Postpartum Depression in Primigravida and Multigravida: Prevalence and Risk Factors in Taif

Introduction

Postpartum depression (PPD) is a significant mental health condition linked to maternal suffering and adverse effects on children. The initial six months after childbirth are a notably critical period for risk 1. The prevalence rates differ significantly across regions, ranging from 6.9% to 12.9% in affluent countries, while surpassing 20% in low- and middle-income nations 2. In a 2022 study of 187 women conducted at King Khalid University Hospital, the prevalence rate was found to be 50.3% 3. Risk factors for postpartum depression (PPD) are a lack of social support, health problems associated with the baby, the baby's temperament, marital discord, domestic violence, trauma history, and negative life events 2. PPD may also run in families, as women are at an elevated risk of developing PPD when they have a mother or sister who has had the condition 4. PPD occurs in up to 15% of women and can often be diagnosed before delivery through psychiatric history, pregnancy-related symptoms, and psychosocial stressors 5. PPD has negative effects not only on mothers but also on infants and the family member 6, with family discord and inadequate spousal or familial support being the main predictors of risk7. Prevention of PPD is not only essential for the well-being of mothers, but it is also important to provide a good, conducive atmosphere for the newborn 8. There was a link between unplanned pregnancies and the occurrence of PPD9. Therapy and antidepressants are the most reliable treatments, while psychoprophylactic methods have proven to be successful in reducing depression and preventing its recurrence 10,11. This study aimed to determine the prevalence of PPD among first-time and experienced mothers in Taif City, and to provide suggestions for enhancing maternal health in Saudi Arabia.

Material and Methods:

Study Design and Settings: This cross-sectional study was conducted from 4 June to 4 August 2024 in Taif City to compare the prevalence of PPD among primigravida and multigravida and to identify the most strongly associated factors.

Study Population: The study sample was based on the 2023 census, including 117,495 Saudi and non-Saudi married women aged 15-44 years in Taif City, and 383 mothers living in Taif City were included in the sample, according to the Raosoft sample size calculator (www.raosoft.com). And excluded all women who did not live in Taif city and women who were not married.

Data Collection Method and Tool: Data were collected via an online questionnaire distributed via Google and social media platforms among mothers living in Taif city, and the questionnaire was based on the Edinburgh Postnatal Depression Scale (EPDS) score and included questions to assess multiple risk factors. The pilot study was conducted on six individuals to ascertain the tool's feasibility, applicability, and clarity. However, five people were excluded from the final analysis of the pilot study.

The questionnaire consisted of four main sections: consent to participate, participants’ socio-demographic details it including age and marital status and nationality and education levels, living conditions and number of child also, if she had a history of PPD, basic knowledge about psychosocial factors and obstetric and child related risk, and diagnostic questions done by EPDS scale ( The Edinburgh Postnatal Depression Scale (EPDS), The scale consists of 10 short questions. Responses were scored 0, 1, 2, and 3 based on the availability of the symptom. Items 3, 5 to 10 were reverse scored (i.e., 3, 2, 1, and 0). The total score was found by adding the scores for each of the 10 items. Those above 12 or 13 should begin receiving medical care because they are not likely to suffer depression.

Statistical analysis:

The Statistical Package for the Social Sciences (SPSS) version 26.0 was used for statistical analysis after the data were entered into an Excel sheet for validation.

Categorical variables were expressed as counts and percentages. The Chi-square was used to assess the association between the prevalence of PPD and multiple risk factors. A test was considered significant if the p-value was lower than 0.05.

Ethical Considerations:

This study obtained ethical approval from Taif University's Ethics Committee (HAO-02-T-105) (reference number 45-346). Confidentiality and informed consent were some of the important ethical considerations. Throughout the study, respondents' information remained confidential.

Results:

The demographic characteristics of the study participants indicated that the majority (68.0%) were aged 31-45 years. Most participants were married (92.2%) and Saudi nationals (96.1%). The education level showed that a significant proportion held a bachelor's degree (69.5%), with a small proportion holding a master's degree or higher (5.7%). In terms of income, 54.4% earned more than 5000 riyals. Employment status revealed that (52.1%) were currently unemployed, (37.0%) were employed, and (10.9%) were previously employed. Most participants lived with their husbands (73.2%), while 24.5% lived with their families and 2.3% lived alone. Regarding children, (63.8%) had three or more children, (21.4%) had one child, and (14.8%) had two children [Table 1].

