Determination of the Prevalence of Postpartum Depression and Risk Factors Among Postpartum Patients at a Tertiary Government Urban Hospital Using the Edinburgh Postnatal Depression Scale-Filipino Translation (EPDS-F): A Cross-Sectional Study

Postpartum depression (PPD) occurs in 10-15% of deliveries worldwide. Unfortunately there is a dearth of local studies on its exact prevalence. Method This cross-sectional study aimed to determine the prevalence of and risk factors for PPD among postpartum patients at a tertiary government hospital using the Edinburgh Postnatal Depression Scale-Filipino Translation (EPDS-F), a 10-point questionnaire translated into Filipino and previously validated. Four hundred patients within 8 weeks postpartum were recruited and their EPDS-F scores and sociodemographic, medical and personal history, and delivery and perinatal outcome data were obtained. (p=0.04). Regression analysis showed that having an abdominal delivery is correlated with a lower EPDS-F score by 0.87% by logistic regression and 0.46 % by probit regression. Having a higher educational attainment and monthly income are associated with a lower EPDS-F score by regression analysis. The prevalence may be skewed because a tertiary government institution caters to delicate pregnancies and those in low socioeconomic brackets. It may be worthwhile to compare responses from a public versus a private institution, also urban versus rural areas. It would be interesting also to evaluate the mode of delivery variable and how exactly it correlates with the development of postpartum depression. Informed Consent form for postpartum women on follow up at the Outpatient Department of the Philippine General Hospital Department of Obstetrics and Gynecology, whom we are inviting to participate in research on postpartum depression. The title of this research project is Determination of the Prevalence of Postpartum Depression and Risk Factors Among Postpartum Patients at a Tertiary Government Urban Hospital Using the Edinburgh Postnatal Depression Scale] This Informed Consent Form has two parts:

(p=0.04). Regression analysis showed that having an abdominal delivery is correlated with a lower EPDS-F score by 0.87% by logistic regression and 0.46 % by probit regression. Having a higher educational attainment and monthly income are associated with a lower EPDS-F score by regression analysis.

Conclusions
The prevalence may be skewed because a tertiary government institution caters to delicate pregnancies and those in low socioeconomic brackets. It may be worthwhile to compare responses from a public versus a private institution, also urban versus rural areas. It would be interesting also to evaluate the mode  The lack of research on this disorder is alarming, because of the burden of the disease not only on the mother but on the child as well. Studies show that 25 % of women with postpartum depression will be depressed 1 year later. And as the duration of depression increases, so too do the number of sequelae and their severity. Also, maternal depression during the first weeks and months after delivery can lead to insecure attachment and later behavioral problems in the child3.
Philipps14 conducted a 4.5-year prospective study of postpartum depression in 70 women. He found that women who had experienced a postpartum depression were predicted to be at increased risk for subsequent depression and poor adjustment of their child. Postpartum depression was directly related to subsequent depression but not child problems. Later depression was related to child problems at 4½ yrs. It was concluded that postpartum depression may increase risk for later maternal depression and in turn increases risk for child behavior problems. Intervening with women who have experienced a postpartum depression may reduce likelihood of future depressions and child behavior problems.
Early recognition is one of the most difficult challenges with postpartum depression because of how covertly it is suffered. Dennis15 conducted a systematic review on help-seeking behavior among women diagnosed with postpartum depression. Forty articles were reviewed, and it was found that a common help-seeking barrier was women's inability to disclose their feelings, which was often reinforced by family members and health professionals' reluctance to respond to the mothers' emotional and practical needs. The lack of knowledge about postpartum depression or the acceptance of myths was a significant help-seeking barrier and rendered mothers unable to recognize the symptoms of depression.
According to the American College of Obstetricians and Gynecologists, there is currently insufficient evidence to make a recommendation for routine depression screening, either during or after pregnancy16. At Parkland Hospital, all women are asked about depression and domestic violence at their first prenatal visit. They are also screened again during their first postpartum visit using the Edinburgh Postnatal Depression Scale (EPDS). In an analysis17 of more than 17,000 of these questionnaires, 6% had scores that indicated either minor or major depressive symptoms. Twelve of these 1106 women also had thoughts of self-harm. Filipinas. This tool can therefore be used to determine the prevalence of the disease as well as the risk factors for its development.

