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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 615-623  

A study of the burden of maternal depression on young mothers and their caretakers


Department of Psychiatry, Dr. D.Y. Patil Medical College, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission26-Nov-2019
Date of Decision11-Jan-2020
Date of Acceptance03-Feb-2020
Date of Web Publication6-Nov-2020

Correspondence Address:
Preethi Menon
Department of Psychiatry, Dr. D.Y. Patil Medical College, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_324_19

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  Abstract 


Aim: This study aims to evaluate the burden of maternal depression in young mothers and their caretakers compared to their non-depressed counterparts. Materials and Methods: This cross-sectional, analytical, case–control study was carried out in a metropolitan tertiary care teaching hospital. Young mothers were screened for probable psychological disorders using 12-item General Health Questionnaire (GHQ-12). The positive cases were administered The Edinburgh Postnatal Depression Scale to identify mothers suffering from depressive illness. All mothers with score above 13, with confirmed diagnosis of depressive disorder by a psychiatrist, were recruited as study subjects. Their caregivers were assessed for burden using burden assessment schedule. The mothers, scoring below the cutoff on GHQ, and their caregivers, were recruited as the comparison group. Fifty consecutive mothers were recruited in both groups. Results: Among depressed mothers 72% had a female child and 28% had a male child. Among nondepressed mothers 60% had a male child and 40% had female child. The caregivers of depressed and nondepressed mothers spent an average of 11.32 h and 9.2 h, respectively, daily. The number of hours spent in caring during any given day was highly correlated with the burden assessment schedule (BAS) score. Greater the number of hours spent-greater was the BAS score. Conclusion: There is a higher likelihood of postpartum depression among mothers if gender of the baby born is a female. There is a considerable burden on caregivers of depressed mothers which is directly correlated with the time the caregiver is providing care for depressed mother.

Keywords: Burden assessment schedule, caretakers, Edinburgh Postnatal Depression Scale, postpartum depression


How to cite this article:
Singh V, Menon P, Chaudhury S, Saldanha D. A study of the burden of maternal depression on young mothers and their caretakers. Med J DY Patil Vidyapeeth 2020;13:615-23

How to cite this URL:
Singh V, Menon P, Chaudhury S, Saldanha D. A study of the burden of maternal depression on young mothers and their caretakers. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Nov 26];13:615-23. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/615/300143




  Introduction Top


Depression is the fourth leading contributor to the global burden of disease and affects people in all communities across the world.[1] Depressive disorders often start at a young age; they reduce people's functioning and often are recurring. For these reasons, depression is the leading cause of disability worldwide in terms of total years lost due to disability.[1],[2] There are several factors that contribute to the unique picture of depression in women, from reproductive hormones to social pressures to the female response to stress.[3] It is a major public health problem that is twice as common in women as in men during the childbearing years.[3] It affects social life, family relationships, career, and one's sense of self-worth and purpose.

Maternal depression is an all-encompassing term for a spectrum of depressive conditions that can affect mothers (up to 12 months' postpartum) and mothers-to-be.[4] Postpartum depression is defined as an episode of nonpsychotic depression according to standardized diagnostic criteria with onset within 1 year of childbirth.[5] Approximately 10%–20% of women experience depression either during pregnancy or in the first 12 months' postpartum. It is estimated that in young mother prevalence of major depression is 7.1% and major and minor depression combined amounts to19.2%.[4]

Literature on burden of diseases and burden of care has largely focused on the context of chronic mental illnesses. There are few studies on caretaker burden in patients suffering from depression.

Maternal depression in particular poses a unique problem. The new mothers have to be the caretakers of their babies. Responsibilities of being a new mother in it can pose demands which even the healthiest mothers may find as daunting. Depressed mothers inevitably experience the burden of caring for the babies and that may add to their vulnerability.[6] Childbirth is a positive life event for those healthy mothers who also enjoy support of their immediate family. Couples with planned pregnancies had higher prepregnancy satisfaction scores. Despite this, studies indicate that parenthood hastens marital decline even among couples who are relatively satisfied and who choose to make this transition. However, prepregnancy marital satisfaction and planned parenthood generally protect marriages.[6] It is but natural that when the mother has some issues with health be it physical or mental the difficulties experienced by the spouse is immense. Caregiver burden may be defined as the strain and difficulties experienced by the caregiver of persons with psychiatric disorders, and include a range of physical, social, psychological, emotional, and financial problems. It has been observed that the spouses of persons with depression reported higher levels of symptoms of anxiety and depression and lower levels of subjective well-being compared to general population.[7] In the Indian context, the support system of a new mother is her spouse and often her biological family as well as marital family. There is a cultural sanction for the families to take on active responsibilities of the child care and the care of the new mother. The young mothers often are allowed to transition into primary caretaker of the child over days and weeks.

