Postpartum anxiety, depression and social health: findings from a population-based survey of Australian women.

Abstract

Whilst the prevalence and correlates of postpartum depression are well established, far less is known about postpartum anxiety. Studies have described the association between socio-demographic factors and postpartum depression, yet few have explored the association between stressors in women's lives around the time of having a baby and maternal psychological morbidity. This study aimed to describe the population prevalence of postpartum depression, anxiety, co-morbid anxiety and depression and social health issues; and to examine the association between postpartum psychological and social health issues experienced in the six months following birth.
Population-based survey of all women who gave birth in Victoria and South Australia in September/October 2007. Women were mailed the survey questionnaire six months following birth. Anxiety and depression were measured using the Depression Anxiety Stress Scales (DASS-21).
Questionnaires were completed by 4,366 women. At six months postpartum the proportion of women scoring above the 'normal' range on the DASS-21 was 12.7% for anxiety,17.4% for depression, and 8.1% for co-morbid depression and anxiety. Nearly half the sample reported experiencing stressful life events or social health issues in the six months following birth, with 38.3% reporting one to two and 8.8% reporting three or more social health issues. Women reporting three or more social health issues were significantly more likely to experience postnatal anxiety (Adj OR = 4.12, 95% CI 3.0-5.5) or depression (Adj OR = 5.11, 95% CI = 3.9-6.7) and co-morbid anxiety and depression (Adj OR = 5.41, 95% CI 3.8-7.6) than women who did not report social health issues.
Health care providers including midwives, nurses, medical practitioners and community health workers need to be alert to women's social circumstances and life events experienced in the perinatal period and the interplay between social and emotional health. Usual management for postpartum mental health issues including Cognitive Behavioural Therapy and pharmacological approaches may not be effective if social health issues are not addressed. Coordinated and integrated perinatal care that is responsive to women's social health may lead to improvements in women's emotional wellbeing following birth.

Full text

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RESEARCH ARTICLE Open Access
Postpartum anxiety, depression and social health:
findings from a population-based survey of
Australian women
Jane Yelland1*, Georgina Sutherland1, Stephanie J Brown1,2
Abstract
Background: Whilst the prevalence and correlates of postpartum depression are well established, far less is known
about postpartum anxiety. Studies have described the association between socio-demographic factors and
postpartum depression, yet few have explored the association between stressors in women’s lives around the time
of having a baby and maternal psychological morbidity. This study aimed to describe the population prevalence of
postpartum depression, anxiety, co-morbid anxiety and depression and social health issues; and to examine the
association between postpartum psychological and social health issues experienced in the six months following
birth.
Methods: Population-based survey of all women who gave birth in Victoria and South Australia in September/
October 2007. Women were mailed the survey questionnaire six months following birth. Anxiety and depression
were measured using the Depression Anxiety Stress Scales (DASS-21).
Results: Questionnaires were completed by 4,366 women. At six months postpartum the proportion of women
scoring above the ‘normal’ range on the DASS-21 was 12.7% for anxiety,17.4% for depression, and 8.1% for co-
morbid depression and anxiety. Nearly half the sample reported experiencing stressful life events or social health
issues in the six months following birth, with 38.3% reporting one to two and 8.8% reporting three or more social
health issues. Women reporting three or more social health issues were significantly more likely to experience
postnatal anxiety (Adj OR = 4.12, 95% CI 3.0-5.5) or depression (Adj OR = 5.11, 95% CI = 3.9-6.7) and co-morbid
anxiety and depression (Adj OR = 5.41, 95% CI 3.8-7.6) than women who did not report social health issues.
Conclusions: Health care providers including midwives, nurses, medical practitioners and community health
workers need to be alert to women’s social circumstances and life events experienced in the perinatal period and
the interplay between social and emotional health. Usual management for postpartum mental health issues
including Cognitive Behavioural Therapy and pharmacological approaches may not be effective if social health
issues are not addressed. Coordinated and integrated perinatal care that is responsive to women’s social health
may lead to improvements in women’s emotional wellbeing following birth.