Significance of the study
Currently there are only a few available local studies on postpartum depression.
It is fortunate that we have available the Edinburgh Postnatal Depression Scale that has been translated into Filipino and validated in a 2005 study13. This study also recommended that future research would have a larger sample size in order to obtain a more accurate estimate of prevalence of PPD in the country.
Participation in the study may diagnose existing postpartum depression or identify patients at risk for its development. The results may be used for further research on postpartum depression and will thus also be beneficial for future generations of postpartum women. Also, answering the questionnaire will serve as screening for postpartum depression and should postpartum depression be detected, it can be managed immediately with referral to a psychiatrist. 3. To determine the risk factors for developing postpartum depression.

Study design
A cross-sectional study was conducted among postpartum patients at a tertiary government hospital using the Edinburgh Postnatal Depression Scale-Filipino Translation (EPDS-F).

Selection of subjects and sample size calculation
Based on the Annual Perinatology and Neonatology Statistics done at this tertiary government hospital, there were 5126 deliveries in the year 2016. This number was used as the population size. The worldwide estimated prevalence of depression among recently delivered women at 10-15%, and the prevalence found by Torres study 7.3%, though with a small sample size of 191. The prevalence was thus set at 50% and the confidence level at 95%, the computed sample size was 357. Ten percent was added to account for incomplete information and losses; hence the sample size was set at 400.
Inclusion criteria: Patients at least 18 years of age who have delivered a fetus of more than 20 weeks age of gestation, weighing more than 500 grams, within the last 8 weeks, whether vaginal or abdominal delivery, term or preterm, alive or dead.
• Those who have previously been diagnosed with a depressive disorder.
• Those who cannot speak Filipino.

Data collection
In 2016, the tertiary government hospital had a total of 5126 deliveries. It is thus an ideal setting for research on postpartum women. It was decided that the data

Data processing and analysis
Analysis of the data from the actual survey included computation of prevalence and descriptive statistics to calculate the risk factors based on patient demographics and profile. Chi-square test was used to determine the association.
Once the data was extracted by the investigator from the charts of the patients, all the information was manually entered into an electronic spreadsheet for data processing and analysis. The socio-demographic and clinical variables were presented in frequencies and percentages for categorical variables such as sex, marital status, mode of delivery and reasons for removal; or mean, standard deviation or range for continuous variables such as age, gravidity and parity.
For the general objective, the prevalence of PPD were presented as frequency and percentage, the denominator being the total number of subjects included in the study. A 95% confidence interval of the prevalence rate was computed.
For the first specific objective, independent t-test was used to compare variables such as age, number of pregnancies and children between those who were noted by the scale to have PPD and otherwise. Chi-square test of association was used to determine differences across categorical variables such as marital status, employment status, presence of co-morbidities, and use of contraception in terms of PPD status from the EPDS-F. Regression analysis was performed for all the variables, specifically multivariate regression estimated through ordinary least squares (OLS).
Analysis was performed using the software Stata 13. The level of significance for all sets of analysis was put at 0.05 using two-tailed comparisons.

RESULTS
Of the 400 participants, 58 had EPDS-F scores 10 and higher, classifying them as at risk for developing postpartum depression. All 58 were referred to Psychiatry for further evaluation and management.
The overall prevalence of PPD was thus computed to be at 14.5%. This is within the known worldwide prevalence of 10-15%1 but higher than in the local study done by Torres13 in 2005 (7.3% in 191 women). The mean EPDS-F score of the depressed group was 13.1, as opposed to 3.0 in the non-depressed group.
Tables 1, 2, and 3 show the breakdown and percentages of the sociodemographic variables, medical and personal history variables, and deliveryrelated and perinatal outcome variables, respectively.  The mean age of all 400 respondents was 28.7 (SD ± 6.2) . Mean age for the high EPDS-F score group was 28.3 (SD ± 5.4) and 28.8 (SD ± 6.4) for the low EPDS-F score with no significant difference between groups. The majority or   0.09 0.09 0.09 t-Statistic in brackets. Significance at 1 percent (***), 5 percent (**), and 10 percent (*) levels.