The medical history, risk factors, and characteristics of PPD among the participants showed that (53.6%) had no history of PPD with a previous delivery, while (34.6%) had experienced it. For 86.5% of the participants, it was not their first pregnancy. Comorbidities included depression and anxiety or other mental problems (38.5%), hypothyroidism or hyperthyroidism (21.9%), gestational diabetes (14.1%), and hypertension (12.0%). Most participants (83.6%) had regular menstrual cycles, and 58.3% had planned their pregnancy. A majority (92.4%) were not disappointed with their baby's gender. The last labour occurred two years or more ago for (57.6%) of participants. Normal delivery was the most common mode of delivery (66.4%), and most pregnancies were single (90.6%). The delivery experience was moderate for (59.9%) of participants. Medical problems during or after pregnancy included depression and anxiety due to stressful life events (14.8%), complicated labour (8.6%), and preterm labour (8.3%). Among those who suffered depression and anxiety during or after pregnancy (N=57), reasons included family problems (19.3%), fear of giving birth (15.8%), and not getting help (17.5%). Additionally, (84.1%) had no prior family history of PPD, and (73.7%) reported having supportive husbands. The main reasons husbands were not supportive included indifference (46.5%) and not knowing how to help (22.8%). Family and friends were supportive for 87.8% of the participants [Table 2].

The analysis showed that about 213 (55.5%) women had PPD according to the Edinburgh Postnatal Depression Scale (EPDS), as shown in Figure 1.

The relationship between PPD and demographic characteristics showed significant variations across different age groups (p=0.028). Participants aged 26-30 had the highest prevalence of PPD (70%), while those aged 31-45 had the lowest (51%). Marital status and nationality did not show significant differences in PPD prevalence. Education level indicated that uneducated participants had a higher prevalence of PPD (83.3%), although this was not statistically significant (p=0.176). Income and employment status did not show significant differences in PPD prevalence. Living status also did not significantly impact PPD prevalence. However, the number of children showed a significant relationship with PPD (p=0.034), with participants having two children showing a higher prevalence of PPD (66.7%) compared to those with one child (62.2%) or three or more children (50.6%) [Table 3].

The relationship between PPD and delivery characteristics and risk factors revealed several significant associations. Participants with a history of PPD with previous delivery had a much higher prevalence of PPD (78.2%) compared to those without such a history (39.8%) (p<0.001). First-time pregnancies also showed a higher prevalence of PPD (73.1%) compared to those who had previous pregnancies (52.7%) (p=0.006). A disappointing gender of the baby was significantly associated with a higher prevalence of PPD (82.8%) compared to those not disappointed (53.2%) (p=0.002). The type of pregnancy was significant, with twin pregnancies showing a much higher prevalence of PPD (92.3%) compared to single pregnancies (55.5%) (p=0.004). The delivery experience was highly significant, with those describing it as horrible having a higher prevalence of PPD (70.3%) compared to those with moderate (48.7%) or easy experiences (50.0%) (p<0.001). Suffering from depression and anxiety during or after pregnancy was strongly associated with PPD (87.7%) compared to those who did not (49.8%) (p<0.001). A family history of PPD also showed a significant relationship, with a higher prevalence of PPD (70.5%) compared to those without such a history (52.6%) (p=0.010). Lack of support from husbands was associated with a higher prevalence of PPD (68.3%) compared to those with supportive husbands (50.9%) (p=0.002). However, menstrual cycle regularity, planning the pregnancy, time since the last labor, mode of delivery, and support from family and friends were not significantly associated with PPD [Table 3].

