Postpartum depression (PPD) is a psychiatric disorder, characterized by a predominance of depressed mood, associated with sleep disorders, feelings of worthlessness and guilt, excessive worry, difficulty concentrating, weight changes, among other symptoms, which in extreme cases can lead women to suicidal thoughts . These symptoms can appear during the gestational period, soon after birth, or up to one year after delivery. PPD causes personal suffering and social dysfunction, in addition to interfering in the mother's relationship with the child [2-4]).
According to the World Health Organization , about 10% of pregnant women and 13% of postpartum women worldwide suffer from some mental disorder, depression being the main one. In developing countries, this prevalence is 15.6% and 19.8% for pregnant and postpartum women, respectively. The different forms and methods used for diagnosis, and the characteristics of the populations studied, interfere in the estimation of the prevalence of PPD .
In clinical practice, screening is ideally done by asking two questions that investigate whether, in the last month, the woman has been troubled feeling depressed or hopeless; or has had little interest or pleasure in doing daily tasks . If the answer is affirmative for either of the two questions, screening for PPD is recommended by applying the Edinburgh Postnatal Depression Scale - EPDS . This scale is able to identify symptoms that may be associated with depressive conditions. However, the diagnosis of PPD depends on further medical evaluation to define the diagnosis .
PPD has a multifactorial etiology. Among the agents involved in its causality are the rapid drops in hormone levels, previous negative life events, individual susceptibilities to the development of depressive conditions, low levels of social support, marital instability, domestic violence, as well as work overload, changes in routine and sleep patterns, and the feeling of disability involved in the postpartum period [8,9].
Recent researches investigate the association between mistreatment, disrespect and abuse in childbirth care - situations defined as obstetric violence - with the development of symptoms and presentation of PPD [10,11]. Obstetric violence is a public health problem, experienced worldwide by many women, and can be defined as a violation of human rights in a period of women's vulnerability [10,12]. Categorized as a gender-based violence, it can be expressed by verbal disrespect, physical or psychological abuse, discrimination, neglect, lack of privacy, limitation in access to information, and application of unconsented procedures [13-15].
The magnitude of obstetric violence varies widely, according to the different surveys conducted, with prevalence ranging from 6–98% [13,16,17]. This variation arises from the heterogeneity in the measurement of the phenomenon and recognition (or non-recognition) of the different practices performed by health professionals as abusive, disrespectful and without an evidence base for their benefits [16,18].
In the international context, studies show the existence of an association between traumatic experiences in childbirth and higher incidence of post-traumatic stress, anxiety and depression in the early (one week after birth) and late postpartum (04, 06, 12 and 24 weeks postpartum) [19,20]. In this same direction, there are the results of research conducted in Brazil, which demonstrated an association between having suffered disrespect, abuse or violence during childbirth and having PPD [10,21]. When analyzing its subcategories, significant association was found between having suffered verbal violence and developing moderate and severe PPD and having suffered physical violence and developing severe PPD.
The harms of PPD are not restricted to the women. Studies show that children of women with this condition are at higher risk of hospitalizations (RR 1.93; CI 95% 1.02-3.64) and mortality in the first year of life (RR 1.44; CI 95% 1.10 - 1.89) . In the long term, these children are twice as likely to develop behavioral disorders, anxiety, depression, concentration deficits, and lower performance in school subjects such as mathematics [23,24].
Therefore, early identification of PPD symptoms and screening of women at higher risk for this disorder is essential for diagnosis and management. Considering that obstetric violence seems to be a risk factor for developing PPD, it becomes relevant to further explore this association, making it possible to intervene in order to promote the women’s quality of life, including a positive motherhood experience. Thus, the aim of this study is to verify the existence of an association between obstetric violence and symptoms suggestive of PPD in a sample of women four weeks postpartum.