Socio-Demographic Variables (
Regression analysis was performed for all the variables. Using the multivariate regression estimated through ordinary least squares (OLS), the mode of delivery, level of education, and monthly family income were found to be significant in determining the EPDS-F score. Women who underwent abdominal delivery had a lower EPDS-F score on average by 1.60 points.
Meanwhile, women who have finished elementary, high school, and college education have EPDS-F scores lower by 1.23 points, 2.46 points, and 3.69 points, respectively, compared to women who have no educational attainment.
In addition, having a higher level of family income was found to be associated with a lower EPDS-F score.
The same results were found to be robust using the logistic and probit regression approaches. Having an abdominal delivery is correlated with a lower EPDS-F score by 0.87% using the logistic regression and 0.46% using the probit regression. Similar to the results from the OLS approach, having a higher level of educational attainment and monthly family income are associated with a lower EPDS-F score.

DISCUSSION
The characteristics that were noted to be significant in the development of postpartum depression as determined by the Edinburgh Postnatal Depression Scale-Filipino Translation (EPDS-F) are low educational attainment (below tertiary education, p <0.01) and lower family income (below PhP10,000 below family income, p <0.01). Both are consistent with the Torres study9.Low family income was also a significant risk factor in an Indian study18. Interestingly, abdominal delivery was found to be correlated to a high EPDS-F score (p <0.05). Previous studies showed no effect of route of delivery on the development of PPD. A meta-analysis in 201719 showed that caesarean section increases the risk for PPD. It is important to note that the rate of abdominal delivery for this study is quite high at 53.3% (the ideal rate according to the World Health Organization is only 10-15%20). This could be attributed to the fact that this study was conducted in a tertiary hospital that caters to more complicated pregnancies, many of which require delivery by caesarean section.
In 2016, 43% of deliveries at this hospital were by caesarean section.
Among all of the above characteristics, based on the computed p-values and regression analysis, it appears that the ones that proved significant for having a high EPDS-F score are the following: having low educational attainment (below tertiary), having lower family income (less than PhP10,000), vaginal delivery, and use of epidural anesthesia. The finding that those with high EPDS-

LIMITATIONS
As this is a cross-sectional design, the data is reflective of the prevalence and risk factors of postpartum depression only at the point in time they were obtained. It is recommended that further studies using a cohort design to determine lifetime prevalence of postpartum depression be conducted.
Causality cannot be established as well.

CONCLUSIONS
The Edinburgh Postnatal Depression Scale Filipino Translation (EPDS-F) is a useful screening tool for postpartum patients. It is an ideal tool because it consists of only ten items and is self-administered.
The prevalence of postpartum depression in this study was found to be 14.5%.
The variables that were found to be significant in those who had high EPDS-F scores were monthly family income below PhP10,000, educational attainment below tertiary, and vaginal delivery.
The higher prevalence noted in this study may be due to risk factors present in the population-such as low socioeconomic status and low educational attainment. It may be worthwhile to compare responses from a public versus a private institution, as well as urban versus rural, non-hospital based areas. It would be interesting also to further evaluate the mode of delivery variable and how exactly it correlates with the development of PPD.
Obstetricians, midwives, and all those who care for pregnant women will do well to remember that the duty to each patient does not end with a safe delivery. It is imperative to ensure her complete physical and mental well-being even in the puerperium and beyond. Screening during a critical period of vulnerability such as in the puerperium will allow early detection, prevention and treatment. Data collection only ensued upon approval. This study was funded by the primary investigator only. Written consent was obtained from the participants and they were also given copies of the informed consent form. No conflict of interest was identified among the investigators, the patients and the institution.
It is important to note that answering items on the EPDS-F might cause participants to think about feelings of depression, worthlessness, and selfharm. Participants who were classified as at risk for developing PPD based on their EPDS-F score were referred to Psychiatry for further evaluation and management.

