Edited by: Harshad Thakur, Tata Institute of Social Sciences, India
Reviewed by: Kim Matthew Kiely, Australian National University, Australia; Milka Dancevic Gojkovic, Public Health Institute of Federation of Bosnia and Herzegovina, Bosnia and Herzegovina
Specialty section: This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health
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Postpartum depression (PPD) among women is a common mental health concern. It occurs at a time of major life change, coupled with the increased responsibilities associated with the care of a newborn infant. In Vietnam, the prevalence of depressive symptoms after giving birth has not been fully investigated. Research in the Northern provinces, in Ho Chi Minh City, and in Hue suggests postnatal depressive symptoms among women are common. This research aims to (1) estimate the prevalence of PPD symptoms among married women in one Vietnam city (Danang) and (2) identify the social and personal factors associated with postpartum depressive symptoms.
This cross-sectional study was conducted from July 2013 to August 2014 in 10 wards of Hai Chau District, Danang. A total of 600 mothers who gave birth 4 weeks to 6 months prior to being interviewed were recruited. Interviews were conducted using structured questionnaires, which included several dimensions: demographics, family living arrangements, expectations of pregnancy, expectations of infant gender, the woman’s relationship with her husband, exercise after birth, infant health, and anxiety about matters other than the birth. The Edinburgh Postpartum Depression Scale (EPDS) was used to examine PPD symptoms, with a cutoff point of 12/13.
EPDS scores indicated the prevalence of PPD symptoms was 19.3% (95% CI: 16.16–22.50). Among women with PPD symptoms, 37.9% had suicidal thoughts in the previous seven days. Multivariate logistic regression indicated that the following key factors were significantly associated with PPD symptoms: Not being able to rely on their husband for help, having a husband who does not spend time to discuss problems, having anxiety about matters other than the birth, not exercising after giving birth, and having an ill baby.
These findings should be interpreted in relation to other recent research in Vietnam. A consistent pattern of prevalence estimates and associated social factors is emerging that has implications for the postpartum care of mothers.
Postpartum depression (PPD) is a common perinatal mental disorder among women, occurring 4 weeks to 1 year after giving birth. Research reveals that PPD is a “silent killer” that contributes to maternal mortality and can have health and developmental consequences for children (
An increasing number of epidemiological studies on depression and perinatal mental health have been conducted in Vietnam during the last 10 years. According to mental health surveys conducted in the country, at least 57% of people have never attended a medical appointment where they were screened for common mental disorders (
In Vietnam, it is important to develop services to promote the early identification of PPD and to help physicians with identification and treatment of common perinatal mental disorders. Research, such as the study reported here, contributes to the evidence based on common perinatal mental disorders in Vietnam, which can be used to inform services and interventions. For the above reasons, we conducted the study, “ To estimate the prevalence of postpartum depressive symptoms in married women in one Vietnamese city (Danang). To identify social and personal factors associated with postpartum depressive symptoms.
This was a cross-sectional prevalence study. Data were collected between July and December of 2013. The research participants were married women who were interviewed 4 weeks to 6 months after giving birth.
The sample size was calculated using the formula “estimating a proportion of the population” (
A two-stage cluster sampling method was applied [probability proportional to size (PPS)]. The sample size was multiplied by the design effect (DEFF). We chose a DEFF = 1.5, which indicated that
The PPS sampling and simple random sampling (SRS) were conducted as follows:
Step 1: All wards in Hai Chau District were numbered. A cumulative frequency table was generated, which produced the total number of married women giving birth from 4 weeks to 6 months in Hai Chau District, identified as Step 2: PPS sampling ( The sample size of each ward was: 600/ Step 3:Sampling frames were created based on the list of women eligible to participate in each selected ward, SRS was applied to select the number of women in each ward (
The sampling procedure was summarized in Figure
A questionnaire was used to directly interview women from the 10 selected wards of Hai Chau District from July to December 2013. The questionnaire included questions about the respondents’ demographics as follows:
Age, employment, working conditions, education, and whether their family experienced financial difficulties (defined as earning <VND 9,600,000/person/year); Family living arrangements (mother’s economic dependence on husband, living with parents, living with in-laws or renting); Expectations regarding the pregnancy; expectation of the gender of the infant; the woman’s relationship with her husband (that the woman could rely on her husband for help, whether she could discuss all problems with her husband, if she felt frightened of her husband in the past year and if she had been beaten by her husband in the past year); Exercise after birth; infant illness; and feeling anxiety about matters other than the birth.
