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Antenatal depression symptoms in Pacific women: evidence from Growing Up in New Zealand

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INTRODUCTIONPacific women in New Zealand (NZ) have higher rates of antenatal depression than women from other ethnic groups. AIMTo identify factors that are significantly associated with depression symptoms in pregnant Pacific women living in NZ. METHODS Data were collected from 5657 pregnant women, 727 of whom identified their ethnicity as Pacific Island. Antenatal depression symptoms were measured using the Edinburgh Depression Scale with scores above 12 indicating elevated antenatal depression symptoms (ADS). RESULTSPacific women had significantly higher rates of ADS than non-Pacific women, with 23% of pregnant Pacific women experiencing ADS. Factors associated with ADS for Pacific women included age <25 years, moderate to severe nausea during pregnancy, perceived stress, family stress and relationship conflict. Not seeing the importance of maintaining one’s Pacific culture and traditions and negative feelings towards NZ culture were also significantly associated with ADS in Pacific women. One in three Pacific women aged <25 years experienced ADS. Pregnant Pacific women without a family general practitioner (GP) before their pregnancy were 4.5-fold more likely to experience ADS than non-Pacific women with a regular GP. DISCUSSIONFurther attention is required to providing appropriate primary health care for Pacific women of child-bearing age in NZ. Better screening processes and a greater understanding of effective antenatal support for Pacific women is recommended to respond to the multiple risk factors for antenatal depression among Pacific women.
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A B S T R A C T
INTRODUC TION: Paci c women in New Zealand (NZ) have higher rates of antenatal depression
than women from other ethnic groups.
A I M : To identify factors that are signi cantly associated with depression symptoms in preg-
nant Paci c women living in NZ.
M E T H O D S : Data were collected from 5657 pregnant women, 727 of whom identi ed their
ethnicity as Paci c Island. Antenatal depression symptoms were measured using the
Edinburgh Depression Scale with scores above 12 indicating elevated antenatal depression
symptoms (ADS).
R E S U L T S : Paci c women had signi cantly higher rates of ADS than non-Paci c women, with
23% of pregnant Paci c women experiencing ADS. Factors associated with ADS for Paci c
women included age <25 years, moderate to severe nausea during pregnancy, perceived
stress, family stress and relationship con ict. Not seeing the importance of maintaining one’s
Paci c culture and traditions and negative feelings towards NZ culture were also signi -
cantly associated with ADS in Paci c women. One in three Paci c women aged <25 years
experienced ADS. Pregnant Paci c women without a family general practitioner (GP) before
their pregnancy were 4.5-fold more likely to experience ADS than non-Paci c women with a
regular GP.
DISCUSSION: Further attention is required to providing appropriate primary health care for
Paci c women of child-bearing age in NZ. Better screening processes and a greater under-
standing of ef fective antenatal support for Paci c women is recommended to respond to the
multiple risk factors for antenatal depression among Paci c women.
Antenatal depression symptoms
in Paci c women: evidence from
Growing Up in New Zealand
Frances McDaid , BHSc ;
1 Lisa Underwood , PhD ;
2
,
7 Jacinta Fa’alili-Fidow , MPH ;
3 Karen E. Waldie , PhD ;
4
Elizabeth R. Peterson , PhD ;
4 Amy Bird , PhD ;
5 Stephanie D’Souza , PhD ;
6 Susan Morton , FNZCPHM
2
,
3
1
Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Auckland, New Zealand.
2
School of Population Health, University of Auckland, PO Box 18288, Auckland, 1743, New Zealand.
3
Centre for Longitudinal Research, University of Auckland, PO Box 18288, Auckland 1743, New Zealand.
4
School of Psychology, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
5
School of Psychology, University of Wollongong, North elds Ave, NSW 2522, Australia.
6
COMPASS Research Centre, University of Auckland, Private Bag 92019, Auckland, New Zealand.
7
Corresponding author. Email: l.underwood@auckland.ac.nz
2019;11(2):96–108
J PRIM HEALTH CARE
doi:10.1071/HC18102
Received 20 December 2018
Accepted 23 May 2019
Published 18 July 2019
KEY WORDS: Antenatal depression; Edinburgh Depression Scale; Paci c pregnant women;
perinatal depression; primar y healthcare
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Introduction
Paci c peoples in New Zealand (NZ) are inequi-
tably exposed to the determinants of health and
illness, leading to more adverse health outcomes
than people of other ethnic groups.
1 , 2 P a c i c peo-
ples’ or ‘Paci c women’ is used in this research
to describe people who self-prioritise a Paci c
ethnicity.  e NZ government has, on numerous
occasions, committed to improve the health and
access to health care of Paci c peoples in NZ.
3
6
e prevalence of antenatal depression among
pregnant women is 7–13%.
7 8 However, rates vary
considerably between studies.  is can be ex-
plained, in part, by the di erent measures used to
detect depression
7 and di erences in the underly-
ing risk for depression among study participants.
9
Implications of antenatal depression for women
are increased risk of postnatal depression,
10
post-traumatic stress and psychiatric morbid-
ity. 11 N e g a t i v e e ects of antenatal depression for
child health include impaired child behavioural,
cognitive and emotional development,
12 13 a s w e l l
as intrauterine growth retardation,
14 lower Apgar
scores, smaller head circumference and increased
risk of infant mortality.
