An Analytical Study of Contributory Factors of Postpartum Depression Among Women in Punjab, Pakistan

AN ANALYTICAL STUDY OF CONTRIBUTORY FACTORS OF POSTPARTUM DEPRESSION AMONG WOMEN IN PUNJAB, PAKISTAN

By Faiza Anjum 2012-GCUF-08939

Thesis is submitted in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY IN SOCIOLOGY

DEPARTMENT OF SOCIOLOGY GOVERNMENT COLLEGE UNIVERSITY, FAISALABAD

August 2017

DEDICATED To Hazarat Muhammad (Peace Be Upon Him) And My adorable and affectionate Parents

DECLARATION

The work reported in this thesis was carried out by me under the supervision of Dr. Zahira Batool (Associate Professor) Chairperson of Department of Sociology, Government College University, Faisalabad, Pakistan.

I hereby declare that the title of thesis “An Analytical Study of Contributory Factors of Postpartum Depression among Women in Punjab, Pakistan” and the contents of thesis are the product of my own research and no part has been copied from any published source (except the references, standard mathematical or genetic models /equations /formulas /protocols etc). I further declare that this work has not been submitted for award of any other degree /diploma. The university may take action if the information provided is found inaccurate at any stage.

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We certify that the contents and form of thesis submitted by Miss Faiza Anjum, Registration No. 2012-GCUF-08939 has been found satisfactory and in accordance with the prescribed format. We recommend it to be processed for the evaluation by the External Examiner for the award of degree.

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TABLE OF CONENTS Sr. # Title Page # List of Abbreviations ix Acknowledgement xi Abstract xii 1 INTRODUCTION 1 1.1 Postpartum 2 1.2 Postpartum Depression 3 1.3 Symptoms of Postpartum Depression 4 1.4 Measuring Postpartum Depression 4 1.5 Postpartum Depressive Disorders 5 1.6 Factors of Postpartum Depression 9 1.7 Significance of the Study 14 1.8 Objectives of the Study 15 1.9 Theoretical Framework 16 1.10 Conceptual Framework 19 2 REVIEW OF LITERATURE 20 2.1 Relevant Review of Literature of the Study 20 2.2 The Present Study 39 2.3 Hypothesis of the Study 39 3 MATERIALS AND METHODS 42 3.1 Study Design 42 3.2 Study Area 43 3.3 Sample Size 45 3.4 Sampling Plan 47 3.5 Data Collection 48 3.6 Description of Measurements 48 3.7 Aspects to Improve the Quality of Data 50 3.8 Developing Sensitive and Relevant Questions 51 3.9 Coding 51 3.10 Time and Sequence of Questions 51 3.11 Pilot Testing 52 3.12 Analysis 52

3.13 Univariate Analysis 53 3.14 Bivariate Analysis 54 3.15 Multivariate Analysis 56 3.16 Conceptual and Operational Definitions of the Variables 57 4 UNIVARIATE ANALYSIS 60 4.1 Socio-demographic Characteristics of the Respondents 62 4.1.1 Summary: Socio-demographic Variables 69 4.2 Information on Previous Pregnancy/delivery 70 4.2.1 Summary: Information on Previous Pregnancy/delivery 73 4.3 Information on Last Pregnancy/delivery (12 month baby) 74 4.3.1 Summary: Information on Last Pregnancy/delivery (12 month 83 baby) 4.4 Attitude and Factors of Postpartum Depression 84 4.4.1 Summary: Attitude and Factors of Postpartum Depression 102 4.5 Psychological and Physical Problems 103 4.5.1 Summary: Psychological and Physical Problems 109 5 BIVARIATE ANALYSIS 112 5.1 Testing of Hypothesis: Exploring Relationship 112 5.2 Socio-demographic Variables 113 5.3 Obstetric Variables 120 5.4 Cultural Variables 127 5.5 Psychosocial Variables 133 5.6 Effects of Postpartum Depression 144 5.7 Summary: Bivariate Analysis 147 6 MULTIVARIATE ANALYSIS 150 6.1 Introduction 150 6.2 Multiple Linear Regression Model 151 6.3 Suitability of Multiple Linear Regression 151 6.4 Results and Discussion 155 6.5 Summary: Multivariate Analysis 165 7 QUALITATIVE ANALYSIS 167 7.1 Focus Group Discussion 167 7.2 Ethics of Focus Group Discussion 168

7.3 Advantages of Focus Group Discussion 168 7.4 Limitations of Focus Group Discussion 168 7.5 Selection of Participants and Location 169 7.6 Precession of Focus Group Discussion 169 7.7 Role of the Moderator 170 7.8 Beginning the Focus Group Discussion 170 7.9 Conducting the Focus Group Discussion (Recording and 171 Written Notes) 7.10 Some Aspects to Improve the Quality of Data 172 7.11 Analysis of Focus Group Discussion 173 7.12 Results and Discussion 174 8 SUMMARY: FINDINGS, CONCLUSION AND 180 RECOMMENDATIONS 8.1 Main Findings 180 8.2 Conclusion 195 8.3 Recommendations 197 8.4 Recommendations for Future Study 199 REFERENCES 200 APPENDICES 225

LISTS OF TABLES Table # Title Page # Distribution of the respondent according to their current age and 1. 62 age at marriage 2. Distribution of the respondents according to their marital status 63 Distribution of the respondents and their husbands according to 3. 64 their education Distribution of the respondent’s husband according to their current 4. 65 age, and age at marriage Distribution of the respondents and their husband, according to 5. 66 their occupation 6. Distribution of the respondents according to their economic status 68 7. Distribution of the respondents according to their family type 69 Distribution of the respondents according to the total number of 8. 70 their family members Distribution of the respondents according to their number of 9. 71 children and history of previous pregnancy and delivery Distribution of the respondents according to the sex and age of 10. 75 their last baby Distribution of the respondents according to their planned birth of 11. 76 baby Distribution of the respondents according to their complications 12. 77 during last pregnancy Distribution of the respondents according to the checkup during 13. 78 their pregnancy Distribution of the respondents according to the place of birth of 14. 79 their last baby Distribution of the respondents according to the type of their last 15. 80 delivery Distribution of the respondents according to their complications 16. 81 during last delivery Distribution of the respondents according to their infant health 17. 82 problems during pregnancy and late neonatal care

Distribution of the respondents according to breastfeeding and 18. 83 difficulty in breastfeeding Distribution of the respondents according to their knowledge and 19. 84 history of antenatal and postpartum depression Distribution of the respondents and husband’s feelings about 20. 85 pregnancy and after birth of baby Distribution of the respondents according to the pressure to have a 21. 86 baby boy Distribution of the respondents according to their opinion of son 22. 87 preference Distribution of the respondents according to the attitude of 23. 88 husband, in-laws and doctors towards them Distribution of the respondents according to attitude towards 24. 89 mother life Distribution of the respondents according to their experiences of 25. 91 social/cultural taboos Distribution of the respondents according to their knowledge and 26. 93 uses of family planning methods Distribution of the respondents according to their uses of non-food 27. 95 items Distribution of the respondents according to their husband’s 28. 96 violent attitude Distribution of the respondents according to their stressful life 29. 98 events 30. Distribution of the respondents according to their social support 99 Distribution of the respondents according to share their feelings 31. 100 when depressed Distribution of the respondents according to getting help when 32. 101 depressed during pregnancy or after delivery Distribution of the respondents according to their problems 33. 102 experienced before marriage Distribution of the respondent according to their feelings and 34. 102 experiences during pregnancy

Distribution of the respondent according to theirfeelings and 35. 104 experience within the first two weeks after delivery Distribution of the respondents according to the problems faced by 36. 105 them in the postpartum period Distribution of the respondents according to their health status 37. 106 since the last two years Distribution of the respondents according to the availability of 38. 107 health care facilities Distribution of the respondents according to their behavior and 39. 109 healthy appearance Distribution of the respondents according to their prevalence of 40. 109 PPD Association between age of the respondents and symptoms of 41. 112 postpartum depression Association between education of the respondents and prevalence 42. 113 of postpartum depression Association between family income of the respondents and 43. 115 prevalence of postpartum depression Association between family members of the respondents and 44. 116 prevalence of postpartum depression Association between health problems of the respondents since the 45. 117 last two years and prevalence of postpartum depression Association between the number of pregnancies and the 46. 119 prevalence of postpartum depression Association between number of abortions of the respondents and 47. 120 prevalence of postpartum depression Association between planned birth of a baby of the respondents 48. 121 and prevalence of postpartum depression Association between pregnancy complications of the respondents 49. 122 and prevalence of postpartum depression Association between complications of the respondents during 50. 124 delivery and prevalence of postpartum depression 51. Association between infant health problems during pregnancy and 125

late neonatal care of the respondents and prevalence of postpartum depression Association between family type and prevalence of postpartum 52. 126 depression Association between sex of baby and prevalence of postpartum 53. 127 depression Association between pressure for birth of baby boy and prevalence 54. 128 of postpartum depression Association between Stereotype and prevalence of postpartum 55. 129 depression Association between health facilities of the respondents and 56. 131 prevalence of postpartum depression Association between attitude of husband, in-laws and doctors 57. 132 towards respondents and prevalence of postpartum depression Association between violence and prevalence of postpartum 58. 133 depression Association between stressful life events and prevalence of 59. 135 postpartum depression Association between social support and prevalence of postpartum 60. 136 depression Association between experiences and feelings of the respondents 61. 138 during pregnancy and the prevalence of postpartum depression Association between experiences and feelings of the respondents 62. within the first two weeks after delivery and the prevalence of 140 postpartum depression Association between difficulty in breastfeeding and prevalence of 63. 141 postpartum depression Association between the physical issues in the postpartum period 64. 142 of the respondents and prevalence of postpartum depression 65. Association between the postpartum depression and mother’s life 143 Association between postpartum depression and respondent's 66. 144 behavior 67. Association between postpartum depression and respondent's 145

healthy appearance Standardized regression coefficients, t values and level of 68. significance of obstetric and psychosocial variables regressed on 151 the prevalence of the postpartum depression Standardized regression coefficients, t values and level of 69. significance of socio-demographic and cultural variables regressed 155 on the prevalence of the postpartum depression Standardized regression coefficients, t values and level of 70. significance of psychosocial and obstetric variables and 158 postpartum score regressed on the mother’s life

LIST OF ABBREVIATION

AND Antenatal Depression BHU Basic Health Unit CPR Contraceptive Prevalence Rate CIA Central Intelligence Agency CI Confidence Interval DHQ District Headquarters EPDS Edinburg Postnatal Depression Scale FGD Focus Group Discussion FPC Family Planning Center GDP Gross Domestic Product LHV Leady Health Visitor LHW Leady Health Worker IUD Intrauterine Device MMR Maternal Mortality Rate NGO Non Government Organization NIMH National Institute of Mental Health OCD Obsessive-Compulsive Disorssder OR Odd Ratio PDPI Postpartum Depression Predictors Inventory PDSS Postpartum Depression Screening Scale PINUM Punjab Institute of Nuclear Medicine PND Postnatal Depression POCD Postpartum Obsessive - Compulsive Disorder PPD Postpartum Depression PTSD Postpartum Post Traumatic Stress Disorder SPSS Statistical Package of Social Sciences TBAs Traditional Birth Attendent UAE United Arab Empires

UAF University of Agriculture, Faisalabad UC Union Councils UK United Kingdom UNESCO United Nations Educational, Scientific and Cultural Organization UNO United Nation Organization USA United State of America USAID The United States Agency for International Development WHO World Health Organization

ACKNOWLEDGMENT

I am highly indebted to Almighty Allah – The most Beneficent and Merciful, who gave me a gift of life and thoughts and deepest Gratitude to Hazrat Muhammad (Peace Be Upon Him), the city of knowledge, the greatest scientist of the world, who has bestowed me with spiritual and physical strength, wisdom and patience to complete this thoughtful and laborious work. First of all, I want to express my deepest gratitude and appreciation to respectable supervisor, Dr. Zahira Batool, Associate Professor, Chairperson of Department of Sociology, Government College University Faisalabad, for her generous guidance, constructive criticism, sympathetic attitude and encourages thought my research. Without her encouragement, moral support and guidance, it would have been impossible for me to complete my research work. I would like to express my gratitude for the encouragement, skillful suggestions and guidance extended by Dr. Babak Mehmood (member of my supervisory committee), Associate Professor of Department of Sociology, Government College University Faisalabad. I also thankful to Dr. Sadaf Mehmood (member of my supervisory committee), Assistant Professor of Department of Sociology, Government College University Faisalabad for her encouragement, enlightening cooperation and help at each stage of research. All credit goes to my loving Father and Mother, who provided me the best initiative of schooling with everlasting prayers of success. Without their prayers and moral support, my studies could not have come to productive. Credit also goes to my sweet Uncle and Aunt for their great patience, prayer and moral support. I am grateful with thanks to my Husband for his credible cooperation, patience and ever best wishes towards me. My loving Sister and Brothers deserve special love for their identifying cooperation, encouragement, prayers and patience during my studies. I would like to say thanks to all my cousins who supported me during my field work. I should add my indebtedness to my friends for their contribution, moral support and great patience.

FAIZA ANJUM

ABSTRACT

A postpartum or postnatal period is a period starting afterward the birth of a child immediately and continued for about 6-8 weeks, may prolong to one year. Postpartum is the most neglected, abandoned and life-threatening phase for both mothers and babies; most complications and deaths occur during the postpartum period. Postpartum depression is a combination of physical and emotional changes that happen to mothers after giving birth; one of the major mental illnesses that affect many women from diverse culture. Socio-economic, demographic, environmental and cultural problems lead to this entire phenomenon in Pakistan. In this context, postpartum depression has received a little attention in Pakistan. A number of risk factors have been identified, but the actual social, obstetric and psychological determinants of postpartum depression among Pakistani women are not tacit. The main purpose of the present study is to investigate the contributory factors of postpartum depression among women; and to view the effects of postpartum depression on the mother’s life. For this purpose, cross-sectional study was conducted, and both the quantitative and qualitative approaches were used to examine the factors. The universe of the study was District Faisalabad, Punjab, Pakistan.

The target population of the study was the postpartum mothers age 15-44 years with a baby up to one year of age in the rural areas of District Faisalabad. A sample of 400 respondents was selected through multistage sampling technique and data were collected through well designed interview schedule. Four rural towns were selected conveniently from District Faisalabad. At the first stage, four union councils were selected randomly from each rural town. At the second stage, 25 respondents were selected randomly from each selected union council. Qualitative data was conducted by using focus group discussion. Eight focus group discussions were conducted; two from each town. Both the descriptive and inferential analysis was carried out. Population based survey was

analyzed through univariate, bivariate and multivariate analyses by using SPSS

(Statistical Package for Social Sciences) to evaluate the responses; and Edinburgh

Postnatal Depression Scale (EPDS) was used to check the level of postpartum depression among women. Focus group discussions were analyzed through content analysis technique. The present study found the most important contributing factor of postpartum depression such as education, family income, number of pregnancies and abortions, complications (pregnancy and delivery), self-crisis, lack of social support and violence.

The most common symptoms of postpartum depression among women are crying incidents, anxiety, changes in eating and sleeping pattern, low energy, irritability and tiredness. So, the provision of maternal health care practices is essential to decline and postpartum depression related problems. The maternal poor health status and inadequate health facilities are a great challenge for government, health practitioners, policy makers,

NGOs and researchers.

Keywords: Postpartum, Postpartum depression, Socio-economic status, Contributing factors and mother’s life.

Chapter 1 INTRODUCTION

Pakistan is one of the populous country of the region with the total population of 207.8 million (Pakistan Bureau of Statistics, 2017); from which 38.8 percent of the population lived in urban areas (UNO, 2015). The life expectancy at birth is 67.7 years, 65.8 years for males and 69.8 years for females (Pakistan Demographics Profile, 2016; CIA World Fact book, 2016). The total literacy rate of the adult population (age 15 and above can read and write) is 58.78 percent; 71.5 percent of adult males and 45.29 percent of adult females (UNESCO, 2016). Females are 49.2 percent of the total population and female population of ages 15 to 49 is more than 47.3 million (Population Reference Bureau, 2013). The total fertility rate is 2.68, mother's mean age at first birth is 23.4 and the maternal mortality rate (MMR) is 178 per 100,000 live births (Pakistan Demographics Profile, 2016). Pakistan has spent only 1 percent of GDP on health care. Consequently, the rate of maternal mortality is higher in Pakistan than its neighbors and other low- income countries of Asia. One in 89 women dies because of pregnancy and childbearing related complications. The major reasons of maternal mortality are malnutrition, hemorrhage, eclampsia, sepsis, severe anemia, inadequate access to antenatal and prenatal care and untrained staff/midwives. The situation of the rural area is worst in terms of maternal and child health care. The rate of maternal mortality is higher in rural areas (23 percent) than urban areas (14 percent). In rural areas, home births are very common because of cultural constraints and lack of availability and accessibility to hospitals. About 74 percent of rural women give birth at home; as compared to 43 percent of women in urban areas (Rau, 2015). Postpartum depression is the most common complication of childbearing affecting approximately 15 percent of women and as such represents a considerable public health problem affecting women and their families (Marcus, 2009). This is a universal phenomenon that not only exists in developing societies but also in modern western societies. In Pakistan, Postpartum depression is common among women with a prevalence rate ranging from 28 percent to 63 percent, placing it among the highest in Asia (Gulamani et al., 2013). Almost 1/3rd of women suffered from postpartum depression, the majority of them are moderately or severely depressed (Muneer et al., 2009). Postpartum depression has devastating effects on mothers, infants and their

families. Demographic, environmental, cultural, economic and social problems lead to this entire phenomenon in Pakistan. Even Pakistani women residing in other countries are also at risk of postpartum depression. There are a number of risk factors contribute to the development of postpartum depression; and the hormonal change can be hypothesized a leading cause of postpartum depression. Another important contributory factor of postpartum depression is the emotional effects; in which includes sleeping disorder, mother infant interaction, anxiety about fatherhood, self-crisis, anxiety due to lack support of a partner or other family members, a feeling of helplessness and loss of control over life. So, the provision of maternal health care practices is essential to decline the mother-child health related problems and symptoms of postpartum depression. The maternal poor health status and inadequate health facilities are a great challenge for government, health practitioners, policy makers, NGOs and researchers. The following section describes the related conceptual issues and its explanation.

1.1 Postpartum A postpartum ‘also known as postnatal’ is a period starting afterward the birth of a child immediately and continued for about 6-8 weeks. Retrieval from childbirth and adaptation to maternity can take a long time. It is the time after birth in which the mother's body, including the reproductive organs, hormone levels and uterus size proceeds to a non- pregnant state. Postpartum is the most neglected, abandoned and life-threatening phase for both mothers and babies; most complications, including deaths occur during the postpartum period (WHO, 2013). The postpartum is a period of vulnerability to psychological disturbance associated with childbirth, which encompasses several mood disorders. The postpartum period has three distinct but continuous phases: ▪ Acute ▪ Sub-acute ▪ Delayed ➢ The first phase is the early acute postpartum period, which lasts 6 –12 hours. During this phase a time of rapid change with a potential for immediate crises such as postpartum hemorrhage, uterine overturn, eclampsia and amniotic fluid embolism. ➢ The second phase is the sub-acute postpartum period, which lasts 2– 6 weeks. During this phase, the changes are less rapid than in the acute postpartum period because the

maternal body is experiencing major changes in terms of genitourinary recovery, hemodynamic, digestion, and emotional status. This period caused severe postpartum depression because the mother is usually capable of self-identifying problems. ➢ The delayed postpartum is the third phase of the postpartum period, which can end up to 6 months or to 1 year, and the pathology is less considered. It is a time when the process of changes is extremely gradual because the connective tissues and restoration of muscle tone changes to the non-pregnant state (Mayo foundation for medical education and research, 2016; Lyon, 2008).

1.2 Postpartum Depression Depression is a state of low mood, lack of concentration and energy that affects the behavior, thoughts, feelings and sense of well-being of a person (Nincolson and Dorothy, 2000). A person feels helpless and hopeless with the feelings of sadness, physical and emotional problems. The causes of depression are the imbalance of neurotransmitters (Chemicals in the brain), or the factors of genetic, psychological and environmental. While, others contributory factors are abusive behavior, stressful life events/crisis (loneliness, divorce, death of loved one and illness in the family), financial strain, unemployment and lack of social support. Depression is a common and widespread health problem which affects women in the postpartum period. Postpartum depression (PPD) is defined as "any non-psychotic depressive illness of mild to moderate to severe, occurring during the first postpartum year" (Scottish Intercollegiate Guidelines Network, 2012). Postpartum depression is a combination of physical and emotional changes that happen to mothers after giving birth; one of the major mental illnesses that affect many women from diverse cultures and religion aspects. It's a common problem, affecting more than 1 in every 7 women within a year of giving birth (American Psychological Association, 2016). PPD is a major depressive episode start within 30 days after delivery, the frequency of mood disorder increases dramatically. The incidence of PPD is on the higher risk in the first three months after delivery and continues for two years approximately (Haris, 2002; American Psychiatric Association, 1996).

1.3 Symptoms of Postpartum Depression Many women experience minor symptoms of postpartum depression, but some others are susceptible when the symptoms are severe and have long period. The most common symptoms of postpartum depression among women are sadness, anxiety, body pain, changes in eating and sleeping pattern, low energy, crying incidents, fear of being alone, loss of concentration and confidence, reduced desire of sex, irritability and thought of self-harm or suicide (WebMD, 2016; Beck & Indman, 2005).

