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Introduction
Postpartum depression (PPD) is a nonpsychotic depressive disorder that affects mothers after childbirth. It is characterized by feelings of sadness, anxiety, diminished self-worth, changes in appetite, sleep, and mood, exhaustion, confusion, guilt, and difficulties in managing daily responsibilities. In severe cases, it can lead to suicidal thoughts [1,2]. These symptoms typically appear within the first 4 to 8 weeks after delivery, a period considered to be of high risk, although they can occur as late as 1 year postdelivery [3]. Mothers affected by PPD often struggle to provide optimal maternal care, which can lead to altered maternal behaviors and impaired maternal-infant bonding. These issues can have long-lasting impacts on the emotional, cognitive, and overall health of the infants, affecting interpersonal relationships, family dynamics, and social development [4,5]. If left undiagnosed and untreated, PPD can have complex effects on both mothers and infants. Moreover, persistent and severe cases of PPD may progress to postpartum psychosis, with statistics showing that 4% to 5% of affected women may commit infanticide or suicide [6]. Therefore, PPD represents a significant public health issue that poses substantial risks to maternal health and caregiving, with far-reaching consequences [7]. It is among the most common and debilitating mental health conditions affecting women of reproductive age [8].
The prevalence of PPD varies between countries and regions, with higher rates observed in developing countries. A pooled global prevalence of 17.22% has been reported [9]. Southeast Asian countries have higher prevalence rates than developed countries; with prevalence rates of 24.3% in Bangladesh [10], 22% in India [11], 19.3% in Pakistan [12], and 14.7% in Nepal [13]. Despite its prevalence, there remains a significant lack of studies, data, awareness, effective preventive measures, and intervention programs, particularly in developing countries [8,13]. Similarly, in Bhutan, mental illness is becoming a rising public health issue [14]. Between 2017 and 2021, the incidence of depression increased more than fivefold, from 6 per 10,000 to 32 per 10,000 population [15]. However, as of now, there are no published studies or official data on PPD and associated factors in Bhutan, to the best of our knowledge [16,17].
Although the main etiology of PPD remains still unknown [4], several factors have been consistently associated with its occurrence. These include sociodemographic factors such as the mother’s age, family income, education level, and family type [18]. In Bangladesh, a low maternal education level and low monthly income have been linked to an increased likelihood of experiencing PPD [10]. Psychosocial factors such as limited social support [19], history of violence or mental illness [20] maternal chronic illness [18], unplanned pregnancy [21], smoking, substance abuse [22], alcohol use [23], and perceived changes in body image after delivery [24], have also been identified as contributing to an increased risk of PPD. Additionally, stress perceived by mothers, along with their social isolation, were identified as risk factors [10]. Obstetric and infant-related factors, including parity [25], formula feeding [12], history of abortions, lower birthweight of the baby [26] cesarean births [27,28], a lack of prenatal checkups, unintended pregnancies, and preterm births were all associated with an increased risk of PPD [27-29]. However, factors such as having good social support, support from a spouse/partner [24], being married, breastfeeding [9], completing recommended prenatal care sessions, and having employed husbands/partners were inversely associated [18].
Bhutan has made remarkable progress in maternal healthcare, achieving a 98.4% rate of deliveries in healthcare facilities and a postnatal care coverage of 74% [15,30]. Postnatal mothers and their newborns receive follow-up care on days 3, 7, 21, and 42 to monitor their health [31]. Recently, Bhutan has introduced perinatal screening for depression, extending into the postpartum period. However, there is still a lack of statistical data and studies on PPD [16,17]. Therefore, the objective of this study was to ascertain the prevalence of PPD and identify the factors associated with it, in order to generate foundational, evidence-based data.
Methods
Ethics statement: Ethical approval for this study was granted by the Research Ethics Committee of the Faculty of Public Health at Chiang Mai University, Thailand (ET020/2023), and by the Institutional Review Board of Khesar Gyalpo University of Medical Sciences in Bhutan (PN/2023-008/1052). All research protocols and procedures adhered to the relevant guidelines and regulations. Written consent was obtained from all participants, and for those under 18 years old, assent was also secured from their legal guardians.
Study design
This cross-sectional study was conducted at the Gyaltsuen Jetsun Pema Wangchuck Mother and Child Hospital (GJPWMCH), a national referral hospital located in Thimphu, the capital city of Bhutan. The study adhered to the STROBE guidelines (https://www.strobe-statement.org/).
