Association Between Social Support and Postpartum Depression

Abstract

Introduction:

Postpartum depression is common; however, little is known about its relationship to social support and postpartum depression. This study examined the association between them among South Korean women within one year of childbirth.

Methods

This study was based on the 2016 Korean Study of Women’s Health-Related Issues (K-Stori), a cross-sectional survey employing nationally-representative random sampling. Participants were 1,654 postpartum women within a year of giving birth. Chi-square test and logistic regression analysis were conducted to analyze the associations between social support (and other covariates) and postpartum depression.

Results

Among participants, 266 (16.1%) had postpartum depression. Depending on the level of social support, 6.0%, 53.9%, and 40.1% of them had low, moderate, and high social support, respectively. Women with moderate or low social support were more likely to have postpartum depression (OR = 1.78, 95% CI = 1.26–2.53; OR = 2.76, 95% CI = 1.56–4.89). This trend was observed in participants with multiparity, pregnancy loss, obese body image, and employed women.

Conclusion

Social support was associated with a decreased likelihood of postpartum depression, indicating the importance of social support, especially for women with multiparity, pregnancy loss experience, negative body image, and employed women for preventing postpartum depression.

Introduction

One of the most important turning points in a woman’s life is pregnancy and childbirth.[1] Women at the prenatal and postpartum periods commonly experience mental health problems because of new roles and responsibilities.[2] The onset of mental health problems can cause devastation and dissension in a woman’s life.[3] Depression is estimated to be the second leading cause of disability by 2020.[4] It is a common and debilitating psychiatric disorder prevalent in South Korea and worldwide.[5, 6] Incidence of depression is approximately two times higher in women than in men, and is particularly common among women of child-bearing age.[7] In Korea, social burden due to mental disorders have significantly increased. The proportion of those who suffered from mental disorders at least once in their lifetime was 30.2% in 2006 and 27.6% in 2011.[8] The consequences of depression during the postpartum period are considerably more deleterious because a woman faces the added responsibility of caring for her newborn infant.[3]

Postpartum affective depression is typically divided into three categories: postpartum blues, postpartum depression (PPD), and puerperal psychosis. Postpartum blues have been reported to occur in 15–85% of women within the first 10 days after giving birth.[9] Although postpartum blues is a common and transient occurrence, its recognition is important because it is a risk factor for subsequent PPD.[9, 10] Puerperal psychosis is the most severe and uncommon form of postnatal affective illness, with a rate of 1–2 episodes per 1,000 deliveries. The symptoms of puerperal psychosis differ from PPD as it comprises delusions, hallucinations, confusion, perplexity, or mania or mixed features.

PPD is the most common complication of childbearing, affecting approximately 10–22% of woman in childbearing age.[11] Women usually experience PPD within the first six weeks following delivery, and recover from it six months postpartum; however, it may continue through the first and second years postpartum.[12] PPD is closely linked with negative outcomes for women and infants, such as maternal suicide, weak maternal interaction with her infant, early termination of breastfeeding, and delays in children’s development.[13, 14] Although PPD is undetected or inadequately treated, it may be remedied by both behavioral and pharmacological treatments.[15] However, studies have found out that pharmacological therapy was unsuitable for postpartum mothers, particularly those who wished to breastfeed, as antidepressant compounds may be passed onto the infant via breastmilk.[16, 17] Thus, prevention is the best method against the onset of depression in new mothers rather than relying on these treatments. While the cause of PPD remains unclear, social support has been shown to be effective in helping women cope with postpartum depression.[18, 19] Social support is defined as an exchange of resources among people perceived by the provider or recipient to be intended to improve the lifestyle of the recipient.[20]

Previous studies have investigated the relationship between PPD and social support.[2, 13, 18] However, there was relatively little consideration for factors affecting social support and postpartum depression. Therefore, the aim of this study was to estimate the prevalence of PPD in postpartum women in South Korea and investigate the relationship between PPD and social support.

Results

A total of 1,654 postpartum women were included in the analysis, of which 266 (16.1%) had PPD and 1,388 (83.9%) did not. The demographic and health characteristics of the study participants were summarised in Table 1. Statistically significant differences were observed between social support and having PPD. There were more women with PPDs in groups with low social support. Additionally, there were differences in education level, household income, current employment status, current breastfeeding status, degree of parenting burden within the last month, subjective health status, perceived body image, stress, past diagnosis of depression, and smoking experience between women with and without PPD.

Table 2 shows social support status among participants: 6.0% of women had low, 53.9% had moderate and 40.1% had high social support. Women with lower levels of social support were significantly more likely to have lower education and income levels, job, abortion experience, higher parenting burden, lower subjective health status, higher stress levels, and depression compared with women with moderate or higher supports.

Univariate and multiple logistic regression were conducted to determine the association between PPD and social support while controlling for potential covariates (Table 3). In univariable logistic regression analyses, the women with moderate (OR = 2.66, 95% CI = 1.93–3.67) and low (OR = 6.89, 95% CI = 4.22–11.24) level of social supports had increased likelihood for PPD compared to women with high level of social support. Further, in multivariable logistic regression analyses, women with moderate and low social support levels were 1.78 (95% CI = 1.25–2.52) and 2.73 (95% CI = 1.54–4.83) times more likely to develop PPD, respectively, compared to the women with high social support levels. Furthermore, there was a significant association of PPD in women with jobs (OR = 2.80, 95% CI = 2.02–3.88), breastfeeding women (OR = 1.48, 95% CI = 1.10–2.01), and those diagnosed with depression (OR = 2.78, 95% CI = 1.34–5.78). Regarding degree of parenting burden, women with moderate and high parenting burden reported 5.10 (95% CI = 2.66–9.98) and 10.09 (95% CI = 5.08–20.04) times higher chances of having PPD, respectively, compared to the women with low level of parenting burden. Also, women with moderate and low subjective health status were 1.48 (95% CI = 1.07–2.05) and 5.41 (95% CI = 2.83–10.36) times more likely to develop PPD, respectively. Women with moderate (OR = 2.28, 95% CI = 1.32–3.95) and higher (OR = 4.76, 95% CI = 2.58–8.79) levels of stress were also more likely to develop PPD. Interestingly, those with higher household income level reported less likelihood of PPD (OR = 0.50, 95% CI = 0.27–0.90).

