.
|Figure 3: Infant feeding of women regularly visiting primary health-care centers in Al-Madinah|
Click here to view
Congenital abnormalities in born infants
Almost one-sixth of the investigated women (16.7%) reported congenital abnormalities among their babies. This is demonstrated in [Figure 4].
|Figure 4: Congenital abnormality of the baby of women regularly visiting primary health care centers in Al-Madina|
Click here to view
Mode of delivery
Cesarean section was reported by more than a third of the participants (38.9%, n = 84), while normal vaginal delivery was reported by the remaining 61.1% (n = 132) of them. Compared to women delivered by CS, those delivered spontaneously through normal vaginal route were at almost three-folded risk of developing PPD (crude OR = 3.30; 95% CI: 1.44–7.53). This is indicated in [Table 1].
Effect of infant's gender on postpartum depression development
PPD development was not associated with infant's gender. This is addressed in [Table 2].
Infant's age at the time of study conduction was not significantly associated with PPD. This is addressed in [Table 3].
|Table 3: Statistical relationship between postpartum depression and infant's age|
Click here to view
Association between infant's feeding method and postpartum depression development
Although PDD was reported more among women who breastfed their babies compared those who artificially fed their babies or those used mixed feeding (27.3% versus 15.9% and 16.1%, respectively, these differences were not statistically significant. Data are addressed in [Table 4].
|Table 4: Statistical relationship between postpartum depression and infant's feeding method|
Click here to view
Congenital neonatal abnormality
PPD was not significantly associated with the presence of congenital abnormality among infants. Data are addressed in [Table 5].
|Table 5: Association between postpartum depression and congenital abnormality among infants|
Click here to view
Planning for pregnancy
PPD was not significantly associated with planning of pregnancy [Table 6].
|Table 6: Association between postpartum depression and planned pregnancy among women.|
Click here to view
Parity of women regularly visiting primary health care centers in Al Madinah was investigated. More than half of the mothers enrolled in this study (n = 124, 57.4%) were multiparous. However, primiparous women (n = 92, 42.7%) were more significantly related to PPD (crude OR = 2.08; 95% CI: 1.05–4.11) [Table 7].
|Table 7: Statistical relationship between parity of women and postpartum depression|
Click here to view
| Discussion|| |
Outcomes and consequences of pregnancy may affect the development of PPD that consequently afflicts women and their families as a whole. Unfortunately, PPD may pass undetected and untreated in many women.
Our study reported that PPD was not significantly associated with the mode of delivery whether women gave birth via normal vaginal delivery or caesarean section [Table 1]. Moreover, our study investigated the impact of infant's gender on PPD development in mothers regularly visiting the primary health-care centers in Al-Madina. Almost half of the infants born to women who participated in the study were males (n = 110, 49.1%) and the other half were females (n = 106, 50.9%), respectively [Figure 1]. However, PPD difference (in women giving birth to either male or female neonate) was not statistically significant [Table 2]. The importance of the baby's gender (male or female) variation in different cultures is quite important.
A study from Sweden reported no relationship between baby's gender and development of PPD risk factors in the mothers 6 weeks to 6 months after delivery. However, birth of a male baby was reported to increase the risk of postpartum mood swings during the 1st week after giving birth. Studies from India and China reported that PPD significantly increased after giving birth to a female baby., In the present study, infant's gender did not affect the development of PPD. This finding may reflect an improvement in concepts of Arabic women' and the whole community particularly in urban regions regarding gender discrimination. In rural and desert areas, the family income may still depend on having a son in addition to the prevailing social concept of the importance of sons to continue the family's name. The ages of participating women's infants ranged between nine and 12 months among almost half of the investigated women (49.1%, n = 106), whereas it was <4 months among 25% of them (n = 54) [Figure 2].
