Analysis of Determinants of Postpartum Mood Disorders

Background The birth of a child entails major changes in a woman’s life. In the perinatal period, the woman is particularly susceptible to emotional problems. The objective of the present paper was to investigate the relationship between global orientation to life and its components on the one hand, and sociodemographic factors on the other, with regard to early postpartum emotional disorders. Methods The study included 643 patients hospitalized in obstetric departments who had had a spontaneous vaginal delivery. Research instruments included: the Edinburgh Postnatal Depression Scale (EPDS), the Orientation to Life Questionnaire (SOC-29), and the authors’ own survey questionnaire to record participants’ characteristics.

negative emotions are most commonly directed towards the newborn baby. Low mood, tearfulness, fatigue, loss of interest, and low self-esteem may occur as early as the second or third trimester of pregnancy, signaling the risk of postpartum depression. The negative consequences of perinatal depression may have a long-term impact on the mother's bond with her child and her family, and may interfere with shaping the woman's role as a mother [6,7]. Therefore, prevention aiming at identifying women at risk of depression and those already affected is extremely important. In Poland, this need is addressed by the Ordinance of the Minister of Health of August 16, 2018, on perinatal care standards.
This document was introduced to ensure a common, correct standard for medical personnel to follow regardless of the setting in which care is provided. It provides for proper prenatal preparation through quality education aimed at reducing the anxiety associated with labor and subsequent care for the newborn baby, and limiting the risk of depression. The Edinburgh Postnatal Depression Scale (EPDS) is the recommended research instrument for identifying postpartum mood disorders [8]. So far, the etiology of postpartum depression has not been clearly identi ed. Global research indicates that the most common risk factors include: high-risk pregnancy, premature birth, hospitalization during pregnancy, high level of neuroticism, history of depression, and low level of social support [9].
The objective of the present study was to investigate the relationship between global orientation to life and its components on the one hand, and socio-demographic factors on the other, with regard to early postpartum emotional disorders.

Materials And Methods
The study included 634 patients who had had a spontaneous vaginal delivery and were hospitalized in obstetric departments of university hospitals in Lublin, Poland, in the years 2015-2016. Patients aged ≥18 years, who had had spontaneous vaginal delivery, were recruited on their 3rd or 4th postnatal day.
Exclusion criteria were as follows: birth before week 38 of the pregnancy, and the newborn requiring specialist treatment. Patients were informed that participation in the experiment would be strictly voluntary and anonymous, and that results would only be used for scienti c purposes. The authors obtained approval from the Bioethics Committee (approval no. KE-0254/56/2014) of the Lublin Medical University, written informed consent from all patients, and approval from all the health care institutions involved.

Methods
The study was performed using a diagnostic survey with questionnaires. We used standardized research instruments: the Edinburgh Postnatal Depression Scale (EPDS) and the Orientation to Life Questionnaire (SOC-29), as well as a original survey questionnaire.
The EPDS comprises 10 statements describing various aspects of a woman's mood, including: anhedonia, guilt, anxiety, panic attacks, fatigue/overload, sleep disorders, sadness/depression, tearfulness, and suicidal ideation. The patient chooses one of the proposed responses to each statement. Scores for each statement range between 0 and 3 points. The total score is the sum of all item scores, with a maximum of 30 points. Higher scores indicate a higher probability of postpartum depression.
Increased risk of depression is indicated by scores of 12-13 points or higher. In the overall evaluation, any positive score for suicidal ideation should be considered alarming, even with a low total EPDS score.
The Orientation to Life Questionnaire (SOC-29) designed by Aaron Antonovsky measures the "sense of coherence" (SOC), also called "global orientation to life". It re ects an individual's perception of the world as predictable, manageable, and worthy of commitment. SOC has three components: the sense of comprehensibility -belief in the predictability and coherence of stimuli coming in from one's external environment; manageability -belief in one's ability to meet the requirements posed by these stimuli; and meaningfulness -an attitude of readiness to commit and make an effort. The questionnaire comprises 29 items in three subscales, re ecting the three components of coherence: manageability, meaningfulness, and comprehensibility. The respondent rates each statement in reference to themself and their life on a 7-item scale. The Cronbach's α is 0.85 for the entire questionnaire, and between 0.72 and 0.75 for each subscale [11,12].
Original survey questionnaire included sociodemographic variables like age, education, residence, relationship status, number of children, professional activity (additional le 1).