Background
Having a baby is a significant transitional life event,
especially for women having their first child. It involves
changes in relationships between couples and within
families, and is commonly a cause of additional financial
stress, even among households with relatively high
incomes [1]. The impact of stressful life events and
social health issues on maternal psychological morbidity,
such as depression, has been identified in several stu-
dies. O’Hara [2] noted that stressful life events experi-
enced in pregnancy or early postpartum was a strong
predictor of postnatal depressive symptoms. A Swedish
study identified that one of the factors associated with
depressive symptoms in a large national sample was two
or more stressful life events in the year prior to preg-
nancy [3]. Studies from Australia [4] and the USA [5]
have also found associations between experiencing
stressful life events and maternal depression.
* Correspondence: jane.yelland@mcri.edu.au
1Healthy Mothers Healthy Families research group, Murdoch Childrens
Research Institute, Flemington Road, Parkville Victoria, 3052, Australia
Full list of author information is available at the end of the article
Yelland et al. BMC Public Health 2010, 10:771
http://www.biomedcentral.com/1471-2458/10/771
© 2010 Yelland et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

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Internationally there is increasing recognition that
maternal depression is a major public health issue, with
potential long term consequences for women’s health
and the health of her infant and other family members
[6,7]. Concern about under-detection and poor manage-
ment of maternal depression has led to development of
guidelines for assessment and screening of pregnant and
postnatal women in many Western countries. Other psy-
chosocial morbidity, including anxiety, has generally been
overlooked in these national responses. This is despite
evidence that symptoms of depression and anxiety com-
monly co-occur [8,9] and that this co morbidity may be
an indicator of severity of psychological ill-health [10].
Antenatal anxiety has been shown to be associated with
preterm birth [11] and predict postnatal depressive disor-
ders [8]. Studies examining outcomes associated with
maternal postnatal anxiety suggest exposure is related to
adverse psychological problems in children [12].
Previous research have used socio-demographic deter-
minants (i.e. income, educational attainment) to describe
social disparities in maternal emotional wellbeing
[13,14]. The few studies examining perinatal stressful
life events and psychological morbidity have focussed on
maternal depression alone [2-5,15,16]. This study
addresses limitations of previous research, drawing on
data from a large Australian population based survey of
recent mothers to examine anxiety, depression and co-
morbid symptoms at six months postpartum, together
with women’s experiences of stressful life events and
social health issues. The primary aims of analyses pre-
sented in the paper are to: (i) determine the prevalence
of maternal anxiety and depressive symptoms, and co-
morbid symptoms, at six months postpartum; (ii) inves-
tigate the association between postpartum anxiety and
depression and stressful life events and social health
issues experienced in the six months following birth.
Method
Sample
The Healthy Mothers Healthy Families Survey question-
naire was mailed to all women who gave birth in a four
week period in Victoria and an eight week period in
South Australia in September/October 2007, excluding
those who had a stillbirth, or whose baby was known to
have died. All public and private maternity hospitals and
homebirth practitioners were asked to facilitate the
study by distributing the questionnaires to women who
gave birth under their care in the study period. All hos-
pitals with births in the study period (n = 110 hospitals)
agreed to participate, however one hospital withdrew
from the study at the time of the mail-out. Question-
naires, together with a covering letter inviting women to
take part, an explanation of the study in six community
languages (Arabic, Vietnamese, Cantonese, Mandarin,
Somali and Turkish) and a reply paid envelope for
returning the questionnaire free of charge, were posted
to women at around 6 months postpartum. Two remin-
ders were sent at 2-week intervals; the second of these
included a repeat copy of the questionnaire. The survey
questionnaire was in English only.
Research ethics approval was obtained from the ethics
committee of the Victorian Department of Human Ser-
vices, the South Australian Department of Health, the
University of South Australia, the Royal Children’s Hos-
pital and ten participating hospitals.