The questionnaire was developed by the research team and was validated by a pilot survey. PPD screening was conducted using the Edinburgh Postpartum Depression Scale (EPDS) translated into Vietnamese. The EPDS has been widely used to identify symptoms of PPD and has been verified with a sensitivity of 88% and specificity of 92.5% (
Data were analyzed using the software of SPSS 16.0 Version for Windows. Chi-square tests and multivariate logistic regression using a backward conditional method were undertaken. All variables associated with increased risk of PPD in unadjusted tests were used.
Three principles of research ethics were observed throughout this study: respect for privacy, fairness, and benefit to the participants. Before the interview, research purposes were clearly explained. It was also explained that participation was voluntary. The participants were assured that they could stop at any point, if they so desired, and reassured that all responses would be kept confidential.
The mean age of respondents was 28.76 (±4.99), of whom the youngest was 17 and the oldest was 44. The 20–34 age group made up the highest proportion of respondents (84.8%). In terms of employment, the largest single category was public officials, accounting for 36.7%, while the smallest category was manual workers, which accounted for 13.8% of respondents. Overall, 75% of the mothers reported having stable jobs. The research sample consisted of women of all educational levels. Mothers who had less than a secondary level of education accounted for 17.3% of the respondents, including those who had not attended school and those who attended primary or secondary school only. Those with tertiary education and above made up the highest proportion of respondents, at 82.7%, of which 32.7% were graduates or postgraduates.
The proportion of women with financial difficulties within the family was 13.8%. The percentage of women who were economically dependent on their husband or family was 36.5%. Most women lived together with their husband (98.2%), among which the majority lived with their own parents or parents in law (58.7%).
Women who had undertaken a mental health examination during their previous pregnancies or postnatal period had a higher rate of PPD than women who had not had a mental health examination, but this difference was not statistically significant (
The prevalence of PPD symptoms based on an EPDS score ≥13 was 19.3% (95% CI 16.16–22.50) (
Table
Factors | EPDS score ≥13 |
EPDS score ≤12 |
Total | ||
---|---|---|---|---|---|
% | % | ||||
<20 | 2 | 16.7 | 10 | 83.3 | 12 |
20–34 | 98 | 19.3 | 411 | 80.7 | 509 |
≥35 | 16 | 20.3 | 63 | 79.7 | 79 |
Age (mean, SD) | 28.67 ± 4.98 | 28.77 ± 4.99 | 28.76 ± 4.99 | ||
Public officials | 31 | 14.1 | 189 | 85.9 | 220 |
Manual workers | 13 | 15.7 | 70 | 84.3 | 83 |
Business | 19 | 18.6 | 83 | 81.4 | 102 |
Others | 53 | 27.2 | 142 | 72.8 | 195 |
Junior high school or lower | 27 | 26.0 | 77 | 74.0 | 104 |
Senior high school | 58 | 19.3 | 242 | 80.7 | 300 |
Graduates or postgraduates | 31 | 15.8 | 165 | 84.2 | 196 |
Living with husband | 110 | 18.7 | 479 | 81.3 | 589 |
Widowed/separated | 6 | 54.5 | 5 | 45.5 | 11 |
Yes | 23 | 27.7 | 60 | 72.3 | 83 |
No | 93 | 18.0 | 424 | 82.0 | 517 |
Yes | 2 | 33.3 | 4 | 66.7 | 6 |
No | 114 | 19.2 | 480 | 80.8 | 594 |
116 | 19.3 | 484 | 80.7 | 600 |
Table
Factors | EPDS score ≥13 |
EPDS score ≤12 |
OR | 95% CI | ||
---|---|---|---|---|---|---|
% | % | |||||
Stable | 76 | 16.9 | 374 | 83.1 | 1.79 | 1.16–2.77 |
Unstable | 40 | 26.7 | 110 | 73.3 | ||
Yes | 53 | 24.2 | 166 | 75.8 | 0.62 | 0.41–0.94 |
No | 63 | 16.5 | 318 | 83.5 | ||
Private house | 27 | 13.8 | 168 | 86.2 | 1.75 | 1.10–2.80 |
Parents’ house/rented house | 22.0 | 78.0 | ||||
Yes | 89 | 17.8 | 411 | 82.2 | 1.71 | 1.04–2.81 |
No | 27 | 27.0 | 73 | 73.0 | ||
Yes | 86 | 17.5 | 406 | 82.5 | 1.82 | 1.12–2.94 |
No | 30 | 27.8 | 78 | 72.2 | ||
Yes | 68 | 34.2 | 131 | 65.8 | 0.26 | 0.17–0.40 |
No | 48 | 12.0 | 353 | 88.0 | ||
Yes | 85 | 16.0 | 446 | 84.0 | 4.28 | 2.52–7.26 |
No | 31 | 44.9 | 38 | 55.1 | ||
Yes | 82 | 15.7 | 440 | 84.3 | 4.15 | 2.50–6.88 |
No | 34 | 43.6 | 44 | 56.4 | ||
Yes | 27 | 32.1 | 57 | 67.9 | 2.27 | 1.36–3.79 |
No | 89 | 17.2 | 427 | 82.8 | ||
Yes | 14 | 38.9 | 22 | 61.1 | 0.35 | 0.17–0.70 |
No | 102 | 18.1 | 462 | 81.9 | ||
Yes | 3 | 5.0 | 57 | 95.0 | 0.20 | 0.06–0.65 |
No | 113 | 20.9 | 427 | 79.1 | ||
Yes | 56 | 35.2 | 103 | 64.8 | 0.29 | 0.19–0.44 |
No | 60 | 13.6 | 381 | 86.4 | ||
116 | 484 |