On the contrary, it is possible that multiple deliveries may lower the possibility of PPD development due to decreased pregnancy-related stress and delivery-related stress for unexplained causes. This warrants further research investigations. Complicated labor may be a potential risk factor for PPD development. However, this is still controversial as there are many conflicting results showing no association between the mode of delivery and the risk of PPD development.,,,
Incidence rate of elective cesarean section is continuously increasing worldwide and has become greatly accepted by a considerable proportions of women compared to the painful spontaneous vaginal delivery. This may explain why in this study PPD was significant (P < 0.05) among women who delivered spontaneously compared to those who delivered by cesarean section [Table 1]. Currently, local anesthesia is widely done for women during giving childbirth and postoperative pain management following cesarean section. This may help them to tie more to their babies. Nowadays, delivery by cesarean section is much more acceptable than it was in the past possibly due to decreased pregnancy complications. Caesarean section decreased the risk of PPD, particularly in Beirut but also in the Beka'a Valley (in Lebanon). Caregivers should use pre- and postnatal assessments to identify and address women at risk of PPD.
As shown in our data, infant's gender was not significantly associated with development of PPD [Table 2]. Moreover, infant's age at the time of study conduction was not significantly associated with PPD development [Table 3]. Turning to breastfeeding, it was present in one third of the women (30.6%, n = 66), while formula feeding was present in 40.7% (n = 88) of them [Figure 3]. PPD differences were not statistically significant among those who normally fed their babies versus those who artificially fed their babies (27.3% vs. 15.9%) or those who used mixed feeding and 16.1%) [Table 4]. The presence of congenital abnormalities among babies of women who regularly visited primary health-care centers in Al-Madina were reported by almost one-sixth of the women (n = 36, 16.7%) [Figure 4]. PPD was not significantly associated with the presence of congenital abnormality among infants [Table 5].
Our study reported that PPD was not significantly associated with planning of pregnancy in the investigated women's sample [Table 6].
Different studies had shown controversial results regarding the relationship of parity to PPD where a higher PPD prevalence was reported among multiparous women,, while other studies had found primiparous women at a higher PPD risk. In this study, we report that more than half of the women (n = 124, 57.4%) were multiparous. However, primiparous women had a higher and a significant risk (P < 0.05) of developing PPD (n = 92, 42.7%) [Table 7].
This is in agreement with results of a comparative study by Banasiewicz et al. who reported also that primiparous women had a higher and a significant risk (P < 0.05) of developing PPD.
This may be explained in terms of fears of women having a history of PPD to become pregnant again. Also, women with multiple pregnancies may gain experience regarding PPD that allow its future decrease.
Limitations in our study were data collection through a cross-sectional design. EPDS is a screening test necessitating diagnostic confirmation through detailed interviews. Final prevalence of PPD risk factors may better be evaluated in the future using field research. In this study, we enrolled only women regularly visiting primary health-care centers in Al-Madina. Caution is needed before generalizing these results. Finally, our study enrolled mothers throughout the 1st year after delivery where antenatal depression was assessed by self-reports with no formal assessments done during pregnancy, leading to a possibility of recall bias. Despite our study limitations, there were some important findings.
| Conclusion|| |
More than half of the women having PPD were multiparous. However, primiparous women had a higher and more significant risk of developing PPD. This may be explained in terms of fears of primiparous women having a history of PPD to become pregnant again. Also, women experiencing PPD may gain experience to deal with it in future multiple pregnancies that ultimately decreases PPD development. PPD was not significantly associated with planning of pregnancy, infant's gender, or infant's ages in the investigated women sample. Mothers' PPD was not significantly associated with congenital anomalies in born babies. PPD was more significant among women delivered spontaneously compared to those delivered by cesarean section. Primiparous women had a higher and significant risk (P < 0.05) of developing PPD (n = 92, 42.7%). Infant's gender was not significantly associated with PPD.
To the authors, PPD is a serious medical condition that should be taken into account with all deliveries. Primiparity is a risk factor, and PPD should be anticipated in primiparous women. Psychiatric evaluation and psychotherapy may be needed to help women and alleviate their fears in future pregnancies.
Gynecologists should be aware of PPD and should receive a clinical experience in that. Psychiatric consultation is highly recommended whenever necessary.
Authors are grateful to Medical Research Center at Deanship of Scientific Research of Taibah University for helping this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hirst KP, Moutier CY. Postpartum major depression. Am Fam Physician 2010;82:926-33.
