Social environment and depression among pregnant women in urban areas of Pakistan: Importance of social relations

Article (PDF Available)inSocial Science & Medicine 63(6):1466-76 · October 2006with205 Reads
DOI: 10.1016/j.socscimed.2006.05.019 · Source: PubMed
Abstract
Aspects of the social environment, including social conditions (socio-economic status, household situations, chronic illnesses) and social relations (attitude and behaviors of relations) are major determinants of depression among women. This study evaluates the relative power of social relations and social conditions in predicting depression among pregnant women in Pakistan. In the qualitative phase of the study, social environmental determinants were identified through literature search, and experts' opinions from psychologists, psychiatrists, gynecologists, sociologists and researchers. Along with this, 79 in-depth interviews were conducted with pregnant women drawn from six hospitals (public and private) and two communities in Karachi, Pakistan. Identified determinants of depression were grouped into themes of social conditions and social relations and pregnancy-related concerns. In the study's quantitative phase, the relative power of the identified themes and categories, based on their scores for predicting depression (determined by the Center for Epidemiological Studies-Depression Scale (CES-D scale)), was determined through multivariate linear regression. Social environmental determinants of pregnant women were described under the themes and categories of (1) social relations: involving husband, in-laws and children; (2) social conditions: involving the economy, illness, life events, household work, environmental circumstances and social problems; and (3) pregnancy-related concerns i.e. symptoms of pregnancy, changes during pregnancy, dependency and concern for unborn baby. Multivariate analysis found that among these themes, social relations and pregnancy-related concerns were significantly associated with total CES-D scores. Among the categories besides increasing age and less education, husband, in-laws, household work and pregnancy symptoms were significantly associated with total CES-D scores. The study highlights the importance of social relations compared to social conditions for determining depression in pregnant women.

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Social Science & Medicine 63 (2006) 14661476
Social environment and depression among pregnant women in
urban areas of Pakistan: Importance of social relations
Ambreen Kazi
a,
, Zafar Fatmi
a
, Juanita Hatcher
a
, Muhammad Masood Kadir
a
,
Unaiza Niaz
a
, Gail A. Wasserman
b
a
Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
b
Division of Child and Adolescent Psychiatry, Columbia University, New York City, New York
Available online 23 June 2006
Abstract
Aspects of the social environment, including social conditions (socio-economic status, household situations, chronic
illnesses) and social relations (attitude and behaviors of relations) are major determinants of depression among women.
This study evaluates the relative power of social relations and social conditions in predicting depression among pregnant
women in Pakistan. In the qualitative phase of the study, social environmental determinants were identified through
literature search, and experts’ opinions from psychologists, psychiatrists, gynecologists, sociologists and researchers. Along
with this, 79 in-depth interviews were conducted with pregnant women drawn from six hospitals (public and private) and
two communities in Karachi, Pakistan. Identified determinants of depression were grouped into themes of social
conditions and social relations and pregnancy-related concerns. In the study’s quantitative phase, the relative power of the
identified themes and categories, based on their scores for predicting depression (determined by the Center for
Epidemiological Studies—Depression Scale (CES-D scale)), was determined through multivariate linear regression. Social
environmental determinants of pregnant women were described under the themes and categories of (1) social relations:
involving husband, in-laws and children; (2) social conditions: involving the economy, illness, life events, household work,
environmental circumstances and social problems; and (3) pregnancy-related concerns i.e. symptoms of pregnancy,
changes during pregnancy, dependency and concern for unborn baby. Multivariate analysis found that among these
themes, social relations and pregnancy-related concerns were significantly associated with total CES-D scores. Among the
categories besides increasing age and less education, husband, in-laws, household work and pregnancy symptoms were
significantly associated with total CES-D scores. The study highlights the importance of social relations compared to social
conditions for determining depression in pregnant women.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Pakistan; Social environment; Pregnancy; Social conditions; Social relations; Urban area
Introduction
The studies have found high a prevalence of
depression (28–57%) among women in Pakistan
(Husain, Creed, & Tomenson, 2000; Mumford,
Minhas, Akhtar, Akhter, & Mubbashar, 2000; Ali
et al., 2002). The social environment has been
identified as one of the major determinants of
depression among women (Rabbani & Raja, 2000;
Husain, Gater, Tomenson, & Creed, 2004; Niaz,
2001; Riso, Miyatake, & Thase, 2002), Social
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0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2006.05.019
Corresponding author. Tel.: +92 21 4811 4931.