The results of subgroup analyses on social support awareness and PPD with covariates were summarised in Table 4. Among women with multiparity, those with moderate and low levels of social support were 2.85 (95% CI = 1.68–4.82) and 4.90 (95% CI = 2.14–11.23) times more likely to develop PPD, respectively; but there were no statistical differences in women with primiparity. Further, in case of women who have pregnancy loss experience compared to those with no experience, the lower the social support, the greater the odds ratios of PPD. In women with pregnancy loss experience, the odds ratios of PPD were 10.26 times higher in such women with low social supports (low: OR = 10.26, 95% CI = 2.16–48.73). Women with moderate and low levels of social support who reported their body image as normal or obese were more likely to develop PPD (P value for trend < 0.001). In addition, women with jobs and low levels of social support showed the highest likelihood of PPD (OR = 10.34, 95% CI = 2.34–45.64).

Figure 1 presents the relationship between the level of social support in each scale of the development of PPD, and shows that the lower the social support level in all subscales, the higher the odds ratios of PPD. The results showed a high degree of association in order of family, significant others, and friends.

Discussion

The World Health Organization (WHO) noted that mental health problems such as depression and anxiety are common during pregnancy and after childbirth.[21] However, there was limited information on which women develop PPD. Therefore, this study was conducted to investigate the associated factors of PPD, especially how social support affects depression in postpartum women. Our findings show that postpartum women with low social support had 4.63-fold higher odds of PPD compared with postpartum women with high social support. Further, women who are employed or breastfeeding, or have heavy parenting burden, poor subjective health status, high stress level, and were diagnosed with depression in the past were more likely to develop PPD. Furthermore, this study also showed that higher levels of social support may buffer against probability of PPD after adjusting for confounding variables. Given our results, postpartum women need a high level of social support from family, close friends, and significant others.

Interestingly, the subgroup analysis showed that women with multiparity had a five times higher risk of PPD if their social support was low. Multiparity could increase the level of maternal stress and depression because women need to also care for their previous children and infants. Women with multiparity may not receive the same level of social support as they received during their first time of childbearing because they are considered to be child-care experts despite their need of extra social support to take care of their new-born babies. Thus, the results suggest that as women with multiparity are more likely to have PPD, better social support is needed for preventing PPD.[22]

Another interesting finding in the current study is that women with low social support and previous experience of pregnancy loss were 10 times more likely to develop PPD. Our result is in line with previous studies in which previous pregnancy loss served as an effect modifier between social support and PPD. Pregnancy loss is an event which makes the bereaved women particularly prone to depression, mood disorders, dramatic mental health disorder, and even suicide.[23] According to previous research, women who have lost their babies were seven to nine times more vulnerable to depression than women without a pregnancy loss.[24] These results indicate that postpartum women with history of pregnancy loss needs higher level of social support to prevent PPD.

Body image also acts as an effect modifier between social support and PPD. Like adolescence, the period surrounding childbirth is accompanied by unique and rapid changes in not only body shape and size but also psychological dimensions. Prior studies suggested that about 85% of women during pregnancy experience body image dissatisfaction.[25] In recent years, increasing numbers of women reported to be concerned about their weight gain and appearance during pregnancy and postpartum period.[26, 27] Body image may influence depression and health behaviours in postpartum women.[28] The current study results suggest that social support is an important factor that improves mental health of women with negative body image during postpartum period.

Many countries have implemented paid leave to help working parents.[29] Despite policies like paid leaves, women continue to work for reasons such as career, worried about losing jobs, financial burden, and negative attitudes in the workplace. Women with dual roles of having a job and childbearing are especially vulnerable to PPD.[30] Similarly, the current study results showed that women who have a job were 2.8 times more likely to develop PPD. Job strain often cannot be decreased or relieved, but social support in workplace can buffer the negative effect of overwork, and role ambiguity.[30, 31] In addition to workplace support, social support from partner, family, and friends also decrease job stress in postpartum women.[32]

The strength of the study is that the findings are based on a nationwide survey, making the data representative of Korean women and comprehensively assessed depressive symptoms of the postpartum period.

Methods

Declarations

Acknowledgements: This study was funded by the Korea Center for Disease Control and Prevention (Grant number: 2015ER630300), and a Grant-in-Aid for Cancer Research and Control from the National Cancer Center, Korea (#1910231). 

Authors’ contributions: All authors were involved in the study conception and design. All authors were involved in the study conception and design. HC and KL contributed to drafting and writing the manuscript. HNC, EC, and BP contributed to participate in the initial design of the study and revising the article. MS contributed to revising the article and statistical methodology. HC, YR, and KSC contributed to editing, reviewing, and final approval of article. All authors read and approved the final manuscript.

Competing interests: The authors declare no competing interests.

Additional information: Correspondence and requests for materials should be addressed to K.S.C

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Tables

^aSocial support: Total Multidimensional Scale of Perceived Social Support (MSPSS) score range from 12-24 (low), 25-36(moderate), 37-48 (high)

Boldface indicates statistical significance (p<0.05)