Questionnaire
The questionnaire covered women’s views of antenatal,
intrapartum and postnatal care. Data were also collected
on reproductive history, maternal socio-demographic
characteristics, and maternal psychosocial health issues
in pregnancy and postnatally. Maternal socio-demo-
graphic characteristics included: maternal country of
birth, Aboriginal or Torres Strait Islander, completion of
secondary school, household income, health care con-
cession card holder, relationship status and health insur-
ance status. The reported estimate of before tax
household income has been adjusted by an equivalence
factor (using the modified OECD equivalence scale) [17]
to account for households of different size (number of
people) and composition (adults and children). The
questionnaire was developed drawing on questionnaires
used in three previous Victorian Surveys of Recent
Mothers [18-20] and standardised instruments as out-
lined below. Piloting was undertaken to assess accept-
ability with diverse groups of recent mothers.
Measurement of postnatal anxiety and depression using
the DASS-21
The Depression Anxiety Stress Scales (DASS) [21] is a
self-report instrument designed to measure the negative
emotional states of depression, anxiety and stress. The
DASS depression scale has been shown to correlate
strongly with the Beck Depression Inventory-(BDI-II,
r = .74), and the DASS anxiety scale with the Beck
Anxiety Inventory (r = .81) [21,22].
The 21 item form of the DASS was incorporated into
the questionnaire to measure severity of symptoms com-
mon to anxiety and depression and the prevalence of
co-morbid depression and anxiety. Women were asked
to use a 4-point severity/frequency scale to rate the
extent to which they had experienced each symptom
over the past week from ‘never’ to ‘most of the time’.
Measurement of stressful life events and social health
issues
The questionnaire included a list of stressful life events
and social health issues drawing on items from the
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Pregnancy Risk Assessment and Monitoring Study
(PRAMS) [23] and a review of the impact of life events
and social health issues on health in the perinatal per-
iod. Women were asked “Have any of the following
things happened to you in the months since your baby
was born?’ and asked to tick yes or no to the list of
items including major life events, such as separation and
divorce, moving house, losing your job, death of a close
family member or friend and social health issues, such
as having a lot of bills you couldn’t pay, not having
enough money to buy food, legal troubles or being
involved in a court case, serious family conflict or being
homeless.
Analysis
To assess the representativeness of the sample we com-
pared data on the social characteristics of study partici-
pants with routinely collected data from the Victorian
Perinatal Data Collection Unit and South Australian
Pregnancy Outcome Unit for all women who gave birth
in the study period, excluding women who had a still-
birth or neonatal death.
Data were analysed using STATA version 11.0 [24]
and involved the calculation of unadjusted and adjusted
odds ratios and 95% confidence intervals. Level of statis-
tical significance was p < 0.01. Scores for the DASS-21
sub-scales of depression and anxiety were derived by
totalling the scores for each sub-scale and multiplying
by two to ensure consistent interpretation with the
longer 42 item version [21]. We classified women
according to the recommended scoring system using
cut-off values to classify participants into the following
categories: normal (0-9 for depression and 0-7 for anxi-
ety), mild (10-13 for depression and 8-9 for anxiety),
moderate (14-20 for depression and 10-14 for anxiety),
severe (21-27 for depression and 15-19 for anxiety), and
extremely severe (≥28 for depression and ≥20 for anxi-
ety). We have referred to women within the ‘normal’
range on the DASS-21 for depressive or anxiety symp-
toms as non-depressed or non-anxious respectively.
Women, who scored in the ‘mild’ to ‘extremely severe’
ranges, were referred to as depressed or anxious. Analy-
sis is based on this dichotomy (i.e. ‘normal range’ versus
‘mild to extremely severe’ symptoms).
Multivariable logistic regression was used to assess the
relationship between number of stressful life events and
social health issues as the exposure of main interest, and
depression, anxiety, and co-morbid depression and anxi-
ety as the primary outcome variables. Three separate
models were developed adjusting for maternal socio-
demographic characteristics. Women with missing
responses on any variable were excluded from these
analyses.