15 Antenatal depression
is also associated with decreased rates of breast-
feeding, which has further implications for child
health and development.
16
Although much is known about factors associated
with antenatal depression internationally, there
are relatively few such studies in NZ populations.
In 2015, Waldie et al.
17 investigated factors associ-
ated with probable antenatal depression (de ned
as a total Edinburgh Depression Scale (EDS) score
>12 during pregnancy) among the Growing Up
in New Zealand cohort. Women of Paci c Island,
Asian and ‘other’ ethnicities were more likely to
experience probable antenatal depression. Other
signi cant variables were perceived stress score, a
diagnosis of anxiety both before and during preg-
nancy and a diagnosis of depression both before
and during pregnancy.
17
Ethnicity is o en identi ed as a factor associated
with increased symptoms of antenatal depres-
sion. 18 However, the sociocultural factors associ-
ated with ethnicity mediate this relationship and
there is currently no evidence to suggest that there
are genetic or biological factors associated with an
ethnic group that cause depressive symptoms.
19 20
It is likely that the association between ethnic-
ity and antenatal depression is due to inequitable
exposure of di erent ethnic groups to determining
factors, 18 including intimate partner violence and
abuse, 18 21 history of depression,
22 low socioeco-
nomic status and unplanned pregnancy.
21
Apart from Growing Up in New Zealand,
research that has examined the relationship be-
tween depression and Paci c peoples includes the
Paci c Island Families (PIF) Study
23 and Te Rau
Hinengaro –  e NZ Mental Health Survey.
24 R e -
sults from these large studies have been used in
government reports to highlight a growing con-
cern for the mental health of Paci c peoples.
6 , 25 , 26
e PIF Study used the EDS to assess postnatal
depression in 1376 NZ Paci c mothers when
their children were 6 weeks old.
23 High rates of
probable depression were found, ranging from
7.6% to 31% among di erent Paci c ethnicities,
with an overall prevalence of 16%. Risk factors
for postnatal depression included low Paci c
Island acculturation (Paci c mothers reporting
low cultural orientation towards Paci c culture,
not valuing or retaining elements of Paci c cul-
ture),  rst birth, stress due to insu cient food, low
household income, di culty with transport, dis-
satisfaction with pregnancy, dissatisfaction with
birth experience, dissatisfaction with baby’s sleep
patterns, dissatisfaction with partner relationship
and dissatisfaction with their home.
23
WHAT GAP THIS FILLS
What is already known: Paci c women in NZ have higher rates of
antenatal depression than women from other ethnic groups.
Antenatal depression is associated with an increased risk of ma-
ternal postnatal depression and post-traumatic stress, as well as
impaired child behavioural, cognitive and emotional development,
and decreased rates of breastfeeding.
What this research adds: Almost one in four pregnant Paci c women
experience antenatal depression symptoms (ADS). One in three
Paci c women aged <25 years experienced ADS. Pregnant
Paci c women without a family general practitioner (GP) before
their pregnancy were 4.5-fold more likely to experience ADS than
non-Paci c women with a regular GP.
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e PIF Study did not take prepregnancy or
antenatal depression symptoms into account when
exploring factors associated with postnatal depres-
sion in Paci c Peoples, and there is no literature
addressing possible reasons for Paci c women in
NZ experiencing high rates of antenatal depres-
sion as reported by Waldie et al.
17 e present
study aimed to  ll that gap in the hope that its
ndings can be used to contribute to the reduction
of health inequities experienced by Paci c peoples.
Methods
General procedure
is research used data collected as part of the
Growing Up in New Zealand study, speci cally
the data collected from pregnant women in the
Antenatal Data Collection Wave in 2010.  e
only inclusion criteria for Growing Up in New
Zealand was pregnant women with a due date be-
tween 25 April 2009 and 25 March 2010, and who
lived, during late pregnancy, in the geographical
area of Auckland, Waikato or Counties Manukau
District Health Boards (DHBs).
27
Ethics approval was obtained from the NZ
Ministry of Health Northern Y Regional Ethics
Committee (NTY//08/06/055). Written informed
consent was obtained from all participants.
Measures
Antenatal depression symptoms :
Symptoms
of antenatal depression were measured using
the EDS, a screening tool designed to screen for
postnatal depression.
28 A cut-o score of 13 is
used to indicate signi cant symptoms of antenatal
depression, referred to as ADS. Although this is
not considered a doctor diagnosis of antenatal
depression, the 13 EPDS cut-o score has a
sensitivity of 0.83 and speci city of 0.90 for
clinical depression.
29
Ethnicity :
Participants were asked, ‘ Which
ethnic group or groups do you belong to?
and could identify as many ethnicities as
they wanted.  ey were then asked, ‘ Which
is your main ethnic group, which is the one
you identify with most? is is known as
self-prioritised ethnicity and identi ed 727
Samoan, Tongan, Cook Islands Māori, Niuean,
Tokelauan, Fijian and Other Paci c women
who were interviewed while pregnant.
