Maternal risk markers of postnatal depression.

Puerperium is a well-established period with increased risk for the development of serious mood disorders.[1] The prevalence of postpartum depression (PPD) is 6%–13% in high-income nations, but it is highly variable in non-Western countries due to variations in methodology and its manifestations across cultures.[2] In India, the prevalence of PPD varies from 11% to 16%,[3] whereas in a recent study in Bangladesh, the prevalence was 39%.[4] PPD represents a considerable public health problem affecting women and their families. Feelings of hopelessness in severe cases can threaten life and lead to suicide.[5] In addition, factors such as fear of harming the baby (36%), weak attachment to the baby (34%), and, in extreme cases, suicide attempts are seen.[6] Therefore, susceptible women need to be identified before delivery to receive proper care measures.

World Health Organization report[1] enumerated a number of risk factors associated with the development of PPD. These are classified according to association and are as follows: strong to moderate [depression or anxiety during pregnancy, stressful recent life events, lack of social support (either perceived or received), and previous history of depression], moderate (high levels of childcare stress, low self-esteem, neuroticism, difficult infant temperament), and small (obstetric and pregnancy complications, cognitive attributions, quality of relationship with partner, socioeconomic status). The factors such as ethnicity, maternal age, level of education, parity, and gender showed no association. The occurrence of depression during pregnancy is a powerful factor in predicting PPD.[7]

The identified risk factors for PPD are socioeconomic (unemployment, low income, low education[8]), social (e.g., emotional and financial support and empathy relations,[9] sexual and domestic violence during pregnancy[10]), obstetrical (nulliparity, caesarean, low breast feeding, parenting stress, mother–child bonding, etc.[11]), biological (young age, glucose metabolism disorders, low serotonin and tryptophan, high oxytocin, rapid decline of reproductive hormones and corticosteroids after delivery[12]), lifestyle-related (food intake patterns, sleep status, exercise, and physical activities), and others (history of depression, negative attitude toward recent pregnancy, low self-esteem, high number of life events, and marital maladjustment[12]).

A relationship has been observed between low hemoglobin at day 7 after delivery (<120 g/L) and postpartum depressive symptoms at day 28.[13] The sufficient consumption of vegetables, fruits, legumes, seafood, milk, dairy products, and olive oil may reduce PPD by 50%.[10] Among the micronutrients, reduced intake of zinc and selenium is linked with the incidence of PPD.[14]

Anthropometric determinants have not been sufficiently researched in relation to suicidality and severity of illness in women with postnatal depression. This study[15] was the first one to look into the relation of anthropometric determinants and postnatal depression and suicidality. The anthropometric determinants assessed included height, weight, weight gain in pregnancy, weight at first antenatal visit, body mass index, and waist-to-hip ratio. The prevalence of PPD was 39%. About 31% had suicidal ideations. Waist-to-hip ratio was the most significant factor in all the models, having a negative correlation with suicidality and severity of depression. The only limitation was a small sample size.

Postnatal period influences infant development and childcare. In an Indian study, postnatal depression was a strong and independent predictor of low weight and length and was significantly associated with adverse mental development quotient scores.[16] Mother–child bonding is shaped during pregnancy and leads to the mental growth and development of infants. It is influenced by different factors, that is, infant-related including delayed birth, breastfeeding, physical problems, and restlessness; parental including attachment style, physical ailments, PPD, and social support networks; and maternal mental health problems. Mother–child bonding has a statistically significant association with mothers' state anxiety, trait anxiety, and depression.[17] The risk for emotional and behavioral problems is high among children of depressed mothers. Infants of prenatally depressed mothers show significantly more growth retardation than controls.[18]

High-risk women should be timely identified for possible early interventions so that the quality of life of mother, infant, and family can be improved.