Source: Beck. (1998). A checklist to identify women at risk for developing postpartum depression.

1.4 Measuring Postpartum Depression Symptoms of postpartum depression is categorized by the level of measurement such as mild, moderate and severe. The severity of symptoms is measured by Edinburg Postpartum Depression Scale (EPDS). EPDS is a self-reported scale containing 10- questions, designed for screening PPD. Each question consists of four points range from 0 -3. The high score is shown the severity of the symptoms of PPD, determined by adding together the scores for each of the 10 items. According to this scale, the selection of answers was based on how a respondent has felt in the past 7 days; and scores in the range of 10 - 30 are generally symptomatic of depression. As regards with categories, depression may be mild, moderate or severe. Women scoring 9 or less are considered not depressed (mild); and woman scores 10 – 12 are representing the minor symptoms of depression (moderate), should be asked follow up questions for further screening. While,

women scoring 13 or above indicating the positive symptoms of major depression (severe); needs an appropriate assessment and possible interventions should be made immediately. (Montazeri et al., 2007; Pallant et al., 2006; Cox et al., 1987).

Table: 1.1 Levels of Postpartum Depression Severity Score Symptoms of PPD Screening range Not depressed 0 – 9 No signs and Normally remains symptoms untreated Minor depressed 10 – 12 May present positive Requires attention for symptoms further screening Major depressed 13 or above Frequently present Needs an appropriate positive symptoms assessment and possible interventions immediately Source: Montazeri et al. (2007), Pallant et al. (2006), Cox et al. (1987)

1.5 Postpartum Depressive Disorders The postpartum period is at high risk for the development of serious mood disorders. Maternal may have symptoms of depression after childbirth resulting from the strain of labor, delivery and procedure of hospitalization as well as labor related expenditures, which mistakenly considered as postpartum depression. The most common symptoms are low mood, sadness, fatigue, sleeplessness, eating disorder and poor concentration on infant care and health. Evidence supported that these symptoms end up approximately two to three days to be a normal adjustment to childbirth commonly known as Normal Postpartum Adjustment. Generally, there are three most common forms of postpartum disorders; ranging from the baby blues (mildest) to postpartum depression (moderate), to puerperal psychosis (severity) (Schimelpfening, 2016; Campbell, 2010; Brockington, 2004). Each one requires different treatment or may no need for treatment because of its unique factors, symptoms and clinical management.

1.5.1 Baby Blues / Postpartum Blues The 'baby blues' or ‘postpartum blues’ are extremely common that experienced by up to 80 percent of new mothers (Schimelpfening, 2016; Campbell, 2010). Because of its higher incidence it should be anticipated as normal as childbirth. Baby blues describe as short term or a mild type of postpartum depression that occur immediately after

childbirth; or, within three to five days after delivery (Campbell, 2010). This condition peaks at five days after childbirth and extend to the end of the second week, usually resolve without treatment (Peterson, 2010). It is considered that the baby blues can change into PPD, if take time longer than two weeks. Most of the mothers experience fluctuating mood, sadness, tears, anxiety and irritation during or after gestation are known as maternity blues. Other additional symptoms are insomnia, fatigue, loss of appetite, hyperactivity and lack of confidence (Schimelpfening, 2016; Beck, 2002). The baby blues are assumed to arise due to hormonal fluctuations attributed to the physical changes, or social/environmental factors (marital stress, lack of support system (Peterson, 2010).

1.5.2 Postpartum Major Depression Postpartum depression occurs in the absence of baby blues or if the symptoms of the blues are prolonged after two weeks. It tends to develop two or more weeks after delivery and may last after a few months, for a year or longer if remain untreated. Postpartum depression can appear any time after a baby birth in the first year, affecting 10 to 20 percent of mothers (Schimelpfening, 2016; Peterson, 2010). The most frequent symptoms of PPD are sadness, difficulty in making decisions, crying episode, insomnia, poor concentration, suicidal thought, hopelessness, low self-esteem, appetite changes and lack of attachment with the baby (NIMH, 2016; Beck, 2002). Women may also experience some physical problems, including exhaustion, fluid retention, sensitivity to cold, dry skin, and constipation. Researches explained that there are a number of factors contribute to the development of PPD. These are first time maternity, uncertainty about keeping gravidity, bipolar, history of PPD, low social support, poor interpersonal relationships, marital adjustment, child care demand, recent stressful events, the gap between women’s personal experiences and social expectations. Sometimes hormonal changes during or after pregnancy caused PPD (NIMH, 2016; Peterson, 2010).

1.5.3 Postpartum Psychosis Postpartum psychosis or puerperal psychosis is the most severe but least common type of postpartum disorders, affecting 1-2 per one thousand of women. In most cases it occurs suddenly within the first two weeks after birth or within three months after birth (NIMH, 2016; Schimelpfening, 2016). The symptoms of postpartum psychosis are intrusive thoughts, delusions (false beliefs), extreme anxiety, hallucinations (false perceptions), distrust, insomnia, hyperactivity, memory loss, confusion, irrational statement, hurting the

baby and severe risk of suicide (Tatono, 2006; Jennifer, 2004; Moses-Kolko & Erika, 2004). Results show that about 5-10 percent of suicide or infanticide is associated with postpartum psychosis (Sue, 2007), and 62 percent of mothers who kill their babies commit suicide (Moses-Kolko & Erika, 2004). There is more chance for postpartum psychosis to develop into severe prolonged depression. Despite its severity, postpartum psychosis needs immediate hospitalization and treatment.

1.5.4 Brief Psychotic Disorder / Postpartum Panic Disorder Panic disorder is a serious condition of anxiety and fear that strike without reasonable cause, different from normal fear and anxiety (WebMD, 2016). Most common postpartum panic disorders related to fear among women, fear of losing self-control and fear of death. Symptoms of postpartum panic disorders are frequent panic attacks, feelings of extreme anxiety, sweating, numbness, dizziness, shortness of breath, chest pain, agitation, nervousness, and heart palpitations (Tatono, 2006). Symptoms of panic disorder may start quickly and last about ten minutes, at least one day or within one month in rare cases. The chances of postpartum panic disorder diagnoses are occurring up to 10 percent postpartum mothers and more common for first time mothers. The significant risk factors are thyroid dysfunction, history of panic disorders, family history, abnormalities in the brain, substance abuse and major life stress. The study supported that once a woman has had symptoms of panic disorders, her chances raise 30-50 percent with each following delivery (Milgrom et al., 1999).

1.5.5 Postpartum Obsessive - Compulsive Disorder (PPOCD) Obsessive-Compulsive Disorder (OCD) is an unwanted thought or behavior have symptoms of repeated thoughts (obsession), repeated behavior (compulsion) or both (NIMH, 2016). It is a common, a chronic and continuing disorder in which a person feels the urge to repetition that can interfere in all aspects of life. Postpartum OCD is a significant problem for mothers to experience an emotional problem can affect both the expected mothers and after the birth of a new baby (OCD-UK, 2016). Postpartum OCD occurs in approximately 3-5 percent of new mothers, yet, the symptoms of OCD are varied from mother to mother (OCD Center of Los Angeles, 2016). The most common obsessions viewed in Postpartum OCD are the intrusive thoughts of accidentally harming the child, throwing a baby or fear of purposely harming the newborn (OCD Center of Los Angeles, 2016; Tatono, 2006; Horowitz & Janice, 2005). The most common compulsions

viewed in Postpartum OCD are removing or throwing all the knives or other sharp objects from the house; changing the diapers even its dry or avoiding change dirty diapers; repeatedly check the baby; and avoiding to feed a baby in fear of poisoning (OCD Center of Los Angeles, 2016; Tatono, 2006; Horowitz & Janice, 2005). Postpartum OCD may develop due to the psychological and biological risk factors. It has been occurred due to profound changes in hormones such as serotonin and estrogen because of hormones disrupt the activity of neurotransmitters in the brain. Disturbances of the serotonin system have been profoundly contributed in the development of Postpartum OCD. The birth of a new born baby brings a number of challenges for the mother. Stress is a major cause of Postpartum OCD when mother has an inadequate support to cope with these challenges (Uguz et al., 2008; Brandes et al., 2004).

1.5.6 Postpartum Post Traumatic Stress Disorder Postpartum Post Traumatic Stress Disorder resulting from real or perceived birth trauma (threaten about serious injury or death to the mother or her baby), approximately 5-9 percent of postpartum women experience this disorder (Postpartum Support International, 2016). These traumas resulting from unplanned C-section, feelings of powerlessness, lack of support during delivery and ignored her emotional needs during hospitalization. Women are also at higher risk for postpartum PTSD who experienced previous trauma (rape or sexual abuse) and prenatal trauma, or experienced severe preeclampsia and postpartum hemorrhage (Postpartum Support International, 2016). The most frequent symptoms are flashbacks, nightmare, anger, anxiety, panic attack, and persistent increased arousal (irritability, difficulty in concentrating and sleeping, hyper vigilance, exaggerated startle response) (NIMH, 2016). Women also have a fear of unreality that they avoid travel to anywhere, even not willing to go near the hospital (Tatono, 2006).

1.6 Factors of Postpartum Depression Postpartum depression is considered as a common mental disorder, and various factors put the women at higher risk for PPD. There is no single one cause that can be interrelated with PPD, it may exist due to a variety of unified factor. Several studies and theories identified a number of risk factors that contribute to the development of PPD. Some common risk factors were:  Hormonal change  Sleeping disorder  Mother infant interaction  Anxiety about fatherhood  Self-crisis  Stressful life events  Lack of support from partner or family members  Feeling of helplessness  Loss of control over life (Field, 2017; Bener et al., 2012; Mohamed, et al., 2011; Beck, 2002; Whiffen and Susan, 1998; Sullivan, 1953). In addition, numerous potential factors such as biological, psychosocial and obstetric factors have been induced for the development of PPD. Evidence supported that not only the genetic or biological factors ascertain the frequency of PPD, but also demographic, cultural and environmental factors may dispose to develop PPD. However, the biological, socio-demographic, obstetric, cultural and psychosocial factors are described in detail.

1.6.1 Biological Factors Researchers have identified the biological factors in the etiology of PPD. The most often associated biological risk factors are endocrine system (hormone level, hypothyroid dysfunction), anemia, genetics, and the immune/inflammatory system. Endocrine irregularities contributing to the development of PPD. The most common biological factor of depression is the changes and imbalance in hormone level. Mothers may at higher risk of PPD due to their sensitivity in estrogen and progesterone level; premenstrual problem, dysmenorrheal (painful periods). The hormonal changes occur in new mothers or those who experienced miscarriage and stillbirth. Mothers’ placenta produces estrogen and progesterone at a very high-level during pregnancy; but the rapid

decline in theses reproductive hormones after childbirth kept the women at higher risk of hormonal changes. With these quick hormonal changes, women’s body faced a problem to adjust non-pregnancy. They frequently feel low mood, sadness or also think about suicide in severe cases. Hypothyroid dysfunction is another endocrine factor that occurs due to the drop in thyroid hormones after childbirth. Researchers have found the association between thyroid dysfunction and postpartum depression, affecting 5 percent to 7 percent of women in the first year after delivery (Keshavarzi et al. 2011; Bhargava, 2006). It resulted in, the most frequent symptoms are difficulty in sleeping, fatigue, irritation, confusion, difficulty in concentration and weight gain. Furthermore, hormonal changes played a significant role in the development of baby blues. In addition to the other influential biological factors on PPD, the anemia is also contributing to the development of PPD. Anemia occurs when the hemoglobin level is low that can be caused by blood loss during childbirth or iron deficiency (Batool, 2010). Iron deficiency and anemic problem occur among most of the women throughout their pregnancy, and may be induced to depression in the postpartum period. Commonly associated symptoms of anemia with PPD are difficulty in concentrating, laziness and irritability (Corwin & Arbour, 2007; Beck & Indman, 2005). A number of studies have found the association between genetic factors and PPD in recent years. Genetic factors relate to variables such as having previously experienced psychiatric symptoms or family history of psychiatric illness. There are more chances for women to develop PPD with a previous history of PPD. Mothers are at higher risk to develop depressive disorders in the postpartum period with the family history of psychiatric illness (Bloch et al., 2000). Studies reported that a previous history of depression was found to be a moderate predictor of developing postpartum depression (Josefsson et al., 2002; Beck, 2001). Evidence from various studies of psychotic illness concluded that the major risk factor for developing the mental problem is genetic. The rates of puerperal psychosis with bipolar disorder was higher who had a family history of puerperal psychosis. The symptoms of puerperal psychosis with bipolar disorder in women was 260 / 1000 deliveries, and for women with a family history of puerperal psychosis was 570 / 1000 deliveries (Jones & Craddock, 2001).

1.6.2 Socio-demographic Factors Socio-demographic factors are measured by defining age, gender, education, marital status, income, occupation, working condition, health behavior and access to health care. The composite of these dimensions has been identified as important factors in explaining the vulnerability of depression. Commonly, the depression is highly influenced by age, level of education and income of the individual. Women are more vulnerable to develop the depression due to the adverse inequalities in socioeconomic status, has nearly doubled the prevalence rate as compared to men. One in every five women has the symptoms of major depression (Lennon, 2002). The disparities by socioeconomic situations, nutritional needs, antenatal care, maternal behavior, stress, physical and work activity, infection, addiction and substance use have been identified for explaining the risks of PPD (Bener et al., 2012; Glasser et al., 2011; Inandia et al., 2002; Mohamed et al., 2011). Maternal marital status, age at marriage, young maternal age or maternal age over 35 and the number of children are the important demographic factor that accounts for much of the variance in the prevalence of PPD (Bener et al., 2012; Hamdan & Tamim, 2011; Kheirabadi et al., 2009; Green et al., 2006). Single mothers who are divorced or separated had a high risk of anxiety disorders (18 percent) and emotional disorders (12 percent) (Australian Bureau of Statistics, 2006). May be the rate of PPD among women depends on maternal demands rather than marital status.

1.6.3 Obstetric Factors Pregnancy is deliberated as one of the most critical periods in a women’s life. It might be influenced by various factors such as unwanted pregnancy, complications, lower education, earlier or older age (Abouzari-Gazafroodi et al., 2015). Obstetrics is the branch of medicine deals with childbirth and the treatment of women during pregnancy and after childbirth. Complications during pregnancy, childbirth and after childbirth, antenatal and postnatal care are studied as obstetric factors. Obstetric complications defined as serious conditions such as hemorrhage, eclampsia and obstructed labor (Sikder et al., 2014). Obstructed labor may result in prolonged labor, when the active period of labor is greater than twelve hours. Obstructed labor can be a major cause of morbidity and mortality among maternal and newborn. Obstructed labor includes a large or unusually positioned baby, a small pelvis (malnutrition and vitamin D deficiency caused by lack of sunlight) and birth canal (a narrow vagina and perineum due to tumors or genital mutilation (WHO,

2008). The risk factors for mothers are having a uterine rupture (may occur during active labor or develop during late pregnancy), getting an infection and hemorrhage. The most frequent complications of obstructed labor for infants are stillbirth, neonatal death and brain damage. Studies have identified a number of obstetric risk factors related to the PPD. The indicated factors are unplanned pregnancy, pregnancy complications, prolonged labor, type of delivery, history of abortion, not breastfeeding, baby’s health problems and infant death (Bener et al., 2012; Mohammad et al., 2011; Glasser et al. 2011; Hamdan & Tamim, 2011; Kheirabadi et al., 2009; Najafi et al., 2007; Eilat-Tsanani et al., 2006). Maternal physical complication during delivery, postpartum hemorrhage, difficulty in breastfeeding and eclampsia (high blood pressure and proteinurnia) also elevate the risks of PPD.

1.6.4 Psychosocial Factors The mental state of an individual is influenced by the psychological factors as well as societal related factors. Psychological factors comprise on individual level process and social factors seen as a social process that external to the individuals. These two notions are known as psychosocial when combined. It means that the physical body is affected by both the social and psychological factors. The effects of social factors are identified through psychological understanding (Stansfeld & Rasul, 2007). In simple words, psychosocial factors consist of personality and the incidence of any psychiatric disorder influenced by environmental factors. These factors increase the risk of an individual in developing a depressive disorder or may decrease the risks (protective factors). Generally, example of psychosocial factors is marital status, social support, social conflict, disruption, social status, loneliness and living or working environment. Social disadvantage and social setup with negative perception are an important cause of basic health inequalities of women. In this context, beliefs and attitudes towards maternal put the women on the higher risks of PPD. “Psychosocial” factors include antenatal depression, previous history of depression, hopelessness, violence, interpersonal relationships, stressful life events and social support seems to be associated with maternal physical and mental health particularly PPD. Several studies have been identified a number of potential psychosocial risk factors expose to the development of PPD among women. Previous history of depression, antenatal depression, interpersonal relationships, stressful life events, conflict with family members, lack of emotional/social support have

been reported repeatedly (Al-Hinai, 2014; Bener et al., 2012; Mohamed, et al., 2011; Agoub et al., 2005; Alkar & Gencoz, 2005; Bugdayci et al., 2004; Chaaya et al., 2002).

1.6.5 Cultural Factors There are a number of factors influence the development of PPD, cultural factors being one of the significant factors. Cultural factors consist of a set of values and beliefs specified for an individual; through which culture decides the particular way to behave. For example, in Pakistan, the joint family system is still a value and family ties is conditioned for children. They stay with their parents till they get married. A woman has a different set of beliefs and habits which she develops from her family background and personal maternal characteristics. The contradiction between her personal experiences and society’s demands put the pressure on women (Beck, 2002). Our cultural patterns have some tradition specified for maternal and infant. Mothers are expected to wear simple dresses, eat specific food items and not allowed to take a bath or go outside the home within the forty days after childbirth. In addition, infants are suspected of black magic, should be kept the iron related material nearby the baby for safety. In this context, cultural factors have an adverse effect on women in the prevalence of PPD. Another contributory factor of PPD is the conflict of a mother’s role and lack of mother’s knowledge about antenatal and postnatal depression (Ghubash & Eapen, 2009). It has negative effects on their mental health when didn’t understand the term depression as a type of mental disorder. In another way, Cultural constraints such as family restrictions, family type and in-laws home environment did not allow the women to share their feeling someone. Due to lack of knowledge and family system, mother is not allowed for checkups and treatment during the pregnancy and prefer to deliver the baby at home. The husband and in-law’s response to undesired gender of the newborn baby could lead to PPD. After the birth of a baby girl, most of the mothers experienced the negative behavior of her spouse and mother-in law; they said girls are burdened for them and boy will be the earning hand. A mother herself feel more secure in her in-laws with the birth of a baby boy. These are interrelated sets of cultural factors that could be highly influenced to elevate the incidence of PPD.

1.7 Significance of the Study Gender development plays an important role in the development of any country. In contrast, Pakistani women are only responsible for reproduction, caring children and other household chores. They did not allow to participate in the development process. Women reproductive and health issues remained unstated due to religion, cultural barriers of subject identification, participation and other restrictions. In this context, postpartum depression has received a little attention in Pakistan; research literature found few studies about postpartum depression and most of them are conducted in Karachi. A number of risk factors have been identified, but the actual social determinants of postpartum depression among Pakistani women are not tacit. Postpartum depression is a significant burden for mother and having a negative impact on her livelihood. Therefore, the present study is a good step to address the issue and to determine the factors associated with postpartum depression in District Faisalabad, Punjab, Pakistan. The present study will helpful to suggest policy measures to decrease the incidence of postpartum depression.

1.8 Objectives of the Study

▪ To study the socioeconomic and demographic characteristics of the respondents ▪ To investigate the contributing factors of postpartum depression among respondents ▪ To find out the consequences of postpartum depression ▪ To identify the relationship between factors and postpartum depression ▪ To suggest some policy measures to minimize the postpartum depression among respondents

1.9 Theoretical Framework The theoretical framework explains a number of factors contribute to the development of postpartum depression. They stalk from various frameworks such as feminist theory, medical traditional theory, interpersonal theory, attachment theory, and self-labeling theory. There are a number of theoretical paradigms that have been trying to explain the postpartum depression. In the present study, Beck’s theory of postpartum depression, attachment theory and interpersonal theory are applied to understand and support the postpartum depression among women. Here, the theoretical model of postpartum depression is built on the basis of these theories.