Sample and sampling
Mothers who visited GJPWMCH for postnatal checkups constituted our study population. We invited all mothers who were between 4 to 8 weeks postdelivery and willing to provide written consent to participate. Non-Bhutanese mothers and those unable to respond for any reason were excluded. We employed a convenience sampling method to recruit participants.
The sample size was calculated using a formula for a single population proportion, with the following assumptions: a reference prevalence of PPD in Bangladesh at 25% [10], a 95% confidence level, a 5% margin of error, and an additional 10% to account for potential incomplete data. Based on these calculations, the minimum required sample size was 285. To accommodate the risk of incomplete data, 315 eligible mothers were invited to participate, ensuring equal opportunity for all. After one participant withdrew, data from 314 postpartum mothers were analyzed (Figure 1).
Measurements
Questionnaires were used to collect data; the 10-item Edinburgh Postnatal Depression Scale (EPDS) was employed for screening PPD, with the highest possible score ranging from 0 to 30, where a higher score indicates a depressive mood [1]. Researchers have utilized different EPDS thresholds, with averages ranging from 9 to 14 [18]. However, this study adopted an EPDS threshold of ≥11, as a recent comprehensive review and meta-analysis identified this threshold as providing the optimal balance between sensitivity (81%) and specificity (88%) [32]. The questionnaires were verbally translated into a simple and comprehensible local language and were pilot-tested on 30 Bhutanese postpartum mothers, who were not part of the main study. The standardized α-coefficient of the original EPDS was 0.87, indicating high reliability [1]. Cronbach’s alpha for the pilot test was .72, and for this study, it was .85.
Based on a comprehensive review of existing literature and with a focus on investigating potential factors associated with PPD, additional questionnaires were developed. These questionnaires included three domains: (1) sociodemographic factors such as age, education level, monthly family income, and type of family living arrangement; (2) psychosocial factors including social relationships, history of domestic violence, mental health issues, perceived stress during and after pregnancy, pregnancy intention, alcohol and drug use, and perceived changes in body image postdelivery; (3) obstetric and infant-related factors such as the number of living children, antenatal visits, mode of delivery, complications during antenatal, intrapartum, and postpartum periods, gestational age, and the birth weight of the baby. A panel of experts reviewed the questionnaires before implementation.
Data collection and statistical analysis
The questionnaires were administered verbally by a trained research assistant in a separate room at GJPWMCH. The coded data were entered into an Excel spreadsheet and processed using STATA version 15.1 (StataCorp LLC). A descriptive analysis was conducted to compare the characteristics of participants with PPD using the chi-square test, and the results were presented in frequencies and percentages. Only significant variables were further analyzed using simple logistic regression. Independent variables with a significance level of p≤.05 were reexamined using multivariable logistic regression following a backward elimination process. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) and a p-value of ≤.05 as an indicator of statistical significance were utilized to assess the strength of associations.
Results
Characteristics of the participants
The participants’ ages ranged from 17 to 48 years, and 195 (62.10%) were between 25 and 35 years. More than half of the participants (n=176, 56.10%) had attained an education level of high school, and (n=174, 55.41%) did not have any direct income (Table 1). A significant number of participants (n=171, 54.46%) experienced a change in their body image after giving birth, and more than half of the participants reported heightened stress after delivery (n=190, 60.50%) (Table 2). Fewer than 50% of the participants had eight or more antenatal visits. Most deliveries occurred between 37 to <41 weeks of gestation (n=256, 81.52%), while negative birth experiences were expressed by (n=80, 25.48%) of participants (Table 3).
Prevalence of postpartum depression
The prevalence of PPD was found to be 14.97% (95% CI, 11%–19%) when using a cutoff point of ≥11. The mean score was 14.17 (standard deviation, ±3.44).
Table 4 presents the response rates for each question on the EPDS, following participant regrouping. Responses were regrouped based on their original values, with scores of 0 and 1 categorized as “no” and scores of 2 and 3 categorized as “yes.” For Q10, a score of 0 was categorized as “no,” while scores of 1, 2, and 3 were categorized as “yes” [18]. The highest percentage of symptoms were reported for Q4 (78.72%) and Q3 (72.34%) relating to anxiety, whereas the lowest was noted for Q1 (1.50%) and Q2 (2.25%), relating to anhedonia. Q10 (7.01%), pertains to having thoughts of self-harm at least once within the last 1 week, which is concerning.
