Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-034458 on 21 June 2020. Downloaded from Prevalence and risk factors of postpartum depression, general depressive symptoms, anxiety and stress (PODSAS) among mothers during their 4-­week­postnatal­follow-­up­in­five­ public health clinics in Perak: A study protocol for a cross- sectional study Saidatul Akmar Mohammad Redzuan ,1 Priyasini Suntharalingam,2 Thenmoli Palaniyappan,3 Venotha Ganasan,1 Puteri Normalina Megat Abu Bakar,4 Paream Kaur,5 Lili Zuryani Marmuji,1 Subashini Ambigapathy,2 V Paranthaman,5 Boon How Chew 6 To cite: Mohammad ABSTRACT Strengths and limitations of this study Redzuan SA, Suntharalingam P, Introduction Postpartum depression, general depressive Palaniyappan T, et al. symptoms, anxiety and stress (PODSAS) are often Prevalence and risk factors of ► This study will examine the point prevalence of de- overlooked, and may cause morbidity to new mothers, postpartum depression, general pression (postpartum depression and general de- depressive symptoms, anxiety their babies and families. This study aims to determine pressive symptoms, combined and separately) and and stress (PODSAS) among the point prevalence of depression (post partum and other psychological well- being (anxiety and stress) mothers during their 4- week general), anxiety and stress among mothers in five public at 4- week post partum that have not been studied postnatal follow- up in five health clinics in Perak at 4 weeks postdelivery and identify in depth before. public health clinics in Perak: http://bmjopen.bmj.com/ their associated risk factors. Findings from this study ► Five public health clinics in urban and suburban ar- A study protocol for a cross- will be used to identify the needs for early screening and eas of Perak may not be representative enough as to sectional study. BMJ Open detection, encourage development of interventions to 2020;10:e034458. doi:10.1136/ attribute the findings to the nationwide population. reduce its occurrence and support mothers with PODSAS. bmjopen-2019-034458 ► Self- administration of the questionnaire is encour- Methods and analysis This cross- sectional study will aged and facilitated to improve data quality. Prepublication history and ► recruit 459 postpartum mothers during their 4- week ► Respondents will not reflect the incidence or preva- additional material for this postnatal follow- up in five selected public health linicsc lence rate of depression, anxiety and stress at other paper are available online. To in Perak from September 2019 to May 2020. Participants time points, or prevalence of these conditions during view these files, please visit will be mothers aged 18 years and above at 4 weeks on September 27, 2021 by guest. Protected copyright. the journal online (http:// dx. doi. the first few weeks after delivery or months later in org/ 10. 1136/ bmjopen- 2019- postdelivery who are able to understand the English and the postpartum period. 034458). Malay languages. Non-Malaysians and mothers with known diagnosis of psychotic disorders will be excluded Received 20 September 2019 from the study. Sociodemographic information and Results of this study will be reported and shared with Revised 08 May 2020 possible risk factors of the participants will be captured via the local health stakeholders and disseminated through Accepted 20 May 2020 a set of validated questionnaires, postpartum depression conference proceedings and journal publications. (PPD) will be measured using the Edinburgh Postpartum Registration number This study is registered in the Depression Scale questionnaire and general depressive Malaysian National Medical Research Register with the ID: © Author(s) (or their symptoms, anxiety and stress will be measured using NMRR-19-868-47647 employer(s)) 2020. Re- use the 21-item Depression, Anxiety and Stress Scale. Data permitted under CC BY-NC. No analysis will be conducted using SPSS V.25.0 (IBM). INTRODUCTION commercial re- use. See rights Besides descriptive statistics, multivariable regression and permissions. Published by analyses will be done to identify possible risk factors and After childbirth, a woman undergoes BMJ. their independent associations with depression (PPD and multiple changes associated with physical and 1 For numbered affiliations see general depressive symptoms, combined and separately), emotional domains. Some common physical end of article. anxiety and stress. changes experienced during pregnancy are Correspondence to Ethics and dissemination The study protocol was weight gain, hair growth and stretch marks, Dr Boon How Chew; reviewed and approved by the Medical Research Ethics while after pregnancy, the most common chewboonhow@ upm. edu. my Committee, Ministry of Health Malaysia