Boath EH, Pryce AJ, Cox JL. Postnatal depression: the impact on the family. J Reprod Infant Psychol 1998;16:199-203.
Dennis CL. Preventing and treating postnatal depression. BMJ 2009;338:a2975.
Hearn G, Iliff A, Jones I, Kirby A, Ormiston P, Parr P, et al.
Postnatal depression in the community. Br J Gen Pract 1998;48:1064-6.
Fisher JR, de Mello MC, Izutsu T, Tran T. The Ha Noi Expert Statement: Recognition of maternal mental health in resource-constrained settings is essential for achieving the Millennium Development Goals. Int J Ment Health Syst 2011;5:2.
Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Womens Ment Health 2006;9:343-6.
Al Dallal FH, Grant IN. Postnatal depression among Bahrain women: Prevalence of symptoms and psychosocial risk factor. East Mediter Health J 2012;18:439-45.
Oweis A. Relationships among the situational variables of perceived stress of the childbirth experience, perceived length and perceived difficulty of Labor, selected personal variables perceived nursing support, and postpartum depression. In: Primiparous Jordanian Women. Amman, Jordan: University of Jordan, Faculty of Nursing; 2001.
Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011;27:e238-45.
O'Hara MW, Swain AM. Rates and risks of postpartum depression: A meta-analysis. Int Rev Psychiatry 1996;8:37-54.
Josefsson A, Berg G, Nordin C, Sydsjö G. Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 2001;80:251-5.
Aljehani YT, Alanzi ME, Aljehani ST, Alghamdi KS, ALHarthi NA, Alshareef A, et al
. Prevalence and factors associated with postpartum depression among women attending primary health care centers in Al-Madina, Saudi Arabia. Res Psychol Behav Sci 2020;8:18-24.
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.
Wisner KL, Parry BL, Piontek CM. Clinical practice. Postpartum depression. N Engl J Med 2002;347:194-9.
Sylvén SM, Papadopoulos FC, Mpazakidis V, Ekselius L, Sundström-Poromaa I, Skalkidou A. Newborn gender as a predictor of postpartum mood disturbances in a sample of Swedish women. Arch Womens Ment Health 2011;14:195-201.
Patel V, Rodrigues M, DeSouza N. Gender, poverty, and postnatal depression: A study of mothers in Goa, India. Am J Psychiatry 2002;159:43-7.
Xie RH, He G, Liu A, Bradwejn J, Walker M, Wen SW. Fetal gender and postpartum depression in a cohort of Chinese women. Soc Sci Med 2007;65:680-4.
Goker A, Yanikkerem E, Demet MM, Dikayak S, Yildirim Y, Koyuncu FM. Postpartum depression: Is mode of delivery a risk factor? ISRN Obstet Gynecol 2012;2012:616759.
Breese McCoy SJ, Beal JM, Saunders B, Hill EN, Payton ME, Watson GH. Risk factors for postpartum depression: A retrospective investigation. J Reprod Med 2008;53:166-70.
Koo V, Lynch J, Cooper S. Risk of postnatal depression after emergency delivery. J Obstet Gynaecol Res 2003;29:246-50.
Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: Prevalence and determinants in Lebanon. Arch Womens Ment Health 2002;5:65-72.
Hegde S, Latha KS, Bhat SM, Sharma PS, Kamath A, Avinash K, et al. Postpartum depression: Prevalence and associated factors among women in India. J Womens Health Issues Care 2012;1:1.
Danaci AE, Dinç G, Deveci A, Sen FS, Içelli I. Postnatal depression in turkey: Epidemiological and cultural aspects. Soc Psychiatry Psychiatr Epidemiol 2002;37:125-9.
Kheirabadi GR, Maracy MR, Barekatain M, Salehi M, Sadri GH, Kelishadi M, et al. Risk factors of postpartum depression in rural areas of Isfahan Province, Iran. Arch Iran Med 2009;12:461-7.
Banasiewicz J, Zar-ba K, Bi-kowska M, Rozenek H, Wójtowicz S, Jakiel G. Perinatal Predictors of Postpartum Depression: Results of a Retrospective Comparative Study. J Clin Med 2020;9: 2952.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]