For comparison, we used two ethnicity groups,
namely ‘European’ and ‘other’, as an alterna-
tive to a generic ‘non-Paci c’ group. ‘European’
included women who self-prioritised European
ethnicity and the ‘other’ category included all
women who did not self-prioritise as Paci c or
European. Asian women and Māori women were
not considered separately in this study, but we
acknowledge that they are important groups to
consider with regard to antenatal depression.
17
Other categorical variables :
Other variables
included in the analyses are listed in Table 1 .
Variables signi cantly associated with ADS in
Paci c women at univariate level are in Table 2 .
Continuous variables :
At the antenatal
interview women completed questions the
following standardised rating scales.
Perceived maternal stress was measured using
the abbreviated (10-item) Perceived Stress Scale,
30
where a higher score indicates higher perceived
stress with a maximum score of 40.  is scale has
established reliability and validity, with a Cron-
bachs reliability coe cient of 0.89.
31
A nine-item Warmth and Hostility Scale
32 a n d
a six-item con ict scale
33 were also completed
by women, requiring them to think of a time
in the past 4 weeks they and their partner had
spent time talking or doing things together.  e
Warmth and Hostility scale is made up of a set
of nine statements with a seven-point response
scale ranging from ‘all the time’ to ‘never’ (eg
act lovingly and a ectionately towards each
other).  e Con ict scale used the same seven-
point response scale to respond to six con ict-
related statements (eg break things when
arguing).  ese scales are derived from the Iowa
Family Interaction Rating Scales, with proven
reliability. 32
e women also completed a six-item Family
Stress scale, developed speci cally for the Growing
Up in New Zealand study.  is comprised six
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Table 1. List of categorical variables tested at the univariate level
Variable Levels Measu re use d and description
Age group (years) 25
<25
Originally categorised as <18, 18–25 and 25 years,
but groups <18 and 18–25 years were very similar in
analyses and group <18 years was very small
Two groups with a cut-off of 25 years were used in the
nal analyses
Education No secondary school quali cation
Secondary school, trade or diploma
Bachelor’s degree or higher
Highest level of education attained
Workforce participation Employed or student
Unemployed or not in workforce
Self-report
Household income (NZ$) >70000
>30000–70000
30000
Self-report
Relationship status Married or civil union
Cohabiting
Dating or no relationship
Self-report
Dwelling type Family ownership
Private rental
Public rental
Self-report
Household structure Parent alone
Two parents
Parent(s) with extended family
Parent(s) living with non-kin
Self-report
Prepregnancy health status Good to excellent
Fair to poor
Self-report
Five-point Likert scale from ‘excellent’ to ‘poor’ from
the SF-36 general health questionnaire
Prepregnancy depression Yes
No
Self-report
Ever diagnosed with depression by a doctor before
this pregnancy
Nausea in pregnancy None or mild
Moderate to severe
Self-report
Pre- and during pregnancy smoking
patterns
Non-smoker
Stopped smoking
Continued smoking
Self-report
Other smoker in the same room Yes
No
‘Does anyone currently (during pregnancy) regularly
smoke in the same room as you?’
Alcohol consumption before
pregnancy (drinks per week)
None or <1
1–3
4–19
20
Self-report
Alcohol during pregnancy (drinks per
week)
0–1
>1
Self-report
Deprivation Index Low–medium
High
NZ Deprivation Index42
Pregnancy planned Yes
No
Self-report
Current disability Yes
No
Disability survey43
‘Do you currently have a disability that is long term,
lasting 6 months or more?’
Exercise before pregnancy Yes
No
The International Physical Activity Questionnaire44
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Variable Levels Measu re use d and description
Exercise in rst trimester Yes
No
The International Physical Activity Questionnaire44
Exercise after rst trimester Yes
No
The International Physical Activity Questionnaire44
Born in NZ Yes
No
Self-report
Age at migration to NZ (years) <18
18
Self-report
Speci c Paci c ethnicity Samoan
Cook Island Māori
Ton g a n
Niuean
Other
Self-identi ed
Rurality groups Urban area
Rural area
Parity First born
Subsequent
Self-report
LMC Yes
No
Do you have an LMC?
Choice of LMC Yes
No
Did you have a choice of midwife or other LMC during
this pregnancy?
Time to nd an LMC (weeks) <1
1–<13
13
How long did it take you to nd an LMC from the time
you began looking?
Motor vehicle available for personal
use
Always or sometimes
No or do not drive
Self-report
Family doctor before pregnancy Yes
No
Did you have a family doctor or GP before you
became pregnant?
Seen family doctor/GP since being
pregnant
Yes
No
Have you seen any family doctor or GP since you
became pregnant?
Frequency of thinking about own
ethnicity
Never to at least once a year
At least once a month to once a week
At least once a day to hour (constantly)
Self-report
Victim of ethnically motivated attack Yes
No
Self-report
Ever treated unfairly because
of ethnicity in NZ by a health
professional, in housing, in a job,
in nance, in the justice system, in
education?