E-mail address: ambreen.kazi@aku.edu (A. Kazi).
environment is often hostile to women in Pakistan
(Husain et al., 2000; Mumford et al., 2000;
Mumford, Nazir, Jilani, & Baig, 1996; Mu mford,
Saeed, Ahmad, Latif, & Mubbashar, 1997). Women
are encouraged to be subservient, and wife batter-
ing, conflict with spouse and in-laws are common
problems in Pakistan (Niaz, 2001).
Although it was thought that pregnancy may act
as a protection against mental illnesses, a high
prevalence of depression among pregnant women
contradicts such beliefs (Benne tt, Einarson, Taddio,
Koren, & Einarson, 2004). A study conducted in a
rural area of Pakistan found that 25% of women
during pregnancy and 28% in the postpartum
period suffered from depression (Rahman, Iqbal,
& Harrington, 2003). Pregnant women who were
depressed had more likely experienced life-threaten-
ing events and lack of social support (Rahman
et al., 2003). Studies indicate that depression leads
to adverse pregnancy outcomes such as preterm and
low birth weight babies (Dole et al., 2003; Mulder
et al., 2002; Wadhwa et al., 2001). In spite of this
high prevalence, no study has looked at the relative
importance of various determinants in the social
environment in predicting depression among preg-
nant women in Pakista n.
Many studies have measured social environmen-
tal variables in terms of income, education, occupa-
tion and number of social supports (Koniak-Griffin,
Lominska, & Brecht, 1993). These might be called
social conditions which include socio-economic
status (SES), major life events, relatives’ health
status, household responsibilities and supports
(Nilsson, Engberg, Nilsson, Karlsmose, & Laurit-
zen, 2003). In additi on, a woman’s social relations
should be such as the quality of relationship with
her husband, in-laws, parents and children (Barnet,
Joffe, Duggan, Wilson, & Repke, 1996; Nitz,
Ketterlinus, & Drandt, 1995; Stu chbery, Matthey,
& Barnett, 1998). Concerns related to pregnancy are
an added burden during pregnancy and may include
signs and symptoms of pregnancy, changes due to
pregnancy and concern for the baby (Huizink,
Robles de Median, Mulder, Visser, & Buitel aar,
2003; Stotland, 1995). Therefore, it is prudent to
study pregnant women’s perceptions of social
conditions, social relations and pregn ancy-related
concerns together as potential determinants of
depression.
The objective of this study was to measure
the prevalence of depression among pregnant
women and to determ ine the relative importance
of social conditions, social relat ions and pregnancy-
related concerns for predicting depression among
pregnant women in Karachi, an urban area of
Pakistan.
Methods
The study was conducted in Karachi, the capital
city of the province of Sindh, Pakistan, during
December 2003 to September 2004. While most of
the residents of Karachi are Urdu-speaking, it has
considerable socio-economic and ethnic diversity
and has a population of more than 14 million. The
majority of the women typically stay at home and
their lives are centered on their families. Girls and
boys receive different levels of education: 70% of
males and 57% of female are literate in Karachi
(Government of Pakistan, 1998).
The study had two parts the qualitative part
during which social environmental determinants
were identified and the quantitative part during
which prevalence of depression and relative im-
portance of social determinants for depression were
analyzed. Phase 1 was conducted from July 2003 to
May 2004. Phase 2 was undertaken during June–
September 2004.
Phase 1—Qualitative study
Initially, textbooks and published literature re-
garding social environment were reviewed. Inter-
views were conducted with 25 experts to identify
determinants. These experts included psychologists,
psychiatrists, gynecologists, sociologists, social
workers and researchers. Many of these experts
were working at Aga Khan University & Hospital
and had more than 10 years experience of working
with pregnant women. In addition, gynecologists
belonging to the study hospitals and organizations
were also approached for their expert opinion (list
of the organizations is given in Table 1 ).
Interviews with pregnant women
Based on initial work, semi-structured guidelines
were developed to interview pregnant women.