Factors influencing postpartum depression
To examine the relationship between potential factors and PPD, twelve variables that were significant in the chi-square test were reanalyzed using simple logistic regression. These variables include monthly family income, relationship with friends, relationship with in-laws, history of mental health problems, perceived changes in body image, perceived stress during pregnancy, perceived stress after delivery, complications during pregnancy and delivery, overall birth experience, number of antenatal visits, gestational age, and the birthweight of the baby (Supplementary Table 1).
Table 5 presents the final model, which utilized multiple logistic regression with a backward elimination process. Participants who reported a perceived change in body image (AOR, 4.40; 95% CI, 1.91–10.17; p=.001), increased stress after delivery (AOR, 3.74; 95% CI, 1.45–9.67; p=.006), a poor relationship with their in-laws (AOR, 2.57; 95% CI, 1.24–5.30; p=.011), and a negative birth experience (AOR, 2.42; 95% CI, 1.17–5.00; p=.016) had higher odds of experiencing PPD. Conversely, participants with a higher monthly family income of ≥ Bhutanese ngultrum (Nu.) 20,000 to <Nu. 50,000 (AOR, 0.35; 95% CI, 0.13–0.92; p=.033) and >Nu. 50,000 (AOR, 0.37; 95% CI, 0.13–1.07; p=.067) compared to <Nu. 20,000, as well as those with advanced gestational ages of ≥37 to <41 weeks (AOR, 0.25; 95% CI, 0.09–0.71; p=.009) and ≥41 weeks (AOR, 0.08; 95% CI, 0.00–0.75; p=.028) compared to <37 weeks, significantly reduced the risk of PPD.
Discussion
To our knowledge, this is the first study to identify the prevalence of PPD and associated factors among Bhutanese mothers. The research was conducted at the largest hospital in Thimphu, the capital city of Bhutan, and included participants from diverse backgrounds with varying educational levels and socioeconomic statuses. The prevalence of PPD was 14.97%, which is lower than that in Bangladesh at 24.3% [10] and China at 34% [19], but higher than that in Thailand at 10.4% [28]. These differences may stem from variations in research design, sample size, timing of screening, and outcome evaluation. For example, the study in Bangladesh was conducted at 24 weeks postpartum with an EPDS threshold of ≥10 [10]. In Sri Lanka, different prevalence rates have been determined for mothers at 10 days (15.5%) and 4 weeks postpartum (7.8%) using the same EPDS threshold of ≥9 [18]. Nonetheless, the prevalence of this study is comparable to that in Nepal (14.7%) [13]. Similarly, a comprehensive assessment of global PPD prevalence revealed a comparable rate of 13.53% for South-East Asia [9]. While the prevalence of 14.97% may not be notably high compared to other countries in the region, it remains significant and warrants concern for Bhutan.
In terms of factors associated with PPD, after adjusting for other variables, women who perceived a change in their body image postdelivery were more than four times as likely to experience PPD. This finding is consistent with a report indicating that PPD was more prevalent among obese women with limited social support compared to their counterparts in Korea [24]. In Ethiopia, overweight women also reported higher rates of PPD [33]. Similarly, in Spain, postpartum women who were dissatisfied with their body image tended to exhibit depressive symptoms more frequently [34]. However, a meta-analysis and comprehensive review identified only a weak association between body image dissatisfaction and PPD, despite consistent reports of the link [3]. To encourage a positive perception of body image changes after childbirth, it could be beneficial to inform and prepare mothers during the antenatal period and provide the necessary support to improve their body image postdelivery [34]. This study focused exclusively on the perceived feelings expressed by the participants, without considering their actual body weight or body mass index.
The finding that heightened perceived stress after delivery significantly increases the risk of PPD, with participants nearly four times more likely to be affected compared to those who reported no stress or a decrease in stress levels, aligns with previous studies from Bangladesh [10] and Iran [35]. Additionally, it has been noted that stressful life conditions, including significant life transitions, can contribute to PPD [3].