Biological and psychosocial risk Postpartum factors; Inconsistency between depression society’s expectations and mother’s Theory personal feelings

Strong emotional attachment with Attachment infant; low attachment with intimate partner Postpartum Theory Depression

Interpersonal relationships; life Interpersonal events; social experiences; social support Theory

Theoretical Modal for Postpartum Depression Source: Beck, 2002; Whiffen and Susan, 1998; Sullivan, 1953

1.9.1 Theory of Postpartum Depression Cheryl Tatano Beck (1949 – present) obtained the master’s degree in maternal-newborn nursing and certificate in nurse midwife from Yale University in 1972. In 1982, she received a doctorate of nursing science from Boston University. She has served as a consultant of understanding, treatment and prevention of mental illness related to childbirth. She began her research with women’s labor and their emotional responses to

childbirth process and the postpartum period. Specifically, the main focus of her study was on the postpartum mood disorders. It resulted in, she is succeeded to develop the theory of postpartum depression, Postpartum Depression Screening Scale (PDSS) and Postpartum Depression Predictors Inventory (PDPI). She conducted a number of studies on women’s postpartum depression who were discharged from hospitals. She was of the view that women were on the higher risks of maternity blues at home due to the earlier discharge from the hospital. Because the symptoms of baby blues appeared within a first week of postpartum. She is able to make the differences between maternity blues, postpartum depression and postpartum psychosis. On the basis of these conceptual phenomenological studies, Beck developed Postpartum Depression theory (entitled- teetering the edge) in 1993, based on loss of control using grounded theory methodology. Loss of control was identified as a basic psychosocial problem that women experience in all aspects of their lives. It stalks from four stages of attempted coping. Encountering Terror: consisted of horrifying attack and anxiety, enveloping fogginess and obsessive thinking. Dying of Self: consisted of alarming un-realness, isolating oneself, contemplating and attempting self-destruction Struggling to Survive: consisted of battling the system, praying for relief, seeking solace at the support group Regaining Control: consisted of unpredictable transitions, mounting lost time, and a guarded recovery From the concept of loss of control, Beck identified a list of risk factors for Postpartum Depression. These factors are sleeping and eating disorders, emotional attachment, anxiety, loss of self, thought of harming oneself, guilt/shame and cognitive impairment, low socioeconomic status, prenatal depression, history of previous depression, prenatal anxiety, marital status, marital satisfaction, social support, maternity blues, stressful life events, low self-esteem, childcare anxiety, unplanned/unwanted pregnancy and difficult infant temperament. In 2002, she explained that society places the actor in such conditions which create a contradiction to continue the normal routines of everyday life. Socio-cultural expectations of motherhood are related to a particular behavior; and postpartum depression may occur when there is inconsistency between socio-cultural expectations of motherhood and mother’s personal feelings and experiences (Beck, 2002).

1.9.2 Attachment Theory Attachment is a profound emotional bond that attaches one person to another across time and space (Ainsworth, 1973; Bowlby, 1969). The attachment theory explains that postnatal/postpartum depression can develop when the mother feels inaccessible because her attachment needs are not being met by her partner. Specifically, the attachment theory focuses on the strong emotional association between infant and mother. This theory proposed that when mother and father are securely attached to another, obviously they will support to fulfill the needs of each other. Problems can occur when partners are avoiding to attach to each other’s, that leads to the postpartum depression (Whiffen and Susan, 1998).

1.9.3 Interpersonal Theory Harry Stack Sullivan (1892–1949) was an interpersonal psychoanalysis who proposed the interpersonal theory of personality. He explained the role of interpersonal relationships, social experiences and the importance of current life events. Theory provides the theoretical basis for depression; explains that depression develops in the context of adverse events, or interpersonal loss (Sullivan, 1953). The interpersonal theory is based on the interpersonal interactions with others that provides the understanding about the causes and treatments of mental disorder. The struggle to maintain the interpersonal relations have a significant effect on the mental health of an individual (Egeline, 2008). Childbirth is a transitional stage in the life of women, and social support has a diverse effect on their mental status. Marital conflict and insufficient social support may consider the leading cause to develop the PPD. Postpartum/postnatal events are arbitrated by a number of disruptions in their interpersonal experience and contradiction between desired level of support and the actual level of support they receive.

1.10 Conceptual Framework

CONCEPTUAL FRAMEWORK

Background Variables Independent Variables Dependent Variable

• Occupation Socio- • Age at marriage

demographic • Marital status • Number of children & Cultural • Addiction Variables • Health problems (diabetes; chronic pain; anemia) • Dietary habits • Knowledge about postpartum depression • Attitude towards health facilities • Antenatal and postnatal services Socio economic, Demographic & Cultural Variables Symptoms of (age, education, Postpartum income, family • Interpersonal relationships • Antenatal depression Depression members, family Socio- type, social taboos) psychological • Stressful life events • Social support Variables • Violence • Attitude

•

• Type of delivery Obstetric • Number of pregnancies Variables • Pregnancy and labor complications • Number of live and dead births • Abortion • Breastfeeding • Unplanned/Unwanted pregnancy • Infant health problems •

Chapter 2 REVIEW OF LITERATURE

Review of literature focuses on a specific topic of interest, including a critical analysis of different researches and its relationship. The literature review provides a base for research work such as thesis or dissertation and theoretical framework (Galvan, 2006). Its aim is to develop the scope of the research and enhance the importance of the research work. This chapter consists of a literature review of the most important variables of the study.

2.1 Relevant Review of Literature of the Study Field (2017) analyzed the effects of PPD on the mother’s life and its related risk factors. The prevalence rate of PPD was approximately 20 percent among mothers. The symptoms of PPD have an adverse effect on mothers in terms of their behavior and cognitive problems. The associative risk factors for PPD were low education and low income, being an immigrant and experiencing complications during pregnancy and delivery. Also, the psychological factors contribute in the etiology of postpartum depressive symptoms, including social support, sleep disturbance, prenatal depression and early childhood experiences (maltreatment, attachment and sexual abuse). Hansotte et al. (2017) concluded that low income women were on the higher risks of PPD because of their problems remain without diagnose and treatment. The obstacles of treatment were the social barriers (low educational and income level) and cultural barriers (family type, restrictions to gain antenatal and postnatal care and services). Underwood et al. (2017) concluded that the depressive symptoms were higher in the postpartum period among women. Depression is not only affected on the prenatal and postnatal mothers, it also has an adverse effect on partner, children and other family members. A husband who has poor health or stress had elevated the depressive symptoms during their wife’s pregnancy and afterward the birth of a child. Fathi et al. (2017) demonstrate the relationships of self-efficacy and PPD. The results determine the strong positive relationship between self-efficacy and low income. In addition, the maternal self-efficacy is highly affected by self-satisfaction, low educational level, spouse age and occupational status. The provision is necessary for early diagnosis and treatment of postpartum depressive symptoms to improve the maternal self-efficacy.

Silverman et al. (2017) found that the symptoms of postpartum depressive disorders were more than 20 times higher for those women who had a history of depression as compared to those who had not. Other significant factors such as young age, mild or moderate preterm delivery, assisted or cesarean delivery and gestational diabetes increased the risks of PPD among women. Mori et al. (2017) analyzed that almost 20 percent of mothers experienced PPD. The depression had a significant association with the symptoms of physical health issues (during pregnancy or subsequently childbirth) during the first 6 months postpartum. The most of the symptoms were tiredness, dizziness, loss of appetite, thirst, backache, headache, eye infection and body swelling. Tobin et al. (2017) illustrated that the immigrant and refugee women are at higher risks of PPD due to the stress of migration. Furthermore, the other complex issues were loneliness, lack of understanding of their condition, cultural practices, untreated illness and barriers to obtain health facilities. Sharma et al. (2017) depicts that bipolar disorder is common in the PPD with the prevalence rate of 21–54 percent of women. The most frequent causes of bipolar disorder were younger ages, illness, history of bipolar disorder among self and the family members. Jin et al. (2016) examines the risk factors for postpartum depression among immigrant Chinese women in Japan. These women are at high risk for postpartum depression when they give birth for the first time. The information was gathered by those women who just discharge from hospital. The data were collected by using the EPDS (Edinburgh Postnatal Depression Scale), social support scale (to measure the cross-cultural stressors in the postpartum settings, visual analogue scale for stress and demographic information. Low household monthly income, social support and new mother were highly associated with postpartum depression. These new mothers reported that they are depressed because they could not adopt a Zuoyuezi tradition (postpartum Chinese tradition) in the Japanese hospital. Ayele1 (2016) explained different factors that have a significant association with PPD. The study concluded that age of the mother at marriage and conceive a baby at an early age was the causes of depression. The depression was found to be higher among those women whose age ranges were between 14 to 19 years than the age group of 20 to 29 years. The other factor, which increased the chance of depression was a mother’s occupation. Depression among the housewives were twice as compared to the

government employee. Social support during pregnancy had lower risk of depression, this might help the maternal to share problems and gain knowledge about pregnancy complications. Mother’s first-time pregnancy is another associative factor with PPD. Women who conceive first time pregnancy were at higher risk of being depressed in comparison with at least two numbers of previous pregnancies. This might happen because the mother stance for different psychological and social problems or fear of pregnancy related complications. Regular visits to antenatal care services played a crucial role in the health of mother and baby. The continuity in gaining support of health care professionals might be a protective effect of depression. Mothers who visited to centers on a regular basis would gain help with different issues and get proper counseling of the pregnancy. Women who had not visited to health care centers during pregnancy were at 11 to 12 times at higher risk for depression. Even though, if women are not satisfied by the health care services were about five times higher risk for depression. But in another way, existence study did not find any significant association between antenatal depression and income, residency, husband support, wanted or unwanted pregnancy and previous pregnancy complication and its outcomes. Pope & Dwight (2016) identified the relationships between breastfeeding and PD, but the exact nature and trend of this relationship is equivocal. Naveed and Fouzia (2015) explained that lack of social support, interpersonal relationship, self-neuroticism and anxiety plays an important role in the development of postpartum depression. In the context of Pakistani culture, the woman is responsible for the birth of a female child. In most of the families, the attitude of husband and in-laws is changed when they know that woman giving birth to a female baby. Her spouse and in- laws stop supporting woman, which makes her life unhappy, more disturbed that leads to the symptoms of postpartum depression. Haque (2015) argued unpredictable results regarding a relationship between the prevalence of PPD and the mode of delivery. Vaginal delivery was associated with a higher rate of PPD among women in Lebanon, while women who delivered by cesarean section expressed more negative feelings after delivery in the UAE. Afzal and Ruhi (2014) studied that the emotional support of the intimate partner leads to the postpartum depression. Depression occurred due to her partner’s inability to understand the requirements and adjustments of motherhood. Furthermore, the study found a strong negative association between the social support and postnatal/postpartum depression among Pakistan mothers.

Poomalar & Bupathy (2014) analyzed that various factors contribute to the postpartum depression. A type of marriage, duration and number of pregnancies and recent stressful life event such as family history of psychiatric problem and an addiction in husband was significantly associated with postpartum depression. Figueiredo et al. (2014) illustrated that mother who breastfeeding has less incidence of PPD than those who rely on formula feeding. Nursing a baby can lower stress overall, because the mother feels positive with attaching her baby. Evidence supported that significant decrease is viewed in depression among women who maintained breastfeeding from childbirth to 3 months postpartum period. A Study conducted by Kazmi et al. (2013) in Hazara Division to measure the prevalence of postpartum depression among women and to check the relationship of social support with the level of severity of postpartum depression. The result indicated that most women are affected with postpartum depression in the age group of 18-45. The present study found that low social support is a contributing risk factor to develop postpartum depression; and more symptoms of postpartum depression among women are observed in nuclear family setup as compared to the joint family system. Gulamani et al. (2013) examined the contribution of mother-infant interaction and parenting stress to postpartum depression among mothers of preterm infants. The study concluded that the rate of postpartum depression was significantly higher with the adjusted odds increasing by 2.68 in mothers of preterm infants. Significantly more depressed mothers of preterm infants did not receive any type of support from their husbands and had difficulty in feeding. A large proportion of mothers reported no support from friends in rearing children. The study also concluded that preterm birth was a significant excess risk of depression among Pakistani women. Evidence for the causes of preterm birth were women’ age, number of children and birth weight. Therefore, low birth weight was significantly associated with high infant mortality rate and limited health care resources. Pope et al. (2013) mentioned that the intentional self-harming behavior and suicide were greatly influenced by mood disorders during the postpartum period. The prevalence of thoughts of self-harm and suicide was examined by using EPDS item 10 and Hamilton Depression Rating Scale item 3, respectively. Furthermore, the study also examined a significant relationship between thoughts of self-harm or suicide and levels and symptoms of depression.

Nunes & Phipps (2013) compared the incidence of PPD among adolescent and adult mothers and its related risk factors. The effects of maternal age-related risk factors were analyzed by logistic regression model; and an important variation was viewed in the odds ratio for risk factors. In prior to the results, the postpartum depressive symptoms among adolescents were associated with low social support and previous history of depression. While, the postpartum depressive symptoms among adults were influenced by unintended pregnancy, maternal race, stress and antenatal depression and social support. Gani and Ali (2013) concluded that economic problems, inadequate infrastructure, untrained staff and cultural practices are the numerous factors that have a dangerous effect on women’s health, particularly in their reproductive period. In its context, a number of factors associated with postpartum hemorrhage, such as age, age at marriage, difficulty and duration of labor, avoidance of breastfeeding, homemade remedies and rest during the postpartum period. The prevalence of postpartum hemorrhage was about 21.3 percent among the respondents. A study by Kalar et al. (2012) revealed that the majority of the sample was married with low level of education and house wives. The study found that that almost 1/3 of the women had a high risk of PPD. It is likely to be started for the first week after delivery, but not considered as a psychological problem. The other strong predictive risk factors for PPD were poor family relationships, cesarean delivery, infant health, the number of female children and lack of social support. Also, almost half percent of mothers who had cesarean delivery had a prevalence of postpartum depression. The mother who gained help from husband and family members having less evidence of postpartum depression than those of women who have not. The prevalence of PPD rate was found to be higher than developed countries because of inadequate health services, high birth rate and insufficient social security system. The study also concluded that postpartum depression is a common mental syndrome in the local population; the preexisting of postpartum depression is the resultant of chronic disorder, antenatal depression and morbidity. Faisal-Cury and Paulo (2012) concluded that postpartum depression is highly associated with antenatal depression, which prevailed in the primary care setting. Independently associated factors with postpartum depression are higher scores for assets, higher education, daily contact with neighbors and antenatal depression. The prevalence of antenatal depression (PND) and postnatal depressions (PND) was double in Brazil than other countries. It may express by socio-economic characteristics of women and lack access to health care services in developing countries. But in Brazil, the associated

socioeconomic variables with PND were year of education and assets score in the presence of AND. Yount & Smith (2012) viewed that rate of PPD is higher in Middle Eastern and Arabs population than the Western population. Poor social support, frustration, patriarchal kinship, difficulty in to prepare mother themselves to adapt motherhood and physical or psychological violence are the important factors in contributing PPD. Furthermore, physical complications during delivery and difficulty breastfeeding were also associated with PPD. Some other key factors of PPD were the sex of the baby, poor relations with in-laws, death of husband, polygamy and women’s dependency on the patriarchal family system. The relationships with mother-in-law is important in women’s lives because it has a strong association with the prevalence of PPD. The study hypothesized that decreased PPD may be related to the positive relations with mother-in-law. Sundaram et al. (2012) viewed the significant association between morbidity (maternal or infant illness), obesity and PPD. Babatunde1 & Moreno-Leguizamon (2012) conducted a study on African immigrant women in South East London. The study illustrated that the immigrant women received less emotional, social and practical support before, during and after delivery of their babies. These women have the sigh of postnatal depression because they compel to cope with their emotional distress alone. The inadequate family environment and extended family type are the barriers to infer that support. Due to lack of awareness and acknowledgement their husband, family members as well as healthcare services barely understand what the maternal actual wants. Hamdan & Tamim (2012) conducted a study on Arab women during pregnancy and postpartum, and breastfeeding related to postpartum consequences. The results concluded that mothers who breastfeed their infant from childbirth to 4 months were less likely to be diagnosed with PPD. Also, PPD may reduce the rate of breastfeeding indicating the mutual association between these two variables. Insaf et al. (2011) reported a negative association between depressive symptoms and intend to breastfeed among Hispanic women by using EPDS. The study found that women with the depressive symptoms (miner depression or major depression) were less likely to intend to breastfeed as compared to without depressive symptoms. In addition, the antenatal depressive symptoms were the elevated predictors intend to breastfeed.

Brandon et al. (2011) was of the view that the care of preterm infants has been associated with anxiety, sadness, frustration, parental stress and emotional sorrows which contributing in PPD. Darcy et al. (2011) reported a number of risk factors contribute to the development of PPD among women. The most influencing factor was marital status and maternal young age at marriage or at the time of the first childbirth with lower education. Mental and physical health problems (mother or child) were higher among those women who were unmarried, separated or belong to the poorer families. Blom et al. (2010) describes that several complications of prenatal period are highly associated with postpartum depression. The associative prenatal complications with postpartum depression were several pregnancies, emergency caesarean section, hospitalization, feelings of fetal pain, pre-eclampasia, medical facilities of the maternal and child provided by the caretakers. The non-associative factors with postpartum depression were clotting, meconium-stained amniotic fluid and unplanned pregnancy. A study Callisteret al. (2010) demonstrated that in some cultures, women are unable to understand the term postpartum depression due to lack of knowledge. Although, when they suffer from depression, might be possible to use the concept of unhappiness. Non- western culturally diverse women are not able to pursue help because culturally prescribed norms expected that women fulfill their prohibited social roles with dignity and humble. Callisteret al. (2010) conducted an in-depth study of diverse cultures in order to know about the cultural beliefs and practices for the mother during the postpartum period. Ethno kinship refers to cultures in which family members are considered as a primary source of care for mothers and infants. The study explained social taboos and practices that is experienced by women during or after pregnancy in different countries in their own respective cultural context. Korean mothers performed “sam chil sam il”, which is the most significant cultural event associated with childbearing. A rope hung across the door of the home to declare the birth of a baby. During 3 weeks after delivery the mothers and infant are kept in isolation, not everyone allowed to meet them. Chinese mothers’ practice “do the month” (zuyue), during this time period women did not allow to perform some specific activities and dietary restrictions. Japanize women practice “satogaeri bunben” pregnant women move into her mother’s home in preparation for the upcoming birth and stay till 4 to 6 weeks of postpartum retrieval. Serving traditional foods and bathing the new mothers and infants by a midwife (Dai) in Punjab. Also, a woman in her seventh or

eighth month of gestation is moving to their parental home for childbearing. Women practiced “lacuarenta” in Mexico, they adopted a 30-day postpartum rest period. Women are secluded for 5 days after childbirth in birth houses in Eastern Europe. Father and other family members are not allowed to meet them and wait for welcome to a newborn baby and mother. In Latin America, maternal abdominal binding and body massage is common. For Nigerian women, ritual celebration is held in warm up welcome, a symbol to enhance the status of women in the society. In Somalia, women wear earnings made of garlic to prevent “evil eye” and celebration is organized after 40 days postpartum period. The duration of secluded for new mothers is lengthy in Uganda, as its continued till 3 months postpartum. Hayes et al. (2010) concluded that PPD affect 20 percent of women and a risk factor of morbidity and mortality among both mother and children. The situation is worst in developing world, because very less number of women have the knowledge of PPD. Also, the rate of PPD belongs higher among women in the Asian and Pacific Islander ethnic or racial group compared with white women. LaCoursiere et al. (2010) evaluated psychosocial factors to determine the prevalence of PPD. A number of psychosocial risk factors were found to be common among the study sample: financial problems (49.1 percent), self-emotional behavior (35.0 percent), husband’s negative attitude (19.8 percent), previous history of depression (16.7 percent), history of abuse (11.7 percent), and traumatic (10.3 percent). Vernon et al. (2010) examine the relationships of maternal stress and depressive symptoms with body mass index and physical activities during the first year of postpartum. The maternal stress was evaluated by different controlled variables such as physical activities (light or moderate) and overweight. The linear regression analyses was used to measure the hypothesized association among these factors. The mean score of daily performing hours of low and moderate physical activities was 11.2 ± 3.0 and 4.5 ± 3.0 respectively. Higher maternal stress was associated with low physical activities; where, the moderate physical activities were negatively associated with the postpartum depressive symptoms. Ali et al. (2009) mentioned that lack of empowerment of women, gender discrimination and patriarchal culture of Pakistani society did not allow women to plan pregnancy. The prevalence of postpartum depression and anxiety was found to be 28.8 percent among women; and unplanned pregnancy, domestic violence, difficulty with breast feeding at birth were found to be significantly associated with postpartum depression and anxiety.

Not only the patriarchal family system contributes to the unplanned pregnancy. Other factors such as lack of knowledge, cost and accessibility of contraceptive methods are strongly associated with unplanned pregnancy. About 1/3 of the deliveries had complications due to inadequate antenatal care and services and stressful life events. Setse et al. (2009) concluded that a significant number of women experienced the symptoms of PPD from diverse cultures. The prevalence rate among these women is found to be 7 percent to 50 percent, have the effect on women’s own health and their infants. The risk factors for PPD were pregnancy complications, maternal age, partner’ behavior with the incidence of violence, family relationships and insufficient social support. Adrienne (2009) revealed that low energy level, restlessness and anxiety were major characteristics of depression. The non-postpartum mother can be differentiated from postpartum depression symptoms by reporting sadder mood, more suicidal ideation, and more reduced interest. In contrast, restlessness, anxiety and decision-making were most prominent for postpartum depression while the sad mood was less prominent. Dennis & Karen (2009) suggested that in the postpartum period women with depressive symptoms negatively influences infant-feeding outcomes; including increased breastfeeding difficulties, decreased breastfeeding duration and decreased levels of breastfeeding self-efficacy. Evidence also suggests that women with depressive symptoms may be less likely to initiate breastfeeding. Muneer et al. (2009) illustrated that almost 1/3rd of the study participants (women) suffered from postpartum depression and the majority of them were moderately or severely depressed. The demographic and socioeconomic profile of depressed mother showed that they were young; most of them were around 25 years with low level of education; married for less than 5 years; had small families with less than 3 children; the majority were from extended families (living with in-laws); and came from the socioeconomic adversity. Kheirabadi et al (2009) related the PPD to the first childbirth, they are at high risk of depression as they struggle to adapt to motherhood. The study also identified that multiple deliveries reduce the vulnerability to PPD, due to general declines in stress that are associated with pregnancy and delivery complications. Among Iranian women, the associative characterizations of PPD were low level of education, unemployment, unplanned pregnancy, maternal’ young age, history of depression and undesired sex of the baby.