Guidelines included inquiry into all the issues which
pregnant women perceived as ‘‘difficulties’’ or
‘‘stressful situations’’ in their life. Seventy-nine in-
depth interviews were conducted with pregnant
women in the local language, Urdu, by a female
to generate a list of determinants. Women who had
difficulty in understanding or speaking Urdu were
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A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–1476 1467
not included in the study. On an average, each
interview took one to one and a half hour. Sample
size was based on sampling to redundancy, i.e.
interviews were stopped when no new determinants
were being identified. Also pregnant women
coming for their antenatal checkup were selected
from six hospitals (public and private) (Table 1 ).
Pregnant women in the two communities were
approached with the help of the local organizations
working in the area (see Table 1). These sites
were purposely selected to include socio-economic-
ally diverse population in order to capture a
wide range of determinants. Written consent was
taken from the pregnant women and their husbands
(when requested by women) after explaining
the purpose of the study. Consideratio n was also
given to include pregnant women of all parities
and trimesters. Socio-demographic profile of preg-
nant women for the qualitative phase is given in
Table 2.
Pretesting and phrasing of items on determinants
Identified determinants were pretested on a
separate sample of 70 pregnant women. After every
10 interviews, identified problems were discussed by
the research team and determinants were rephrased
and tested again for clarity and content. Over-
lapping statements were dropped and eventually 89
items were finalized with the help of the experts
(mentioned above).
Phase 2—Quantitative study
During this phase, 292 pregnant women were
interviewed during their antenatal visits. They were
selected from four hospitals in Karachi catering to
different socio-economic groups. Among the four
hospitals, Public Health School provides outpatient
maternal and child care preventive and curative
services free-of-charge to women and children of
lower socio-economic group. Aziza Husseini Hos-
pital and Aga Khan Hospital for Women, Karima-
bad are two private hospitals that provide fee-based
services to the middle socio-economic strata of
pregnant women. Mid-East Hospital Clifton is a
private hospital that serves higher socio-economic
group of pregnant women (Table 1).
Female psychologists and sociologists were pro-
vided with a week long training for conducting the
interviews. Interviews were conducted in the while
women were waiting for their antenatal checkup.
Women who had difficulty in speaking or under-
standing Urdu were not included in the study. Each
woman was first approached by the study coordi-
nator who explained the study purpose and asked
for a written consent. If a woman consented, she
was guided to a separate room for the detailed
interview. On average, each interview lasted 45 min.
The interviewer read out 89 questions concerned
with the 13 categories of potential determinants.
Women responses were marked (1) if the item was
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Table 1
Institutions and hospitals taken in the study to interview pregnant women during the Qualitative and Quantitative phases in Karachi
No. of pregnant women
Phase 1—Qualitative study
(a) Communities
1. Malir colony 9
2. Zia colony of Landhi 12
(b) Hospitals and MCH centers
1. Lyari Community Development Program maternal and child health center 12
2. Civil Hospital Karachi 8
3. Jinnah Postgraduate Medical Center 8
4. Aga Khan Maternity Health Center Karimabad 7
5. Liaquat National Hospital 11
6. Aga Khan University Hospital 12
Total 79
Phase 2—Quantitative study
1. Aga Khan Maternity Center (AKMC) Karimabad (middle SES) 50
2. Aziza Husseini Hospital, Gulberg (middle SES) 70
3. Public Health School (lower SES) 101
4. Mideast Hospital (high SES) 71
Total 292
A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–14761468
applicable (1) and (0) if not applicable in the past
month. An index was developed by calculating the
total score for each of the three theme s and 13
categories as in Appendix A. For example, in the
husband category, there were 10 questions; there-
fore, the possible score for a pregnant woman would
range between 0 and 10. The refusal rate o5%.
The translated version (in Urdu language) of
Center for Epidemiological Studies—Depression
(CES-D) scale was administered by a separate
interviewer (blind) to the same women. CES-D is
a multicultural validated instrument and has been
used in many countries including India and
Bangladesh to measure depression among a variety
of populations including pregnant wom en (Gavin et
al., 2005; Jain, Sanon, Sadowski, & Hunter, 2004;
Orr, James, & Blackmore Prince, 2002; Sharp &
Lipsky, 2002; Tsutsumi et al., 2004). CES-D consists
of 20 items. Each item has a score range of 0–3.