Women’s factors associated with PPD: women’s working conditions, their economic dependence on husbands, current place of residence, pregnancy expectation, expected baby gender, their anxiety about other matters in addition to giving birth, reply on their husbands for help, sharing all problems with their husbands, feeling scared of their husbands during 12 months, violence against women by husbands, exercise after giving birth, and infant illness in postnatal period (
Table
Independent variable | Adjusted OR |
|
---|---|---|
Yes | 1 | |
No | 2.26 (1.36–4.81) | 0.004 |
Yes | 1 | |
No | 2.45 (1.35–4.45) | 0.003 |
Yes | 1 | |
No | 0.33 (0.21–0.52) | <0.001 |
Yes | 1 | |
No | 4.86 (1.44–16.39) | 0.011 |
Yes | 1 | |
No | 0.29 (0.18–0.46) | <0.001 |
The prevalence of PPD symptoms within the research population was 19.3%. Other researchers who also used the EPDS and a cutoff point of 13, and conducted their studies on women in various periods within the first year after giving birth, have found differing rates of prevalence. For example, Aydin et al. conducted a study in a Turkish community of women after giving birth from 1 to 12 months and found the PPD prevalence to be 40.1% (
The prevalence found in the study reported here was similar to that found in Murray et al.’s study, and also the findings of a large systematic review of common perinatal mental disorders in low-and-middle-income countries where context-specific as well as gender-sensitive factors considerably contributed to PPD (
Our findings indicated that the number of mothers with unstable jobs with symptoms of PPD was higher than that of those who had stable jobs (26.7 vs 16.9%). In addition, the women who were financially dependent on their husbands or families had a higher rate of PPD (24.2%) than those who were financially independent (16.5%). Vietnam has strong policies promoting gender equality, which means both men and women have opportunities for studying and working. However, if a mother did not have stable employment outside of the home, or unemployed or freelances, she could not make financial contributions to the family and thus becomes economically dependent on her husband. Child rearing is a major task, and mothers must spend a number of months caring for their newborn child. Not having independent earnings or paid maternity leave can therefore increase the financial burden on the family. The results of the study here were similar to the study by Trinh (
Regarding family living arrangements, mothers who lived in rented houses or who were living with their parents had higher rates of symptoms of PPD (22.0%) than those living in their own houses (13.8%). The study by Ekuklu et al. also concluded that living in a rented house was a factor related to PPD [c.f. (
The results also found that mothers who had an unexpected pregnancy were more likely to have symptoms of PPD than that of those who had an expected pregnancy (27.0% compared with 17.8%). This result was consistent with the findings of Klainin and Arthur (
Expectations of infant gender were also associated with symptoms of PPD. In all, 27.8% of the mothers with PPD symptoms did not expect the gender of their baby (primarily, those who hoped for baby boy but gave birth to baby girl). The prevalence of PPD symptoms in these mothers was higher than those with an infant whose gender was expected (17.5%). These results were similar to the study by Klainin and Arthur (
Our results indicate that women who were anxious about matters other than giving birth had a higher rate of PPD (34.2%) than those without anxiety (12.0%). Siu et al. (
Regarding women’s relationships with their husbands, the analysis showed that women who did not get support from their husband had a higher rate of PPD (44.9%) than those who had support from their husband (16.0%). As shown in the multivariate logistic regression analysis in Table
Thirty-two percent of women who felt afraid of their husband in the first year post-childbirth had symptoms of PPD, which was associated with higher EPDS scores. In addition, there was a difference in the prevalence PPD symptoms among women who were hit by their husbands (38.9%) compared to those who did not experience being hit (18.1%). This result was similar to that of the study by Murray et al. (
Physical health during the postpartum period was also relevant to the findings. We found that women who exercised were less likely to have PPD symptoms than those who did not (20.9 vs 5.0%, respectively). Our study concluded that not exercising after giving birth was a factor related to PPD symptoms (OR = 4.86; 95% CI: 1.44–16.39). There was evidence that postnatal exercise can help women recover postpartum, regain strength, and reduce stress. Diem and Nguyen (