Statistical analysis
Statistical analyses of data from the questionnaires were performed using the SPSS Statistics 25.0 software. Correlations between socio-demographic factors, the incidence of early postpartum emotional disorders, and the global SOC and its components were calculated using the non-parametric Spearman's rho correlation coe cient. Predictors of postpartum mood disorders were identi ed using stepwise hierarchical regression analysis. This method involves stepwise inclusion in the model of variables with the most signi cant impact on the dependent variable, thus limiting the problem of variable correlation. Based on standardized regression residual values, 6% of outliers were removed. To nd which variables, out of SOC components and socio-demographic factors, are signi cant predictors of mood disorders in the postpartum patients, hierarchical regression analysis was used. In the rst step, SOC was considered, and in the second, marital status and education were also included. The dependent variable was the severity of postpartum mood disorders. Two models were built: one for SOC components, and another for global SOC. Findings at p<0.05 were considered statistically signi cant. Table 1 shows respondents' characteristics. The most numerous age bracket was 31-35 years (30.1%).

Results
Most respondents declared having completed higher education (54.6%), lived in province capitals (38.0%) or other cities (38.0%), were married (81.1%), had two or more children (50.5%), and were professionally active (59.9%).   Table 3 shows the associations between global SOC and its components on the one hand, and postpartum mood disorders on the other. Statistically signi cant, moderately strong negative correlations were found between postpartum mood disorder severity and global sense of coherence (p = 0.001), comprehensibility (p = 0.001), manageability (p = 0.001), and meaningfulness (p = 0.001). This indicates that more severe postpartum mood disorders are associated with a lower level of global sense of coherence and its components. Statistically signi cant correlations were found between postpartum mood disorder severity, and patients' marital status (p < 0.05) and education (p < 0.05). More severe postpartum mood disorders were associated with being single and with lower education levels (table 4).  Table 5 presents a summary of hierarchical regression coe cients for global SOC and its components on the one hand, and postpartum mood disorders on the other. The analysis demonstrated that global SOC was signi cantly associated with postpartum mood disorders. A weaker global sense of coherence was a predictor of more severe postpartum mood disorders (β = -0.54; p = 0.001). The model accounted for 54% of variance in the dependent variable. Another model for predicting postpartum mood disorders included two SOC components: meaningfulness and comprehensibility. It accounted for 53% of variance in the dependent variable. More severe postpartum mood disorders were predicted by a weaker sense of meaningfulness (β = -0.33, p = 0.001) and a weaker sense of comprehensibility (β = -0.26, p = 0.01).

