To our knowledge, this study was among one of the first studies with respect to the psychological responses of the delivery women in mainland China. The prevalence rate of PPD was as high as 30.0%. The present figure was higher than the prevalence of PPD reported in other studies carried out in China using the EPDS scale[17-19]. For example, in Hebei province of north China, 20.3% of women had elevated levels of postpartum depressive symptoms[17]. In Shanghai of east China, 6 weeks after delivery, the estimated prevalence of PPD was 11.8%[18]. In Guangzhou of south China, the rate of reporting PPD was 27.4%[19]. However, our result is consistent with reports in Asian countries which indicated the prevalence of PPD ranged from 3.5% to 63.3%[20]. Another cross-sectional study in Brazil found a similar prevalence of PPD (27.9%) among low income women[10]. Higher rates of PPD in this study may be explained by two evident differences between other studies and the current one. First, the present data were obtained during the COVID-19 pandemic. Although the COVID-19 outbreak in Guangzhou may not be regarded as severe, the number of imported cases is increasing during the time the study was conducted. According to Behavioral Immune System theory, people are likely to develop negative emotions and avoidant behaviors when faced with public health emergencies[11]. The uncertainty and unpredictability of COVID-19 may cause cognitive dissonance and insecurity, thus providing a feeling of mental discomfort. In addition, with the closure of schools and business as well as social-distancing regulations, negative emotions experienced by individuals are compounded. Therefore, these COVID-19 related factors have helped to add the stressful impact on women’s mental health. Second, the present study was entirely drawn from Guangzhou, one of the most affluent metropolitant in south China. As Guangzhou is one of the major air transportation hub with more than 130 international flight connecting main countries in the world, the potential impact of global COVID-19 outbreaks is high. Moreover, with the lockdowns eased gradually to ensure smooth resumption of work and production, a large number of internal immigrants who were originally from the poor and rural areas in the western and central inland provinces migrated to the southern developed regions for better job opportunities and income. Guangzhou is one of the favorite destinations. The convenience of long-distance travel could increase the incidence of local cases through respiratory droplets (e.g., from exhalation sneeze) and contact routes[21]. And the possibility of transmission by asymptomatic carriers could further enhance it's spread[21]. Such occurrence of both imported and domestically transmitted cases has significant potential for psychological contagion, resulting in widespread fear, helplessness, and a variety of adverse mental health outcomes[7].
The findings of this study show that immigrant women were significantly more likely to develop PPD compared to local women, which is consistent with the findings of previous studies that immigrant women were at increased risk of depression prenatally and postnatally[22]. Because the utility and allocation of public resources are based on household registration policy, immigrants do not have the same rights and benefits as local residents in a variety of areas, such as healthcare, social services, off-spring education and housing. Social exclusion resulting from this policy as well as other economic and cultural factors contribute to the adverse mental health consequences of immigrants. We also reported a strong association between social support and PPD which is consistent with a previous study [19]. One possible reason was that during the pandemic, the pace of the whole society was slowed down. This could have been created more opportunities and time among family member to support and care for each other. In addition, there was increased communication with community members and friends because people were asked to avoid going to public places and stay at home. These positive impacts may have helped women cope with the challenges surrounding the postpartum period.
In addition, we explored the relationship between mental health and physical symptoms as well as concerns about COVID-19 among delivery women during the pandemic. The presence of a persistent fever was significantly associated with PPD. Similarly, a higher perceived likelihood of contracting COVID-19 during the current outbreak was significantly associated with PPD. Amid this moment, women were bombarded with various discomforting network information about COVID-19, including clinical signs, routes of transmission, medicines or vaccines, et al. After presentation to the clinic with a fever, they may be sent home, hospitalized for further observation, or quarantined. Some evidence suggests that up-to-date and accurate information during the pandemic are responsible for lower levels of stress, anxiety and depression[7]. Moreover, higher satisfaction with the health information received by the whole population is contributing to reduce the impact of rumors and this may avoid adverse psychological reactions.
Also, our findings suggest that precautionary measures adopted to prevent the spread of COVID-19 have had a positive psychological effect. Women who had avoided the sharing of utensils (e.g, chopsticks) during meals were significantly less likely to develop PPD. There has been no evidence to suggest the reason for the difference, but saliva is one of the most common ways for food-borne diseases to spread. Communal eating habits have been a part of Chinese culture for centuries. Chinese people prefer to use chopsticks to pick up food commonly shared in the table during meal times to show their respect and cleanness. The experiences of the SARS-COV epidemic in 2013 may have changed the perception of the general public towards precautionary measures. Many cities in China have already launched initiatives to order separate meals. As this healthy habit is related to people's health and safety during the pandemic, it's not unexpected that avoidance of sharing utensils during meals is significantly associated with less psychological impact on women.
Our findings will provide vital guidance for health care professionals to tackle mental health issues among delivery women during a pandemic. First, health authorities need to identify high-risk groups such as immigrants for early intervention. Second, accurate and up-to-date health information during the pandemic need to be provided, especially on the number of recovered individuals to alleviate the concern and reduce the impact of rumors. Third, government and health authorities need to expand public awareness of healthy lifestyle.
This study has several limitations. First, the cross-sectional study using snowballing sampling strategy did not allow for establishing causal relationships between PPD and the factors associated with it. Second, a self-reported scale was employed to define PPD instead of clinician administered structured interview. Participants might have provided responses they feel socially desirable. Third, the short time frame might not allow us to observe it's long-term impacts on mental health among delivery women.