The multivariate regression analysis identified several significant predictive factors of PPD [Table 4]. Age, Education level, nationality, income, employment status, living status, number of children, comorbid conditions (such as diabetes mellitus, gestational diabetes, hypertension, and thyroid disorders), and support from family and friends were not significant predictors of PPD (p>0.05). Significant predictors included having a horrible delivery experience [OR =2.35 (1.39-3.99), p=0.002], a history of PPD in previous deliveries [OR of 3.53 (2.00-6.24), p<0.001], and suffering from depression and anxiety during delivery was also a strong predictor [OR=4.45 (1.84-10.80), p=0.001]. The type of pregnancy was a significant predictor, with multiple pregnancies [OR = 9.50 (1.11-81.50), p=0.040] and twin pregnancies [OR = 0.635 (0.21-1.87), p=0.411] having lower ORs than single pregnancies. Support from the husband was protective against PPD [OR=0.53 (0.29-0.97), p=0.041]. Other factors, such as having a disappointing gender of the baby, mode of delivery, and family history of PPD, were not significant predictors in this model.

Discussion:

PPD is a mood disorder characterized by ongoing feelings of sadness, loss of pleasure, a lack of interest in usual activities, and a lack of focus. Also, guilt, insignificance, and low self-esteem. Symptoms include changes in feelings, thoughts, and behaviours, which in turn affect daily activities, despair of life, and thoughts of suicide in advanced cases.

This study aimed to assess the relationship between multiple risk factors and the prevalence of PPD among multigravida and primigravida in the general female population of Taif City in Saudi Arabia. Compared to past studies conducted in other parts of Saudi Arabia, our results contribute to the already existing and increasing worry that PPD is a universal issue. Taking Riyadh (2020) and Jeddah (2021) as examples, both locations showed prevalence rates of 38.5% and 20.9%, respectively; however, a probe in Jazan revealed an even more alarming figure of 75.7% 8,9,12. Differences in the populations examined may explain variation in prevalence across regions. It was nevertheless noted that PPDs were prevalent in Saudi Arabia at an alarmingly high level and are increasing.

According to our survey, a high proportion of Saudi females had PPD, especially among unemployed women, despite reporting relatively high household incomes. A previous study found that residents of Japan who held professional or technical jobs or full-time employment reduced their risk of PPD, and the risk of PPD was unrelated to household income or maternal and paternal educational levels 13. Besides, in another previous study in tertiary care hospitals, they found the PPD prevalence was 30.84% and was linked to low maternal educational attainment, rural living, and low monthly family income 14.

From our study, it can be deduced that mothers with two children went through postpartum depression more often than those with just one baby. On the other hand, some studies have indicated that first-time mothers face a higher risk of PPD than subsequent ones. A descriptive systematic review of 30 studies published between 2000 and 2017 found inconsistent findings: 13 studies reported a link between parity and PPD, 16 found no statistically significant association, and the remaining 18 didn't support a relationship between the number of pregnancies and PPD prevalence. These varying outcomes highlight the difficulty of parity as a risk factor 15.

The type of pregnancy significantly influenced the prevalence of PPD in our study. Mothers of twins often experience higher levels of PPD than those who have single births. Likewise, an earlier study revealed that the likelihood of experiencing PPD symptoms increases by 43% in mothers of multiple births compared to those with singleton births16. Additionally, a study reported that 35% of mothers of twins experienced depression within the first six months following delivery 17. Additionally, this study demonstrated that mothers who were disappointed with the gender of their child were significantly more likely to experience PPD than mothers who were satisfied with the gender of their child. In Central Java, Indonesia, a cross-sectional study of adolescent postpartum mothers was conducted, which found that dissatisfaction with the baby's gender was significantly associated with PPD 18.

There was no significant link detected in our study between the method of delivery and PPD. This finding was in alignment with a previous study conducted in Egypt that also found no relationship between mode of delivery and PPD 19. However, another study found the prevalence of PPD significantly higher in emergency caesarean sections compared to elective caesarean sections or normal vaginal deliveries 20. Another risk that was not linked to PPD in this study was an unplanned pregnancy. Similar findings were reported by other studies, which found no significant association between unplanned pregnancy and PPD 21,22. However, some studies have shown associations between unplanned pregnancy and PPD 23,24. Our study revealed that menstrual cycle regularity was not significantly associated with PPD. A previous study found that menstrual disturbances, including menstrual irregularities and premenstrual dysphoria, did not show any statistically significant association with PPD 25.