Discussion
Affective disorders are a widespread clinical problem among women in their postpartum period. The most commonly observed ones are postpartum blues and postpartum depression. According to researchers, the incidence of postpartum depression symptoms ranges between 30 and 75%, and varies depending on the research instruments used, study sample size, and study timing [14]. Niyonsenga et al. found a high level of postpartum depressive symptoms in 48% of the teenage mothers studied [15]. In a study by Tambaga et al., the prevalence of postpartum blues among women in the 2nd and 3rd month after giving birth was 34.5% [13]. The analysis by Edhborg showed that as many as 64% of women exhibited symptoms of postpartum blues in the rst days after giving birth, but only 24% did after a week.
Women with a history of postpartum depression were twice as likely to have subsequent depressive episodes in the 5-year follow-up period [16].
The results of the present study indicate a signi cant association between postpartum mood disorders and global orientation to life. We con rmed that more severe postpartum mood disorders are associated with a lower level of global sense of coherence. This is consistent with Antonovsky's concept of salutogenesis, where one's sense of coherence (SOC) or "global orientation to life" describes one's way of seeing the world as predictable, manageable, and orderly. Research by Antonovsky indicates that SOC changes during one's lifetime, affected by one's life experiences. It also depends on an individual's strength and ability to adapt effectively to stressors encountered in life [12]. These ndings are also in line with those obtained by Sekizuki et al., who con rmed that a high level of SOC increases the effectiveness of coping with stress [17]. Results from a study by Ogawa suggest that women with low SOC scores were less resistant to stress, and their reactions to stress were more intense, increasing the risk of developing depression [18].
Signi cant predictors of postpartum mood disorders in the present study included global SOC and two of its components: meaningfulness and comprehensibility. This nding corroborates Antonovsky's concept, as the author attributed a particular role in shaping the sense of coherence to meaningfulness [19]. The sense of meaningfulness determines an individual's motivation to act. A study by Rados et al. indicates that people with a strong sense of meaningfulness treat problems as challenges that are worth their effort and commitment [20]. Kurowska et al. observed that this group of people uses all their defense mechanisms to try and change their situation for the better [21].
Many studies sought to identify the relationship between socio-demographic factors and postpartum depression. In the present analysis, there was a notable association between postpartum mood disorders and the women's marital status. A study by Fei-Wan Ngai demonstrated that women in steady relationships have a high level of family-related sense of coherence, which helps them adapt to new life situations [22]. In turn, Charline El-Hachem did not observe any signi cant impact of relationship status on the prevalence of postpartum depression among single women [23]. Małus et al. reported that women who were more satis ed with their relationships were characterized by better psychological condition after giving birth [24]. Umuziga et al. found more severe symptoms of mood disorders after giving birth among respondents having four or more children, who had a poor relationship with their partner, compared to those who only had one child [25]. An association between postpartum depression symptoms and marital con ict was also observed by Brackington. One may suppose that the sense of security provided by a stable relationship is a precondition for a high quality of life [26].
The present study suggests that better self-esteem due to one's higher educational level may have a protective effect against mood disorders. Postpartum blues symptoms were higher in intensity in less educated respondents. A similar nding was reported by David et al. [27]. These observations may be explained by the relationship between education and household income, which in turn affects women's concerns about raising a child. Contrasting data were reported by Vaezi et al. and Maliszewska et al., who found no association between postpartum depression and education [28,29].
There are reports indicating the impact of age on psychological changes after giving birth. Available studies suggest that younger women are more susceptible to negative emotions and more likely to exhibit symptoms of postpartum blues [30,31]. An interesting nding was reported by Rihua Xie et al., who demonstrated a twofold increase in postpartum depression risk among women giving birth by cesarean section. A higher rate of postpartum mood disorders was found among women with medical indications to cesarean delivery than in those with psychiatric indications [32]. Researchers have demonstrated that women with a strong desire to have a spontaneous vaginal delivery were at a higher risk of postpartum depression in the case of an unplanned cesarean section than those who delivered vaginally [33]. In turn, a study by Olieman shows that women having elective cesarean section demonstrated higher levels of prenatal depression, but similar levels of postnatal depression, compared to those having a vaginal delivery [34].
Considering the cited reports from Polish and international authors, measures should be developed to control the ever-increasing rate of cesarean deliveries [37]. While women increasingly opt for elective cesarean section, they are not fully aware of the negative psychological outcomes that are more likely to occur after surgical delivery, and which affect the subsequent development of parental attitudes.
One major limitation of the present study is the inclusion of hospitalized patients only in the rst postpartum days, which prevented generalization to the entire population of mothers. In subsequent studies, a longitudinal design should be applied to provide more complete information on postpartum depression.
Though the correlations between socio-demographic factors and postpartum depression observed here are weak and differ from other authors' ndings, they may become the starting point for further research, ultimately leading to a clearer understanding of factors predicting postnatal emotional disorders.

Conclusions
Factors affecting postpartum mood disorders include the global sense of coherence and its components, namely comprehensibility and meaningfulness, as well as socio-demographic variables -marital status and education. Higher levels of SOC reduce the risk of postpartum blues.