Yes
No
Self-report
Knowledge about Kiwi or NZ culture Not very or not at all knowledgeable
Somewhat knowledgeable
Very or fairly knowledgeable
Self-report
Involved in Kiwi or NZ culture Not very or not at all involved
Somewhat involved
Very or fairly involved
Self-report
Feelings towards NZ culture Slightly or very negative feelings
Neither positive or negative feelings
Very or fairly positive feelings
Self-report
Associate with Kiwis or New
Zealanders
Not often or almost never
Sometimes
Most of the time or often
Self-report
Table 1. (Continued)
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Variable Levels Measu re use d and description
Important to maintain Kiwi or NZ
culture
Not very or not at all important
Somewhat important
Very or fairly important
Self-report
Knowledge of own culture Not very or not at all knowledgeable
Somewhat knowledgeable
Very or fairly knowledgeable
Self-report
Involved in own culture Not very or not at all involved
Somewhat involved
Very or fairly involved
Self-report
Feelings towards own culture Slightly or very negative feelings
Neither positive or negative feelings
Very or fairly positive feelings
Self-report
Associate with people from own
culture
Not often or almost never
Sometimes
Most of the time or often
Self-report
GP, general practitioner LMC, Lead Maternity Carer NZ, New Zealand SF-36, 36-Item Short Form Health Survey
An LMC is a health professional that coordinates the maternity care for a pregnant woman. It can be a womans GP, an independent midwife, a hospital midwife,
an obstetrician or shared care between the GP and midwife.
Table 1. (Continued)
Table 2. Frequency distributions and Chi-squared test results for sociodemographic variables across each ethnic groups
Variabl e Paci c (n = 727) European (n = 3168 ) Other (n = 1762) Pearson’s 2
Age group (n = 5657) 198.171**
25 years
<25 years
484 (66.6)
243 (33.4)
2754 (86.9)
414 (13.1)
134 0 ( 76.0)
422 (24.0)
Born in NZ (n = 5657) 658.069**
Yes
No
336 (46.2)
391 (53.8)
2528 (79.8)
640 (20.2)
837 (47.5)
925 (52.5)
Age at migration (n = 1952) 215.974**
10 ye ars
11–17 years
18 year s
84 (21.6)
96 (24.7)
209 (53.7)
154 (24.1)
50 (7.8)
434 (68.0)
51 (5. 5)
82 (8.9)
792 (85.6)
Education (n = 5646) 417.3 67 * *
No secondary school quali cation
Secondary school, trade, diploma
Bachelors degree or higher
86 (11.9)
562 (77.7)
75 (10.4)
118 (3.7)
149 4 (47.2 )
1552 (4 9.1)
147 (8.4)
983 (55.9)
629 (35.8)
Workforce participation (n = 5657) 293.505**
Employed or student
Unemployed or not in workforce
298 (41.0)
429 (59.0)
2270 (71.7)
898 (28.3)
979 (55.6)
783 (44.4)
Household income (n = 4809) 517.86 4* *
>70 000 NZ$
>30 000–70 000 NZ$
30 000
180 (3 3.7 )
242 (4 5.3)
112 (21.0 )
2091 (72.8)
667 (23.2)
114 (4.0)
658 (46.9)
523 (37.3)
222 (15.8)
Rurality groups (n = 5657) 156.923**
Urban area
Rural area
723 (99.4)
< 10 (< 1)
2810 (88.7)
358 (11.3)
170 0 (9 6.5 )
62 (3.5)
Relationship status (n = 5644) 112. 8 6 9 * *
Married or civil union
Cohabiting
Dating or no relationship
395 (54.6)
200 (27.6)
129 (17.8)
2105 (66.5)
867 (27.4)
193 (6.1)
1072 ( 61.1)
496 (28.3)
187 (10.7)
Unless indicated otherwise, data are given as n (%). ** P 0.01. NZ, New Zealand
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questions about sources of stress in the family,
with a four-point response scale ranging from
‘not at all stressful’ to ‘highly stressful’ (eg to
what extent do you worry about family members
getting along?). A higher score re ected a higher
level of family stress.
A six-item family support scale was also used,
developed speci cally for use in Growing Up in
New Zealand but based on the sources of family
support identi ed by Dunst et al.
34 Women were
asked to report on sources of family support
they expected to have available, and how helpful
they expected each source to be, once their baby
was born. A similar six-item external support
scale 34 was used, this time asking mothers what
sources of external support (eg general practi-
tioner (GP), books, internet) they expected to
have available, and how helpful they expected
each source to be, once their baby was born. A
higher score in both the Family Support and
External Support scales re ects higher expected
helpfulness.
A Neighbourhood Integration Scale with proven
reliability was used (Cronbach’s α = 0.85).
35 is
scale has 10 questions with a  ve-point response
scale ranging from ‘strongly disagree’ to ‘strongly
agree’ (eg ‘my neighbours treat me with respect’).
e scores were used as a continuous variable for
analysis, with higher scores relating to stronger
feelings of neighbourhood integration.
Maternal height and prepregnancy weight were
self-reported, and prepregnancy body mass index
(BMI) was calculated (weight (kg) divided by
height squared (m
2 )), with BMI 25 kg/m
2 de ned
as overweight and 30 kg/m
2 de ned as obese.