on 7 August 2019. changes are weight loss, hair loss and sagging Mohammad Redzuan SA, et al. BMJ Open 2020;10:e034458. doi:10.1136/bmjopen-2019-034458 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-034458 on 21 June 2020. Downloaded from breasts.1 Mothers with a new or additional baby also (DSM-5) categorises PPD as a major depressive episode experience emotional changes related to breast feeding ‘with peripartum onset if onset of mood symptoms occurs demands, childcare stress and problems relating to during pregnancy or within 4 weeks following delivery’.9 maternal dissonance and difficult infant temperament.2 Symptoms can persist up to several months, and if left In addition, there are also social demands that may untreated, PPD may lead to subsequent emotional, contribute to the general depressive symptoms and stress behavioural and cognitive problems of the child.6 10 such as compliance to the traditional postpartum care Despite these concerns, PPD remains underdiagnosed practices, financial strain related to low socioeconomic and undertreated in clinical practices in Malaysia.11–13 status, and social and sexual relationship with the partner This might be due to social taboos associated with psychi- or caretaker of the child.2 3 Other emotionally draining atric diseases.14 Other factors that contribute to the low aspects are biological, obstetric, clinical, psychological, detection rate include low screening rate for PPD and social and infant factors which may also contribute to lack of awareness of the illnesses among mothers and care- the prevalence of postpartum depression (PPD), general takers.11 Studies showed that between 1990 and 2002, the depression and stress.2 3 Some of the risk factors for PPD prevalence of PPD ranged between 10% and 15% within such as history of physical abuse, mode of delivery and 12 months post partum in western societies compared sex of the baby2 differ between developing and developed with the more varied prevalence rates of between 3.4% countries. A systematic review by Villegas et al4 reported and 63.9% among Asian countries within the similar that an increased risk of PPD in developing countries is postpartum period and timeframe.3 6 In Malaysia, studies related to some unique risk factors associated with poor reported that the incidence and prevalence of PPD were relationship with the partner or in-laws, having an unem- 9.8% and 20.7%, respectively.12 13 ployed and uneducated husband, husband’s psychopa- A systematic review suggested that a history of general thology, years of marriage, having more than five children, depression, stressful life events, low social support, having two or more children under the age of 7 and antenatal anxiety, unplanned pregnancy, preference of gender of the infant. Although the risk factors for PPD infant’s gender and low income were risk factors leading are considered multifactorial, studies have consistently to PPD in Asian countries such as India and Bangladesh.15 identified the significant role of social support. Studies A study in Thailand reported that a history of lifetime in both developed and developing countries have shown major depression and depressive symptoms during preg- that lack of social support is an independent predictor of nancy were the most important risk factors for PPD.16 For PPD.3 5 Asian culture that dictates Asians to follow certain Malaysian women, depressive symptoms during late preg- traditional rituals after delivery to protect the mother and nancy, an emergency delivery, preterm birth, application child is one example of the stressors specific to the Asians, of traditional postpartum practices, marital problems, as while poor marital relationship, stressful life events, child well as low income were likely to be associated with an http://bmjopen.bmj.com/ care stress, negative attitude towards pregnancy and increased risk of developing PPD.6 17–19 On the other learned helplessness are common and important psycho- hand, a local study suggested that a planned pregnancy logical stressors predisposing to PPD.3 may prevent the risk of PPD.12 PPD is a significant health issue that can impact the With regards to general depression in the postpartum health of the mother, her marital relationship, interac- period, the general depressive symptoms during the tion with the newborn as well as infant growth.5 Although postpartum period include experiencing continuous the prevalence of PPD and general depression is between low mood or sadness, feeling hopeless and helpless, 10% and 15% in the first 3 months of post partum, having low self-esteem and feeling tearful that the on September 27, 2021 by guest. Protected copyright. an increasing trend in prevalence was observed after mother is unable to take