Therefore, an individual score of women on the
CES-D scale may range from 0 to 60. A cut-off of
16 and above has been recommended to diagnose
depression. Below this level, the scale determines
milder depressive symptoms (Radloff, 1977). The
alpha coefficient of the translated version of CES-D
scale among Karachi sample was 0.88.
Data were analyzed with identifier numbers by a
separate person to maintain confidentiality. Coun-
seling was provided to those women who were
diagnosed as depress ed by the psychologist or they
were referred for furt her assessment and treatment.
The study was started after getting approval from
the Ethical Review Committee of the Aga Khan
University.
Analysis plan
The identi fied potential determinants were
grouped into themes of: social relations, social
conditions and pregnancy-related concerns. Infre-
quent determinants (o5%) were not included in the
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Table 2
Socio-demographic profile of pregnant women in phase 1 and 2 in
Karachi, Pakistan
Phase 1–Qualitative study n ¼ 79ð%Þ
Age (mean) 27.3 (SD 4.7) years
Educational status of women
No Schooling 29 (36.7)
Primary (1–5) 11 (13.9)
Secondary (6–10) 12 (15.1)
Graduation (11–14) 16 (20.2)
Professional 11 (13.9)
Mother tongue
Urdu 37 (46.8)
Sindhi 14 (17.8)
Balochi 14 (17.8)
Punjabi 7 (8.8)
Miscellaneous
a
7 (8.8)
Educational status of husband
No Schooling 25 (31.6)
Primary (1–5) 4 (5.0)
Secondary (6–10) 21 (26.5)
Graduation (11–14) 10 (12.6)
Professional 19 (24.0)
Occupation of women
Housewives 50 (63.2)
Working 29 (36.8)
Occupation of husband
White collar workers 25 (31.6)
Blue collar workers 49 (62.0)
Jobless 5 (6.3)
Income group
b
p5000 Pak rupees (60 Pak Rs ¼ 1US $) 28 (37.8)
45000 Pak rupees 46 (62.2)
Gravida
Primigravida (first pregnancy) 27 (34.2)
Multigravida (2–4 pregnancies) 39 (49.4)
Grand-multigravida (5th or more
pregnancies)
13 (16.4)
Trimester of pregnancy
1st (1–3 months) 12 (15.2)
2nd (4–6 months) 17 (21.5)
3rd (7–9 months) 50 (63.3)
Phase 2—Quantitative study n ¼ 292ð%Þ
Age (mean) 25.8 (SD 4.5) years
Education
No Schooling 39 (13.4)
Primary (1–5) 21 (7.3)
Secondary (6–10) 57 (19.6)
Graduation (11–14) 140 (48.6)
Professional 33 (11.4)
Trimester of pregnancy
b
1st (1–3 months) 42 (16)
2nd (4–6 months) 100 (38)
3rd (7–9 months) 121 (46)
Table 2 (continued )
Gravida
Primigravida (first pregnancy) 116 (39.7)
Multigravida (2nd onwards pregnancy) 176 (60.3)
History of abortion 74 (26.0)
a
Include Pushto, Memon, Gujrati, Bengali.
b
Missing number are due to non-response.
A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–1476 1469
list. Within each theme, categories were identified
for similar issues (see Appendix B).
The scores on all quantitatively assessed variables
were analyzed as continuous variables. Univariate
linear regressions between scores of major themes
and categories and total CES-D scale scores were
conducted to investigate at the association between
the determinants and depression. In addition,
associations between age, education and total
CES-D scores were also determ ined.
Finally, two separate multivariate analysis mod-
els were developed to determine the independent
effect of the identified determinants with total CES-
D scores, with major themes and categories,
separately.
Results
Phase 1—Qualitative results
In qualitative phase, the mean age of pregnant
women was 27.3 (SD 4.7) years. The majority were
Urdu speaking. About 37% were uneducated and
63% were housewives and 34% were primigravida
(Table 2 ).
The social environmental framework for preg-
nant women (with themes and categories) is
presented in Fig. 1. The determinants were reviewed
in depth by 25 experts (see ‘‘methodology’’ for
details) to categorize them into themes of Social
Conditions, Social Relations and Pregnancy-Related
Concerns. The items related to the pregnant
women’s social relationship with her husband,
children, parents and in-laws, in a Pakistani context,
were included under Social Relations. Determinants
related to the characteristics of the pregnant woman
and her en vironment were called Social Conditions
and included economic problems, health status,
household issues, personal and social problems.