Marcus (2009) explained that illness is a common phenomenon among women and the precise vulnerability of a woman is a time of pregnancy. Major depressive disorder occurs due to the gender differences in the process of socialization, hormonal influences and genetics. A number of studies demonstrate that a negligible part of women seek treatment or having access to utilize care and services during antenatal and postpartum period. The most common symptoms of postpartum depression are low mood and energy, sleep and appetite change. The associative factors of depression during postpartum period were complications of pregnancy, premature birth, weight gain, increased substance/alcohol use, perceived stressful life-event, personal or family history of depression, poor health, anxiety predicted lower birth weight and under-utilization of prenatal care. Ghubash and Eapen (2009) identified that the most of the women did not express about the concept of postnatal depression and not considered it as a psychological issue. In its contrast, they thought that the problem occurred as a result of “Jinn” or “evil eye”. The study emphasized that lack of support from husband, mother-in-law and other family members, conflict between wife and husband were the factors of depression during pregnancy. Difficult labor, health of baby, poor attachment with baby, conflict between social expectation regarding the mother role and actual role play by mother. The study concluded that the leading cause of PPD is the lack of mother’s knowledge about PPD, they didn’t consider it as a psychological disorder. Doucette & Letourneau (2009) mentioned that attempting suicide and idea about suicide are significant factors associated with PPD for women in the West, but not currently associated among Arab and Middle Eastern women. Cheng et al. (2009) analyzed the depression of women associated with unintended pregnancies. The results found that women were at higher risks of PPD who reported unintended pregnancy. In addition, unwanted pregnancy had negative effects on to initiate maternal care and breastfeeding. Krause et al. (2009) analyzed the risk factors of PPD among obese and overweight new mothers. Obesity is considered a cause of depression among general people as well as postpartum mothers. The prevalence rate of PPD was 9.2 percent, measured by EPDS score of 13 or above. The postpartum depressive symptoms were higher with low level of education, marital status, inadequate income and chronic illness.

Cheryl (2008) mentioned that women are expected to run a household, care for their new infants and other children, continue marital and social relationships, participate in community activities, and sometimes provide income for their families. These responsibilities kept women in depression may be unable to perform these tasks. In another way, women did not seek help for postpartum depression or other health-related matters. Lau & Wong (2008) mentioned that peiyue (authorized family postpartum support) is a traditional ritual for mothers that is associated with a lower severity of PPD. But in another way, weak relationships exist between mother and her mother-in-law due to the generational gap between modern lifestyles and cultural traditions. O'Brien et al. (2008) found the symptoms of PPD among 44 percent of the mothers. The psychological factors such as anxiety, negativity, self-efficacy and planned duration and expectations of breastfeeding had more influenced on breastfeeding duration rather than socio-demographic factors. Centers for Disease Control and Prevention (2008) mentioned that PPD is the most common complication related to childbirth; and a significant health problem affecting women, their infant and families. Approximately, 15 percent of the mothers had the symptoms of depression in the postpartum period. The most frequent causes of depressive symptoms were maternal young age with low level of education; stress due to husband verbal or physical abuse; and domestic violence. Lincoln et al. (2008) provides an insight on maternal depressive symptoms in the postpartum period. Mother-child attachment and the demands of child care practices may increase the chances of depression among women. The results found that 1/4 of the women indicate the depression within 2-6 months of postpartum. Adolescents and mother’s ages of 20-24 had the symptoms of depression twice and 2.5 respectively, as compared to women’s age of 35 or above. In addition, the strong influencing predictors of PPD were unplanned pregnant and worry about delivery related expenditures. Those women who gain health facilities were less likely to induce PPD. Dennis & McQueen (2007) analyzed the relationships between infant feeding methods and maternal satisfaction and self-efficacy related to postpartum depressive symptoms. Results show that mothers with postpartum depressive symptoms wants to continue breastfeeding either they were unsatisfied and experience problems.

Rahman & Creed (2007) mentioned that the rate of antenatal and postnatal depression is very high in the developing countries. It may continue and take a long time to diagnose due to the ignorance and lack of knowledge about maternal complications. About 56 percent of the mothers were depressed; and the higher risks for depression were poverty, illiterate husband, having five or more children, low self-confidence and impaired infant growth. Dindar & Erdogan (2007) reported the prevalence of PPD among Turkish women. The rate of major depression (12 or above) was 25.6 percent of the sample and the rate of minor depression was 16.7 percent of the sample, measured by using EPDS. The strongest risk factors of depression were previous psychiatric illness, abortion or loss of a baby, smoking, lower family income, conflict with husband, the birth of a baby girl, mother-in-law attitude and lower social support. Ho-Yen et al. (2007) demonstrated that depression after childbirth have the negative effects; not only for the mother but also her infant growth. In multivariate analysis, stressful life events, husband’s drunkenness, polygamy, smoking, antenatal depression and previous depression were the significant factors with the elevated score of depression. In addition to the analysis, some cultural practices such as arranged marriages, lived in the maternal home after childbirth and traditional practices also contribute to developing the depression among postnatal women in Nepal. Liabsuetrakul et al. (2007) reported that the rate of minor or major PPD were diagnosed among 10 percent of the sample in Thailand. Anxiety was identified as a strong predictor of antenatal depression; and anxiety and social support both were found to be the significant predictors of PPD. After factor analysis, 10 items of anxiety, 10 items of social support, four items of stressors and five items of self-esteem were identified, with a standardized reliability coefficient of 0.85, 0.82, 0.81, and 0.82; and a coefficient of 0.84, 0.82, 0.85 and 0.84 during pregnancy the postpartum period respectively. Goyal et al. (2007) illustrated that most of the new mothers experienced sleeping disturbance during pregnancy or after childbirth due to a number of physical or psychological problems. A sleep disorder may influence to elevate the depression among women in the postpartum period. Although evidence demonstrates that culturally prescribed practices may or may not be the cause of increasing or decreasing the occurrence of PPD.

Husain et al. (2006) mentioned that postpartum depression is an important public health problem worldwide. Evidences form the various studies suggests that prevalence of postpartum depression is higher in developing countries in comparison with developed countries. Thirty six percent women scored ≥12 on EPDS that indicates a high prevalence of postnatal depression in Pakistani women. High postpartum depression score was associated with increased stressful life events, lower social support and extreme anxiety and pain in the antenatal period. In Islamic point of view, women are encouraged to breastfeed for two years. A number of passages in the Qur’an and hadith reveals the importance of this relationship. Green et al. (2006) not conference these religious expectations and emphasize that breastfeeding could be stressful. Consequently, it would increase the likelihood of women experiencing depression. Green et al (2006) identified the risk factor for PPD, findings are deliberated in relation to socio-cultural and physical factors in the context of Islamic culture in UAE. Assessment of PPD was made by using EPDS, and the facts were analyzed in three categories; such as, no depression (scores of < 9), borderline depression (scores of 10-12) and depression (scores of ≥ 13). According to the results, 17.3 percent of the sample falling in depression category and 20.8 percent of the sample falling in the borderline depression category. The higher contributory factors were poor physical health, giving birth for the first time, body image change, weight gain or weight loss, not breastfeeding, marry at an older age and relationships with mother-in-law. Becoming a mother for the first time as mothers experience new physical and emotional changes may find themselves in difficulty to meet with these changes. The study also illustrated that the diversity of cultures has an effect on maternal life around the world. The thought of a thin and round body as looking smart and beautiful was linked with Western culture. But, now with the influx of globalization and western media, women are surprisingly weight concerns and interested towards body shapes have changed in Arab and Middle Eastern. Conversely, dissatisfaction with their body image and weight gain viewed to be stressful that leads to the PPD. Moehler et al. (2006) demonstrated that postpartum depression has continued effects on child mental and emotional development. The first few months after childbirth is highly sensitive to maternal, affecting the mother - infant relationship. The maternal postpartum depressive symptoms were viewed from 2 weeks to four months postpartum period. However, mild or moderate symptoms of depression had a significant effect on maternal bonding to the child during first four months.

Chien et al (2006) emphasized that cultural practice “doing the month” among Chinese women residing throughout the world has been associated with slightly lower risk of physical illness and PPD. McLearn et al. (2006) determined the relationships of maternal depressive symptoms with mothers' early child-rearing practices. Most of the depressive symptoms were common among mothers form neonatal period to 4 four months postpartum, having the negative effects of child care. Goyal (2006) conducted a study on immigrant Asian women in the United states to analyze the cultural factors in relations to the occurrence of PPD. The data show that about 28 percent of the women have a minor depressive symptoms and 24 percent have a major depressive symptom. Immigrant Asian women were experiencing PPD symptoms as white women; no differences were found on the bases of gender of the newborn baby and arranged marriage. Sayil et al. (2006) examined the maternal well-being by analyzing antenatal anxiety and postnatal depression. The data were collected from those mothers who were married, aged 20 years or its above and working women. Lower personal income, self-efficacy and self- esteem were the factors related to the antenatal anxiety. Furthermore, unplanned pregnancy, higher antenatal anxiety and perceived lower satisfaction with social and partner support were significantly associated with maternal depressive symptoms in the postnatal period. All these risk factors might create contradiction for the postnatal maternal well-being as well as throughout their life. Kitamura et al. (2006) describes that the risk factors of antenatal depression such as maternal’ negative attitude towards pregnancy and young age were strongly associated with the development of PPD. While, another associative factor of PPD was unwanted sex of the baby, poor emotional attachment with the baby and inadequate social support. Azidah et al. (2006) mentioned that the prevalence of PND was 20.7 percent of the population in 4-6 weeks postpartum period in Malaysia. Depressive symptoms of pregnancy, first week postpartum depressive mood, worry about child care, pressure for traditional medication and practices were related to the PND at 0.05 level of significance. Sabuncuoglu et al. (2006) concluded that 30 percent of the participants had postpartum depressive symptoms on the EPDS, with a cutoff score of ≥ 11. Symptoms of postpartum depression had significant association with maternal attachment style, where the mother feels insecure by the close relationships. The maternal behavior regarding infant attachment may elevate to develop the symptoms of depression.

Nakku et al. (2006) concluded that depression is a most common psychological disorder of the postpartum period in women. Evidence suggested that the prevalence of PPD is three times higher in the developing countries than in developed countries. Demographic and social background put the women on the higher risks of PPD. The associative factors of PPD were young age, marital status (single, divorced or separated), unintended pregnancy, undesired sex of the baby, physical health problem (mother or infant) and negative life events. Ayvaz et al. (2006) reported the incidence of PPD in Trabzon Province, Turkey. The incidence of depression found 28.1 percent, according to the EPDS. The high score in Beck Anxiety Inventory, scores ≥ five in General Health Inventory in pregnancy and previous history of depression were the strongest predictors of postpartum depression. Limlomwongse & Liabsuetrakul (2006) identified the depressive symptoms and its causes in antenatal and postpartum period, assessed by the EPDS. The incidence of depression was 20.5 percent and 16.8 percent of the women during pregnancy and postpartum period respectively. Marital status, maternal attitude (happy, unhappy) towards pregnancy were the associative factors for depression in pregnancy. Religion, attitude towards pregnancy, fear of pregnancy and delivery related complications were associated with PPD (p < 0.01). Where the negative attitude towards pregnancy put the women on the higher risk of depression. Pippins et al. (2006) identified the potential risk factors associated with initiating and continuing breastfeeding; and did not find the variations based on race or ethnicity. Depressive symptoms during or after pregnancy had a significant effect on the initiation and continued breastfeeding. Leung et al. (2005) explained five major factors in the development of PPD among Hong Kong Chinese mothers. These identified factors were adapted of parenthood, the gap between social expectations and actual performance, mind set about the baby sex, childcare strains and conflict with tradition and cultural patterns. Women faced a unique challenge that may occur due to the influence of east and west culture. Such as, the in- law’s attitude was getting changed with women when they knew about the birth of a baby girl and these practices are frequently seen in Africa, Asia and Turkey. The study also collected an in-depth information to examine the lived experience of postpartum stress in related to the well-being and mood of the depressed mothers. Chinese mothers faced a number of challenges such as residing in urban areas, cultural diffusion or conflict of east and west. These challenges may cause anxiety, stress or other depressive disorders in the

postpartum period, if not properly accomplished. The most frequent causes of postpartum stress among women were; childcare demands and competence; gap between social expectations and personal experiences; and conflict with cultural prescribed rules and tradition. McMahon et al. (2005) demonstrated that high levels of anxiety, interpersonal relationship, anger and high levels of hostility played a major role in the progression of PPD. A study by Rizk et al (2005) found that in the UAE, 13.2 percent of mothers have the knowledge about their postpartum depression and described it as feelings of sorrow, anger, fear, remorse, jealousy, guilt, dissatisfaction and sense of failure. Greor (2005) found the breastfeeding as a protective indicator of stress and negative mood. Breastfeeding mothers had less perceived stress, lower anger and depression, and more positive moods than formula feeders. Aydin et al. (2005) conducted a study in Eastern Turkey to identify the causes and prevalence of postnatal depression among women. Almost 35 percent of women had symptoms of depression with score 13 or above, measured by using EPDS. The prevalence rate of PND was higher among Eastern Turkish women than the descriptive rate of western countries. The risk factor related to PND were unemployed husband, some stressful life event during pregnancy or after childbirth, lack of husband's support, infant health problem, difficult labor and previous history of depressive symptoms. Chee et al. (2005) were of the view that, conflict to maternal experiences and expectations was a significant predictor of PPD among women in Singapore. In detail, the related risk factors of PPD were lower emotional and social support, unplanned pregnancy, history of depression, antenatal depression and dissatisfaction of relatives over childcare. The prevalence of PPD was 6.8 percent of the women. Kim & Buist (2005) supported that traditional practices and family support played a positive role to minimize the depressive symptoms of Korean postpartum mothers. In this perspective, lack of social support put the mothers on the higher risks of PPD. Lindahl et al. (2005) found to be the variations in thought of self-harm and suicidal ideation, attempt and deaths during pregnancy and postpartum. The thought of self-harm was common among maternal, ranging from 5 to 14 percent. Suicide attempts and deaths during pregnancy and the postpartum were found to be lower than the general population of women. Where, suicide deaths were estimated about 20 percent of postpartum deaths, considered the leading cause of death in postpartum.

Bloch et al. (2005) examined the risk factors related to the development of postpartum mood disorders. The criteria were fixed to assess the incidence of the postpartum blue or postpartum depression. According to this criterion, about 10 percent were identified as at high risk (major depression) and 6 percent as at low risk (minor depression or blue). Depressive mood during pregnancy and the first 2-4 days postpartum, premenstrual dysphonic disorder, previous history of depression and contraceptive behavior were found to be associated with postpartum mood disorders. Other than these factors, diversity in hormonal sensitivity can contribute to the development of postpartum mood disorders. Oates et al (2004) describes that the main causes of unhappiness during pregnancy are discomfort, physical illness and physically traumatic delivery in all centers of eleven countries (UK, France, Italy, Ireland, USA, Uganda, Sweden, Austria, Portugal, Switzerland and Japan). Women expressed the view that unwell feeling and nausea in early pregnancy; and tiredness, their size and lack of sleep in later pregnancy as a contributor to discomfort. Good social support played an important role for maternal during pregnancy or after delivery. The study concluded that the strongly associated factors with unhappiness following delivery were poor relationships with intimate partners, unsatisfactory time spend together, family conflict, lack of social and emotional support, interference from relative’s tiredness and loneliness. Interestingly, the attitude of mother-in-law is strongly caused of unhappiness in all countries where the data were collected (except Sweden). Women were of the view that their marital life disturbed due to confliction about sexual activity. Horowitz & Goodman (2004) sought to examine the variations in maternal depressive disorders from childbirth to 2 years after delivery. Parental conflict, lower social support and history of depression raised the maternal depression scores. However, depression score decreased within the passage of time, but the significant variations are viewed from 8 weeks to 14 weeks postpartum rather than from 14 weeks to 18 weeks postpartum. In addition, postpartum depression symptoms may continue at 2 years after delivery. Lee et al. (2004) identified the socio-cultural risk factors of PPD among Chinese women. Maternal well-being and their lived experiences are highly influenced by the socio- cultural prescribed rules and expectations. Peiyue (family support) is a cultural practice of the Chinese postpartum mother, associated with lower risk of PPD. Furthermore, marital problems, conflict with mother-in-law, antenatal depression and experiences of previous depression were the factors contributing to the development of PPD. In addition, negative attitude of in-laws in an important source of stress in most of the Asian countries.

Fisher et al. (2004) concluded that the prevalence rate of PPD was higher in Vietnam than described rates in developed countries. The postpartum depressive symptoms were measured by using EPDS. According to this, 33 percent of the women had range of > 12 scores on EPDS; among them, 19 percent were identified in the risk of suicidal ideation. In a logistic regression model, 77 percent of depressive cases (range of > 12 scores on EPDS) were properly classified in a model, such as unplanned pregnancy, unemployment, feeling uncomfortable with the baby, less than 30 days complete rest after delivery, inadequate proper food and low attachment with husband. Robertson et al., (2004) illustrated that PPD affects 15 percent of the mothers. The strongest predictors of PPD were teenage mothers; lower socioeconomic status; anxiety and depression during pregnancy; stressful life events during or within the first two weeks; a previous history of depression; and low social support. Small et al. (2003) conducted a study on immigrant women in Australia. Women were on the responses that there are a number of factors of depression in their lives, yet, the childbirth is dominant to elicit depression. Lack of emotional and social support, family relations, marital status, isolation, fatigue, weakness, chronic health problems are interrelated with the birth of their baby. Women’s divergent socio-demographic background was found to be less important for depression. Tammentie (2002) made the assessment of the prevalence of postnatal depression and determine the contribution of socio-demographic factors. The data was examined through questionnaire and EPDS. The prevalence rate of postnatal depression was 15 percent of the mothers. The study found that low level of mother’s education, poor family relationship, mother’s family history of depression and shorter duration of breastfeeding were associated with depressive symptoms. Other factors such as the mother’s age, number of pregnancies, number of deliveries and type of delivery were not associated with depressive symptoms. Danaci et al (2002) expressed that women experiencing a range of stressful life events such as financial problems, low emotional and social support, poor relationships and mental stressors during pregnancy and after delivery. Also, women receive better care and good support after the birth of a baby, but within the passage of time this supports drops off.

Danaci et al. (2002) found that 14 percent of mothers had depressive symptoms scored ≥ 12 on the EPDS in Manisa province, Turkey. The contributory factors of PPD were found to be similar as in other countries; such as the number of children, health problem of the newborn baby, residing in shanty towns, previous history of depression, any psychiatric disorder of the husband, and negative relations with husband and in-laws. Harriet et al. (2001) concluded that maternal previous personality disorder, stressful life events and psychological status are the risk factor for postpartum depression. Other causes of depression may be the biochemical or hormonal factors, pregnancy complications, number of pregnancies, duration of illness, older age and psychosocial stressors. Chaudron et al. (2001) conducted a cohort study of women to determine the incidence of PPD. In a logistic regression analysis, antenatal depression, maternal age, fear of death and difficulty in sleeping were the predictive variables of PPD. Other variables such as type of delivery, breastfeeding, education of the mother and family income did not contribute to PPD. Nielsen et al. (2000) analyzed the potential risk factors of PPD through community-based survey. The interview schedule and Edinburgh Postnatal Depression Scale were used to collect the information on the previous history of psychological distress, psychiatric disease and social support. Evidence supported that about 6 percent of the mothers have the symptoms of depression. The predictive elevated factors identified by multivariate logistic regression analysis. The complications during pregnancy or delivery have no significant association with PPD. Stress during pregnancy and fear of isolation were the strong predictive factors in the development of PPD among 1/3 of the sample.

2.2 The Present Study From the review of literature, no clear picture has appeared of the demographic, obstetrician and psychosocial factors. Although, there are a number of demographics, obstetrician and psychosocial factors, which might be associated with the prevalence of PPD. But in a prospective study, these factors have not been examined simultaneously. Another limitation of many previous studies is a failure to evaluate the symptoms of PPD with the mother’s life, means not accessed the effects of PPD on the mother’s life. In addition, previous research has not evaluated the association between PPD and mother’s behavior and healthy appearance (effects of PPD on mother’s behavior and healthy appearance). Often, in the context of Pakistan’s study, the subject matter is normally taken from hospitals or clinic with small samples. It represents samples that are comparatively homogeneous with respect to socioeconomic background which may hinder the generalization of the results. Clearly, it’s a requirement for longitudinal designs that keep away from the practical problems found in previous research, as far as possible. Particularly, there is a massive need to identify the factors that increase the risks of developing postpartum depression in Pakistan. The purpose of the present study was: firstly, to examine the prevalence of PPD in the general Pakistan sample. Secondly, to examine the role of social and demographic factors (age, education, income, number of family members); and obstetric factors (unplanned pregnancy, abortion, pregnancy, delivery and infant health complications) in the development of postpartum depression. In addition, the contribution of various psychosocial factors such as attitude of husband and in-laws, violence, antenatal depression, stressful life events, social support and feelings during pregnancy and in the postpartum period was also studied.