36
Continuous variables signi cantly associated
with ADS in Paci c women, univariably, are
given in Table 3 .
Tabl e 3 . Univariate associations with antenatal depression symptoms (ADS) status for statistically signi cant variables
Variabl e No ADS (n = 556) ADS (n = 171) Pearson’s 2
Age group (n = 727) 19.535**
25
<25
394 (81.4)
162 (66.7)
90 (18.6)
81 (33.3)
Education (n = 723) 10.273* *
No secondary school quali cation
Secondary school, trade or diploma
Bachelors degree or higher
55 (64.0)
436 (77.6)
63 (84.0)
31 (36.0)
126 (22.4 )
12 (16.0)
Workforce participation (n = 727) 8.188**
Employed or student
Unemployed or not in workforce
244 (81.9)
312 (72.7)
54 (18.1)
117 (27. 3 )
Relationship status (n = 724) 9.307**
Married or civil union
Cohabiting
Dating or no relationship
320 (81.0)
144 (72.0)
91 (70.5)
75 (19.0)
56 (28.0)
38 (29.5)
Dwelling type (n = 709) 10.483 **
Family ownership
Private rental
Public rental
188 (8 3.6)
215 (74.9)
139 (70.6 )
37 (16.4)
72 (25.1)
58 (29.4)
Household structure (n = 727) 10.6 39 *
Parent alone
Two parents
Parent(s) with extended family
Parent(s) living with non-kin
28 (80.0)
197 (82.8)
319 (73.5)
12 (60 .0 )
<10 (20.0)
41 (17.2)
115 (26.5 )
<10 (40.0)
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Variabl e No ADS (n = 556) ADS (n = 171) Pearson’s 2
Household crowding (n = 725) 6.686*
Low
Medium to high
44 (91.7)
289 (75.7)
<10 (8.3)
93 (24.3)
Prepregnancy health status (n = 726) 13.779**
Good to excellent
Fair to poor
464 (79.3)
91 (64.5)
121 ( 20 .7)
50 (35.5)
Prepregnancy depression (n = 724) 6.302*
Yes
No
31 (62.0)
523 (77.6)
19 (38.0)
151 (2 2.4)
Nausea in pregnancy (n = 727) 8.464**
None or mild
Moderate to severe
308 (80.8)
248 ( 71.7)
73 (19.2)
98 (28.3)
Pre- or during pregnancy smoking patterns (n = 723) 15.542 **
Non-smoker
Stopped smoking
Continued smoking
394 (80.1)
101 ( 73.7)
58 (61.7)
98 (19.9)
36 (26.3)
36 (38.3)
Other smoker in the same room (n = 727) 5.083*
Yes
No
56 (66.7)
500 (77.8)
28 (33.3)
143 (22.2)
Alcohol consumption before pregnancy () (n = 727) 21.302**
None or <1 drinks per week
1–3 drinks per week
4–19 drinks per week
20 drinks per week
348 (80.7)
93 (73.2)
108 (71.5 )
<10 (38.9)
83 (19.3)
34 (26.8)
43 (28.5)
11 (6 1.1)
Alcohol during pregnancy (n = 726) 8.760**
1 drink per week
>1 drinks per week
478 ( 78.5)
77 (65.8)
131 (21.5 )
40 (34.2)
Feelings towards NZ culture (n = 725) 6.810*
Slightly or very negative feelings
Neither positive or negative feelings
Very or fairly positive feelings
<10 (44.4)
95 (72.5)
455 (77.8)
<10 (55.6)
36 (27.5)
130 (22.2 )
Important to maintain own cultures/traditions (n = 727) 8.866*
Not very or not at all important
Somewhat important
Very or fairly important
22 (71.0)
44 (62.9)
490 (78.3)
<10 (29.0)
26 (37.1)
136 (21.7 )
Family doctor before pregnancy (n = 727) 13.353* *
Yes
No
527 (78.1)
29 (55.8)
148 (2 1.9 )
23 (44.2)
Unless indicated otherwise, data are given as n (%). * P 0.05 ** P 0.01. NZ, New Zealand
As de ned by an Edinburgh Depression Scale score of 13.
Table 3. (Continued)
Data analysis
IBM SPSS Statistics version 22.0 was used to carry
out the quantitative data analysis. Chi-squared tests
for independence were used to determine univari-
ate associations between depression status and
other variables. t -Tests were used when the items
were continuous. Binary logistic regression was
used to test multivariate associations between ADS
and other factors. Only variables that were found to
be signi cantly associated with ADS at α = 0.01 in
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Chi-squared analyses were used as covariates in the
logistic regression analysis. Statistical signi cance
in the logistic regression was assumed at α = 0.01.
Results
e sample comprised 5657 women who were
interviewed while pregnant. Of these, 56% were
of self-prioritised European ethnicity, 12.9% were
self-prioritised Paci c ethnicity and 31.1% were
from other ethnic groups.  ese three groups
were signi cantly di erent according to a range
of key sociodemographic variables, as indicated
in Table 4 .