Pregnancy-related concerns included general ap-
praisal of pregnancy such as pregnancy symptoms,
pregnancy-related changes, dependency due to
pregnancy and concern for unborn baby.
Descriptive statistics (mean, SD and range) of the
index of determinants for themes and categories are
given in Table 3. Out of 88, 18 determinants were
related to social relations, 44 to social conditions
and 26 to pregnancy-related concerns.
Among social relations, husband-related issues
were more common than in-laws or children issues.
Concerns related to the personal and the parents
category were identified through the in-depth inter-
views but they were less o5% frequent. Among the
social conditions, economy-related issues were the
most common. Results for pregnancy -related con-
cerns found that symptoms of pregnancy and
changes due to pregnancy were the most common
issues, whereas dependency and concern for unborn
were comparatively less common.
Phase 2—Quantitative results
The mean age of 292 pregnant women for
quantitative phase was 25.8 (SD 4.5) years and
their mean education (in years) were 10.31 (SD 5.1).
Other descriptors are found in Table 2.
Prevalence of depression, based on the cut-off
score of 16 or more on CES-D scale, was 39.4%
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SOCIAL CONDITIONS
SOCIAL REALTIONS
PREGNANCY CONCERNS
Symptom
Changes during Pregnancy Dependency
Unborn
Illness
Life event
Household
Work
Environmental
Circumstances
Social
problem
Economy
Husband
In-laws
Children
Fig. 1. Social environment framework for pregnant women.
A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–14761470
(112/292) among pregnant women. The mean CES-
D score (SD) was 14.53 (12.43).
Univariate linear regression (see Table 4) showed
significant association between scores of themes of
social relations, social conditions and pregnancy-
related concerns and total CES-D score. Results
found that with one unit increa se in the scores for
social relation, social conditions and pregnancy
concerns there was 0.64, 0.50, 0.55 increase in the
score on the CES-D scale. With each year of
increase in education, there was a 0.17 decrease
in scores on the CES -D scale, while age of
mother, number of alive children and gestational
age (in weeks) were not associated significantly with
CES-D score. With increasing number of gravidity
and abortion, there was an increase in CES-D
scores.
Univariate linear regression showed significant
association between categories and total CES-D
scores (see Table 4). Increase in the scores on
husband, in-laws and children categories led to 0.58,
0.52 and 0.17 increase in the CES-D score,
respectively. Among the social conditions cate-
gories, illness, economy, life events, household
work, environmental circumstances and social
problems led to an increase in the CES-D score.
Finally, among the pregnancy-related categories,
pregnancy symptoms, pregnancy changes, depen-
dency and unborn baby led to increases in the CES-
D scores.
Multivariate analysis results are presented in
Table 5. In the first model, only major themes were
entered. Among these, social relations and preg-
nancy-related con cerns were significantly associated
with total CES-D scores , whereas social conditions
were not associated significantly. The adjusted R
2
for themes model was 46%, meaning these variables
explained approximately 46% of variance in depres-
sion among pregnant women.
All the categor ies along with age and education
were entered in the second model. With increasing
years in age, there was an increase in depression
scores, while with increasing years in education,
there was a decrease in the depression scores.
Among the categories husband, in-laws, household
work, pregnancy symptoms and pregnancy changes,
there were increases in the CES-D scores, respec-
tively. The adjusted R
2
for the categories model was
51%. The categories related to children , illness,
economy, life events, environmental circumstances,
social problems, dependency and unborn child were
not significant in the multivariate model.
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Table 3
Descriptive statistics of total, categories and subcategories of social environmental determinants among pregnant women in Karachi,
Pakistan
No. Determinants
a
No. of determinants Mean SD Range
Total determinants 88 20.23 11.38 0–55
Themes
Social relations 18 2.93 2.57 0–12
Social conditions 44 7.78 5.75 0–29
Pregnancy-related concerns 26 9.39 4.71 0–21
Categories
1 Husband 10 1.40 1.50 0–7
2 In-laws 6 0.66 0.91 0–4
3 Children 2 0.72 0.86 0–2
4 Illness 7 1.35 1.27 0–6
5 Economy 15 3.02 3.55 0–14
6 Life events 7 1.17 1.02 0–4
7 Household work 5 0.98 1.07 0–5
8 Environmental circumstances 6 0.75 0.92 0–4
9 Social problems 4 0.52 0.78 0–3
10 Pregnancy symptoms 8 3.07 1.71 0–7
11 Concern for changes during pregnancy 10 2.94 1.89 0–8
12 Dependency due to pregnancy 4 1.38 1.30 0–4
13 Concerns of unborn baby 4 2.0 1.06 0–4
a
Details of determinants under categories and subcategories are given in Appendix.