In case of maternal depression, however, this course of change of roles may be delayed. The mother's dysfunctionality during the active phase of depression may add to the responsibilities of the caretakers. This has the potential of caretakers experiencing the burden of care depending on multiple variables such as severity and course of maternal depression, overall baby's health status and resources of the family. Apart from the illness, these factors in the immediate environment of the young mothers may have impact on recovery. Effects of maternal depression and burden of caretakers hence becomes a problem of clinical significance. Hence, the present study was undertaken to evaluate the burden of maternal depression in young mothers and their caretakers in comparison to their normal counterparts.


  Materials and Methods Top


This analytical, cross-sectional, case–control study was carried out in a metropolitan tertiary care teaching hospital. The proposal of the study was submitted to the Institutional Ethical Committee and work began after approval of the same.

Sample

A young mother was operationally defined as women of age from 18 years to 35 years with babies in the age range of newborns up to 12 months. The doctors attending to the young mothers in pediatrics' and obstetrics departments were sensitized about the study to refer the cases to psychiatric care. The study group as well as comparison group was recruited using a two stage method of case selection. Consecutive mothers on each of the recruitment day were screened for probable cases of psychological disorders using 12-item General Health Questionnaire (GHQ-12). Those who scored >2 were administered the Edinburgh Postnatal Depression Scale (EPDS) to identify mothers suffering from depressive illness of varying severity. All the mothers with score above 13, was assessed for confirmation of the diagnosis of depressive disorder by a psychiatrist. The confirmed cases were recruited as study individuals. Fifty consecutive cases fulfilling inclusion and exclusion criteria constitute the study group and their caregivers were assessed for burden using burden assessment schedule (BAS) scale. The mothers, who were screened as negative on GHQ were consecutively recruited as the comparison group. Fifty consecutive mothers were recruited in this group [Figure 1].
Figure 1: Plan of study

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Inclusion criteria

For the study group

All young mothers with scores above 2 on the GHQ and diagnosis of depression confirmed by a psychiatrist.

For the control group

Young mothers who were screened below the cutoff and did not receive the diagnosis of depression on the depression rating scale.

Exclusion criteria

Mothers whose babies had major medical conditions requiring continued medical help.

Mothers with medical conditions warranting continued medical help.

Mothers suffering from major psychiatric morbidity such as postpartum psychosis, schizophrenia, or intellectual disability.

Tools

The 12-item General Health Questionnaire

The GHQ12 has been widely used worldwide as a brief screening instrument. For the purpose of its use as screening instrument for case detection, the shorter GHQ is remarkably robust and works as well as the longer instrument.[8]

Edinburgh Postnatal Depression Scale

The 10-question EPDS is easy to administer and has proven to be an effective screening tool. Mothers scoring >13 are probably suffering from a depressive disorder. The EPDS should be supplemented with a careful clinical assessment to confirm the diagnosis.[9]

Burden Assessment Schedule

The BAS is a brief, reliable, and practical tool with excellent validity and reliability. The use of the BAS in two separate studies reveals the scale to have a stable factor structure, whether it is self or interviewer-administered. The scale differentiates between family samples with different levels of burden and is sensitive to changes over time.[10]

Methodology

Written informed consent of the subjects and the caretakers were recorded after informing them about the objectives of the study. All the cases thus recruited as study group and comparison group were administered a specially designed pro forma for the documentation of sociodemographic information as well as illness information. Caretakers of the mothers were operationally defined for the purpose of the present study as a family member/relative who has been living with the young mother, providing day-to-day support and sharing caretaking of the mother and the baby would constitute the caretaker. The caretakers of mothers in both the groups were administered the BAS.

Statistical analysis

Frequency distribution of demographic variables as percentages was computed. Intragroup analyses on frequency variables were done using Chi-square tests. Other comparisons were done using t-test, Mann–Whitney U test as appropriate. Spearman's rho was used for correlations. A P < 0.05 was considered statistically significant.


