Postpartum depression first gained medical attention in the 1970’s.  While postpartum depression is similar to depression occurring at other times in a woman’s life, we have learned over time that many women with what we typically call “postpartum depression” also have significant anxiety symptoms.  In addition, some women present with only anxiety symptoms, and appear to have generalized anxiety disorder or obsessive compulsive disorder, although many women with anxiety disorders also develop comorbid depression.

Most studies on risk factors for perinatal mood and anxiety disorders have focused on depression, and we have less information on predictors of perinatal anxiety symptoms.  A recent study from the Netherlands has examined risk factors for postpartum depression and anxiety symptoms.  

This study included data from 1406 mothers enrolled in the Post-Up Study from the Netherlands, a  prospective study of the effectiveness of screening for  postpartum depression as part of well-child care. Information on potential risk factors was collected at 3 weeks postpartum using an online questionnaire.  Data on life events was collected at 12 months postpartum.   Depression was measured at 4 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS), and anxiety symptoms were assessed using the  6-item State-Trait Anxiety Inventory (STAI-6).  Stepwise logistic regression was used to identify relevant risk factors.

Several factors were associated with an increased risk of developing postpartum depression and/or anxiety. Some factors were associated specifically with a  higher risk  of either depression or  anxiety; others were associated with a  higher risk  of  both. 

Risk factors for postpartum depression: Higher risk was associated with lifetime history of depression, speaking a foreign language at home, low maternal self-efficacy, and poor physical health of  the  mother. Risk of depression was lower in women who did not initiate breastfeeding; however, not breastfeeding at 3 weeks postpartum was associated with a higher risk. 

Risk factors for postpartum anxiety: Higher risk was associated with lifetime history of depression, lower education, preterm birth, inadequate support from the partner, low maternal self-efficacy, and poor physical health of the mother.  Experiences occurring at the time of childbirth and during the first week after delivery also increased risk of anxiety symptoms at week 4:  negative experiences associated with delivery and/or the first postpartum week, crying experienced as excessive.  Although these experiences were labeled as risk factors for postpartum anxiety, it is possible that the more negative perceptions are, in fact, the earliest symptoms of postpartum anxiety.

The Importance of Maternal Self-Efficacy

The factor that was the most robust predictor of both postpartum anxiety and depression was low maternal self-efficacy.  This was measured using the Maternal Self-Efficacy in the Nurturing Role Questionnaire (SENR; Pedersen et a, 1989), a 16 item questionnaire regarding the mother’s perceptions of her competence in caring for her infant. A low SENR score was the most robust predictor for both depression (OR 5.84, CI 3.59-9.49) and anxiety (OR 10.01, CI 6.21-16).  In this community sample, low maternal self-efficacy was a much better predictor of postpartum depression and anxiety than having a history of depression.  

Given the importance of self-efficacy as a modulator of risk for postpartum depression and anxiety, this study suggests that there may be interventions which we could institute after delivery which improve maternal self-efficacy and, in this way, decrease risk for postpartum depression and anxiety.  Over the years we have seen a number of programs which provide parental support and focus on developing parenting skills – for example, Practical Resources for Effective Postpartum Parenting or PREPP.  Not only do these programs improve maternal self-efficacy, they appear to reduce risk for postpartum depression.  

Ruta Nonacs, MD PhD

van der Zee-van den Berg AI, Boere-Boonekamp MM, Groothuis-Oudshoorn CGM, Reijneveld SA.  Postpartum depression and anxiety: a community-based study on risk factors before, during and after pregnancy.  J Affect Disord. 2021 Mar 4; 286: 158-165. 

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