Depressive disorder (also known as depression) is a common psychiatric disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. Depression is different from regular mood changes and feelings about everyday life. It can affect all aspects of life, including relationships with family, friends and community. It can result from or lead to problems at home and at work. Depression can happen to anyone. People who have lived through abuse, severe losses or other stressful events are more likely to develop depression ¹ Approximately 280 million people in the world have depression. Depression is about 50% more common among women than among men. Worldwide, more than 10% of pregnant women and women who have just given birth experience depression².  The triggers for depression appear to differ, with women more often presenting with internalising symptoms and men presenting with externalising symptoms³. Women also experience specific forms of depression-related illness, including premenstrual dysphoric disorder, postpartum depression and postmenopausal depression and anxiety, that are associated with changes in ovarian hormones and could contribute to the increased prevalence in women.After childbirth, mothers may experience "baby blues," characterised by temporary sadness and tearfulness, which typically resolve within two weeks. In contrast, postpartum depression (PPD) affects approximately one in seven women, lasting longer and significantly impacting maternal function and the mother-infant relationship, often persisting for up to 12 months⁴. There is also a stigma around new mothers in that disclosure may lead to abandonment and fear of lack of support⁵. Reports from the World Health Organization (WHO) in 2017 suggested that more than 322 million people suffered from depression⁶. The Global Burden of Diseases study in 2015 systematically analysed the data of 17 low and middle-income countries (LMICs) and reported an 18.4% prevalence of PPD⁷. Postpartum depression (PPD) effects 6.5% to 20% of women⁸, commonly occurring within 6 weeks of childbirth and influenced by factors such as low socioeconomic status⁹, lack of social support¹⁰,and history of mental illness, antenatal depression¹¹. Effective postpartum care, including a comprehensive 12-week follow-up22 as recommended by ACOG, is crucial for addressing both PPD and other health issues to improve maternal and infant outcomes¹². However, barriers like cultural differences and lack of insurance contribute to inadequate postpartum care, potentially leading to undiagnosed and untreated PPD with serious consequences. According to the Pregnancy Mortality Surveillance System (PMSS), Non-hispanic blacks have the highest maternal mortality ^13,14. Once postpartum depression is identified, rapidly implemented treatment is essential. Without prompt treatment, patients are at risk for lengthy illness that could lead to impaired functioning, worsening symptoms, treatment resistance and suicide. Similar to the management of major depressive disorder outside of childbearing, the evidence-based mainstays of PPD treatment are focused psychotherapy and/or antidepressant medication¹⁵. The Hamilton Depression Rating Scale was developed in the late 1950s to assess the effectiveness of the first generation of antidepressants and was originally published in 1960¹⁶. This scale is the standard measure of depression severity for clinical trials of antidepressants¹⁷. The Hamilton depression scale is  the most commonly used scale for measure of depression¹⁸. Many studies have tried to determine the level of prevalence and explore the influencing factors on PPD but most of them were conducted before covid-19, thus we plan our study to estimate the present prevalence of postpartum depression in postpartum females and identify associated

factors.

AIM

To estimate the prevalence of postpartum depression by Hamilton depression rating scale and identify associated factors.

MATERIALS AND METHODS

The study was designed as a hospital-based cross-sectional investigation, conducted at the Department of Obstetrics and Gynaecology, PBM Hospital in Bikaner, a tertiary care facility serving a significant portion of Rajasthan, India. The study spanned one year, from August 2023 to July 2024, focusing on postpartum women who delivered at the hospital. Inclusion criteria encompassed women aged 18 years and older, those willing to participate, and those within 2 days postpartum. Exclusion criteria included individuals who refused consent, had acute illnesses or systemic diseases, were lost to follow-up, or had known psychiatric disorders. Convenience sampling was used to select participants for the study.

SAMPLE SIZE: 

A sample size of 200 postpartum females required at 80% study power and alpha error 5%. MEDCALC statistical software was used for sample size. Prevalence of postpartum depression in postnatal women is 13.00% as per reference article.3 

Alpha - 5% 

Power of study - 80%

N =4 pq/l2

After taking 10% lost to follow up, minimum 250 cases was taken

including fulfilling the eligibility criteria.