Samoan (42.8%) and Tongan (28.6%) women made
the biggest contribution to the sample of 727 Paci c
women in this study, followed by Cook Islands Māori
(17.2%) women and Niuean women (6.6%). A small
number of Tokelauan, Fijian and other Paci c peo-
ples made up the rest of the sample.  is is a similar
pro le to the total Paci c population in NZ.
37
ADS in Paci c women
As reported by Waldie et al.,
17 P a c i c women had
signi cantly higher levels of ADS than European
and Other women 23% of Paci c women had ADS,
compared with 14.2% of Other women and 7.9% of
E u r o p e a n w o m e n ( X 2
Y a t e s ( 4 , n = 5657) = 151.428,
P 0.01). However, European women had the high-
est proportion of doctor-diagnosed depression be-
fore pregnancy (22.4%) and Paci c women had the
l o w e s t ( 6 . 9 % ; X 2
Y a t e s ( 2 , n = 5653) = 136.287, P 0.01).
Factors associated with ADS in
Paci c women (univariate analysis)
Variables signi cantly associated with ADS in
pregnant Paci c women at the univariate level
are presented in Table 2 .
Sociodemographic factors :
Age group,
education, workforce participation, household
income and relationship status were signi cantly
associated with ADS, but being born in NZ,
age at migration, deprivation and rurality
were not. No signi cant association was found
between ADS and speci c Paci c ethnicity.
Physical environment :
Dwelling type,
crowding and household structure
were signi cantly associated with ADS.
Neighbourhood integration was signi cantly
reduced in women with ADS.
Relationships :
Paci c women with ADS had
lower warmth and hostility relationship scores,
lower relationship con ict scores (and therefore
more con ict in their relationship) and higher
family stress scores than women without ADS.
Not considering it important to maintain their
own cultures and traditions and slightly or
very negative feelings towards NZ culture were
signi cantly associated with ADS in Paci c
women. No signi cant associations were found
between ADS and being a victim of an ethnically
motivated attack, or ethnic discrimination
in any setting (health professional, housing,
justice system,  nance). ere was no signi cant
association between ADS and family support
or external support in Paci c women.
Lifestyle :
Smoking before and during pregnancy,
others smoking in the same room and alcohol
consumption before and during pregnancy
were signi cantly associated with ADS.
Maternal health :
ere were signi cant
associations between three maternal health
variables and ADS in Paci c women: fair to
poor self-reported prepregnancy health status,
self-reported doctor-diagnosed prepregnancy
depression and moderate to severe nausea during
pregnancy. Other measures of maternal health
(long-term disability, whether the pregnancy
was planned, health issues before pregnancy
Table 4. Comparison of perceived stress, con ict, warmth and hostility, family
stress and neighbourhood integration for Paci c mother s with and without
antenatal depression symptoms (ADS)
Variable No ADS
(n = 556)
ADS
(n = 171)
t
Perceived stress score14.11 ± 5.78 21.47 ± 4.88 –16.497**
Con ict37.90 ± 4.33 34.18 ± 6.91 6.277**
Warmth and hostility§48.43 ± 7.06 43.55 ± 8.58 6.393**
Family stress†† 11.75 ± 4.63 14.38 ± 4.72 6.480**
Neighbourhood integration‡‡ 34.58 ± 5.14 32.99 ± 5.48 3.479**
Unless indicated otherwise, data are given as the mean ± s.d. ** P 0.01
Higher scores relate to higher perceived stress.
Higher scores relate to les s con ict in the relationship.
§ Higher scores relate to more warmth and less hostility in relationship.
†† Higher scores relate to higher family stress.
‡‡ Higher scores relate to greater neighbourhood integrati on.
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and prepregnancy BMI) were not signi cantly
associated with ADS in Paci c women. Pregnant
Paci c women with ADS had signi cantly higher
perceived stress scores than women without
ADS (see Table 3 ). Having a Lead Maternity
Carer (LMC), having a choice of LMC and the
length of time it took to  nd an LMC were
not associated with ADS in Paci c women.
Having a regular GP before pregnancy was
signi cantly negatively associated with ADS
in Paci c women, but not ADS in European
or Other women. Seeing a GP since becoming
pregnant was not associated with ADS.
Predicting ADS in Paci c women
(multivariate analysis)
Hierarchical binary logistic regression was
performed using only variables signi cantly
associated with ADS in univariable analyses at
α = 0.01. Variables were added in a hierarchical
manner, with variables that were not signi cant
removed at each step. Results from the  nal
logistics regression are presented in Table 5 .
Variables that remained signi cantly associated
with ADS in the  nal model were: GP before
pregnancy ( P 0.01), age group ( P = 0.001), nau-
sea during pregnancy ( P 0.01), perceived stress
( P 0.001), relationship con ict ( P = 0.001) and
family stress ( P 0.05).
Further analyses found that around one in three
pregnant Paci c women aged <25 years experienced
ADS, compared with one in six pregnant
European women aged <25 years ( X
2
Y a t e s ( 2 , n = 1079)
= 26.339, P 0.001).
Pregnant Paci c women without a GP before
pregnancy were 4.5-fold more likely to experience
ADS than non-Paci c women who had a regular
GP before pregnancy ( P < 0.001). However,
Paci c women were signi cantly more likely to
have a regular GP before pregnancy (92.8%) than
European (90.7%) and Other women (85.8%
X 2
Y a t e s ( 2 , n = 5657) = 39.787, P 0.001).