A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–1476 1471
Discussion
This is the first study to identify and study in
detail the framework for social environmental
determinants associated with depression among
pregnant women in an urban area in Karachi,
Pakistan. Consistent with the (Rahman et al., 2003)
study in Pakistan, we also found a high prevalence
of depression among pregnant women. Of the three
social environmental themes, we found social
relations and pregnancy concerns to be the most
predictive of depression, whereas social conditions
were not. This finding is also supported by other
studies conducted elsewhere (Stevenson, Maton, &
Teti, 1999; Aro, Nyberg, Absetz, Henriksson, &
Lonnqvest, 2001; Lee & Powers, 2002).
This study found that poor social relations with
husband and in-laws were strongly related with
depression among pregnant women, as has been
found in other cultures as well (Barnet et al., 1996;
Jain et al., 2004; Nitz et al., 1995; Stuchbery et al.,
1998). Poor relationship with husband may be
because of his extramarital affairs, physical and
verbal abuse, not spending enough time with the
family and putting unnecessary restriction on the
women. Similarly, the study found that physical or
verbal abuse and too much interference by the in-
laws, either by living in a joint family system or by
their influence over the household, affected the
relationship. Another factor identified by the study
is competition among different female members
belonging to the same family, such as mother-in-law
or sister-in-l aw. Competition is related to who has
the more say in the family and whose decisions are
being accepted. These again result in having a poor
relationship with in-laws. Positive social relations
have a protective effect against depression (McCor-
mick et al., 1990; Mubarak, 1997 ; Norlander,
Dahlin, & Archer, 2000; Sprusinska, 1994; Wilk-
inson & Marmot, 1998).
When studied separately, by various researchers,
social conditions such as poverty, lack of education,
unemployment, living in poor housing, life events
and working conditions contribute individually and
synergistically to depression among women (Bobak,
Pikhart, Hertzman, Rose, & Marmot (1998);
Nilsson et al., 2003; Zimmermann-Tansella et al.,
1991). This study also suggests that poor social
conditions are related with increased depression
among pregnant women but only in the univariate
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Table 4
Univariate linear regression analysis between categories and major themes of social environmental determinants and CES-D among
pregnant women in Karachi
B Beta 95% CI P value
Themes
Social relations 3.05 0.64 2.63, 3.47 o.0001
Social conditions 1.08 0.50 0.86, 1.29 o.0001
Pregnancy-related concerns 1.45 0.55 1.20, 1.71 o.0001
Categories
Age (years) 0.18 0.06 0.13, 0.49 0.26
Education of women (years) 0.42 0.17 0.70, 0.14 0.003
Gestational age (weeks) 0.07 0.05 0.24, 0.08 0.36
Number of alive children 0.91 0.08 0.28, 2.1 0.13
Abortion 3.45 0.20 1.49, 5.41 0.001
Gravida 1.47 0.18 0.56, 2.37 0.002
Husband 4.81 0.58 4.05, 5.59 0.00
In-laws 7.2 0.52 5.85, 8.54 0.00
Children 2.4 0.17 0.80, 4.07 0.004
Illness 2.51 0.25 1.42, 3.60 0.00
Economy 1.41 0.40 1.04, 1.78 0.00
Life event 3.1 0.25 1.74, 4.46 0.00
Work related 4.5 0.39 3.27, 5.73 0.00
Environmental circumstances 3.06 0.22 1.55, 4.58 0.00
Social problems 4.99 0.31 3.25, 6.73 0.00
Symptom 3.30 0.45 2.56, 4.05 0.00
Concern for changes during Pregnancy 3.23 0.49 2.57, 3.89 0.00
Dependency 4.47 0.46 3.49, 5.44 0.00
Unborn baby 3.26 0.27 1.96, 4.56 0.00
A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–14761472
analysis. However, in the multivariate model, only
two of the social conditions namely household work
and illness of the relatives were significantly
associated with depress ion. Very few responsibilities
and too many responsibilities have been found
elsewhere to be associated with depression, while
moderate responsibilities are favorable for women
(Lee & Powers, 2002). It has been argued that
number of household responsibilities and illness of
the relatives in Pakistani culture are more strongly
associated with quality of social relations (Niaz,
2000). The better the social relations are with in-
laws, husband and children, the more evenly the
work is distributed in terms of responsibilities.