  Results Top


Demographic and clinical characteristics of the young mothers included in the study are shown in [Table 1]. There were no significant differences between the mothers with depression and mothers without depression with regard to age, domicile, education, religion, occupation, duration of marriage, total number of children, total number of abortions, type of delivery of present baby, and duration of hospitalization. However, in our study depressed mothers had significantly higher number of female child (P ≤ 0.004), and had significantly higher scores on EPDS (P < 0.001) than mother's without depression [Table 1].
Table 1: Characteristics of depressed and nondepressed mothers

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There were no significant differences between caregiver of mothers with depression and caregivers of those without depression with regard to age, marital status, and relationship [Table 2]. However, there were significant differences with regard to unemployment, duration of care giving in hours and BAS score [Table 2] and [Table 3]. A statically significant correlation was observed between hours spent per day taking care of depressed mothers and BAS score of care givers (Spearman's rho = 0.746; P < 0.001) [Figure 2]. Correlation between total months taking care of depressed mothers and BAS was statistically significant with P < 0.001 [Figure 3]. However, the association between age, relationship, occupation and education with BAS score was not significant [Table 4].
Table 2: Characteristics of caregivers of depressed and nondepressed mothers

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Table 3: Burden of caregiving

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Figure 2: Correlation between number of hours spent in a day taking care of depressed mothers and BAS score of care givers

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Figure 3: Correlation between total amounts of months taking care of depressed mothers

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Table 4: Association between age, relationship, occupation and education with burden assessment schedule score

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  Discussion Top


The study was carried out in a metropolitan tertiary care teaching hospital. The aim was to study the burden of maternal depression in young mothers and studied the burden of maternal depression on the caretakers and compared it with the burden on caretakers of nondepressed mothers.

Age of mothers

The mean age of depressed mothers was slightly higher than nondepressed mother (25.56 years and 24.70 years) but the difference was not statistically significant [Table 1]. This finding is in agreement with two earlier Indian studies.[11],[12] A meta-analysis of 19 Indian studies also observed that the mean age of mothers with maternal depression was ≤25 years.[13]

Domicile of mothers

In the present study, no significant difference was noted in depressed mothers and control group with regard to domicile. This finding is in agreement with a previous Indian study.[12] However, this finding was not in agreement with reviews of Post partum depression (PPD) information from 2000 to 2015 which showed that there was a higher proportion of PPD on urban young mothers.[13],[14],[15]

Education status of mothers

The differences between cases and controls with regard to education were not statistically significant. This is in agreement with an earlier Indian study.[12] UN data from 2017 show 26.7% and 74.5% of female receiving tertiary and secondary education, respectively.[16] This discrepancy may have occurred due to the nature of the local population which has a large proportion of daily wage, unskilled, and migrant workers. In low- and middle-income countries (LMICs) the higher rates of PPD are reflective of reduced protective factors acting as barriers to onset of PPD. This is borne out by the combined facts the better educated women are less likely to become depressed but at the same time fewer women are likely to receive secondary to higher education in LMICs.[17],[18] Ertel et al. also found that with lower levels of education, lower income, lack of a job, and being a single mother, led to higher rates of depression.[11]

Occupation of mothers

The difference between depressed and non-depressed mothers with regard to occupation was not statistically significant. Most of the women in this community are home makers. According to 2011 census, an average of 31.5% of women were employed in various categories which was much higher than our findings.[18] However, our findings are in agreement with an earlier Indian study which reported that 10.75% of young mothers were employed and that no specific type of job affected the rate of PPD.[12] Among many communities it is not considered suitable for a new mother to be employed. Among certain sectors, significant paid maternity leave is not the norm and many women perforce leave their jobs for long periods of time to take care of their children. This may explain the difference in employment rates in the present study population and general population. The inability to work may through reduction in economic status and a reduction in financial independence with the attendant reduction in self-esteem is contributory to maternal depression in mothers.[11] However, this was not studied specifically and needs further research.

Duration of marriage (mothers)

Among depressed and nondepresedmothers there was no statistically significant difference in mean duration of marriage. All ladies in the study were married. While being single is a minor predictor of maternal depression the literature does not show any relation between duration of marriage and PPD. There is however the fact that higher the duration of marriage higher will be the age of the mother. Studies have shown that increasing age portends reduced likelihood of PPD.[13]

Total number of children

The number of children of depressed mothers and mothers without depression was not found to be statistically significant in present study. This is in agreement with an earlier study that did not find any association between number and age of children and PPD.[11] However, a study that included 86 women assessed within 6 weeks after delivery, reported that having two or more children is more likely to be associated with the incidence of depression probably because the psychological burden on the mother increases with the number of children.[19] An extensive longitudinal study also found higher depression in younger mothers with more children.[20],[21] This is particularly of concern because of their finding that early onset of symptoms also predicted persistence of symptoms.