2.3 Hypothesis of the Study From the literature review of postpartum depression, several predictions were made. Hypothesis 1: Higher the age of the respondents, lower the prevalence of postpartum depression Hypothesis 2: Higher the education of the respondents, lower the prevalence of postpartum depression; lowers the educational attainments, higher the prevalence of postpartum depression Hypothesis 3: Higher the family income of the respondents, lower the prevalence of postpartum depression

Hypothesis 4: Higher the total number of family members of the respondents, higher the prevalence of postpartum depression Hypothesis 5: Higher the health problems of the respondents for the last two years, higher the prevalence of postpartum depression Hypothesis 6: Higher the number of pregnancies of the respondents, higher the prevalence of postpartum depression Hypothesis 7: Higher the number of abortions of the respondents, higher the prevalence of postpartum depression Hypothesis 8: An association between planned birth of a baby of the respondents and prevalence of postpartum depression Hypothesis 9: Higher the pregnancy complications of the respondents, higher the prevalence of postpartum depression Hypothesis 10: Higher the complications of the respondents during delivery, higher the prevalence of postpartum depression Hypothesis 11: Higher the infant health problems during pregnancy and late neonatal care of the respondents, higher the prevalence of postpartum depression Hypothesis 12: An association between family type and prevalence of postpartum depression Hypothesis 13: An association between sex of baby and prevalence of postpartum depression Hypothesis 14: An association between pressure to have a baby boy and prevalence of postpartum depression Hypothesis 15: An association between social taboos and prevalence of postpartum depression Hypothesis 16: Higher the provision of health facilities to the respondents, lower the prevalence of postpartum depression Hypothesis 17: Association between attitude of husband, in-laws and doctors towards respondents and prevalence of postpartum depression Hypothesis 18: Higher the violence of the respondents, higher the prevalence of postpartum depression Hypothesis 19: Higher the history of stressful life events of the respondents, higher the prevalence of postpartum depression Hypothesis 20: Higher the social support of the respondents, lower the prevalence of postpartum depression

Hypothesis 21: An association between experiences and feelings of the respondents during pregnancy and the prevalence of postpartum depression Hypothesis 22: An association between experiences and feelings of the respondents within the first two weeks after delivery and the prevalence of postpartum depression Hypothesis 23: An association between difficulty in feeding and prevalence of postpartum depression Hypothesis 24: Higher the physical issues in the postpartum period of the respondents, higher the prevalence of postpartum depression Hypothesis 25: An association between the postpartum depression and the mother’s life Hypothesis 26: An association between postpartum depression and respondent's behavior Hypothesis 27: An association between postpartum depression and respondent's healthy appearance

Chapter 3 MATERIALS AND METHODS

The methods section gives a detailed picture of the procedure or techniques, followed in completing the research process. A variety of different methods are used to identify, understand and analyze the research problem. It allows the readers to evaluate the reliability and validity of the study. The main purpose of the methodology section is to describe the techniques of data collection and its analysis in detail (Kallet, 2004). Considering the importance of methodology, it is quite important to provide sufficient information for the generalization, and make recommendations based upon the findings. In the social sciences, specific methods are used to address the social problems empirically. This type of research provides a justification for a specific topic selection; focuses on objective knowledge and research questions; formulate the hypothesis and operational definitions of variables for measurement and sampling procedure (Zevedo, et al 2011). Qualitative method is an explanatory approach, construct the nature of reality that seeks to describe how and why social experiences are created (Denzin and Yvonna, 2000). Quantitative approach focuses on gathering data in numerical form through a questionnaire or survey methods to explain a specific phenomenon (Babbie, 2010). The present study is designed to investigate how different factors contribute to the development of postpartum depression among women. For this purpose, both the quantitative and qualitative approaches were used to examine the factors. Primary and secondary sources of data collection were also used. The methodology consists of study design, study area, sample size, sampling plan, data collection, description of measurements, aspects to improve the quality of data, data analysis and conceptual and operational definition of the variables.

3.1 Study Design Postpartum depression is the most problematic time of childbearing. The main purpose of this study is to identify associated factors and prevalence of postpartum depression among women. The cross-sectional study was conducted. Both the qualitative and quantitative approaches were used. The universe of the study was District Faisalabad, Punjab, Pakistan. The target population of the study was the postpartum mothers age 15-44 years with a baby up to one year of age in the rural areas of District Faisalabad. A sample of

400 respondents was selected through multistage sampling technique and data were collected through well designed interview schedule. Four rural towns were selected conveniently from District Faisalabad. At the first stage, four union councils were selected randomly from each rural town. At the second stage, 25 respondents were selected randomly from each selected union council. Eight focus group discussions were conducted; two from each town. Both the descriptive and inferential analysis was carried out. Population based survey was analyzed through univariate, bivariate and multivariate analyses by using SPSS (Statistical Package for Social Sciences) to evaluate the responses; and Edinburgh Postnatal Depression Scale (EPDS) was used to check the level of postpartum depression among women. Focus Group Discussion (FGD) was analyzed through content analysis technique. The detailed methodology is described as below.

3.2 Study Area Faisalabad is the third largest and one of the most populous city of Pakistan. It is a highly populated city with the total population of 7,873,910 (Pakistan Bureau of Statistics, 2017). The total number of divisions is nine in Punjab i.e. Lahore, Rawalpindi, Faisalabad, Sargodha, Bahawalpur, Multan, Dera Ghazi Khan, Sahiwal and Gujranwala (Punjab Portal, 2016). Faisalabad Division was selected from Punjab through simple random sampling technique. There are four districts in Faisalabad division, i.e Faisalabad, Chiniot, Jhang and Toba Tec Singh. Faisalabad district was selected from the four through simple random sampling technique. The study was conducted from the rural towns of district Faisalabad. The total number of rural towns is four; and the study was collected from all the four rural towns to gain maximum variation in the data. The distribution of the study area was consisted a number of union councils from the rural towns of Faisalabad District, which also were selected randomly.

3.2.1 Profile of District Faisalabad The total area of Faisalabad District is 58.56 square kilometers, while, 1,280 square kilometer area is controlled by the Faisalabad Development Authority. It lies between 30 o and 31.5 o north latitude and 73 o and 74 o east longitude; and 605 feet above from sea level. The river Chenab flows on the western and Ravi on the eastern boundary of the district. The main source of the irrigated water is lower Chenab canal, supplies 80 percent of cultivated land (City District Government Faisalabad, 2016; Mustafa, 2009). The

district has vast agriculture and industrial sector. It has rapid growth in the field of industry that contribute over 70 percent of textile export market of Pakistan. However, Faisalabad is known as a Manchester of Asia for its wider growth of industrial sector, contributes approximately 20 percent to Pakistan's annual GDP (Institute of Soil and Environmental Sciences, UAF, 2015). The textile industry of Faisalabad constitutes more than 65 percent of the textile export market of Pakistan (Pak Green Enviro-Engineering, 2015). The climate of the district is touching too extreme in both seasons summer and winter. The maximum temperature in the summer seasons reaches up to 50 °C (122°F). In winter season, it may harsh, at times fall below the freezing point. There is very little amount of rainfall throughout the year. The maximum and minimum temperature in summer are 39°C and 27 °C respectively, but in winter, 21°C and 6 °C respectively (Punjab Portal, 2016).

3.2.2 Population Faisalabad district is one of the highly populated districts of Punjab, and the density of population is 927 per square kilometer. The total population of Faisalabad district is 7,873,910 with the annual growth rate of 1.97 (Pakistan Bureau of statistics, 2017). Faisalabad district consists of 8 towns, four urban and four rural; namely Lyallpur Town, Iqbal town, Madina Town, Jinnah Town (urban towns); Jaranwala Town, Tandlianwala Town, Sammundri Town and Jhumrah Town (rural towns). The district consists of 289 union councils (City District Government Faisalabad, 2016). Table: 3.1 Population Characteristics of District Faisalabad, Punjab, Pakistan Total Population - T. Population: 7,873,910 (Male, Female) - Male population: 4,034,515 - Female population: 3,838,854 Rural Population - T. Population: 4,113,582 (Male, Female) - Male population: 2,102,745 - Female population: 2,010,623 Urban Population - T. Population: 3,760,328 (Male, Female) - Male population: 1,931,770 - Female population: 1,828,231 Annual Growth Rate - Total: 1.97 (Rural, Urban) Continue……….

- Rural: 1.48 - Urban: 2.5 Number of Household - Total: 1,225,266 (Rural, Urban) - Rural: 631,434 - Urban: 593,832 Source: Pakistan Bureau of Statistics. (2017) 3.2.3 Health There are a number of public and private sector hospitals for providing health care facilities to its citizens. More than 40 hospitals run by various government departments in Faisalabad district. Notably, government hospitals are Allied hospital, District Headquarter Hospital, PINUM Cancer hospital, Institute of Child Care (Second largest children’s hospital of the world and largest children’s hospital of Asia), General Hospitals in Samanabad and Ghulam Muhammadabad and Faisalabad Institute of Cardiology. In addition to the government-run hospitals, there are a number of private hospitals, laboratories and clinics run by different welfare institutions having specialized healthcare professional. Table: 3.2 Maternal Mortality and Morbidity in District Faisalabad Mortality Morbidity - Hemorrhage - Indigestion - Eclampsia - Diarrhea - Hypertensive disorder - Hypertension - Unsafe abortion - Anemia - Prolonged labor - Respiratory problems - Tuberculosis - Malnutrition - Hepatitis - Chronic pain - Chronic liver disease - Heart disease Source: Sultana et al. (2017), Asim et al. (2017), Ara et al. (2012)

3.3 Sample Size Cross-sectional study was conducted to examine the contributory factors and prevalence of postpartum depression of the respondents. Both the quantitative and qualitative approaches were used to explore the study objectives. The study was conducted from

rural areas of Faisalabad district, and all four rural towns were selected to capture maximum variations in order to enhance the scope of the study. Multistage sampling technique was used for the selection of final sample units (respondents). At the first stage, four union councils were selected through simple random sampling from each rural town. At the second stage, a sample of 400 (25 women from each union council) mothers having a child up to one year of age was selected randomly. In a qualitative study, 8 focus group discussions (two from each rural town) of 6-10 mothers were collected for detailed and in-depth information. The description and process of conducting focus group discussion are described in chapter 7.

3.3.1 Sampled Union Councils Sr. Town’s Name UC # Birth Registration TOTAL Oct 2015 – Dec 2015 Jan 2016 – Sep 2016 1 Jhumrah 1 304 4 600 9 695 2141 14 542 2 Jaranwala 21 301 33 378 41 794 2254 68 781 3 Tandlianwala 78 244 80 445 1,777 84 625 90 463 4 Samundri 108 544 113 413 2,642 116 941 120 744 4 (Rural Town) 16 (Union 8814 Councils)

3.4 Sampling Plan

3.5 Data Collection Qualitative and quantitative methods were used to get the detailed and meaningful information. Data on socio-demographic variables (age, education, occupation, income, family type), obstetric variables (pregnancy intention and complications, type of delivery), psychosocial variables (attitude, violence, stressful life events, social support), depressive symptoms and other explanatory variables were gathered through an interview schedule. Both the open ended and close ended questions were developed to collect the responses. Before starting to collect the actual data, a pilot study was conducted with 35 postpartum women to check the sensitivity and workability of the questionnaire and to make sure the questions are understandable to the respondents (women).

3.6 Description of Measurements a. Structured Questionnaire In order to obtain the specific nature of the sample a structured questionnaire was developed. The main purpose of the questionnaire was to examine the socioeconomic and demographic background of the respondents and to identify the factors of PPD. The questionnaire was developed according to the study objectives with the help of related review literature. A range of background data was obtained through socioeconomic and demographic information. The socioeconomic and demographic information was consisted on the age, age at marriage, marital status, education, occupation, family income, knowledge about postpartum depression, attitude towards health facilities, addiction habit, social expectations and social taboos and antenatal and postnatal services. The obstetric information was comprised on maternal characteristics (no of pregnancy, abortion, live and dead births, pregnancy and delivery complications, type of delivery), unplanned/unwanted pregnancy, pre-eclampsia (high blood pressure, proteinuria) and health problems. Additionally, information regarding psychosocial variables, including interpersonal relationships, antenatal depression, stressful life events, social support and violence was also collected. The specific questions about factors of PPD are supported with the help of different useful scales; i.e. Postpartum Depression Screening Scale (PDSS); Postpartum Depression Predictors Inventory (PDPI); Maternity Social Support Scale (MSSS). Postpartum Depression Screening Scale (PDSS) and Postpartum Depression Predictors Inventory (PDPI) are the screening tools for PPD developed by Beck (1998). Beck

developed a checklist to identify the risk factors for developing PPD among women. This scale consists of 7 domains such as sleeping and eating disorders, emotional attachment, anxiety, loss of self, thought of harming oneself, guilt/shame and cognitive impairment. Postpartum Depression Predictors Inventory (PDPI) is another useful tool used by a health care professional and nurses to identify women at risk for developing PPD. This tool was made up of thirteen risk factors, through two meta-analyses, that are used to identify the women most at risk. These factors include low socioeconomic status, prenatal depression, history of previous depression, prenatal anxiety, marital status, marital satisfaction, social support, maternity blues, stressful life events, low self-esteem, childcare anxiety, unplanned/unwanted pregnancy and difficult infant temperament. Maternity Social Support Scale (MSSS) measures the social support during pregnancy or after childbirth. These social factors associated with PPD. These factors characterize as low social support of husband, family and friends, conflict with husband and feelings controlled by the husband. This scale provides useful dimension for researchers, health care providers and professional to examine the level of support women receive (Webster et al., 2000). The questionnaire is shown in Appendix A. b. Edinburgh Postpartum/Postnatal Depression Scale (EDPS) The most widely use of screening tool for postpartum depression is the Edinburgh Postpartum/Postnatal Depression Scale (EDPS). Specifically, this test is designed for women who are pregnant or just having a baby. This is a self-reported scale containing 10-question that has been proven to be an efficient and effective method of identifying risk for “postpartum” depression. Each question is rated on a four-point scale ranging from 0 – 3, in which high scores are shown the severity of the symptoms (Cox, et al., 1987). The total scores are determined by adding together the scores for each of the 10 items. The scale indicates that woman scoring 9 or less are considered not depressed; and woman scores 10 – 12 are representing the minor symptoms of depression, should be asked follow up questions for further screening. Woman scoring 13 or above indicating the positive symptoms of major depression, needs an appropriate assessment and possible interventions should be made immediately. The EPDS scale is only a screening tool; didn’t consider it as a depression diagnosis. This scale has been translated into numerous languages and has online provision to analyze PPD among women.

In the present study, the prevalence of PPD was measured by Edinburgh Postpartum/Postnatal Depression Scale (EDPS). According to this scale, the selection of answers was based on how a respondent has felt in the past 7 days; and scores in the range of 10 - 30 are generally symptomatic of depression. There are some debates on the cutoff score as what should be used for the symptoms of depression. The American Academy of Pediatrics recommends that a cutoff score of 10 or greater would be more appropriate for identifying the symptoms of depression. According to the original 10-item EPDS cut point is ≥ 9. This allowed each person to be identified as not depressed (range 0–9); minor depressed (range 10–12) or more major depressed (range 13 or more) (Pallant, et al., 2006). The score of 13 or more is considered to be a significant 'case' of postnatal depression, while scores of 10 to12 represent 'borderline' and 0 to 9 'not depressed' (Montazeri et al., 2007). In primary care settings this is often the threshold used to indicate a risk that depression is present and a woman should receive further evaluation (Cox, et al., 1987). Others preferred a cutoff score of 13 or greater to indicate a positive screen. Although a number of cut points are used, but the present study chooses to regard an EPDS score ≥10 as indicating depression. Postpartum depression is categorized into three levels of not depressed (range 0 to 9), moderately/minor depressed (range 10 to 12) and severely/major depressed (range 13 or more). This provides the opportunity for maximum variations in the responses to see the level of PPD. The Scale is shown in Appendix B.

3.7 Aspects to Improve the Quality of Data Data were collected from the postpartum mothers. There are some limitations in the study regarding the data collection; only those mothers were selected who, having a last child up to one year of age. The level of postpartum depression was assessed by using EPDS. Quality of data plays a crucial role through all the steps of the social research process in both qualitative and quantitative methods. It is a continual process starts from a research questions and data collection, to the analysis and interpretation of the results (Bergman & Anthony, 2005). There are some aspects that are very important to improve the quality of data in order to achieve the objectives of the study. The following aspects are sequenced and sensitivity of questions, coding, pilot testing, data editing, focused on relevant questions, training and field management (Fisher et al. 1983). It’s necessary for a researcher to consider the importance of these aspects while in developing and designing

the questionnaire. All these points were assured in this study to improve the quality of data.

3.8 Developing Sensitive and Relevant Questions Avoiding biases and sensitive questions are the key principles to motivate and win the trust of the respondents during interview. These principles helped the interviewer to gain the maximum responses from the respondents (Foddy, 1993). During the formulation of questionnaire some biases such as slang, confusion, jargon, double barreled questions, double negative, ambiguity and threatening questions were avoided. Also, the emotional language and prestige biases were avoided. The validity of the study depends on including the questions relevant to the study objectives. This principle also kept in mind by the researcher, only relevant questions related to the study objectives were considered in the formulation of the questionnaire.

3.9 Coding The questionnaire comprised of both the open ended and close ended questions to get the accurate information. Because the dependency on only close ended questions may distort the results. To make sure the accuracy of the responses, the majority of the questions were pre-coded for data collection and its process and analysis. After that, the data was shifted to coding sheets. The Statistical Package of Social Sciences (SPSS) version 20.0 was used for data analysis.

3.10 Time and Sequence of Questions The sequence of questions may influence the respondent’s answers. Fisher et al. (1983) suggested that the format of the questionnaire should be in a sequence for flow of responses. In order to design the interviewing schedule, contents and sequence of the questions were taken into account to eliminate the confusion and discomfort of the respondents. In addition, the maximum care was utilized to avoid the mixing of questions on different issues. By starting of the questionnaire, information about respondent’s and husband age, age at marriage, occupation, monthly income and family type was obtained. Afterward, the information related to the obstetrician, psychological and physical health issues was obtained.

How much time is required for conducting the questionnaire depends on the survey design. Mostly, half to one hour is consumed for face to face interviews. If the researcher takes much time for a questionnaire, may the respondents fad up. In order to get the required information, time span should be less to develop the interest of the respondents. The average time consumed for conducting the interview was half an hour. For the validity of the questionnaire, all the questions were proceeding for data analysis.

3.11 Pilot Testing Before starting the actual data collection, the questionnaire was piloted to examine the validity and accuracy. It’s a good idea to modify the interview schedule according to the situation. Also, helpful to determine the time required to complete a questionnaire. Commonly, the sample of the pilot test depends on the actual sample, but typically a sample of around 30-50 is usually considered enough to identify the drawbacks. The pilot study was conducted with 35 postpartum women to make sure the questions are understandable to the respondents (women). In this regard, the sensitivity of the questions was also examined. The time required to complete a questionnaire was 25 – 35 minutes. After pilot testing, the questionnaire was modified and some questions were excluded, some included and some reshaped.

3.12 Analysis Various statistical techniques were used to analyze the quantitative data such as univariate, bivariate and multivariate techniques. In univariate analyses, frequency, percentage and measures of central tendency was applied to explain the data. In bivariate analyses, the association among different variables were examined by applying chi-square and gamma tests. The multivariate analyses were used to examine the relative significance of independent variables in explaining the dependent variable.

3.12.1 Use of SPSS Statistical Package for the Social Sciences (SPSS) was used for analyzing data. It is a comprehensive system and the most widely used software for statistical analysis in the field of social sciences. Social researcher, health researcher, market researcher, educational researcher and others do their statistical analyses by SPSS. SPSS can read and take data in almost any type of format (numeric, alphanumeric, binary, date and time) and

use them to generate tables, charts, tabulated formats and plots as well as descriptive and complex statistical analysis. It has a very flexible capability of handling highly complex data and its manipulation with a simple command.

3.13 Univariate Analysis The distributions of the unit of analyses of any data set are examined through descriptive statistics. Univariate analysis is a simplest form of statistical methods deals with one variable, in which each variable describes separately to determine the level of measurement of variables. The main purpose of univariate analyses is to interpret and summarize data, finds patterns in the data and trend of responses. It also describes the range and measures of central tendency (mean, mode and median) and standard deviation. Each value of the different variables is calculated with frequency distribution. The lowest and highest values of each variable are identified by frequency distribution and arranged all the values from lowest to highest. The set of data can be presented in tables and graphical form.

3.13.1 Percentage The values of frequency distribution can also be presented in the form of percentage and cumulative percentage. A percentage is used for estimation and comparison that indicates the proportion. The percentage is calculated by following formula: P = F/N X 100 Where: P = Percentage F = Number of observations N = Total number of frequencies

3.13.2 Mean and Standard Deviation Each variable in any set of data set is explored separately in the univariate analysis. The data also analyzed at the mean (average of the values) and the standard deviation (dispersion of a set of data values). It describes the trend and patterns of response to the variable. The mean is used to calculate the central tendency of a set of numbers; and the standard deviation is used to measure the spread of scores within a set of data. Normally, a small standard deviation means that the data is close to the mean or the dataset being on

average. Where, a large standard deviation reflects that the date set are far away from the mean, on average means a large amount of variation in the group that is being studied.