To date, no study in Pakistan has looked at
pregnancy-related concerns in pred icting depres-
sion. In the multivariate analysis, pregnancy symp-
toms and changes due to pregnancy were
significantly associated with depression. A pregnant
woman not only undergoes physical changes but
along with this sh e has to make several adjustments
to cope with the other daily responsibilities. Physical
changes may cause her to become dependent on
others for carrying out daily household chores,
which also affects her socialization. The condition
of pregnancy has been found to be associ ated with
increased depression in many other studies con-
ducted elsewhere (Dole et al., 2003; Mulder et al.,
2002; Wadhwa et al., 2001).
This study supports the hypothesis that increasing
age and lower levels of education are associated
with increasing depression. Increasing biological age
has been found to be associated with increased
depression in other studies conducted in Pakistan
(Husain et al., 2004; Nisar, Billoo, & Gadit, 2004).
Increasing level of education lead to increased social
capital and that may increase the capability of
women to cope with the social environment
(Averina et al., 2005; Chaaya et al., 2002; Husain
et al., 2004).
Depression refers to a clinical spectrum that
ranges from a clinical syndrome (disorder) to the
milder symptom of feeling down (Carson, Butcher,
& Mineka, 1998). The CES-D scale has been used
cross-culturally and has shown good reliability for
measuring depression among pregnant women and
the general population (Gavin et al., 2005; Jain
et al., 2004; Orr et al., 2002; Radloff, 1977; Sharp &
Lipsky, 2002; Tsutsumi et al., 2004). Depressive
symptoms have been found to have the same
economic burden on health care as the depressive
disorders (Johnson, Weissman, & Klerman, 1992).
Therefore, it is important to note that use of
continuous score of CES-D in the analysis not only
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Table 5
Two multivariate linear regression models between categories and major themes of social environmental determinants and CES-D among
pregnant women in Karachi
B Beta 95% CI P value
Model for themes
a
Social relations 2.25 0.47 1.68, 2.82 o.0001
Pregnancy problems 0.71 0.27 0.42, 1.01 o.0001
Model for categories
b
Age 0.38 0.14 0.15, 0.61 0.001
Education of women 0.25 0.10 0.45, 0.04 0.02
Husband 2.63 0.32 1.81, 3.44 o.0001
In-laws 2.37 0.17 0.95, 3.79 0.001
Children 0.28 0.02 1.16, 1.72 ns
Illness 0.43 0.49 1.41, 0.54 ns
Economy 0.03 0.01 0.35, 0.42 ns
Life events 0.90 0.07 0.17, 1.98 ns
Work related 1.51 0.13 0.41, 2.61 0.007
Environmental circumstances 0.65 0.04 1.91, 0.61 ns
Social problems 0.36 0.02 1.14, 1.86 ns
Symptoms 1.18 0.16 0.47, 1.89 0.001
Concern for changes during pregnancy 0.67 0.10 0.05, 1.39 ns
Dependency 0.76 0.08 0.34, 1.87 ns
Unborn 0.72 0.06 1.88, 0.44 ns
a
Adjusted R
2
for themes ¼ 46%.
b
Adjusted R
2
for categories ¼ 51%.
A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–1476 1473
determines the factors associated with depressive
disorders but also those which are associated
with depressive symptoms. These have a similar
burden on the population and the same policy
implications.
The study emphasizes the importance of social
relations, which may be modifiable through inter-
ventions such as counseling and family support.