A previous history of postpartum depression is a major indication of the possibility of a second occurrence. Women with a history of postpartum depression are at a higher risk of experiencing the condition again during a subsequent pregnancy, possibly due to biological influences or ongoing stress. Through their identification as high risk, along with the provision of early psychological support and monitoring, the recurrence can be lessened and the outcomes improved, as shown in our study. Preventative strategies, including early psychological support and intervention, could help manage the risk of recurrence. A poor delivery experience correlates with studies connecting traumatic birth experiences to a higher risk of PPD. Adverse or traumatic delivery experiences can result in increased levels of stress, fear, and emotional turmoil, which may play a role in the onset of PPD. This relationship underscores the critical need for healthcare providers to prioritize not only the physical aspects of delivery but also the emotional and psychological support they provide to mothers during labour.

Women experiencing significant psychological distress during delivery were more likely to develop PPD, suggesting that early intervention and support are critical 27,28. Studies show that experiencing significant psychological distress during labour and delivery was not merely an uncomfortable side effect; it signifies a heightened vulnerability to PPD 29-31. This vulnerability stems from a complex interplay of factors. The dramatic hormonal fluctuations during labour, while essential for physiological processes, can also exacerbate existing mental health conditions and trigger new episodes of anxiety and depression 32. Labor and delivery were inherently physically and emotionally demanding. For women already grappling with anxiety and depression, these stressors can become overwhelming, depleting coping mechanisms and increasing susceptibility to PPD 26. It was also reported that difficult or traumatic births, even in the absence of pre-existing mental health conditions, can lead to PTSD-like symptoms, contributing to anxiety, fear, and difficulty bonding with the infant, all of which increase PPD risk 33.By including mental health screening in standard prenatal care, women who are suffering from anxiety and depression can be helped to identify early 32.

The protective effect of husband support against PPD emphasizes the critical role of partner involvement in maternal mental health. Evidence shows that women who receive support from their partners are less likely to experience PPD, suggesting that relational solid support can buffer against the psychological stressors associated with childbirth 34,35. Husbands provide a safe space for mothers to process the emotional rollercoaster of new parenthood, offering validation for their experiences, normalizing their feelings, and helping them regulate difficult emotions 36. This emotional support was crucial for mitigating feelings of isolation, anxiety, and overwhelm that can contribute to PPD. Partners who share in household chores, infant care, and logistical tasks provide tangible relief, reducing maternal stress and promoting feelings of competence and control 37. Additionally, it was reported that husbands who express confidence in their partner's abilities as a mother and provide encouragement and reassurance can bolster maternal self-efficacy, a critical factor in preventing PPD 38.

A significant association between hypertension, thyroid disorders, and postpartum depression was found in our study, which confirmed the previously present speculation on the matter. This was consistent with the study conducted at Avicenna Hospital in Lahore, where 27% of women suffering from hypertension were diagnosed with PPD. Chronic medical conditions with maternal mental health issues might indicate common biological pathways like hormonal imbalance and stress on blood vessels, besides the psychological burden of carrying such a long-term illness diagnosed in the postpartum period39. Additionally, a prior systematic review study sought to determine the prevalence of PPD in pregnant women with thyroid conditions during pregnancy and the postpartum period. The findings regarding 8.3% and 36.0% of pregnant women with thyroid problems were estimated to have PPD. Furthermore, some authors believe that having positive anti-TPO antibodies may indicate a person's susceptibility to depression 40.

Therefore, efforts to improve family support, such as teaching partners how to provide adequate support and fostering better communication between partners, could significantly reduce the incidence of PPD. We also advise married or even pregnant women to have counseling sessions before deciding to have a baby or in the first month of pregnancy. Additionally, this study was intended to raise awareness about the serious problem of depression signs after delivery and to give the public knowledge on how to deal with this problem to reduce risk factors that were significantly associated with PPD and provide the mothers with ways to cope with PPD.