3.14 Bivariate Analysis In contrast to univariate analysis, bivariate analysis deals with two variables in order to check the relationship/association between the independent and dependent variables. Bivariate analysis is used to view the relationship between two sets, which means that the distribution of values of the two variables are associated. Simply, it helps to understand the relationship, measure the strength of the relationship and testing hypotheses. Bivariate analysis was applied to find out the association of demographic, socioeconomic and psychological variables with the prevalence of postpartum depression among women. The association predicts to how much the independent variables relate to the dependent variable in explaining the contributory factors of postpartum depression and its symptoms and level of PPD among women. The chi-square test and gamma statistics was used for testing hypotheses and to check the strength of association.

3.14.1 Chi-Square test Testing hypotheses of association are confirmed by applying the chi-square test. Chi- square is defined as, “a statistical test used to compare the observed frequencies with expected frequencies, it would expect to obtain, according to a specific hypothesis also to determine the degrees of independence” (Fisher, 1928). The chi - square test is denoted by symbol χ2. The chi-square value is calculated by following formula: 2 χ = Σij (Oij – Eij)2 / Eij where:

Oij = Observed values

Eij = Expected values

Σij= Total sum Chi-square is the sum of the squared difference between observed (frequencies) and the expected (frequency) values and divided by the expected value (frequency) in all possible categories. The high value of chi-square shows a large difference. For the significance of the results, the acceptance or rejection of hypotheses is made by the chi-square value and level of significance. The level of significance is taken as 5 percent. The association was

considered significant with the calculated value of chi-square, that is greater than or equal to the table value at 5 percent level of significance. Assumptions of chi-square data is based on numbers (frequencies), not ratio or percentage. The expected value is not less than 5 in any category. The chi-square value only explained the relationships rather than the strength of the relationship. The strength of the relationship was checked by gamma statistics.

3.14.2 Gamma Statistics Gamma test is a symmetrical measure of association between two variables measured at the ordinal level, also known as Goodman and Kruskal's gamma test. Gamma test was used to check the strength of the association with an indication of the direction and the value of the independent variable to predict the value of the dependent variable. Gamma value varies from 0.0 to ±1, means no association, positive or perfect/negative association between the independent and dependent variables. ▪ A value of +1 reflects the strongest level of association for a positive or direct relationship. ▪ A value of – 1 indicates the strongest level of association for a negative or perfect relationship. ▪ A value of 0 indicates the no or weakest level of association. The gamma value is calculated by following formula:

Where: Ns (same order pairs): More Ns pairs show a positive association. Nd (inverse order pairs): More Nd pairs show a negative association. Gamma will be positive, if there are more Ns pairs, gamma will be negative, if there are more Nd pairs and gamma will be zero, if there is Ns = Nd.

3.15 Multivariate Analysis Human behavior (attitude, emotions, cognitions) is a very complex phenomenon that cannot be describe or measure directly in terms of one or two factors/variables. These traits must be inferred and measured by multiple variables or factors to explain the relationship between a response variable and more than one explanatory variable. Multivariate is a form of statistical analysis to explore how many variables relate simultaneously to each other’s. Simply, the multivariate analysis containing a number of variables instead of one (univariate) or two (bivariate) using matrix algebra. It is a widely used statistical technique for analyzing multiple independent/predictor variables with multiple dependent/outcome variables. The most frequent use of multivariate analysis are multiple linear regression, variance, covariance, and path analysis. Before applying any statistical method, the researcher sees whether method is suitable for the data; and also, the data fulfill all the required assumptions for the application of the method. Regression analysis is a statistical technique that estimates the relationship between one dependent and more than one independent variable. In considering more than one independent variable, multiple linear regression is the most commonly method that is used to examine the significance of each independent (predictor or explanatory) variable to the dependent (response) variable (Maki, et al., 1978). The detailed methodology of multivariate analysis is described in chapter 6.

3.15.1 Multiple Linear Regression Model Multiple Linear Regression is the most common form of regression analysis, used to explore the relationship between one dependent variable from two or more independent variables. The term multiple regression analysis was first used by Pearson in 1908, to explain the maximum variation in the response variable by applying more than one predictor variable, called multiple linear regression analysis. It summarizes the strength of the linear relationship between each pair of response variables. The model for multiple linear regression is described as follows:

Y = α+ b1X1 + b2X2 + b3X3... + bnXn + e Explanation of the regression equation: Y = estimated dependent variable X = each independent variable

c = constant (which includes the error term that indicates the proportion of unexplained variance in the dependent variables). b = regression coefficients (estimate the amount of change in the dependent for a unit change in the dependent variables). α= Intercept, (indicates the value of y when all the x values are zero).

3.16 Conceptual and Operational Definitions of the Variables Conceptual definitions are used to operationalize scientific variables in the research work process, in order to determine and clarify their meanings. Operationalization is a process through which we define the variables and categorized into simpler parts to observe and measure. 3.16.1 Age Age is an important factor that affects the attitude, behavior, activities and decision making of an individual. For the present study, the age of the respondents refers to the number of years, she had completed at the time of interview. Furthermore, the women’s age of 15 – 44 (fertility period) were taken. 1. 15 – 20 2. 21 – 25 3. 26 – 30 4. 31 – 35 5. 36 and above 3.16.2 Marital Status Marital status is defined as a person’s state of being as married or unmarried/single, divorced, widowed or separated. This study describes marital status as given below: 1. Married 2. Widow 3. Divorced 4. Separated 3.16.3 Education It is also an important factor that affects the attitude, knowledge and prestige of the individual. Formal education was taken the respondent’s education as how many numbers of classes a respondent had passed. 1. 0

2. 1 – 5 3. 6 – 10 4. 11 and above 3.16.4 Occupation Occupation is defined as a person’s activity in which he/she is engaged as a means of livelihood. The term was characterized as: 1. Govt. employee 2. Private employee 3. Laborer 4. Livestock/agriculture 5. Housewife 3.16.5 Household Monthly Income Monthly or daily income is an important contributory factor describes the economic status of an individual or family. Economic status indicates the people’s expenditure percentages of their income on different needs. Household monthly income consists of the combined incomes (from all resources) of all members shared a particular household over a given period of time. The monthly income was categorized as follows: 1. Up to 20000 2. 20001 – 30000 3. 30001 – 40000 4. 40001 or above 3.16.6 Family Type Family is a smallest unit of society, a group of people united by birth, by marriage or any other blood relations (siblings, families). The most common types of family are:

▪ Nuclear family consists of parents and their unmarried children living together;

▪ The joint family comprises of more than one generation living together (grandparents, father, mother and their children);

▪ Extended family consists of all married and unmarried from grandparents to grandchildren, uncle, aunts and other relatives living together in a common house. In the present study, family type was categorized into three types as mentioned above.

3.16.7 Postpartum A postpartum is a period starting afterward the birth of a child immediately and continued for about 1 year. In the present study, postpartum period refers to the mother having last child up to one year of age.

3.16.8 Postpartum Depression The term postpartum depression means "any non-psychotic depressive illness of mild to moderate severity occurring during the first postnatal year" (Scottish Intercollegiate Guidelines Network, 2012). In the present study the postpartum depression is defined as experiencing symptoms of low mood, anxiety, lack of concentration, weight loss/gain, eating and sleeping disorders, following childbirth (postpartum period).

Chapter 4 UNI-VARIATE ANALYSIS

4.1 Socio-demographic Characteristics of the Respondents Table: 1 Distribution of the respondents according to their current age and age at marriage n = 400 Current Age (Years) Frequency Percentage

15 – 20 50 12.5 21 – 25 88 22.0 26 – 30 168 42.0 31 – 35 76 19.0 36 and above 18 4.5 Mean = 2.81, Std. Deviation = 1.028 Age at marriage (Years) Up to 20 218 54.5 21 – 25 143 35.7 26 – 30 35 8.8 31 – 35 4 1.0 Mean = 1.56, Std. Deviation = 0.694

Current age of the respondents: In the present study, mothers were selected under the age category of 15-49 (reproductive age) years. Table 1 shows that the majority of the respondents (42.0 percent) belonged to the age category of 26-30 years, 22.0 percent belonged to 21-25, 19.0 percent belonged to 31-35 and 12.5 percent belonged to 15-20. While, 4.5 percent belonged to the age group of 36 and above years. The mean current age was 2.81 years with standard deviation 1.028 years. Another study concluded that the average age of the sample was 24.3 years (Ghajati et al., 2015). Age at marriage of respondents: The study reveals that the majority of the respondents (54.5 percent) got married in the age group of up to 20 years, 35.7 percent of the respondents got married at age of 21-25 years, and 8.8 percent had their marriages in age of 26-30 years, while only 1.0 percent were married when they were at age of 31-35 years. In the study area, a large proportion of females are being married at young ages. Most of them reported that they got married in their teen ages, even at the age of 13 or 14.

In rural areas of Pakistan, parents prefer to marry their daughters in early ages. Marriage at an early age has a negative effect on their educational status. Due to the social status in society, female’s psychological, economic and reproductive health status affected harmfully. The study depicts that the pattern of early marriage is still implemented in rural areas as the mean age at marriage was 1.56 with standard deviation 0.694 years. In terms of etiology, young age at marriage for females have physical and reproductive health complications such as abortion, premature births and stillbirths. Antenatal and postpartum depression may result in these complications. Studies identified that early age at marriages have adverse effects on women’s health (psychological/physical) due to the excessive childbearing, low level of literacy, unawareness of childbearing process and lack of control over their own bodies (Batool, 2010; Beck, 2002). Another study concluded that the most complication occurs between the teenage mothers and in the age group of 20-24; the frequencies of pregnancy induced anemia, eclampsia and hypertension that were found to be highly significant with teenage mothers (Ashok, 2007). Metha and Nidhi (2014) found a strong significant association between PPD and teenage mothers as well as older age at their marriage.

Table: 2 Distribution of the respondents according to their marital status n = 400 Marital status Frequency Percentage Married 385 96.3 Separated 10 2.5 Widow 3 0.7 Divorced 2 0.5

The table shows that the majority 96.3 percent of the respondents were married. 2.5, 0.7 and 0.5 percent of them were separated, widow and divorced, respectively. Results indicate that the majority of them were married. Many of the women reported that their husband are in abroad for laborer or in other cities of their own country. Exchange marriage is a cultural pattern in some traditional families of rural Pakistan. In Pakistan, the term exchange marriages known as “Whatta Satta” means husband’s sister get married with wife’s brother (sister’s marriage with brother-in-law). It has a negative impact on their life and marital relations. If one couple divorced or separated, it should be compulsory for another couple to do act as same. In other side, if husband got second

marriage, his brother-in-law also get second marriage. The marital status of postpartum mothers have a considerable influence on the risk of developing postpartum symptoms. The depressive symptoms are highly increased among divorced and separated/living alone mothers as compared to those who lived with their husbands (Kleiman, 2009; Podolska et al., 2009).

Table: 3 Distribution of the respondents and their husbands, according to their education n = 400 Education (Years of Frequency Percentage schooling) Illiterate 192 48.0 1 – 5 85 21.3 6 – 10 81 20.2 11 and above 42 10.5 Mean = 1.93, Std. Deviation = 1.049 Husband’s education (Years of schooling) Illiterate 123 30.8 1 – 5 83 20.7 6 – 10 122 30.5 11 and above 72 18.0 Mean = 2.36, Std. Deviation = 1.099

Education of the respondent: Table 3 shows that almost half percent of the respondents were illiterate. About 21 percent of the respondents had education up to primary level (1- 5 years of schooling), 20.2 percent had up to metric level (6-10 years of schooling), and 10.5 percent had up to intermediate (12 years of schooling) and above level of education. The mean of educational level was 1.93 years of schooling with a standard deviation of 1.049 years of schooling. The female literacy rate is lower than male in both rural and urban areas of Pakistan. The educational rate for rural women is more than five times lower than for urban women (Batool, 2010). The estimated literacy rate is 57.9 percent; and among male and female it is 69.5 percent and 45.8 percent, respectively (CIA World Fact Book, 2016). A vast number of the female population was illiterate due to lack of facilities in Pakistan, specifically in rural areas. Long school distance, low economic resources and traditional values are the main reasons behind the female low literacy rate.

Early age at marriage is another important reason of women’s lower literacy rate. Parents prefer to marry their daughters over schooling. The health status of an individual is highly associated with education. Uneducated women due to lack of knowledge and health related information are lacking to maintain their health. They are deprived to gain basic health facilities due to the social injustice against women. Almost half, 48.0 percent of women had a primary level of schooling (Ghajati et al., 2015). Other studies found a strong correlation between the women’s personal education and PPD; The level of education is an important indicator to eradicate the problem of PPD (Mazaheri et al., 2014; Tannous et al., 2008; Serge et al., 2007). Husband’s education: Table reveals that 30.8 percent of the respondent’s husbands were illiterate. 20.7 percent had education up to primary level (1-5 years of schooling), 30.5 percent had up to metric level (6-10 years of schooling), and 18.0 percent had up to intermediate (12 years of schooling) and above level of education. The mean of the educational level was 2.36 years of schooling with a standard deviation of 1.099 years. The study found a 70 percent literacy rate among males in rural areas of Pakistan. It reflects a huge disparity between wife’s and husband’s years of schooling (male, 70 percent; female, 52 percent). The major role of the female is to bear and rear her children and look after family elders. Bread earner is a massive responsibility for male.

Table: 4 Distribution of the respondent’s husband according to their current age, and age at marriage n = 400 Husband’s current Age Frequency Percentage (Years) Up to 25 56 14.0 26 – 30 98 24.5 31 – 35 124 31.0 36 and above 122 30.5 Mean = 2.78, Std. Deviation = 1.032 Age at marriage of the husband Up to 20 80 20.0 21 – 25 188 47.0 26 – 30 103 25.8 31 – 35 26 6.5 36 and above 3 0.7

Mean = 2.21, Std. Deviation = 0.862

Current age of the respondent’s husband: Table 4 shows that the majority 31.0 percent of the respondent’s husband belonged to the age category of 31-35 years, 30.5 percent belonged to 36 and above, 24.5 percent belonged to 26-30 and 14.0 percent belonged to up to 20. The mean age of husband was 2.78 years with a standard deviation of 1.032 years. Age at marriage of respondent’s husband: Results indicate that the majority 47.0 percent of the respondent’s husband got married in the age group of 21-25 years, 25.8 percent had their marriages in age 26-30 years, 20.0 percent got married up to 20 years, and 6.5 percent were married when they were at age 31-35, while only 0.7 percent got married at age 36 and above. The mean of husband’ marriage age was 2.21 years with a standard deviation of 0.862 years. In the study area, results depict a difference between the respondent’s age at marriage and their husband as shown in the above table. Parents preferred to marry their daughters at an early age rather than sons. Boys are the earning hand of their families, parents did not marry their boys even they got jobs.

Table: 5 Distribution of the respondents and their husband according to their occupation n = 400 Respondent’s occupation Frequency Percentage

Govt. employee 8 2.0 Private employee 11 2.8 Laborer 36 9.0 Livestock/agriculture 43 10.7 Housewife 302 75.5 Husband’s occupation Agriculture 69 17.3 Non-agriculture 331 82.7 If non-agriculture, then occupation Laborer 151 45.6 Private employee 87 26.3 Business 53 16.0 Govt. employee 34 10.3

Unemployed 6 1.8 Total 331 100.0

Occupation of the respondents: Occupation is engaging in a specific sustained activity as a source of income or in earning one’s living. It describes the economic status and position of an individual. Occupation is directly effected on the living pattern of the people. Most of the residence of rural society sdirectly depend on agricultural land and livestock. Table 5 shows the working status of rural women. According to the results, 75.5 percent of women were house wife, 10.7 percent participated in agricultural activities or cared for livestock and 9.0 percent worked as a laborer, while only 2.8 and 2.0 percent were private and government employee, respectively. A study found that the symptoms of PPD were more common among housewives (Mosalanejad et al., 2005). On the other side, Mazaheri et al, (2014) concluded a significant relationship between symptoms of PPD and respondent’s employment; as PPD was more common in mothers who are employed. In rural Pakistan, the participation of rural women in economic activity is still lower as indicated the above results, only 25 percent of the total were engaged in economic activity. It indicates that women’s access to education, property and employment are considerably lower as compared to men. Predominantly patriarchal family system in Pakistan is highly affected the participation of women in economic activities. Outside home related activities depend on the permission of male head. In addition, opportunities for women, traditional values, responsibility of rearing children and household chores may consider the leading cause behind this (Mirza, 2014; Batool, 2010). Husband’s occupation: This table also explains the occupation of the respondents’ husband. Results indicate that 82.7 percent of the respondent’s husband were belonged to the non-agriculture occupation, while 17.3 percent were belonged to the agriculture. Batool (2010) highlighted that almost 34.0 percent of the respondent’s husband was engaged in agriculture sector. The trend of rural society in the involvement of agricultural economic activity is declining day by day, but it is viewed very low in the present study. Low percentage of farming and low level of production per hectare put the pressure on rural community to engage themselves in other different occupations. The other contributory factor is dividend of land among inheritors. The farmers have not enough resources due to the reduction in farm size. Unawareness and lack of accessibility to pesticides and modern tools can cause low productivity. It would discourage the

investment and unable to apply the pesticides. All these are strong predictive factors to induce the interest of farmers in agriculture. It resulted in, the young are preferred migrate to urban to earn their livelihood. If non-agriculturist then: Majority of non-agriculturist 45.6 percent were laborers, 26.3 percent were private employee as worked in factories located nearby their areas, 16.0 percent doing their own business, 10.3 percent were government employees, while 1.8 percent of them were unemployed. Rural people engaged in different occupations as the diversity of occupation are viewed in the results.

Table: 6 Distribution of the respondents according to their income n = 400 Personal income (Rs) Frequency Percentage

Up to 10000 83 20.7 10001 – 20000 8 2.0 20001 – 30000 5 1.3 30001 and above 2 0.5 Not applicable 302 75.5 Husband’s income (Rs) Up to 10000 174 43.5 10001 – 20000 153 38.2 20001 – 30000 46 11.5 30001 and above 21 5.3 Not applicable 6 1.5 Family income (Rs) Up to 20000 228 57.0 20001 – 30000 56 14.0 30001 – 40000 44 11.0 40001 and above 72 18.0

The monthly income of the respondents: Income is defined as the maximum amount of an individual can spend during a specific period. Income is an indicator of economic status and social position of someone in society. It determines the health status of the individuals as well as their families. Poor families spend a large amount of their income on food rather than on education and health. The good health of women relies on economic status. Table 6 describes that 75.5 percent of the respondents had no income

because they were housewives. The majority of them could not gain the work opportunities because they had low levels of education. 20.7 percent was earned up to 10000 rupees. Most of them worked on farms, livestock or as a laborer (stitching, weaving and house maid) and 2.0 percent earned 10001 to 20000 rupees. About 1.3 percent earned 20001 to 30000 rupees, while 0.5 percent earned 30001 and above. Almost 5 percent of women earned 10001 rupees and its above, as they were government or private employee. The status of rural women is a symbol of housewives as the present study indicates. They preferred to live at home because the traditional values of the villages did not allow them to go outside the home to work. In other side, they are responsible to perform domestic work, rearing the children and look after their siblings and parents. Husband’s monthly income: The data show that the majority 43.5 percent of respondent’s husband earned up to 10000 rupees per month, 38.2 percent earned an income 1000 –20000, 11.5 percent earned 20001–30000, while 5.3 percent had 30001 and above. Almost 1.5 percent had no income because they were unemployed. Family monthly income: Family monthly income is a total compensation (salaries and wages, capital gain, pensions, child support, social security and bonus) received by all peoples sharing a particular household. The study also indicates the family monthly income of the respondents. More than half, 57.0 percent of the respondent’s family monthly income was up to 20000 rupees, 14.0 percent had 20001–30000, 11.0 percent had 30001–40000 and 18.0 percent had 40000 and above.

Table: 7 Distribution of the respondents according to their family type n = 400 Family type Frequency Percentage

Nuclear 150 37.5 Joint 232 58.0 Extended 16 4.0 Other 2 0.5

Family type: Family is a smallest unit of society, a group of people united by birth, by marriage or any other blood relations (siblings, families). Emotional support (companionship, intimacy, belongings), economic support (food, clothing, shelter, education), socialization of children and control of sexuality are the basic functions of the

family. The types of family vary in all countries based upon society’s living and cultural patterns. Commonly, nuclear, joint and extended are the three types of the family system in Pakistan. But the nuclear and joint is the most common in both rural and urban areas. Most of the rural families are living in joint family system, but rapidly change into nuclear families. Now, also the rural residence preferred to live in a nuclear family system to meet their needs properly. The results reveal that 58.0 percent of the respondents belonged to joint family and 37.5 percent of them belonged to nuclear family. Batool (2010) also described the same results as found 58.2 percent of the respondents lived in a joint family system and 41.8 percent of the respondents lived in a nuclear family system.

Table: 8 Distribution of the respondents according to the total number of their family members n = 400 Family members Frequency Percentage ≥ 3 26 6.5 4 – 5 76 19.0 6 – 7 97 24.3 8 – 9 80 20.0 10 and above 121 30.2

Total number of family members: The distribution of family income is considerably affected by total number of family members. Families of low income with a number of members are compelled to live hands and mouth. They are massive deprived of food, education and health facilities. This table shows that the majority 30.2 percent of the respondent’s family consists of 10 and above members, 24.3 percent had 6-7 members, 20.0 percent had 8-9 members and 19.0 percent had 4-5 members. A negligible proportion, 6.5 percent of the sample had 3 members or less than 3. Results indicate that 1/3 part of the sample has more than 10 family members. If add up the findings, half percent of the respondent’s family members consist of more than 8 members. It depicts the high ratio of family members in rural areas of Pakistan. Mother and infant needs more nutritional food than other family members. Mothers remain unhealthy because they could not maintain their balance diet. Most of the pregnancy and delivery complications occurred because of poor diet and a deficiency of iron and vitamins. The higher incidence of these complications elevates the risks in the development of PPD.