This study also observed that having a poor relationship with in-laws significantly increases the risk of PPD, with affected individuals facing more than twice the risk. This finding aligns with research conducted in India, which found that women ill-treated by their in-laws were nearly five times more likely to experience PPD [36]. A comprehensive study by Wang [9] revealed that nearly 80% of women with PPD had poor relationships with their mothers-in-law. Similar findings have been reported in other studies as well [37,38]. Strengthening the bond between a new mother and her mother-in-law has been shown to decrease the incidence of PPD in China [39]. A poor relationship with in-laws can be perceived as a diminished support system, exacerbating the emotional challenges and making women more susceptible to PPD. This is particularly significant as familial support is highly valued in Asian countries [3].
Our study found that participants who had negative birth experiences were more than twice as likely to experience PPD. Similarly, a study in Brazil reported that ill-treatment of women during childbirth was linked to a 50% increase in PPD symptoms [40]. Additionally, reduced satisfaction with the delivery process was identified as a strong indicator of PPD [41]. Consistent support throughout childbirth has been shown to decrease adverse experiences and improve outcomes for both mother and infant [42]. In Bhutan, approximately 12,000 to 13,000 women give birth annually, with 98.9% attended by skilled health professionals [15,43]. A previous study on respectful maternity care in Bhutan revealed that 41.8% of women had dreadful birth experiences [44]. Although the percentage of participants who reported negative birth experiences in this study was lower (25.48%), it remains a significant concern. The birth experience in this study may not fully reflect the care provided in health facilities but also includes support from husbands/partners and family members. This underscores the need for ongoing training of health professionals in comprehensive delivery care. Additionally, educating husbands/partners and family members about the importance of their support during this critical time is essential to ensure that women receive satisfactory care during birth and thereafter.
In addition to identifying risk factors, this study also highlighted factors that alleviate the risk. A higher monthly family income was inversely associated with PPD, mirroring findings from a Brazilian study where an improved financial status reduced the prevalence by nearly 50% [40]. Conversely, low family monthly income was linked with a raised probability of PPD in Indonesia [21] and Cameroon [20]. Furthermore, this observation is consistent with the World Health Organization’s STEPS survey in Bhutan, which emphasized socioeconomic factors as key elements in the mental health of women of reproductive age [45].
Advanced gestational age was identified as another mitigating factor, and similar findings were reported in Myanmar [29], and northwestern Ethiopia [26], where preterm delivery occurring before 37 weeks of gestation was inversely associated with PPD. A comprehensive review on preterm birth revealed that mothers of preterm babies are more likely to develop PPD compared to mothers of term babies [46]. This study found a preterm birth rate of 9.23%, slightly higher than that of a prior study (6.4%) [47]. The earlier study also noted that half of the preterm infants required admission to the neonatal intensive care unit. As the likelihood of newborn mortality and morbidity increases with decreasing gestational age, these factors might have contributed to the decreased risk of PPD as gestational age advances.
Although variables such as a history of mental health problems, inadequate antenatal visits, and complications during or after delivery did not reach statistical significance in the final model after adjusting for other factors, they were significant in the univariable analysis. Previous studies have reported associations between these variables and PPD, underscoring their potential importance: a history of mental health problems [23,35] not having the recommended number of antenatal checkups [18,29], and complications during/after delivery [38]. Therefore, further exploration of these factors and their relationship with PPD could provide a more comprehensive understanding.
A limitation of this study is that it examined various sociodemographic, psychosocial, and obstetric and infant-related factors, but did not include biological factors, which have been shown to be associated in previous studies. Additionally, the translation process of the EPDS was not independently verified; future studies should consider conducting psychometric testing. Furthermore, because this study was cross-sectional, it cannot establish causality or ensure generalizability.
In conclusion, nearly 15% of Bhutanese postpartum mothers experienced PPD. Mothers who perceived a change in body image, experienced increased stress after delivery, had poor relationships with their in-laws, or had negative birth experiences were at a greater risk of developing PPD. Conversely, a higher monthly family income and advancing gestational age were associated with a reduced risk of PPD. To mitigate the prevalence and reduce the risk of PPD, screening strategies and interventions should prioritize women with the aforementioned factors. Since these factors span all three domains, a multidisciplinary and comprehensive approach is essential. This study provides a foundational understanding of PPD and its associated factors among Bhutanese mothers, serving as a reference for future researchers. The integrated screening of perinatal depression with maternal and child health should be uniformly carried out, made accessible and available [5], and the involvement of healthcare professionals in perinatal screening should be enhanced to ensure that mothers at elevated risk for developing PPD are identified as early as possible [23]. Moreover, standard protocols on interventions are essential to guide health professionals in mitigating further risks and addressing associated implications.
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