Results
Response & characteristics of the sample
Questionnaires were mailed to 8,597 women six month
after childbirth. The adjusted response fraction exclud-
ing questionnaires that had been ‘returned to sender’,
duplicate responses and women who gave birth outside
the study period was 52% (4366/8468). See Figure 1.
Table 1 shows selected demographic and obstetric
characteristics of the sample. Participants were aged
between 16 and 46 years, with a mean age of 31 years.
More than half the sample was multiparous (56%). One
in five participants (19%) were born outside Australia,
one in ten (12%) in countries where English is not the
primary language. Three-quarters of participants (76%)
were married and 19% were living with a partner. Forty-
eight percent of women had private health insurance,
with the remainder covered by Medicare, Australia’s
universal health insurance scheme.
Women taking part in the survey were largely repre-
sentative in terms of parity, method of birth and infant
birthweight compared with women who gave birth in
the study period according to data collected by the Peri-
natal Data Collection Unit in Victoria and the Preg-
nancy Outcome Unit in South Australia. Women born
overseas of non-English speaking background, Aborigi-
nal and Torres Strait Islander women, women under the
age of 25 years and single women were under-repre-
sented. The estimated response fractions for women
born overseas of non-English speaking background, and
young women (under 25 years) were 34% and 30%
respectively.
Depression and anxiety
At six months postpartum the proportion of women
reporting symptoms in the ‘mild’ to ‘extremely severe’
range on the DASS-21 scales was 12.7% for anxiety and
17.4% for depression, 8.1% of women reported co-morbid
symptoms, i.e. combined anxiety and depressive symp-
toms. Of the 918 women who experienced symptoms of
anxiety and/or depression, 385/918 (41.9%) scored as
depressed alone, 189/918 (20.6%) scored as anxious
alone, and 344/918 (37.5%) scored as both depressed and
anxious. Around 2% of women could not be classified
due to missing values. Figure 2 shows the severity of
anxiety and depressive symptoms, according to scores on
the DASS 21.
Stressful life events and social health issues
Nearly half of women reported experiencing one or
more stressful life events or social health issues in the
six months following birth (47.6%, 2076/4359), 37.8%
(1646/4359) reported one or two stressful life events or
social health issues and 9.9% (430/4359) reported three
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or more social health issues. Data were missing for
seven women who did not complete this section of the
questionnaire. Reported life events and social health
issues are shown in Table 2. The most common life
events, affecting one in ten women, were death or illness
of friend or family member, and moving to a new
house/place to live. Common social health issues affect-
ing around one in ten women were: having a lot of bills
you couldn’t pay, and serious conflict between members
of your family. Nearly five percent of women reported
not having enough money to buy food.
Table 3 describes the relationship between the num-
ber of stressful life events and social health issues, and
social and obstetric characteristics. Women who
reported three or more social health issues were more
likely to: be under 25 years (OR 2.63 [95% CI 2.1-3.3]),
unmarried (OR 1.97 [95% CI 1.7-2.3]), of Aboriginal or
Torres Strait Islander origin (OR 2.69 [95% CI 1.2-5.9]),
not to have completed secondary school (OR 1.43 [95%
1.2-1.6]), to have a low income (OR 1.94 [95% CI 1.6-
2.3]), health care concession card (OR 2.14 [95% CI 1.8-
2.5]) and not to have private health insurance (OR 1.48
[95% CI 1.3-1.7]).
Association between depression, anxiety and social
health
Associations between maternal socio-demographic char-
acteristics, stressful life events and social health issues,
and anxiety and depression are shown in Table 4. Unad-
justed odds ratios indicate that women who scored
above the cut-off score for depressive symptoms were
more likely to: be young (under 25 years of age), living
Hospitals & home birth practitioners identified all women
who gave birth in:
South Australia (1stSeptember – 26thOctober 2007)
n=2900
Victoria (1stSeptember – 28thSeptember 2007)
n=5755
Excluded:
Stillbirths: 41
Neonatal deaths: 16
Maternal death: 1
Questionnaires mailed out
n= 8,597
Excluded:
Questionnaires
‘returned to sender’
n= 80
Completed questionnaires received
n=4,415 (4415/8517)
Total number of participants
n= 4,366 (4366/8468)
Excluded:
Births outside study
period:
n=49
Figure 1 Flow chart of survey participation.
