The effect of social support around pregnancy on postpartum depression among Canadian teen mothers and adult mothers in the maternity experiences survey

Social support is a multi-faceted complex concept that has been extensively studied to define and measure. Broadly defined, social support is a voluntary act from one individual (the donor) that is given to another individual (the recipient), which elicits an immediate or delayed positive response in the recipient [1]. The voluntary act can be given by a family member, friend, husband/partner, and/or others, and it may be given in different forms: informational, physical, emotional (e.g. empathy, caring, love), instrumental (e.g. financial), and appraisal (e.g. information promoting self-evaluation) [2]. Groundbreaking research from the 1970s has shown that the social environment has a direct benefit to health outcomes, such that social support was shown to prevent disease [3]. The consensus of research in the past thirty years have shown that individuals who have greater social support are at odds of greater longevity than those with fewer social ties [4]. Research regarding the association between social support and health moved from mortality risk to morbidity risk, affecting pregnancy outcomes such as fetal (e.g. preterm birth), infant (e.g. low birth weight), and maternal health (e.g. postpartum depression).

Postpartum depression (PPD) is a mood disorder that affects 10–20 per cent of women, and can begin any time during first year after delivery lasting for months [5, 6]. Its symptoms include sadness, fatigue, changes in sleeping and eating patterns, reduced libido, crying episodes, anxiety, irritability, feelings of loneliness, emotional lability, and even thoughts of harming oneself and/or the child [6]. Some significant risk factors for PPD include smoking [7, 8], low levels of social support [9], low socioeconomic status, obstetric complications, and stressful life events during pregnancy [10]. Postpartum depression is associated with self-inflicted injury and morbidity for the mother [10] and poorer responsiveness to infant cues and disengaged parenting behaviours that ultimately lead to harmful cognitive and emotional development in infants [11].

Evidence has shown that social support may decrease risk of depression during pregnancy, which leads to positive health and pregnancy outcomes [4, 12–15]. The level of social support received around pregnancy is different for teen mothers (15–19 years old) and adult mothers (20+ years old) [12, 13]. Teen mothers reported receiving significantly less social support than adult mothers as they had poorer ability to make and maintain relationships with others [12, 13]. It was observed that teen mothers were more deprived in terms of lower education, lower social class (higher unemployment rate), and were more likely to be single compared to adult mothers [12, 13]. Studies have indicated that mothers who received social support during pregnancy and/or after childbirth were significantly less likely to experience PPD [16–18]. However, theses studies were either limited in generalizability, observed only teen mothers, did not include age of mother, or observed only social support received during pregnancy [16–18].

Other studies using the Maternity Experiences Survey have examined PPD as a function of outcome among mothers. Recent study by Kingston, Heaman, Fell, and Chalmers examined the maternity experiences and behaviours among three groups of mothers – adolescent mothers, young adult mothers, and adult mothers, and found that adolescent and young adult mothers were more likely to experience PPD [19]. Vigod and colleagues examined area of residence and risk of PPD [20], and found that prevalence of PPD was greater among mothers living in urban areas compared to rural areas. An epidemiology study by Dennis and colleagues determined that low postpartum support was a significant indicator of PPD among Canadian mothers [21]. However, in all these studies, the relationship between social support and PPD in the context of observing the differences in teen mothers and adult mothers has not been examined.

The purpose of this study was to examine the association of social support received during pregnancy and after childbirth on PPD in a nationally representative sample of Canadian women and identify if the relationship is different for teen mothers (15–19 years old) compared to adult mothers (20+ years old).

The sample size of 6,421 was analyzed in this study, which was weighted to represent 76,508 Canadian women. Out of 6,421 Canadian women, 6,304 had complete information on PPD and thus were included in the analysis. A total of 288 were teen mothers aged 15–19 years.

Socio-demographic characteristics such as immigration status, level of education, and previous depression diagnosis was a significant predictor of PPD. Mothers who immigrated to Canada were almost twice as likely to experience PPD (95% CI, 1.44-2.57) and those who had a previous depression diagnosis were more than twice as likely to experience PPD (adjusted OR, 2.44, 95% CI, 1.88-3.17). However, holding a graduate education degree reduced the likelihood of experiencing PPD (adjusted OR, 0.54, 95% CI, 0.33-0.88).

Pregnancy-related characteristics such as health problems during pregnancy, work during pregnancy, and drug use during pregnancy were significant predictors of PPD. Mothers who received enough information about PPD after birth were 62% less likely to experience PPD (adjusted OR, 0.38, 95% CI, 0.28-0.51).

The purpose of this study was to examine the effect of social support received during pregnancy and after childbirth on PPD in a nationally representative sample of Canadian women and to determine if the relationship differed for teen mothers and adult mothers. Results showed that the relationship between social support and PPD is not different for teen mothers and adult mothers after adjusting for confounding variables.