Total number of abortions

In the present study, 24% of depressed mothers had one or more (spontaneous or medical) abortions as compared to 12% among the nondepressed mothers. This was not statistically significant. A previous Indian study did not register any association between abortion - their mode and numbers - with PPD.[12] In contrast to this few studies report that abortions by different modes are a risk factor in the development of depression in women. A study of urban young mothers found that increasing number (but not the mode) of abortions led to an increasing risk of subsequent depressive episodes including in the postpartum period. They also found an increase in anxiety and occurrence of Post traumatic stress disorder (PTSD) after childbirth in mothers who had previous abortions.[22] Abortions in India are fraught with numerous adverse cultural implications.[23] In recognition of the implications of abortion on women's mental health, the government sector in India does provide for paid leave of 45 days in case of abortion.

Type of delivery

Among depressed mothers 56% had normal vaginal delivery and 44% had cesarean section however among mothers without depression 54% vaginal delivery and 46% had caesarean section. The difference was not statistically significant. This finding is in agreement with earlier studies.[12],[23],[24]

Gender of baby

In the present study, 72% of depressed mothers had a female child and 28% had a male child. Among the mothers who did not have depression 60% and 40% had male and female children respectively. This was highly statistically significant.

In previous Indian research, the effect of gender of the newborn has been consistently found to be significant. There was an elevated risk of marital violence post the birth of a girl which in turn potentiated persistent depression in the mother. Indian society has a persistent and frequently pernicious preference for a boy rather than a girl. Combined with few and far between facilities providing reproductive health guidance causing diminished control on fertility this preference causes elevated risk for PPD. Mothers take the blame for having had a female child and this sentiment may get internalized as feeling of guilt for having let the family down. it is obvious that such a sequence of event causes greater stress in mothers.[25],[26] Parsons finds the birth of a female child in India is associated with development of PND.[17] Patel et al. suggest counseling parents with an aim to improve communication in the marriage and gainsaying the preference for boys should be made a routine component of ANC. this is because they found the infant sex bias with poverty and domestic violence caused PPD.[25] Chandran et al. found a decreased level of physical support being made available to mothers after the birth of a daughter.[27] Shidhaye and Giri found that preference for males cause significant family and relationship problems.[28] They showed that these along with low social status were crucial factors causing depression. Saldanha et al. demonstrated the severity of the problem when they found 47.85% mothers in their study expressing a wish for a boy as opposed to a mere 5.38% wanting a girl.[12]

Duration of hospitalization

The mean duration of hospitalization among depressed mothers and mothers without depression was not statistically significant. In India, women delivering in hospitals often have stay lesser than 48 h. This short duration removes the opportunity for health workers to engage with the mother and for any counseling that the mother might need with respect to childcare and her own well-being. It also decreases opportunities to screen for PPD.[13]

Edinburgh Postnatal Depression Scale

The EPDS is an extremely useful screening tool with great efficiency in recognizing postnatal depression.[29] A previous Indian study found that EPDS scores had a mean of 16.6, 16.8, and 15.3 at 2, 4, and 6 weeks, respectively, in depressed mothers. The mean score in the mother not facing depression were 7.3, 6.3, and 4.9 at the same number of weeks.[12]

Depression in women occurs at different points in the reproductive cycle including in the premenstrual phase during pregnancy in the postpartum and perimenopausal period. Postnatal depression is a singularly complex problem. New mothers have the daunting responsibility of being the primary caretaker of the new child.[30] In addition, except for the first few weeks Indian mothers have to also be the primary caretaker of the entire home. It is clear that a depressed mother will experience this burden as being significantly higher for them. Depression by its very nature undermines a mother's confidence in her competence at being a parent. This engenders a heavy burden on the mother. Depression also reduces the quality of life and causes an impaired functional capacity.[31]

When we consider the burden of depression it is pertinent to note that the World Health Organization recognizes depression to be the fourth leading contributor to disability adjusted life years (DALYs). Its accounted for 4.46% of all DALYs and 12.1% of years lost to disability.[2] There is greater use of health facilities caused by major depression. However, fewer than 10%–25% of patients with depression receive treatment. This is due to barriers erected by inadequate resources lack of manpower and associated stigma.[2] This is even more the case with PPD where cultural and social pressures prevent a mother from accessing mental health care. Rural patients suffering the more severe forms of PPD are frequently taken to faith healers rather than to medical facilities. Numerous poorly studied or ineffective “home remedies” and “holistic” treatments such as special diets, tonics, and supplements replace well thought out treatment plans from doctors.[2]

The EPDS for these reasons should find higher utilization at the points of contact for young mothers with the medical system. This will prevent the diagnosis from being missed by nonpsychiatrist specialists such as obstetrics and gynecology and pediatricians.