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with their partner or single, divorced or separated rather
than married, not to have completed secondary school
and to have a health care concession card. Women hav-
ing their first baby were less likely to have depressive
symptoms than women having a second or subsequent
baby. There was a very marked association between
number of stressful life events and social health issues
and depressive symptoms. Reporting three or more
stressful life events or social health issues was associated
with greater than a five-fold increase in odds of depres-
sive symptoms. Odds were also significantly raised for
women reporting one or two stressful life events or
social health issues.
A similar pattern is apparent for women with symp-
toms of anxiety. There was a two-fold increase in the
unadjusted odds of reporting anxiety symptoms in
women reporting one to two stressful life events or
social health issues, rising to a five fold increase for
women reporting three or more issues or events.
Women born overseas in a country where English is not
the primary community language were more likely to
report anxiety symptoms than women born in Australia.
There was no association between anxiety symptoms
and parity (Table 4).
When compared with women with no psychological
morbidity, symptoms of co-morbid anxiety and depres-
sion were associated with young maternal age, not being
married, not having completed secondary school, having
a health care concession card and experiencing one or
more social health issues following birth (Table 5).
Multivariable logistic regression models were devel-
oped to provide a more precise estimate of associations
between depressive symptoms, anxiety symptoms and
co-morbid symptoms (primary outcomes) and the vari-
able measuring stressful life events and social health
issues (exposure of main interest). Other variables
included in modelling analyses were: maternal age, rela-
tionship status, maternal country of birth, secondary
education, parity and health care card. The latter was
included as a measure of economic resources in prefer-
ence to household income as there was less missing
data for this item. Women with missing responses on
any variable (or women who did not disclose their
income by selecting response options ‘not sure’ of ‘pre-
fer not to answer’) were excluded from these analyses.
This left a total of 4063 cases for depression, 4078 cases
for anxiety and 4052 cases for the co-morbid depression
and anxiety analysis.
After adjusting for socio-demographic characteristics
and parity, the significant associations between stressful
life events and social health issues and the three out-
come variables (anxiety symptoms, depressive symp-
toms, co-morbid anxiety and depressive symptoms)
remained largely unchanged (Table 4 & 5). In each case
Table 1 Social and reproductive characteristics of
participants in the HMHF Survey (n = 4,366)
No.%
Maternal age (years)
16-24
25-29
30-34
≥35
416
1053
1604
1138
9.9
25.0
38.1
27.0
Relationship status
Married
Living with partner
Not living with partner/divorced/separated/widowed/
single
3318
835
198
76.3
19.2
4.5
Indigenous status
Non-Aboriginal
Aboriginal and/or Torres Strait Islander
4051
31
99.2
0.8
Country of birth
Australia
Overseas - English speaking
Overseas - Non English speaking background
3521
272
526
81.5
6.3
12.2
Education
Completed secondary school
Did not complete secondary school
3429
894
79.3
20.7
Equivalised Household Income*
< $20,000
$20,000-$40,000
> $40,000
938
1958
979
23.9
50.6
25.5
Health Care Card
No
Yes
3597
734
83.1
16.9
Private health insurance for birth
No
Yes
2250
2092
51.8
48.2
Parity
Multiparous
Primiparous
2425
1941
55.7
44.3
Method of birth
Spontaneous vaginal birth
Instrumental vaginal birth
Caesarean section, no labour
Caesarean section, in labour
2338
602
801
615
53.7
13.8
18.4
14.1
Birthweight of the infant
< 2500g
2500-3499g
3500-3999g
≥4000
179
2023
1390
560
4.3
48.7
33.5
13.5
Plurality
Singleton
Twin
Triplet
4275
64
1
98.4
1.5
< 0.1
Denominators vary because of missing values.
*Adjusted by family size and composition using OECD modified equivalence
scale.
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