Discussion
e ndings of this study build on previous re-
search with this cohort
17 and provide new
in-depth understanding of potential factors
contributing to higher rates of ADS in NZ Paci c
women compared with women of other ethnic
groups.  e Paci c women in this study were
signi cantly di erent from European and Other
women, based on a range of sociodemographic
characteristics. Factors signi cantly and indepen-
dently associated with ADS in Paci c women were
not having a regular family GP before pregnancy,
age <25 years, moderate to severe nausea in
pregnancy, high perceived stress and high family
stress. Low con ict in their relationship was pro-
tective against symptoms of antenatal depression.
ese ndings re ect a di erent pro le for Pa-
ci c ADS compared with the overall Growing Up
in New Zealand cohort. Waldie et al.
17 p r e v i o u s l y
found that ethnicity, anxiety, depression before
and during pregnancy and perceived stress
were independently associated with ADS. In the
present study there was no relationship between
anxiety or prepregnancy depression and ADS in
Paci c women.
Some risk factors for ADS commonly identi ed in
the literature were not con rmed in this research.
Unplanned pregnancy, a key risk factor for
postnatal depression in Paci c women,
23 was not
a signi cant risk factor for ADS in Paci c women
Table 5. Binary logistic regression evaluating the associations between antenatal
depression symptoms and sociodemographic, physical environment, relationship,
lifestyle and maternal health variables
Variabl e B (s.e.) OR 95% CI Wald
Family doctor/GP before pregnancy
Yes
No
1.099 (0.420)
3
1.317–6. 834
6.841**
Nausea in pregnancy
None or mild
Moderate to severe
0.633 (0.232)
1.8 83
1.195 2. 965
7. 4 5 3 * *
Age group (years)
25
<25
0.770 (0.239)
2.16
1.3 52 3.4 49
10.3 94**
Perceived stress score 0.247 (0.027) 1.28 1.213–1.351 81.178**
Con ict –0.069 (0.021) 0.934 0.895–0.974 10.216**
Family stress 0.056 (0.026) 1.057 1.005–1.113 4.662*
Note: –2LL = 465.93; R
2 = 0.30 (Cox and Snell), 0.45 (Nagelkerke) Model X
2
( 7 ) = 227.487,
P 0.001. * P 0.05 ** P 0.01. OR, odds ratio; CI, con dence interval; GP, general
practitioner
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in this study, despite almost two-thirds of preg-
nancies in the Paci c sample being unplanned.
Birth country and age at migration to NZ, both
key risk factors for general mental illness among
Paci c peoples in NZ,
24 were also not found to be
signi cant risk factors for ADS in this study.
Further, although Tongan women had signi cant-
ly higher rates of postnatal depression according
to the PIF Study,
23 and in general it is recognised
that there are  aws in treating Paci c peoples as a
homogeneous ethnic group,
38 the present research
found no signi cant di erences in ADS according
to speci c Paci c ethnic groups.
In this study all factors signi cantly associated
with ADS for Paci c women were also signi cant
for European women, except for having a regular
GP before pregnancy.  is relationship is a clear
standout because of its considerable odds ratio
(3.0) and because it is speci c to Paci c women.
Paci c women were shown to have the highest
rates of having a regular GP, but women who did
not have a GP had very high rates of ADS (44%).
is study suggests that primary health care is
working for Paci c women who have access to
it, protecting them from ADS. However, there is
a group of vulnerable, high-risk Paci c women
who do not have that access to care but are in
real need of it.  is nding could, instead, be an
indication of other causal factors that are related
to having a regular GP. For example, women who
had a slightly or very negative view of NZ culture
were at higher risk of ADS and are therefore pos-
sibly less trusting of, or engaged in, NZ institu-
tions, such as health-care providers. If this is the
case, addressing sociocultural factors related to
ADS may better address ADS than simply im-
proving enrolment with a regular GP.  erefore,
there are clear implications for policy in terms of
primary health care for Paci c women.
In this study, Paci c women had the lowest rates
of self-reported doctor-diagnosed depression
before pregnancy (6.9%) and European women
had the highest (22.4%).  is may be because
Paci c women do not disclose symptoms of
depression to their doctor, either through lack of
self-awareness or limited con dence and trust in
their doctor, because doctors do not recognise the
signs of depression in Paci c women or question
the women about their psychological wellbeing,
or because Paci c women are not visiting a doctor
about their concerns.  is may also re ect
di culties in accessing primary care, low
acceptability of care and fear associated with
disclosing symptoms of mental illness.
39
Limitations and strengths
is study has some limitations.  e cross-sectional
nature of this analysis means inferences of relation-
ship are made tentatively and with no directional-
ity. In addition, this studys focus on Paci c women
meant the  nal sample size was much smaller than
the entire Growing Up in New Zealand cohort, and
some statistical analyses may have been limited by
the reduced power. Nonetheless, compared with
contemporary research, our sample of pregnant
Paci c women is large and su ciently diverse.