Limitation:

The study's cross-sectional design prevented the establishment of a temporal relationship between identified risk factors and PPD. The use of self-administered questionnaires may have introduced recall and reporting biases, potentially affecting the accuracy of the data. Additionally, the study population was limited to women in Taif City, which may not reflect the experiences of women in other regions, thereby limiting the generalizability of the findings. However, a key strength of this study was the comprehensive analysis of multiple factors, including social and family support, delivery experiences, family history, comorbidities, and socioeconomic status. This comprehensive analysis provided a deeper insight into factors associated with PPD among the participants.

Conclusion:

The result of this study demonstrated that over half of the women surveyed experienced PPD. 26-25 years old exhibited the highest prevalence rates of PPD, while the lowest prevalence was observed in women aged 31-45. Interestingly, women with two children showed a greater prevalence of PPD compared to those with one child or three or more children. A history of PPD in previous deliveries significantly increased the likelihood of experiencing PPD again, highlighting the importance of monitoring women with such a history. Major predictors of PPD encompassed a traumatic childbirth experience, a previous history of PPD, recurrent episodes of depression and anxiety during successive pregnancies, the type of the pregnancy itself, and the extent of support provided by the husband.

Availability of Data and Materials

The datasets used in this study can be obtained from the corresponding author upon reasonable request.

Competing of interest

The authors declare that they have no conflicts of interest in relation to the publication of this article.

Authors’ contributions:

Shatha H. Alziyadi and Wejdan A.Alkhaldi designed the study. Raghad H. Alswat, Thamer H. Alboqami, Rana Altowariqi, Meshari Althobiti, Shatha H.Alziyadi, and Wejdan A.Alkhaldi performed the interpretation of data and acquisition and analysis, also drafted the manuscript and critically reviewed the manuscript for important intellectual content by Shatha H.Alziyadi.

Funding statement

None.

Consent to participate

Every participant provided written informed consent.

References:

1. O'hara MW, McCabe JE. Postpartum depression: current status and future directions. Annual review of clinical psychology. 2013 Mar 28;9(1):379-407.doi: 10.1146/annurev-clinpsy-050212-185612.

2. Howard LM, Molyneaux E, Dennis CL, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. The Lancet. 2014 Nov 15;384(9956):1775-88. doi: 10.1016/ S0140-6736(14)61276-9.

3. Aljaffer MA, Almadani AH, Almustafa AA, et al. Postpartum depression at a tertiary care hospital in Saudi Arabia: prevalence and associated factors. Cureus. 2023 Apr;15(4).doi: 10.7759/cureus.37758

4. Forty L, Jones L, Macgregor S, et al. Familiality of postpartum depression in unipolar disorder: results of a family study. American Journal of Psychiatry. 2006 Sep;163(9):1549-53.doi: 10.1176/ ajp.2006.163.9.1549.

5. Kroska EB, Stowe ZN. Postpartum depression: identification and treatment in the clinic setting. Obstetrics and Gynecology Clinics. 2020 Sep 1;47(3):409-19. doi: 10.1016/j.ogc.2020.05.001.

6. Alzahrani J, Al-Ghamdi S, Aldossari K, et al. Postpartum depression prevalence and associated factors: an observational study in Saudi Arabia. Medicina. 2022 Nov 4;58(11):1595.. doi: 10.3390/medicina58111595

7. Alshahrani SA, Al-Saleh NF, Siddiqui AF,et al. Burden and risk factors of postpartum depression in Southwest Saudi Arabia. Journal of Clinical Medicine. 2023 May 13;12(10):3444.doi: 10.3390/jcm12103444.

8. Al Nasr RS, Altharwi K, Derbah MS, et al. Prevalence and predictors of postpartum depression in Riyadh, Saudi Arabia: A cross-sectional study. PloS one. 2020 Feb 10;15(2):e0228666.doi: 10.1371/journal.pone.0228666

9. Abdelmola AO, Bahari A, Gosadi I,et al. Prevalence and factors associated with maternal postpartum depression among mothers in Saudi Arabia: A cross-sectional study. InHealthcare 2023 Jan 25 (Vol. 11, No. 3, p. 343). MDPI.doi: 10.3390/ healthcare11030343.

10. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. American journal of obstetrics and gynecology. 2009 Apr 1;200(4):357-64. doi: 10.1016/j.ajog.2008.11.033.

11. Sockol LE, Epperson CN, Barber JP. Preventing postpartum depression: a meta-analytic review. Clinical psychology review. 2013 Dec 1;33(8):1205-17. doi: 10.1016/j.cpr.2013.10.004

12. Alsayed NA, Altayyeb JF, Althuniyyan LS, et al. Prevalence of postpartum depression and associated risk factors among women in Jeddah, Western Saudi Arabia. Cureus. 2021 Apr;13(4).doi: 10.7759/cureus.14603

13. Miyake Y, Tanaka K, Sasaki S, Hirota Y. Employment, income, and education and risk of postpartum depression: the Osaka Maternal Affective Disorder study. Journal of Affective Disorders. 2011 Apr 1;130(1-2):133-7.https://doi.org/10.1016/j.jad.2010.10.024

14. Dubey, A., Chatterjee, K., Chauhan, V.S., et al. Risk factors of postpartum depression. Industrial psychiatry journal, 2021 Oct 1;30(Suppl 1):S127-31. DOI: 10.4103/0972-6748.328803

15. Ay F, Tektaş E, Mak A, Aktay N. Postpartum depression and the factors affecting it: 2000-2017 study results. Journal of Psychiatric Nursing. 2018 Jan 1;9(3):147-52.DOI: 10.14744/phd.2018.31549

16. Choi Y, Bishai D, Minkovitz CS. Multiple births are a risk factor for postpartum maternal depressive symptoms. Pediatrics. 2009 Apr 1;123(4):1147-54. https://doi.org/10.1542/peds.2008-1619

17. Brantmüller É, Gyúró M, Galgán K, et al.Pakai A. Postpartum mental state of mothers of twins. Practice and Theory in Systems of Education. 2016 Feb 1;11(1):1-2.DOI 10.1515/ptse-2016-0001

18. Rahmadhani W, Laohasiriwong W. Gender of baby and postpartum depression among adolescent mothers in central Java, Indonesia. International Journal of Child & Adolescent Health. 2020 Jan 1;13(1).Retrieved from https://www.proquest.com/scholarly-journals/gender-baby-postpartum-depression-among/docview/2443869741/se-2

19. Goweda R, Metwally T. Prevalence and associated risk factors of postpartum depression: a cross sectional study. Archives of Clinical Psychiatry (São Paulo). 2020 Aug 26;47:106-9.https://doi.org/10.1590/0101-60830000000242

20. Meky HK, Shaaban MM, Ahmed MR, et al.Mohammed TY. Prevalence of postpartum depression regarding mode of delivery: a cross-sectional study. The Journal of Maternal-Fetal & Neonatal Medicine. 2020 Oct 1;33(19):3300-7.https://doi.org/10.1080/14767058.2019.1571572

21. Kunwar D, Corey EK, Sharma P, Risal A. Screening for Postpartum Depression and Associated Factors among Women who Deliver at a University Hospital, Nepal. Kathmandu University Medical Journal. 2015 Oct 20;13(1):44-8. https://doi.org/10.3126/kumj.v13i1.13752

22. Do TK, Nguyen TT, Pham TT. Postpartum depression and risk factors among Vietnamese women. BioMed research international. 2018;2018(1):4028913.doi:https://doi.org/10.1155/2018/4028913

23. Burgut FT, Bener A, Ghuloum S, et al.. A study of postpartum depression and maternal risk factors in Qatar. Journal of Psychosomatic Obstetrics & Gynecology. 2013 Jun 1;34(2):90-7.doi:https://doi.org/10.3109/0167482X.2013.786036

24. AKTAŞ D, TERZİOĞLU F. Occurrence of depression during the postpartum period and risk factors that affect the development of the depression. Turkish Journal of Medical Sciences. 2013;43(5):843-50. DOI: 10.3906/sag-1208-88