TABLE 1: Distribution of subjects according to Age:

Maximum 51% subjects were in 19 – 25 years age group followed by 34.5% in 26 – 30 years age group whereas minimum 4.5% in >35 years age group with mean age of 24.79 ± 3.64 years.

TABLE 2: Distribution of subjects according to their HAM-D scale score

According to the depression score at 48 hrs 22 % subjects had >7 score whereas 78% were normal (score <7). At 6 week depression score defines that prevalence of depression in our study was 12% out of  which 8% were in mild, 2% moderate and 2% were in severe depression

TABLE 3: Association of Age with Postpartum depression:

In 19 – 25 years age group 97.06% subjects had ≤ 7 score and 2.94% subjects had score >7. In 26 – 30 years age group 81.16% subjects had score ≤7 and 18.84% subjects had score >7. In 31-35 years age group 70% subjects had score ≤7 and 30 % subjects had score >7. In >35 years age group 77.78% subjects had score ≤7 and 12 % subjects had score >7. The difference of distribution of depression was found to be statistically significant. (P value – 0.0001

TABLE 4: Comparison of depression score of subjects with their Obstetric status

Out of 92 primipara subjects 4 (4.35%) had >7 score whereas 20 (18.51%) out of 108 multipara subjects had >7 score. The difference was  found to be statistically significant. (p=0.0032*) Out of 32 subjects with bad obstetric history 22 (68.75%) had >7 score whereas 2 (1.19%) out of 168 subjects with normal obstetric history had score>7. The difference was found to be statistically significant. (p=0.0001)

TABLE 5: Comparison of depression score of subjects with their present pregnancy

The differences in scores greater than 7 between subjects with and without intrapartum complications and between those who underwent LSCS versus vaginal delivery were statistically insignificant, whereas scores greater than 7 were significantly higher among those with stillbirths and neonatal deaths

TABLE 6: Comparison of depression score of subjects withassociated factors

The study revealed that individuals with postpartum sadness, premenstrual dysphoria, antenatal anxiety, abusive relationships, or lack of social support had significantly higher rates of scores >7 compared to those without these conditions. Statistical analyses confirmed that these differences were significant, with p-values  (p=0.0001**)

In our study, maximum 51% cases were in 19–25years age group followed by 34.5% in 26 – 30 years age group whereas minimum 4.5% in >35years with mean age of 24.79 ± 3.64 yearsSimilarly Rahaney et al (2021)¹⁹ found in their study that Mean age of the participants was  25.53 (standard deviation –3.2).

In our study, according to HAM-D Score at 48 hrs 22 % subjects had >7 score whereas 78% subjects had score ≤7. At 6 week depression score defines that the prevalence of depression in our study was 12% out of which 8% were mild, 2% were in moderate and 2% were in severe depression. Thus the prevalence of PPD was found to be 12%. Similarly Helen Bradshaw et al. (2022)²⁰ found that of all respondents, 9.4% endorsed PDS. Also Rahaney, et al (2021)¹⁹ found in their study that 6.7% of the participants fulfilled the criteria for major depressive disorder. EPDS score also suggested that possible depression was present in 6.7% of the participants. Higher prevalence was seen in a study conducted by Lakshmi Bhuvana G et al. (2016)²¹ on a total of 236 postpartum women were screened for depression using the Hamilton rating scale for depression and about 74(31.4%) were found to be with depression and 30.0% prevalence was found in study conducted by Peiqin Liang et al. (2020)⁴⁵, 20.1% in Bereket Duko et al. (2020)²².

In 19 – 25 years age group 97.06% cases had ≤ 7 score and 2.94% cases had score >7. In 26 – 30 years age group 81.16% cases had score ≤7 and 18.84% cases had score >7. In 31-35 years age group 70% cases had score ≤7 and 30 % subjects had score >7. In >35 years age group 77.78%  subjects had score ≤7 and 12 % subjects had score >7. The difference of distribution of depression in age groups was found to be statically significant. (P value –0.0001).  Rahaney et al. (2021)¹⁹found that Younger (30 years) age at pregnancy were found to be the risk factors for developing PPD. Also Lakshmi Bhuvana G et al. (2016)¹⁹ observed according to the age wise categorization majority of the postpartum depressed women were found between the age group of 21 to 25 years (55.4%), followed by the age group 16 to 20 years (24.3%). Based on the severity of depression, the majority of the postpartum women were of 21-25 years age and most of them were found to be mildly depressed. The difference in prevalence in different age groups could be related to multiple factors such as age at the time of marriage, first child bearing age, working female and also number of cases included in different age groups. Also Rahaney, et al (2021)¹⁹found that more number of participants in the age group of 21–30 years were found to have a HAMD score ≤7 whereas, in the age groups of <20 years and 31–35 years, majority of the participants had HAM-D score of >8 suggestive of higher prevalence of depression among younger and older mothers. These findings were similar to that of the study conducted in rural South India, which suggested that patients under the age of 20 or over 30 are at a higher risk for PPD²³  This finding may be due to higher levels of stress associated with an early or late pregnancy which may manifest as depression.