Another important association with symptoms of PPD was having an infant who was sick in the period between giving birth and the time of the interview. Mothers with sick infants were more likely to have PPD symptoms than mothers whose infants were healthy (35.2 vs 13.6%). The multivariate regression analysis also indicates that having a sick newborn was a factor related to PPD (OR = 0.29; 95% CI: 0.18–0.46). Clearly, the health of the infant can have a considerable effect on their mother’s mood. With respect to this factor, the findings were similar to studies by Xuan Đen (Ho Chi Minh City), Glasser (Israel), Manl, KD (USA) (
We finally only five factors were significantly associated with PPD symptoms after multivariate logistic regression analysis (
This study only used the EPDS to assess postpartum depressive symptoms, thus it was quantitative research providing an estimate of symptoms rather than clinical diagnoses of depression. The social and cultural variables included were based on existing literature. However, a qualitative approach may have revealed more about the subjective factors associated with postpartum depressive symptoms, such as opportunities for social support gained through connection with societies like the women’s union or association of other new mothers. Only married women were included in the sample. Although the number of unmarried mothers in Vietnam is very small, these women might indeed be at high risk for PPD. The study population was located near Danang, which was one of the fourth largest cities in Vietnam. Factors associated with PPD in Danang might be different for women in smaller towns or rural areas. Finally, as the study was cross-sectional; the duration of PPD symptoms, and the relationship between PPD and antenatal depression, was not studied.
The prevalence of postpartum depressive symptoms was 19.3%, which was comparable with other prevalence estimated from Vietnam. After adjusting for other variables in a multivariate logistic regression analysis, the variables associated with postpartum depressive symptoms included reliance on the husband; not being able to discuss problems with their husband; being anxious about matters in addition to giving birth; not exercising after giving birth, and having an ill baby in the postnatal period. The prevalence of PPD symptoms and the factors related to PPD (relationships with husbands and family, exercise, and infant health) should be considered when developing preventive, diagnostic, and therapeutic programs that will promote the long-term health of mothers and their newborns.
In addition, it is important to conduct further research to investigate programs aimed at women at higher risk of perinatal mental illness. Early screening procedures in primary care services may be useful for identifying families in need of more specialized mental health care among pregnant women.
This study was approved by the ethics review panel (Institutional Review Board of Hue University of Medicine and Pharmacy). Respondents were informed about the study, invited to participate, and asked to sign an informed consent form. Of the 600 identified for the sample of the study, 600 agreed to participate, for a response rate of 100%.
TV was the person who was responsible to supervise HD doing this research as her Master of public health thesis and writing this manuscript. HD was MPH student who was responsible developing her research proposal and finishing her thesis. She also wrote this manuscript under TV’s supervision. TH contributed to this manuscript as supporting data analysis at high level using statistical software of SPSS.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors thank Dr. Linda Murray as lecturer of Tasmania University, Australia, for contributing to valuable discussion and editing the manuscript for English language. The authors also wish to thank all married women in Danang city who volunteered their time for this research. The research was administrated through the Hue University of Medicine and Pharmacy. Last but not least, the authors would like to thank the Institute for Community Health Research, Hue UMP, for supporting funding for publication.
The study was funded for publication by the Institute for Community Health Research, Hue University of Medicine and Pharmacy, Vietnam.