4.1.1 Summary: Socio-demographic Variables Respondents were selected under the age category of 15-49 (reproductive age) years. The result concluded that the majority 42.0 percent belonged to age category 26-30 years, 22.0 percent belonged to 21-25, 19.0 percent belonged to 31-35 and 12.5 percent belonged to 15-20, while 4.5 percent belonged to 36 and its above years. The mean current age was 2.81 years with standard deviation 1.028 years. The results of the age at marriage shows that a large proportion of females were married at young ages (majority 54.5 percent got married in the age group of up to 20 years). It means that the early marriage is still applied in rural areas of Pakistan. Almost half percent of the respondents were illiterate and only 10.5 percent had up to intermediate (12 years of schooling) and above level of education. The results highlighted that more than half, 57.0 percent of the respondent’s family monthly income was up to 20000 rupees, and 18.0 percent respondent’s family monthly income was 40000 and above. It is concluded that low socioeconomic status contributes to poor health status (psychological and physical). Mothers face a number of barriers (inadequate diet in terms of quality and quantity, lacked access to attain medical facilities and psychological treatment) due to financial instability; associated with low mood, anxiety and stress among women, may elevate the risks of PPD. The number of family members shows that almost 1/3 part of the women had more than 10 family members. If add up the findings, half percent of the respondent’s family members consist of more than 8 members. It is evident from the results that the distribution of family income is highly affected by the total number of family members, as these families are compelled to live hands and mouth. The study also concluded that mothers who lived in a joint or an extended family system were more prone to develop low mood, mood swings, sadness and anxiety due to family pressure, mother-in-law’s behavior and husbands’ emotional distress for their wife. Most of the mothers remain unhealthy because they could not maintain their diet and utilize their income on health. It resulted in, the pregnancy and childbearing related complications occurred leading to the symptoms of PPD. It is identified that the most common health issues for the last two years among respondents were anemic (54 percent), fever (45 percent), chronic pain (42 percent), cholera (29 percent) and high or low blood pressure (17 percent). It is considered that mothers who suffer from different health problems to a great or some extent were more likely to be depressed than those who have a good health status. There are more chances of low mood, anxiety and stress throughout their life with poor health status.

4.2 Information on previous pregnancy/delivery Table: 9 Distribution of the respondents according to the number of children and history of previous pregnancy and delivery n = 400 Number of children Frequency Percentage

None 96 24.0 1 – 3 156 39.0 4 – 6 81 20.2 7 and above 67 16.8 Mean = 2.30, Std. Deviation = 1.013 Number of pregnancies None 80 20.0 1 – 3 139 34.8 4 – 6 73 18.2 7 and above 108 27.0 Mean = 2.52, Std. Deviation = 1.092 Number of abortions None 281 70.2 1 84 21.0 2 and above 35 8.8 Mean = 1.39, Std. Deviation = 0.643 Blood loss during abortion Yes 94 23.5 No 25 6.3 Not applicable 281 70.2 Number of deliveries None 83 20.8 1 – 3 84 21.0 4 – 6 74 18.5 7 and above 159 39.7 Mean = 2.77, Std. Deviation = 1.179 Number of live births None 91 22.7 1 – 3 95 23.8

4 – 6 92 23.0 7 and above 122 30.5 Mean = 2.61, Std. Deviation = 1.143 Number of dead births None 311 77.8 1 68 17.0 2 and above 21 5.2 Mean = 1.28, Std. Deviation = 0.552

Table 9 reveals the information of the respondents about the number of births and previous history of pregnancy and delivery. The maternal physical and psychological health status are highly associated with the number of pregnancies, abortions and births. The basic purpose of Pakistani women’s marriage is to reproduce the child. The woman’s position becomes stronger when gets pregnant and delivered a baby particularly a baby boy. Number of children: Table shows that 39.0 percent of the respondents had 1-3 number of children, 20.2 percent of them had 4-6 number of children, 16.8 percent of women had more than 7 numbers of children. While, 24.0 percent of samples had no children. The mean of total number of children was 2.30 with a standard deviation of 1.013. The most predictive factors for a number of children in Pakistan are having a desire of son, lack of education, male dominated society and the desire of in-laws for large family. Unintended pregnancy is another strong factor of large numbers of children. The couple would continue to bear children in order to get many numbers of son. Women are compelled to bear more children than they want. Urban families prefer smaller families as compared to rural families. In addition, parents living in the nuclear family system preferred smaller family as compared to those living in the joint or extended family system. Knowledge and uses of family planning methods are highly associated with the dependent couple. A couple can’t use birth control methods without the permission of the family. It resulted in, pregnant women with a number of children have a higher incidence of PPD (Ghajati et al., 2015). The number of pregnancies: Most, 34.8 percent of the respondents got pregnant for 1-3 times, 18.2 percent became pregnant for 4-6 times and 27.0 percent of them got pregnant for 7 and above. More than five numbers of pregnancies among 27.0 percent of the women exemplify the preference of high fertility in rural areas of Pakistan. The mean

number of pregnancies was 2.52 with a standard deviation of 1.092. Most of the women got married at their earlier reproductive age as shown in the earlier table; almost 55.0 percent of the women’s ages were up to 20 years. A young married woman had more chances to become pregnant due to the long reproductive period. Depression can hinder the daily routine activities of women, even multiple pregnancies and abortions make the condition worse. The prevalence of antenatal depression can increase the risk of dead births, premature delivery and low birth weight babies. The results highlighted that 96 women had no children, which means that 304 women had children. Whereas, 80 women had no history of pregnancy, which means that 320 women experienced pregnancy. If discussed the both results, it is concluded that 16 women who have the history of pregnancy, they faced miscarriage or abortion. So, these women had no children, and this baby was their first baby. The number of abortions: The study indicates the women’s experiences of miscarriage and abortion. Abortion means early ending of a pregnancy. A miscarriage is the loss of a fetus up to the 20th week of pregnancy. Spontaneous abortion or miscarriage occurs if the abortion happens on its own. It is concluded that approximately 15 to 20 percent of pregnancies end in miscarriage; and almost 80 percent of miscarriages are more likely to occur within the first three months of pregnancy. The chances of miscarriage are less to occur after 20 weeks of pregnancy; after the 20th week it is known as a stillbirth (Batool, 2010). In the present study, 70.2 percent of the respondents did not experience abortion or miscarriage, 21.0 percent of the women had 1 abortion or miscarriage and 8.8 percent of them had 2 and it’s above. The mean of total number of abortions was 1.39 with a standard deviation of 0.643. Batool (2010) concluded the results in the same line with minor differences, as 66.0 percent had no abortion or miscarriages; and 22.5 and 11.2 percent of women had 1 and more than 2 numbers of abortions respectively. Pakistan has an estimated annual abortion rate of 50 abortions per 1,000 women aged 15-49 in 2012; and in 2002, it was 27.50 per 1,000 women (Junaidi, 2015; Sathar et al., 2014). Heavy blood loss: Abortion can increase the risks of complications towards the next pregnancy. It also puts the women on risks in the development of PPD. Previous history of abortion is highly associated with a women’s fear and negative thinking in the antenatal period leads to the symptoms of PPD. According to the results, 70.2 percent of the respondents did not experience of abortion. In remaining, 23.5 percent of them faced heavy blood loss and 6.3 percent faced light blood loss. Among them, 79.0 percent had experienced heavy blood loss and 21.0 percent had experienced light blood loss. The

study conducted by Batool (2010) in rural areas of Pakistan, concluded that about 75.0 percent of rural women faced blood loss (89 percent heavy blood loss and 11 percent light blood loss), and 25.0 percent did not experience this problem. Number of deliveries: The majority 39.7 percent of the respondents delivered 7 or more babies, 21.0 percent and 18.5 percent of the respondent bear 1-3 and 4-6 babies, respectively. While, 20.8 percent of the sample did not deliver a baby. The mean of total number of deliveries was 2.77 with a standard deviation of 1.179. Number of live births: The study explains that most of the respondents, 30.5 percent delivered 7 or more live births, 23.8 percent delivered 1-3 live birth, and 23.0 percent of them delivered 4-6 live births. While, 22.7 percent of the women did not deliver live birth; they did not conceive, faced the problem of abortion or delivered a dead birth. The mean of live births was 2.61 with a standard deviation of 1.143 years. Most of the women delivered more live births showed the high fertility trend in Pakistan. The most predictive factors for high fertility rate in Pakistan are son preferences, lack of education, male dominated society and the desire of in-laws for large family. Unwanted pregnancy is another strong factor of high fertility trend in Pakistan. The number of dead births: Number of dead births lift up the prevalence of PPD among women. A woman in the history of dead birth is more likely to have the symptoms of antenatal depression leads to the development of PPD. In the total sample, 17.0 percent of the respondents delivered 1 dead birth and 5.2 percent delivered 2 or more than 2. While, the majority of the respondent’s 77.8 percent did not face any dead birth. The mean of dead births was 1.28 with a standard deviation of 0.552 years.

4.2.1 Summary: Information on previous pregnancy/delivery According to the results, majority 39.0 percent of mothers had 1 – 2 number of children and 16.8 percent of them had 5 and more than 5 numbers of children. As the data shows that more than 5 numbers of pregnancies were among 27.0 percent of the women. A young married woman had more chances to become pregnant due to the long reproductive period (15-49); and multiple pregnancies and abortions makes the condition worse. According to the results, almost 30 percent of the women had experienced abortion or miscarriage. Among all who experienced abortion, 79.0 percent of them had the experienced of heavy blood loss. The majority 39.7 percent of the respondents delivered 7 or more babies; and the mean of total number of deliveries was 2.77 with a standard deviation of 1.179. The study indicates that most of the respondents, 30.5

percent delivered 7 or more live births. While, 22.7 percent of the women did not deliver live birth; they did not conceive, faced the problem of abortion or delivered a dead birth. The number of pregnancies and births showed high fertility trends in rural areas of Pakistan.

4.3 Information on last pregnancy/delivery (12-month baby) Table: 10 Distribution of the respondents according to the sex and age of their last baby n = 400 Sex of the baby Frequency Percentage

Boy 218 54.5 Girl 182 45.5 Age of the baby (weeks) Up to 12 139 34.8 13 – 24 128 32.0 25 and above 133 33.2

Table 10 reveals the age and age of the last baby of the respondents. The sex of the baby: To become a mother is a happiest time of her life, but instead of joy she feels depression at the birth of her daughter. This not only the cause of PPD, but also the depressed mothers are more likely to deliver depressed babies. Postpartum depression doesn't affect just the mothers; also fathers feel stress and become clinically depressed from the burden of caring for a sick newborn baby and wife. Results show that 54.5 percent of the respondent’s baby was boys and 45.5 percent of the respondent’s baby was girls. In terms of the sex of a baby, dissatisfaction of infant’s sex (birth of a baby girl) is a risk factor for PPD (Beck, 2002). In Pakistani culture, married couple are expected to have a son for the continuity of descent. Baby boy is considered as a source of income and family feel proud among relatives. Some of them reported that girls are burdened for them; when getting married the family property is transferred to another family in the form of dowry. Women faced serious problems in marital life and in in-laws, who cannot deliver a baby boy (Ho-Yen et al., 2007). Age of the baby (weeks): About 35 percent of the respondent’s baby age was up to 12 weeks (up to 3 months), 32.0 percent baby’s age was 13-24 weeks 4 to 6 months), and 33.2 percent baby’s age was 25 and above weeks (more than 6 months).

Table: 11 Distribution of the respondents according to the planned birth of baby n = 400 Planned birth of baby Frequency Percentage

Yes 198 49.5 No 202 50.5

Planned birth of baby: Unplanned pregnancy increases the chances of anxiety or stress during pregnancy, which leads to PPD. The table shows that almost half, 50.5 percent of the respondent’s baby births were unplanned and 49.5 percent of the respondent’s baby births were planned. Unplanned pregnancies are due to poverty, lack of knowledge, husband and family have religious objection and behavior regards family planning methods. Availability, inaccessibility and poor quality of family planning services are also contributing to unplanned pregnancies. Unplanned pregnancy is not only the problem in developing countries. Finer and Henshaw (2006) reported that nearly half of all pregnancies were unplanned or unintended in the United States. A number of studies found a relationship between unplanned pregnancies and PPD, mothers with unplanned and unintended births are more likely to elevate PPD (Cheng et al., 2009; Nakku et al,. 2006).

Table: 12 Distribution of the respondents according to their complications during last pregnancy n = 400 Complications Yes No Complications Yes No F % F % F % F % Headache 121 30.2 279 69.8 Body swelling 78 19.5 322 80.5 Stomach ache Gestational 135 33.8 265 66.2 42 10.5 358 89.5 diabetes Anemia Urinary 238 59.5 162 40.5 53 13.2 347 86.8 problem High blood Uterus stitches 110 27.5 290 72.5 37 9.2 363 90.8 pressure Low blood Abdominal 140 35.0 260 65.0 171 42.8 229 57.2 pressure pain Proteinuria Vaginal 10 2.5 390 97.5 76 19.0 324 81.0 bleeding Vomiting 193 48.2 207 51.8 Fibroid uterus 27 6.8 373 93.2

Pregnancy complications: This table indicates the pregnancy related complications. Pregnancy complications have a negative effect on both maternal and infant health. The most common pregnancy complications are miscarriage, premature labor, swelling, preeclampsia, bleeding, nausea and vomiting, abdominal pain, anemia, obesity, urinary tract infection and gestational diabetes (American Pregnancy Association, 2017; Center for disease control and prevention, 2016). These complications can cause antenatal and postpartum depression among women. Pakistani rural women are more prone to pregnancy complications due to lack of knowledge about antenatal care and lack of access to antenatal services. Maternal mortality is also high in Pakistan, its major contributory factors are poverty, ignorance, insufficient diet, lack of adequate health facilities, early marriages and more numbers of children. In the present study a number of pregnancy related complications of the respondents were found. 33.2 and 33.8 percent of the respondents faced headache and stomach ache, respectively. More than half, 59.5 percent were anemic and 27.5 and 35.0 percent faced high and low blood pressure, respectively. 48.2 percent have the problem of vomiting and 42.8 percent faced abdominal pain. Body swelling and vaginal bleeding were found about 19.0 percent among them. Gestational diabetes, urinary problem, uterus stitches and fibroid uterus were the complications of the women during pregnancy, having the range between 7 percent to 13 percent. Pregnancy complications have the

impact on women’s life. This is difficult for mothers to live happy and enjoy the movements after experiencing such complications (Mazaheri et al., 2014; Rouhi et al., 2012).

Table: 13 Distribution of the respondents according to their checkup during pregnancy n = 400 Checkup during pregnancy Frequency Percentage

Private hospital / clinic 174 43.5 Government hospital 121 30.2 Basic health unit / Family 26 6.5 welfare center Dai (TBA) 7 1.8 None 72 18.0

Checkup during pregnancy: Pregnancy and childbearing is the most difficult incidence in the women’s life. It may become worse if the husband and family did not care in that period. Husband's responsibility towards wife is to assist and to visit healthcare centers for a checkup. The table shows that majority 43.5 percent of pregnant women visited private hospitals, 30.2 percent of the respondents visited government hospitals. Women were on the view that they prefer private hospitals or clinics for good services, even that hospitals and clinics are situated at a long distance. 6.5 percent visited basic health units or family welfare center. While, 18.0 percent of the respondents did not visit any health care center for checkups during last pregnancy. In the rural areas of Pakistan, the main reasons were lack of health care centers, inadequate access to centers and insufficient paramedical staff. Rural women have lacked access to the health care center due to husband and family restrictions. They did not allow their women to go outside the home for checkup and treatment. In addition, women did not utilize the services because they are unaware about the importance of health, even that the services are available in their areas. Antenatal care is the basic right of women, routine checkups are necessary for women during pregnancy. Women should have proper antenatal and postpartum care. It is recommended that, for normal delivery about seven visits are necessary to aware about the health status of women in Pakistan (Batool, 2010). The number of visits can be increased depends on health status.

Disparities in health care services can lead to poor outcomes for both maternal and her infant (Subramanian et al., 2012). Study depicts that when mother visit to health care providers, the checkup tends to focus on the physical aspects of care, such as breastfeeding and birth control methods; even the emotional distress and other needs are rarely encountered (Fowles et al., 2012). Additionally, postpartum period receives less attention from health care providers than the antenatal period (WHO, 2008). Others, Groh (2013) and Amnesty International (2010) describe that PPD remains untreated because of lack of knowledge among women, and largely neglected by health care professionals. In addition, women’s consultancy with a health care professional to obtain postpartum instructions is beneficial for them because women who attend prenatal and postnatal classes have better knowledge about their health (Corrigan et al., 2015; Ugarriza et al., 2007).

Table: 14 Distribution of the respondents according to the place of birth of their last baby n = 400 Place of birth of baby Frequency Percentage Home 139 34.8 Private hospital / clinic 128 32.0 Government hospital 126 31.5 Basic health unit / Family 7 1.7 welfare center If at home, who attend delivery Dai (TBA) 109 78.4 LHV / LHW 17 12.2 Nurse 9 6.5 Doctor 4 2.9

Place of birth of baby: Table shows that the majority 34.8 percent of the respondents delivered their last baby at home, 32.0 percent at private hospitals or clinics, 31.5 percent in government hospitals. While, 1.7 percent of women delivered their baby in basic health units or family welfare centers. The majority of the deliveries at home indicates the women’s miserable condition and helplessness. Childbirth at home can cause a number of complications for both maternal and infant. It may elevate the chances of postpartum hemorrhage, stillbirth, maternal or infant death, even physical disability of infants. A

number of studies found that almost half percent of rural women delivered their last baby at home under unhygienic conditions (Batool, 2010; Hakim and Zahir, 2001). The condition is worse in less developed areas of Pakistan, whereas, 77 percent of deliveries were occurring at home in the rural areas of district Thatta in Pakistan (Mirza, 2007). The trend of rural families is changed within the passage of time as seen the differences between the latest and past studies.

Table: 15 Distribution of the respondents according to the type of their last delivery n = 400

Type of delivery Frequency Percentage Normal 263 65.8 Caesarean 131 32.7 Assisted delivery 6 1.5

Type of delivery: Type of delivery is an important obstetric factor contributing to the development of PPD. Women are at higher risks of developing PPD, if they delivered babies by caesarean section. The study found that 65.8 of the respondents delivered their last baby in normal case, 32.7 percent with caesarean and 1.5 with assisted delivery type. By another, Zangene at al. (2011) reported that only emergent cesareans are associated with PPD. In contrast, a study (Sharifi et al., 2007) in Iran found no significant relationship between prevalence of PPD and the mode of delivery.

Table: 16 Distribution of the respondents according to the complications during their last delivery n = 400 Complications Yes No Complications Yes No F % F % F % F % High blood Baby pressure 64 16.0 336 84.0 movement 32 8.0 368 92.0 stopped Low blood Early delivery 49 12.2 351 87.8 51 12.8 349 87.2 pressure Body swelling 67 16.8 333 83.2 Difficult labor 93 23.2 307 76.8 Water bag Postpartum 150 37.5 250 62.5 115 28.8 285 71.2 broke hemorrhage Baby was in an unusual 23 5.8 377 94.2 position

Complications during delivery: This table indicates the complications faced by women during delivery. According to the results, 37.5 percent of the respondent’s water bag was broke. Women reported that this normally occurs before the normal childbirth. 28.8 percent faced postpartum hemorrhage and 23.2 percent faced difficult labor. Postpartum hemorrhage is frequently associated with postpartum depression. Almost 17 percent faced high blood pressure and body swelling. 12.8 percent of women gave early birth of their last baby. 12.2 percent faced low blood pressure at the time of childbirth. 8.0 percent of the respondents reported that their baby movement was stopped and 5.8 percent said that their baby was in an unusual position. These both complications also related to the pregnancy complications; may consider a strong predictor of antenatal and postpartum depression. Childbearing complication and difficult labor have the impact on women’s life towards negative feelings. This is problematic for mothers to enjoy the movements happily after experiencing such complications (Mazaheri et al., 2014; Rouhi et al., 2012).

Table: 17 Distribution of the respondents according to the their infant health problems during pregnancy and late neonatal care n = 400 Complications Yes No Complications Yes No F % F % F % F %

Water shortage 43 10.8 357 89.2 Congenital 24 6.0 376 94.0 Premature 53 13.2 347 86.8 Pale skin 102 25.5 298 74.5 Low weight 122 30.5 278 69.5 Stomachache 83 20.8 317 79.2 Heartbeat 33 8.2 367 91.8 Hand, feet cold 39 9.8 361 90.2 Short breathing Problem in 84 21.0 316 79.0 113 28.2 287 71.8 sucking Baby movement 31 7.8 369 92.2 stopped

Infant health problems during pregnancy and late neonatal care: Child health complications during pregnancy and poor health status in neonatal period have a negative effect on the life of mothers. The chances of postpartum depression are more likely to high with poor health status of the baby. The table shows that 30.5 percent of the respondent’s last baby was born with low weight and 13.2 percent were born premature. 21.0 percent faced short breath and 10.8 percent of the babies have the problem of water shortage. 8.2 percent have a heartbeat problem and 7.8 percent baby’s movements were stopped at the time of birth. Neonatal care is the hardest period for mothers. In that period infants are more prone to health complications. Results indicate that 28.2 percent of respondent’s baby has a problem in sucking, 25.5 percent have pale skin, 20.8 percent have stomach ache, 9.8 percent of baby’s hand and feet were cold and 6.0 percent have congenital problem. Mothers feel more depression if their baby has a problem in sucking at the time of breastfeeding. Most of the mothers reported that their child has physical disability due to the untrained Dai.