Literature shows that teen mothers are at greater risk for PPD compared to adult mothers [26–28]. Studies have shown that PPD affects as much as 26% among teen mothers in comparison to 13% among the general population [26, 28, 29], a ratio that is consistent with the present study. The proportional differences in vulnerability to PPD between teen mothers and adult mothers may be partially explained by lifestyle factors and emotional immaturity [27] as teen mothers may lack preparedness for transition into motherhood.

Motherhood requires lots of support in various forms (e.g., financial, appraisal, physical, emotional), and from sources - family, partners, and peers. Generally, adult mothers are known to receive more support regarding their pregnancy compared to teen mothers [12, 13]. Contrary to our study results, literature has shown that teen mothers are reported to have poorer ability to build and maintain interpersonal relationships, indicating the absence of any adequate support compared to adult mothers [13]. One can speculate that this may be due to the fact that teen mothers are not able to readily connect with and relate to majority of their peers who are not going through pregnancy and motherhood. Opportunities to build connections and network with peers and colleagues are not as readily available to teen mothers. Teen mothers usually are unable to finish school and hold lower education and lower social class status than adult mothers [12, 13, 30]. This leads them to be faced with economic burdens as young motherhood may truncate education, which in turn limits opportunities for better employment, and to build and maintain interpersonal relationships [30]. Social support was not defined using a standardized tool in the MES, and is a multi-faceted concept that may be influenced by time and cultural environment. Other factors that were not available in the MES database such as bullying and peer pressure from others may explain and predict risk of PPD even when mothers reported that social support was abundantly received. Needless to say, there is a strong need to further research the cultural-specific definition of social support received among Canadian mothers especially one that draws the distinction between teen mothers and adult mothers.

Results of the present study showed that the relationship between social support and PPD was not significantly different for teen mothers as compared to adult mothers. It suggests that mothers despite their age were at equal risk for PPD when they did not receive any or minimal support after childbirth. Despite the variability in definition of social support, studies have shown that higher levels of support were associated with lower prevalence of PPD among mothers [16–18]. In a study inclusive of women of all ages, Liabsuetrakul et al. [18] found that one of the important and significant post partum predictors of PPD was social support, however, social support during pregnancy was not a significant predictor. In a study by Barnet, et al. [16], the most common support providers for pregnant teens were their mothers and their partners. Teen mothers with high stress and low social support during their pregnancy were at significant risk for depressive symptoms [16]. The absence or lack of support from their partners was eminent among teen mothers as they were more likely to be single (unmarried and/or not living with their partners) [12, 13, 30]. Similarly, in a study by Turner et al. [17], poor family support and poor friend support were predictors of depression among adolescent mothers. Studies have also found that marital status (i.e. single or married) was not significantly associated with the risk of PPD [17, 31], which, the current study also reports. This allows one to speculate that having a partner while pregnant may not be as important, and that specifically looking into partner support will be more crucial for predicting the risk of PPD.

Contrary to literature [7, 8, 32], lifestyle factors such as smoking during pregnancy and alcohol use during pregnancy did not significantly increase the likelihood of experiencing PPD. However, drug use during pregnancy significantly increased the likelihood of experiencing PPD by twofold. Approximately 10% of women in this population smoked cigarettes and drank alcohol during the pregnancy and about 1% used drugs. Although such a minuscule number of Canadian women reported using drugs during pregnancy, it had a profound effect on the risk of PPD among mothers.

Evidence of this present study suggested that education programs on PPD may prove to be an exceptionally important benefit as it acts as a protective factor for PPD. Recent studies have shown that providing education about PPD after childbirth has shown to be effective in decreasing the risk of depression in mothers [33, 34]. In addition, it is more beneficial to give information about PPD to mothers during hospitalization immediately after delivery, as they are more responsive to information about PPD given at that time than in the prenatal stages, as it did not reduce PPD [35–38].

The results found in this study should be cautiously interpreted by taking certain limitations into consideration. Due to the limitation of not being able to release results with cell count ≤5, the following variables were removed from bivariate analysis: immigrant status, level of education, alcohol use, drug use, work status after birth, birth setting, and general experience of labour and birth. Confounding variables that were related to women’s history of depression such as the duration or timing of occurrence, or nature of the treatment received for depression were not provided in the MES database. There is also a potential for recall bias as women’s responses regarding social support may have been influenced by their birth experiences or current circumstances, including their own health or their infant’s health. Furthermore, social support was not defined using a validated standardized tool. Despite the limitations, to our knowledge, no studies have examined the association of PPD and social support around pregnancy after adjusting for confounding variables and examined whether this relationship was similar for teen mothers and adult mothers in Canada.

The present study amplified the need to identify mothers with low levels of support because they are at increased risk for depressive symptoms post partum. To develop effective interventions for mothers who are at more risk to PPD, it is essential to understand the relationship and role of social support during pregnancy and after birth. It is observed that social support after childbirth is important for both teen mothers and adult mothers to have, as it has been found to reduce the risk of experiencing PPD. Educating mothers on PPD soon after birth should be taken into account, as it acts as a protective factor.