Strengths of this research include the use of a
standardised and validated tool for detecting
ADS.  e sample of Paci c women is also a
strength because of its size, and the  ndings are
broadly generalisable to the contemporary NZ
population.  e diversity of variables considered
in this research is also a strength.
Implications
Factors that appear to be speci c to Paci c NZ
women and independently, signi cantly as-
sociated with ADS can inform the way health
professionals identify high-risk pregnant women.
Several trials have targeted interventions towards
women at risk for postnatal depression, and this
has been shown to be more bene cial and fea-
sible than interventions targeted at all pregnant
women. 40 41 Building a risk pro le for ADS in
Paci c women with a complementary screening
tool may be an important starting point.
Competing interests
e authors declare that there are no con icts of
interest.
Acknowledgements
Growing Up in New Zealand has been funded
by: the New Zealand Ministries of Social
Development, Health, Education, Justice and
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ORIGINAL RESEARCH: CLINICAL
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Paci c Island A airs the former Ministry of Sci-
ence Innovation and the former Department of
Labour (now both part of the Ministry of Busi-
ness, Innovation and Employment) the former
Ministry of Women’s A airs (now the Ministry
for Women); the Department of Corrections; the
Families Commission (now known as the Social
Policy Evaluation and Research Unit); Te Puni
Kokiri; New Zealand Police; Sport New Zealand;
the Housing New Zealand Corporation; and the
former Mental Health Commission,  e Uni-
versity of Auckland and Auckland UniServices
Limited. Other support for the study has been
provided by the New Zealand Health Research
Council, Statistics New Zealand, the O ce of
the Children’s Commissioner and the O ce of
Ethnic A airs. e study has been designed and
conducted by the Growing Up in New Zealand
study team, led by the University of Auckland.
e authors acknowledge the contributions
of the original study investigators: Susan M.
B. Morton, Polly E. Atatoa Carr, Cameron
C. Grant, Arier C. Lee, Dinusha K. Bandara,
Jatender Mohal, Jennifer M. Kinloch, Johanna
M. Schmidt, Mary R. Hedges, Vivienne C. Ivory,
Te Kani R. Kingi, Renee Liang, Lana M. Perese,
Elizabeth Peterson, Jan E. Pryor, Elaine Reese,
Elizabeth M. Robinson, Karen E. Waldie and
Clare R. Wall.  e views reported in this paper
are those of the authors and do not necessarily
represent the views of the Growing Up in New
Zealand investigators.
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... 4 The in-depth analysis of this earlier finding adds the new knowledge that having a regular GP before they become pregnant is a solution, reducing the risk of depression for the Pacific women in the study. 5 Two articles in this issue focus on Māori. One uses a Kaupapa Māori approach in investigating the impact of osteoarthritis on the lives of seven Māori women. ...
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To examine individual, interpersonal, family, and community correlates associated with moderate-to-severe depressive symptoms among pregnant adolescents. A total of 249 primarily African American and Hispanic pregnant adolescents ages 15-18 years were recruited into either an intervention group utilizing Centering Pregnancy prenatal care and case management, or to a comparison group receiving case management only. Moderate-to-severe depressive symptoms were defined as a score ≥16 on the Center for Epidemiologic Studies Depression Scale (CES-D). Intervention and comparison groups did not significantly differ on demographic characteristics or depression scores at baseline. A total of 115 (46.1 %) participants met criteria for moderate-to-severe depressive symptoms at entry into the program. Pregnant adolescents who were moderately-to-severely depressed were more likely to be African American, to have reported limited contact with the father of the baby, and to have experienced prior verbal, physical or sexual abuse. Depressed adolescents also experienced high levels of family criticism, low levels of general support, and exposure to community violence. A significant number of pregnant adolescents were affected by depression and other challenges that could affect their health. Comprehensive interventions addressing these challenges and incorporating partners and families are needed.
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Depression during pregnancy has significant implications for pregnancy outcomes and maternal and child health. There is a need to identify which family, physical and mental health factors are associated with depression during pregnancy. An ethnically and socioeconomically diverse sample of 5664 pregnant women living in New Zealand completed a face-to-face interview during the third trimester. Antenatal depression (AD) symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS). Maternal demographic, physical and mental health, and family and relationship characteristics were measured. The association between symptoms of AD and maternal characteristics was determined using multiple logistic regression. 11.9% of the participating women had EPDS scores (13+) that indicated probable AD. When considering sociodemographic predictors of AD symptoms, we found that women from non-European ethnicities, specifically Pacific Islander, Asian and other, were more likely to suffer from AD symptoms. Greater perceived stress during pregnancy and a diagnosis of anxiety both before and during pregnancy were also associated with greater odds of having AD according to the EPDS. The women were in their third trimester of pregnancy at the interview. Therefore, we cannot discount the possibility of recall bias for questions relating to pre-pregnancy status or early-pregnancy behaviours. AD is prevalent amongst New Zealand women. Ethnicity, perceived stress and anxiety are particularly associated with a greater likelihood of depression during pregnancy. Further attention to supporting maternal mental health status in the antenatal period is required. Copyright © 2015 Elsevier B.V. All rights reserved.