Availability of data and materials
All data generated or analyzed during this study are included in this published article.

Competing interests
The authors declare that they have no competing interests.

Funding
This study received no funding. All expenses were shouldered by the primary author.

Authors' contributions
MS was responsible for the conception of the study; the acquisition, analysis, and interpretation of data, as well as drafting and revision of the work.
MH was likewise responsible for the conception of the study; the acquisition, analysis, and interpretation of data, as well as drafting and revision of the work.
All authors have read and approved the manuscript.

CODE _______
As you have recently had a baby, we would like to know how you are feeling.
Please SHADE the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.
Here is an example, already completed. In the past 7 days: 1. I have been able to laugh and see the funny side of things  As much as I always could  Not quite so much now  Definitely not so much now  Not at all 2. I have looked forward with enjoyment to things  As much as I ever did  Rather less than I used to  Definitely less than I used to  Hardly at all 3. I have blamed myself unnecessarily when things went wrong

Pakikipag-ugnayan
Kung kayo ay mayroong mga katanungan maaari po kayo magtanong ngayon o sa susunod kahit pagkatapos ninyo sagutin ang palatanungan. Kung may mga katanungan kayo sa susunod, maaari po kayo makipagugnayan sa mga sumusunod: The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item questionnaire used to identify women who have postpartum depression. It consists of a ten-item self-report scale. You will be asked to answer this questionnaire along with a personal data sheet.

Participant selection
We are inviting you, along with 400 other postpartum women, to participate in this research on postpartum depression.
➢ Voluntary Participation Your participation in this research is entirely voluntary. It is your choice whether to participate or not. Whether you choose to participate or not, all the services you receive at this institution will continue and nothing will change. You may change your mind later and stop participating even if you agreed earlier.

B. Description of the Process
You will be given two forms to fill up: 1. The Edinburgh Postnatal Depression Scale (translated in Filipino) 2. Sociodemographic data sheet. You can accomplish these two sheets while waiting for your turn at the Outpatient Department. We are also requesting your permission to access additional data in your hospital chart.

Risks
Your participation in this research may evoke negative emotions due to the sensitive nature of the questions in the EDPS. If you do develop any of these, please let us know right away and we can arrange for proper counseling with a psychiatrist. Rest assured that any and all expenses incurred for consultation and/or treatment will be shouldered by the Primary Investigator.

Benefits
You participation in this research will benefit those currently suffering from postpartum depression as well as future generations of women who are at risk for developing PPD.

Reimbursement
You will not be asked to spend for anything for this study. Likewise, you will also not receive any compensation for your participation.

Confidentiality
The information that we collect from this research project will be kept confidential. Information about you that will be collected during the research will be put away and no one but the researchers will be able to see it. Any information about you will have a number on it instead of your name. Only the researchers will know what your number is and we will lock that information up with a lock and key. It will not be shared with or given to anyone except the UPMREB.

Sharing the Results
The knowledge that we get from doing this research may be available to you if you are interested. Confidential information will not be shared. It is hoped that the results be published in order that other interested people may learn from our research.

Right to Refuse or Withdraw
You do not have to take part in this research if you do not wish to do so and refusing to participate will not affect your treatment at this institution in any way. You will still have all the benefits that you would otherwise have at this institution. You may stop participating in the research at any time that you wish without losing any of your rights as a patient here. Your treatment at this institution will not be affected in any way.

Who to Contact
If you have any questions you may ask them now or later, even after the study has started. If you wish to ask questions later, you may contact the Primary Investigator: Dr