25. Saldanha D, Rathi N, Bal H, et al. Incidence and evaluation of factors contributing towards postpartum depression. Medical Journal of Dr. DY Patil University. 2014 May 1;7(3):309-16.DOI: 10.4103/0975-2870.128972

26.-Kettunen P, Koistinen E, Hintikka J. The Connections of Pregnancy-, Delivery-, and Infant-Related Risk Factors and Negative Life Events on Postpartum Depression and Their Role in First and Recurrent Depression. Depression research and treatment. 2016;2016:2514317. doi:10.1155/2016/2514317

27. Ahmadpour P, Faroughi F, Mirghafourvand M. The relationship of childbirth experience with postpartum depression and anxiety: a cross-sectional study. BMC psychology. 2023 Mar 3;11(1):58. doi:10.1186/s40359-023-01105-6

28. Corrigan CP, Kwasky AN, Groh CJ. Social support, postpartum depression, and professional assistance: A survey of mothers in the Midwestern United States. The Journal of perinatal education. 2015 Jan 1;24(1):48-60.doi:10.1891/1058-1243.24.1.48

29. Rajabaliev E, LaSorda K, Ibarra A, et al. Association between labor and delivery pain and postpartum pain with symptoms and clinical diagnosis of postpartum depression in patients with overweight and obesity. Archives of gynecology and obstetrics. 2023;307(5):1441-1449. doi:10.1007/s00404-022-06625-x

30. Slomian J, Honvo G, Emonts P,et al. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Women's Health. 2019 Apr;15:1745506519844044.doi:10.1177/1745506519844044

31. Manso-Córdoba S, Pickering S, Ortega MA, et al. Factors related to seeking help for postpartum depression: a secondary analysis of New York city PRAMS data. International journal of environmental research and public health. 2020 Dec;17(24):9328.DOI:10.3390/ijerph17249328

32. Fairbrother N, Young AH, Janssen P, Antony MM, Tucker E. Depression and anxiety during the perinatal period. BMC psychiatry. 2015 Dec;15:1-9. doi:10.1186/s12888-015-0526-6

33. Austin MP, Hadzi-Pavlovic D, Priest SR, et al.Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection?. Archives of women's mental health. 2010 Oct;13:395-401. doi:10.1007/s00737-010-0153-7

34. Qi W, Liu Y, Lv H ,et al. Effects of family relationship and social support on the mental health of Chinese postpartum women. BMC pregnancy and childbirth. 2022 Jan 25;22(1):65. doi:10.1186/s12884-022-04392-w

35. White LK, Kornfield SL, Himes MM, et al.The impact of postpartum social support on postpartum mental health outcomes during the COVID-19 pandemic. Archives of Women's Mental Health. 2023 Aug;26(4):531-41.doi:10.1007/s00737-023-01330-3

36. Stapleton LR, Schetter CD, Westling E, et al. Perceived partner support in pregnancy predicts lower maternal and infant distress. Journal of family psychology. 2012 Jun;26(3):453.. doi:10.1037/a0028332

37. Sivapragasam V, Manjappa AA, Patil AB, et al.Kalaimani M. Prevalence and risk factors of postpartum depression at a tertiary care institute. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2019 Jul 1;8(7):2773-81.

https://go.gale.com/ps/i.do?id=GALE%7CA597716011&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=23201770&p=AONE&sw=w&userGroupName=anon%7E6b1c8e27&aty=open-web-entry

38.XIE RH, Yang J, Liao S,et al. Prenatal family support, postnatal family support and postpartum depression. Australian and new zealand journal of obstetrics and gynaecology. 2010 Aug;50(4):340-5. doi:10.1111/j.1479-828X.2010.01185.x

39. Sarosh M, Ghafoor F, Shakoor S. Association between Hypertensive Disorders in Pregnancy and Postpartum Mental Health. Pakistan Journal of Medical & Health Sciences. 2022 Mar 22;16(02):42-. https://doi.org/10.53350/pjmhs2216242

40.Schmidt PM, Longoni A, Pinheiro RT, Assis AM. Postpartum depression in maternal thyroidal changes. Thyroid Research. 2022 Mar 29;15(1):6.https://doi.org/10.1186/s13044-022-00124-6