Depression during pregnancy leads to adverse
pregnancy outcomes such as low birth weight and
preterm birth (Dole et al., 2003 ; Mulder et al., 2002;
Wadhwa et al., 2001). Therefore, antenatal care
programs may include counseling services for
pregnant women in Pakistan. Intervention pro-
grams have successfully utilized traditional birth
attendants and other health workers to develop
support system for women in urban and rural areas
(Jokhio, Winter, & Cheng, 2005).
In this study, the sample of pregnant women was
varied in terms of socio-economic statu s, trimester
and parity. This provides an opportunity to
determine factors of social environm ent in a
comprehensive way and enables a framework to
be generalized to a larger population. This is a
cross-sectional study and it is therefore not able to
establish a temporal relationship between the
determinants and depression. We inquired about
the difficult experiences perceived by woman during
the last month in order to minimize recall bias. The
refusal rate was not significant and analysis shows
that a varied group with different parities, trimesters
and social class was captured.
In conclusion, this study found high prevalence of
depression among pregnant women of Karachi,
Pakistan; the study highlights the importance of
social relations compared to social conditions for
determining depression in pregnant women.
Acknowledgment
The study was funded by Aga Khan University
Research Council.
Appendix
Determinants of social relations
1. Husband
Second marriage by hus band
Extramarital affair by husband
General worries of husband
Woman’s restriction in making decision
No access to husband’s money
Attention not given by husband
Restrictions of woman by husban d
Verbal abuse by husband
Physical abuse by husband
Husband not having time for family
2. In-laws
Competition with in-laws
In-laws visiting at odd times
Physical abuse by in-laws
Interference by in-laws
Quarrel with relative
Major quarrel with in-laws
3. Children
Concern for children’s education
Concern for children’s future
Determinants of social conditions
4. Illness
Looking after sick relative
Parent’s illness or injury
Sibling illness or injury
In-laws serious illness or injur y
Children serious illness or injury
Husband’s illness
Personal illness
5. Economy
Rented home
Owing money
Parent’s financial problem
Non-earning member in the family
Less money for paying house rent
Having a small house
Husband’s job security
Need money for food
Husband not doing any job
Need money for health facilities
Need money for buying house
Inflated prices of common goods
Need money for clothing
Need money for childr en’s education
Future financial needs
6. Life events
Death of parents
Death of child
Abortion
Death of close relative
Getting married to so meone outside family
Suicidal attempt
Birth of hand icapped child
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A. Kazi et al. / Social Science & Medicine 63 (2006) 1466–14761474
7. Household work
Too many responsibilities
Preparing meals
Problem with maid
Looking after the children
Job problem
8. Environmental circumstances
Parent’s living far
Troublesome neighbors
Living alone
Safety and security
Husband being abroad
Problem due to shifting
9. Social problems
Husband addicted to drugs
Too many pe ople in the house
Living with in-laws
Sibling marriage
Determinants of pregnancy-related concerns
10. Pregnancy symptoms
Weight gain
Headache
Feeling unwell
Eating preferences
Difficulty in sleep
Bleeding per vagina
Vomiting during pregnancy
Not feeling baby’s movement
11. Changes during pregnancy
Physical appearance
Discontinuation of job
Shopping for the unborn baby
Access to health care
Late for work
Unwanted pregnancy
Difficulty in getting up in the morning
Difficulty in prayers
First pregnancy
Previous delivery by caesarian-section
Previous delivery outcome
12. Dependency due to pregnancy
Restricted socialization
Dependency for doing household work
Difficulty in traveling
General dependence
13. Concern of unborn baby
Fear of baby girl
Concerns about well-being of the baby
Concerns about bringing up of the baby
Appearance of the baby
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    • "The order of sessions was important and it was necessary to make psycho-education about depression the first session since it would educate the participant on the symptoms of depression and build rapport with the counsellor. The second session on problem solving was included in order to assist participants to address everyday problems such as employment, housing, conflict with partners and HIV diagnosis -common factors associated with perinatal depression [7, 15] . This second session includes steps on how to look for alternative solutions to one's problems [34, 35]. "
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    • "Existing empirical research also supports the idea that the majority of working women in Pakistan feel that they do not give enough attention to their children because of their jobs (Kamal et al., 2006). Such experiences of multiple demands from the large number of members in the family can lead to severe depression among the professional women in Pakistan (Kazi et al., 2006). The influence of culture on WFC has been acknowledged in existing research (Joplin et al., 2003, Aycan, 2008). "
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