In our study, out of 32 bad obstetric history subjects 22 (68.75%) had >7 score whereas 2 (1.19%) out of 168 subjects with normal obstetric history had score>7 (p=0.0001). Out of 25 subjects of unplanned pregnancy 5 (16.67%) had >7 score whereas 19 (11.17%) out of 170 subjects of planned pregnancy had >7 score.(p=0.149)  Similar results were found in a study conducted by Rahaney et al. (2021)¹⁹ that 75% of the participants with a history of abortion had HAM-D score significantly higher than those with no history of abortion (P = 0.043). This indicates that a history of abortion can act as a stressor and it may worsen the ability to cope with the current stressful situation. Stigma and misconceptions related to abortion may contribute to the same.

In our study, out of 78 subjects with lack of social support 71.79% had score ≤7 and 28.20% had score >7, whereas out of 120 subjects with social support only 1.67% had score  >7. Out of 11 subjects with Abusive relationship 45.45% subjects had score ≤7 and 54.55% had score >7, whereas out of 171 subjects who did not have abusive relationship only 9.52% subjects had score >7. Out of 68 subjects with Antenatal Anxiety 72.37% subjects had score ≤7 and 27.63% had score >7, whereas out of 124 subjects who did not have Antenatal Anxiety only 8.33% had score >7. Out of 129 subjects with Premenstrual dysphoria 84.5% had score ≤7 and 15.5% had score >7, whereas out of 71 subjects who did not have Premenstrual dysphoria only 4 (5.63%) subjects had score  >7. Out of 114 subjects with Post Partum sadness 90 (78.95%) had score ≤7 and 24 (21.05%) had score >7, whereas out of 86 subjects who did not have Post Partum sadness no subjects 0 (0.00%) had score >7.The difference was found to be statistically significant. (p=0.0001**)  Patel et al²⁴ in 2001 found that in the Indian setting most common psychosocial factors which predispose women to develop PPD were preference to male child, violence against women, poverty and lack of social support.However, none of those factors was found to be a risk factor for PPD in this study. Planned pregnancy, family support and support of the husband were found to be protective factors in a study done by Kalar et al. in Karachi, but in this study those factors were not found to be significant²⁵. Some studies have mentioned that multiparous women had lower levels of social support and marital satisfaction which may lead to manifestation of depressive symptoms²⁶. Similarly YoungJae Lee et al. (2015)²⁷ found that The prevalence rate of premenstrual syndrome (PMS) was 9%, in a study conducted in North korea. Among 23 women in the postpartum depression group, eight were determined to have premenstrual dysphoric disorder, yielding a prevalence rate of 34.8% (8/23). Among 143 women in the postpartum non-depression group, seven were determined to have PMS, yielding a prevalence rate of 4.9% (7/143). A correlation between postpartum depression and PMS was thus found (P<0.01).

Postpartum depression is a frequent disorder of puerperal period of which detection is of utmost importance as this has negative effects for both mother herself and family. Social factors predominated in being correlated with postpartum depressive disorder. These included age,  having unplanned pregnancy.  This study has both clinical and research implications. Clinically, the highlighted importance of psychosocial factors such as social support, premenstrual dysphoria, abusive relationships, stressful life events, anxiety symptoms in a new mother calls for consideration of these factors during the designing of antenatal and postnatal care plans. The role of domiciliary visits to new mothers cannot be overemphasized especially in a setting where most women will not or cannot attend the regular antenatal or postnatal clinics even within their community. The findings of this study may form the basis for screening women for risk of psychiatric disorder in the postpartum period to prevent disabling morbidity and suicide in young mothers.

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