Age of caregiver

Mean age of caregiver of mothers with depression was significantly less than mean age of caregivers of those without depression. The present study was unable to find data in literature supporting or refuting this finding. It is possible that with increasing age and with greater life experience there might be a greater ability to deal with stresses and strains involved in caring for a mother. It should be a subject for future research as to whether burden perceptions change with increasing age and whether these perceptions in turn affect the mental health of the caregiver and the mother.

Employment of caregivers

Among caregivers of depressed mothers 28% were unemployed while among caregivers of nondepressed mothers only 4% were unemployed. This difference is statistically highly significant. There is a multitude of ways to grasp this finding. An unemployed caregiver - the majority of whom are husbands - implies a lack of household income. As seen from the literature low socioeconomic status is a risk factor for maternal depression. The mother contemplating the future with a new child is bound to be discouraged when she finds herself with no finances of her own and her caregiver having no way of securing the family finances. From, however, the present study finds that the burden on the caregiver has no statistically significant correlation with the current occupational status. The present study did not find any literature which correlated the two specifically in the context of maternal depression.

Duration of care giving/burden of care giving

The present study compared the duration of care giving at two levels. One at the daily time spent and the second about the total amount of time in months. The caregivers of depressed and nondepressed mothers spent an average of 11.32 h and 9.2 h, respectively, daily which was statistically significant. Similarly, a statistically significant difference existed between the total number of months of care giving received by depressed and nondepressed mothers with them receiving 5.0 and 3.1 months, respectively.

There were no studies which specifically dealt with the number of hours/months of care giving provided to mothers. However, the pertinent points to be noted are that paternal depression is a significant issue that is both prevalent and rarely looked for by health-care professionals. As reported earlier the predictors of paternal depression include parenting stress, partner depression, discord at home and work issues.[13] As we have noted there is greater time spent caring for the mother and the child daily and for a longer term overall.

This has the obvious effect of increasing the stress upon the caregiver. Since most of the caregivers in the study were the husbands - who were mostly employed at the time of the study - there is bound to be an increase in problems adjusting time between work and home requirements. The present study did not specifically look for the diagnosis of depression among the caregivers instead concentrating on the objective and subjective burden. The figures in this study clearly show a higher objective burden on the caregiver.

Edinburgh Postnatal Depression Scale

In the present study, the mean BAS score of the caregivers of depressive mothers is 30.92 while that of nondepressive mother's caregivers is 20.8. This was statistically significant. An earlier Indian study found that high levels of burden predisposed to depressive episodes, drug taking, and anxiety. A connection between increased caregiver burden and decreased family support was also found owing to emergence of the nuclear family model.[32] Another study found that those reporting a greater burden among caregivers of depressed patients had poorer health as well as a weaker sense of coherence. The sense of coherence is the attitude of the person whereby the person feels that the stresses and strains of life are understandable, within their handling ability and sensible. This promotes salutogenesis which is the ability of a person to cope with demands placed upon them.[33]

The present study found that the number of hours spent per day in care giving was highly correlated with the BAS score [Table 3] and [Figure 2]. Greater the number of hours spent-greater was the BAS score. The BAS is a measure of the subjective burden. The subjective burden reported by caregivers has been shown in previous studies to be higher than the objective burden. The current study demonstrates that there is a direct relationship between the two.[32],[33]

Previous studies have shown that changes in mothers occurring before the beginning of the depressive episode causes altered interpersonal relations and roles within the family. Worries about the future and distress arising from the “change” in the patient arise due to ignorance about the causes and effects of depression. Depression alters the communication among partners, which, as the Iowa report shows, predisposes to caregiver depression especially among fathers.[33],[34] This in turn causes a diminished care giving capacity. This establishes a vicious cycle, the outcome of which is compromised mental and physical health of the entire family unit including the newborn child.[33],[34]

Limitations

The study being a hospital based one it may not be correct to generalize the findings to the entire community. The sample size of caregivers of patients was limited because of time and other logistic constraints. Considering the prevalence of maternal depression this sample size is considered as modest. A follow-up study would have been better.


  Conclusion Top


There is a higher likelihood of depression among mothers if gender of the baby born is a female. There is a considerable burden on caregivers of depressed mothers which is directly correlated with the time the caregiver is providing care for depressed mother.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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