Table: 18 Distribution of the respondents according to the breastfeeding and difficulty in breastfeeding n = 400 Breastfeeding Frequency Percentage

Yes 308 77.0 No 92 23.0 Difficulty in feeding To great extent 74 24.0 To some extent 122 39.6 Not at all 112 36.4

Breastfeed to last baby: Breastfeeding has not only the effects on mother and infant, but also have a strong impact on the bonding between infant and mother. It may have a possible psychological connection with postpartum depression. The table shows that the majority 77.0 percent of the respondents were breastfed their last baby, while 23.0 percent were not breastfed their last baby. Respondent’s facing difficulty in breastfeeding: The study found that 24.0 of the respondents were felt difficulty to a great extent when breastfeeding, 39.6 percent of them were felt difficulty to some extent when breastfeeding. While, 36.4 percent of mothers reported that they face no difficulty when breastfeeding. A number of studies reveal the prevalence of PPD is at high risk with decreasing breastfeeding (Stuebe, et al., 2012; Nishioka et al., 2012). In addition, women with difficulties in breastfeeding may increase the risks of depressive symptoms, should be screened for PPD.

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4.3.1 Summary: Information on last pregnancy/delivery (12-month baby) The phenomenon of unplanned pregnancies exists due to lack of knowledge and financial restraint; husband and family have religious objection and behavior regards family planning methods; and availability, inaccessibility, and poor quality of family planning services. The distribution of the mothers, according to the planned birth of baby shows that more than half percent of the respondent’s baby births was unplanned. The most of the pregnancy related complications of the respondents were: anemia (59.5 percent), vomiting/nausea (48.3 percent), abdominal pain (42.8 percent), high blood pressure (35.0 percent), stomach ache (33.8 percent), headache (33.3 percent), low blood pressure (27.5 percent), and body swelling and vaginal bleeding (19.0 percent). It can be expressed that these problems have the impact on maternal life, including low mood, stress, anxiety, hypertension and negative thinking. The study depicts that the majority 43.5 percent of pregnant women did visit private hospitals; 30.0 percent of them did visit a government hospital; and 18.0 percent of them did not visit any health care center for checkups during last pregnancy. The majority 34.8 percent of the respondents delivered their last baby at home, 32.0 percent at private hospitals or clinic and 31.5 percent in government hospitals. The majority of the deliveries at home depicts the women’s miserable and helpless condition. Childbirth at home can cause a number of complications for both maternal and infant. It may raise the chances of postpartum hemorrhage, stillbirth, infant’s physical disability and maternal or infant death. The distribution of the women according to their complications during delivery were found as water bag broke (37.5 percent), postpartum hemorrhage (28.8 percent), difficult labor (23.3 percent), high blood pressure (17 percent), early childbirth (12.8 percent), and low blood pressure (12.3 percent). The study depicts that child health complications during pregnancy and in neonatal period have a negative effect on psychological and physical health status of mothers. The most reported problems during pregnancy were low weight birth (30.5 percent), short breath (21.0 percent), premature (13.3 percent), water shortage (10.8 percent), heartbeat problem (8.3 percent), and the baby’s movements stopped at the time of birth (7.8 percent). The problems of neonatal period were a problem in sucking (28.3 percent), pale skin (25.5 percent), stomach ache (20.8), hand and feet cold (9.8 percent), and congenital problem (6.0 percent).

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4.4 Attitude and Factors of Postpartum Depression Table: 19 Distribution of the respondents according to their knowledge and history of antenatal (AND) and postpartum depression (PPD) n = 400 Yes No Statements Freq. % Freq. %

Knowledge about PPD 187 46.8 213 53.2 AND of the respondents 167 41.8 233 58.2 Family member’s AND 137 34.2 263 65.8 PPD of the respondents at previous delivery 146 36.5 254 63.5 Family member’s PPD 138 34.5 262 65.5

The above table indicates the knowledge and previous history of antenatal and postpartum depression. Knowledge about PPD: The table shows that the majority 53.2 percent of the respondents had not knowledge about PPD. A mother has low self-efficacy and self- esteem due to the high level of illiteracy and ignorance. Bandura (1988) defined ‘self- efficacy’ as one’s own belief and ability to attain a specific task in a given situation. Mother’s low self efficacy changed their health behavior that plays an important role in developing PPD. AND of the respondents: The majority 58.2 percent of the respondents were on the view that they have not previous history of AND. Family member’s AND: The majority 65.8 percent of the respondents viewed that their family member have not previous history of AND. PPD of the respondents at previous delivery: Most, 63.5 percent of the respondents were reported that they have not previous history of PPD. Family member’s PPD: The majority 65.5 percent of the respondents viewed that they have not previous history of AND.

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Table: 20 Distribution of the respondents and their husband’s feelings about pregnancy and after birth of baby n = 400 Happy Normal Unhappy Statements Freq. % Freq. % Freq. % Respondent’s feelings about 288 72.0 61 15.2 51 12.8 pregnancy Husband’s feelings about 305 76.2 75 18.8 20 5.0 pregnancy Respondent’s feelings after 326 81.5 51 12.7 23 5.8 birth of baby Husband’s feelings after birth 316 79.0 66 16.5 18 4.5 of baby

Respondent’s feelings about pregnancy: Feelings about pregnancy played a crucial role in the life of mothers, may have a positive or negative effect on both mother and infant health status. Negative feelings towards pregnancy can contribute the mother’s emotional and psychological behavior. They are more likely at the risks of anxiety, stress and low mood. These factors put the women at the higher risks of developing PPD. The table shows that 72.0 percent of the respondents were happy about their last pregnancy, 15.2 percent have normal feelings about pregnancy and 12.8 percent of them were unhappy. The reason behind unhappiness about pregnancy was the poor health status of mothers and the numbers of children. Women viewed that they were fearful due to the previous history of abortions, pregnancy complications and dead births. Some of them felt anxiety because they become pregnant at the first time; so they did not handle their pregnancy in a better way. Husband’s feelings about pregnancy: Results depict that 76.2 percent of the respondent’s husbands were happy to know about pregnancy, 18.8 percent have normal feelings and 5.0 percent were unhappy. Respondent’s feelings after birth of baby: Results reveal that 81.5 percent of respondents were happy after the birth of a baby, 12.7 percent had normal feelings and 5.8 percent were unhappy. The study indicates that respondents' feelings after birth of baby is changed, as 72.0 percent were happy about their pregnancy and 81.5 percent were happy after the birth of a baby. The reason behind this was they were worried about their previous history of pregnancy complications. This fear is ending up after childbearing. But, a sizeable proportion of mothers had normal feelings or they were unhappy. Mothers

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were of the view that birth of a baby girl is the main reason towards the negative feelings after childbearing. Husband’s feelings after birth of baby: The majority 79.0 percent of the respondent’s husbands were happy after the birth of a baby, 16.5 percent had normal feelings, while, 4.5 were unhappy.

Table: 21 Distribution of the respondents according to the pressure to have a baby boy n = 400 Pressure to have a baby Frequency Percentage boy Yes 192 48.0 No 208 52.0 If yes, who pressurized Husband 19 9.9 Mother-in-law 73 38.0 Both of them 100 52.1

Pressure to have a baby boy: The desire for the birth of a baby boy have a negative effect on the mothers. In Pakistan, husband, mother-in-law and other family members considered that only the women are responsible for the birth of a baby girl. So mothers are pressurized for giving a birth of a baby boy. Due to the unawareness and ignorance they did not know that who is responsible for the birth of a baby boy. It can be said that they are Muslims, but not believe in the creator (Allah).“O mankind! We have created you from a male and a female, and made you into nations and tribes, that you may know one another. Verily, the most honorable of you with God is the one who is the most God-fearing.” (Quran-Al-Hujurat, 49:13). The table shows that 48.0 percent of the respondents faced the pressure to have a baby boy. Gender of the newborn is a central issue for the mothers with relations to PPD. In traditional Eastern societies, it’s a debatable topic, women giving birth to a baby girl are more prone to PPD (Xie et al., 2007; Abiodunet, 2006). In Pakistan, particularly in rural areas, mothers are at higher risks of PPD because they are not supported by their husbands. The attitude of their husband and in-laws is changed when they knew she is going to deliver a baby girl. In contrast to eastern societies, the western parents have a mixed gender preference (Mills & Begall 2010; de Tychey, 2008).

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If yes, who pressurized: It is stated that more than half 52.1 percent of respondent’s husband and mother-in-law pressurized them to have a baby boy; 38.0 percent and 9.9 percent of them had a pressure of the birth of a baby boy by mother-in-law and husband, respectively. If add up the findings, almost 62 percent of the respondent’s husbands and 90.1 percent of respondent’s mother-in law had the desire and pressurized them to have a baby boy.

Table: 22 Distribution of the respondents according to their opinion about son preference n = 400 Yes No Statements Freq. % Freq. %

Family feel proud within relatives 247 61.8 153 38.2 The boy is the earning hand 224 56.0 176 44.0 Mother will be secured 195 48.8 205 51.2 Girls are only shame for them 135 33.8 265 66.2 Girls are burden for them 187 46.8 213 53.2

Respondent’s opinion about son preference: Son preference is a major form of gender discrimination; it is an attitude towards the belief that a boy has higher value than a girl. The desire for the birth of a son is common in South Asian Region. The family feels proud within relatives and boys are source of earning of traditional families are the central points of son preference in Pakistan. As seen in the table, 61.8 percent and 56.0 percent of the respondents said that family feel proud within relatives and boy are responsible for earning, respectively. The study demonstrates that 48.8 percent of respondents said that they want a baby boy, because they will be secured in their in-laws. Respondents were told that a woman feel proud to have a number of sons in the family and she is secured in her in-laws when giving a birth of a baby boy. 33.8 and 46.8 percent of mothers said that the birth of a baby girl is a shame for them and burden for them, respectively. On that base, the girl child has an inadequate access to education, health and economic opportunities; even discriminate in providing food and other basic necessities. A girl child needs more nutritional food than a boy child, because of her complications and reproductive health. Son preference exists in many parts of the world, depends on the particular cultural patterns. A male child is considerably preferred because of economic

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contribution, continuation of the family line and support their parents in old ages (Abdelfattah, 2011). In contrast, a female child is seen as a financial burden for parents when get married in terms of dowry.

Table: 23: Distribution of the respondents according to the attitude of their husband, in-laws and doctors towards them n = 400 Good Normal Harsh Non-reactive Statements Freq. % Freq. % Freq. % Freq. %

Husband's attitude 294 73.5 72 18.0 34 8.5 0 0.0 Mother-in-law’s 184 46.0 125 31.2 68 17.0 23 5.8 attitude Other family members 209 52.2 147 36.8 30 7.5 14 3.5 Doctors/LHV/LHW 247 61.8 142 35.5 5 1.2 6 1.5

Table 23 indicates the attitude of the husband, mother-in-law, family members, doctors and LHV/LHW towards respondents. Husband's attitude towards respondents: Table shows that 73.5 percent of the respondents reported that their husband’s attitude was good with them, 18.0 percent of respondent’s husband had normal attitude and 8.5 percent had a harsh attitude with them. Mother-in-law’s attitude towards respondents: Table shows that 46.0 percent of mother-in-law attitude was good for them, 31.3 percent of respondent’s mother-in-law had normal attitude and 17.0 percent had a harsh attitude towards them. While, 5.8 percent of mother-in-law’s attitude was non-reactive with the respondents. Other family members’ attitude towards respondents: Table shows that 52.3 percent of family members’ attitude was good for them, 36.8 percent of respondent’s family members had normal attitude and 7.5 percent had a harsh attitude towards them. While, 3.5 percent of family members’ attitude was non-reactive with the respondents. Doctors/LHV/LHW’s attitude towards respondents: Table shows that 61.8 percent of doctors and LHW/LHV’ attitude were good for them, 35.5 percent had normal attitude and 1.3 percent had a harsh attitude towards them. While, 1.5 percent had a non-reactive attitude with the respondents. Oates et al. (2004) mentioned that the behavior of health care providers, unsympathetic maternity staff and less time to deal with maternal as a contributor to unhappiness was found to be in all Uk Asian groups and European centers. The good care by health care centers and physically well should be the contributor to

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happiness, but the study mentioned in its contrast that good care by health professionals, feeling physically well and satisfactory birth experience was not stated as contributing to happiness.

Table: 24 Distribution of the respondents according to their attitude towards mother life n = 400 Good Fair Poor Statements Freq. % Freq. % Freq. %

Life as a mother 174 43.5 176 44.0 50 12.5 Care for baby 127 31.8 189 47.2 84 21.0 Diet habit 123 30.8 156 39.0 121 30.2 Perform domestic work 140 35.0 203 50.8 57 14.2 Attachment with baby 158 39.5 205 51.3 37 9.2 Attachment with husband 147 36.8 182 45.5 71 17.7

Life as a mother: Childbirth is the most beautiful experience of a woman’s life. But in some cases, mothers sacrifice a lot to adapt motherhood, it is probably unhealthy for both maternal and infant. Mothers are insecure when the competition exists to compare the mother’s personal skills with other mothers of family or neighborhood. Table 24 shows that the majority 44.0 percent of the respondent’s life as a mother was fair, 43.5 percent of mother’s life was good and 12.5 percent of mother’s life was poor. Mothers were on the view that they are depressed when they didn’t fulfill the desire expectations of motherhood defined by the society. Theory of postpartum depression also supported that socio-cultural expectations of motherhood are related to a particular behavior. Postpartum depression may occur when there is a discrepancy between these expectations of motherhood and mother’s personal feelings and experiences (Beck, 2002). Care for baby: Mother’ nature is too caring for baby, it’s a God gifted. Mothers are unsure to care for their baby because they are expected to perform specific activities. Results show that majority 47.2 percent of respondents care their babies in fair means, 31.8 percent care their babies in a good way. While, 21.0 percent of respondents reported the poor care for their baby. Childcare anxiety occurs when mothers can’t care their babies in a better way leads to PPD (Beck, 2002).

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Diet habit: Diet intake depends on knowledge of nutrition and availability of resources. In Pakistan, the families with poor socioeconomic status are more vulnerable to care about diet and nutrition deficiencies. These are the major factors increase the risk of reproductive problems (miscarriage/abortion, preterm birth), lower productivity and maternal health status (Batool, 2010). Malnutrition reduces the learning abilities of females, they caught in a vicious circle of low mood, anxiety and stress. Findings show that the majority 39.0 percent of respondent’s diet habit was fair, 30.8 percent of respondent’s diet habit was good and 30.2 percent of respondent’s diet habit was poor. According to the results, almost 1/3 part of the sample had poor diet habits. Women expressed that they have inadequate access to better food because of the low level of family income. They can only take a meal (chappati/roti) twice a day hardly. Perform domestic work: It is stated that 35.0 percent of women were performed domestic work in a better way, 50.8 percent performed domestic work fairly and 14.2 percent performed work poorly. In rural areas of Pakistan, women are not only responsible to prepare food and look after their children; but, also look after their elders and involved in livestock and agricultural activities. The burden of work negatively affects not only the physical health of women, but also on psychological health. They are more prone to anxiety and stress when could not perform domestic work during pregnancy and after childbirth. Attachment with baby: Attachment with baby is defined as a special bond and an emotional relationship between mother and an infant expressed through gestures, movements and sounds to the emotional responses to the baby’s cues. Mother is considered the primary object of infant’s attachment, provides the affectionate and consistent care of a baby (Costello, 2016). The study reveals that 39.5 percent of respondents had good attachment with their baby, 51.3 percent of respondents had fair attachment with their baby and 9.2 percent of respondents had poor attachment with their baby. Attachment theory proposed that a strong emotional association between infant and mother is helpful to decrease the depression among mother (Whiffen and Susan, 1998). Attachment with husband: The secure marital relationship based on love, affection and respect. Anxiety about the relationships arise when they are avoiding each other (Berg, 2016). Results indicate that 36.8 percent of respondents had good attachment with their husbands, 45.5 percent had fair attachment with their husbands and 17.7 percent of respondents hd poor attachment with their husbands. Anxiety and stress among mothers arise when their attachment needs are not being met by their partner. The attachment

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theory explains that when the husband and wife are securely attached to another, obviously they will support to each other. Difficulties occur when intimate partner is avoiding to attach that leads to depression, specifically in the postpartum period (Whiffen and Susan, 1998).

Table: 25: Distribution of the respondents according to their experiences of social taboos n = 400 Yes No Statements Freq. % Freq. % Don't leave house during pregnancy at sunset 131 32.8 269 67.2 time Eat specific things during pregnancy 199 49.8 201 50.2 Detachment with that woman, who face abortion/miscarriage or death of infant within 229 57.2 171 42.8 forty days Negative and positive signs for birth of baby boy 231 57.8 169 42.2 and baby girl Eat butter in the last month of pregnancy 201 50.2 199 49.8 Stay home for forty days after baby's birth 202 50.5 198 49.5 Wrap newborn baby tightly 181 45.2 219 54.8 Don't give newborn cloths beyond forty days 214 53.5 186 46.5 Congratulations on just birth, have another 163 40.8 237 59.2 Baby is susceptible to black magic 296 74.0 104 26.0 Hair will begin falling, when baby started to talk 356 89.0 44 11.0

Social taboos: Taboo means “marked off” a customary prohibition to a particular person or to general use. Taboos are determined as an unthinkable action in certain societies. Traditional societies place the women in such conditions which create a contradiction to continue the normal routines of everyday life (Beck, 2002). A mother receives health care services from family during pregnancy and postpartum period rather than rely on health institutions. Culture influences the several aspects related to maternal life. Women required a specific behavior, attitude, habits and activities based on beliefs and customs. Society creates a complex relationship network around the mother and the newborn. Women are instructed about self care and newborn from diverse cultures. Postpartum is a period for women in which they have to follow specific rules for diet, hygiene, breastfeeding maintenance, sexual activity and care in order to avoid obtaining disease.

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Table 25 shows that 32.8 percent of the respondents said that they did not allow to go outside the home at sunset time during pregnancy. Traditional families believe that pregnant women are at higher risk of susceptible to supernatural things (sayya, jin). Almost half percent of women were experienced to eat specific things during pregnancy. For example, pregnant women are forced to eat “koila” for the white color of the baby; and eat butter (ghee) for a healthy baby. About 57.2 percent of women were not allowed to meet with that woman whose baby is expired during pregnancy or after birth. Even some of them reported that their mother-in-law didn’t allow them to eat or use such items gifted by certain women’s house. 57.8 percent of mothers viewed that all the negative signs (Nausea, ugly, faster heartbeat) mean it will be a girl and all the positive symbols (sweet tooth, beauty) point to a boy. OR look so huge! You have twins. Almost 50.5 percent of women were forced to eat butter (ghee) in the last month of pregnancy to increase the chances of normal delivery; and stay at home for forty days after the baby is born, maybe something bad happens. 45.2 percent of newborn babies were wrapped tightly to extend the child's arms and legs in length. 53.5 percent of mothers didn't keep newborn's clothes beyond forty days at home. It may bad luck and dangerous for their infant, should be given to others or bury. In other side, the remaining reported that they didn’t give to others. 40.8 percent experienced the greetings in the way of congratulations on just giving birth! Now quickly have another one. Either they have more than five or six children. Baby is also susceptible to black magic during the first 40 days, is a strong superstitious in Pakistan, should be cover newborn with cloth and putting iron near the baby. 74.0 percent of respondents put the iron (knife) and matches nearby the newborn or lock to his/her bed (caught/charpai). Mothers have a strong myth about this and we're very confident to put the iron nearby the newborn. They were of the view that there is no fear about the health complications of infant and effect of Jin (sayya). The most 89.0 percent of the mothers were reported that they hear about their hair will begin falling when baby starts talking. The women replied that this is reality and they experienced hair fall when their baby starts to talk. Hair falling may occur because of maternal health complications or weakness, but they relate it’s with baby’s begin to talk. Hanlon et al. (2009) concluded that the postpartum mothers and her newborn are more vulnerable to supernatural attack behind many of the caring ceremonies following childbirth. It is believed that the severe illness or death occurring in the postpartum period is due to the violation of postpartum taboos; or avoiding to perform prescribed practices

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exposing both mother and child to risks of spiritual attack (sayya). The woman and her newborn baby are considered to become victim to a different set of threats: possession, evil eye, spirit attack, affect by witchcraft or magic and expose to destructive sunrays (mitch) and draughts of air (nefas). Such beliefs entailed restrictions how a mother should behave, required to speak softly and walk slowly. She should use traditional medicines to protect her and reinforced to use excessive butter on her hair. All these practices and protective rituals are inforced by a special group of women in the postpartum period could be threat to mental health that increase the level of anxiety. Furthermore, the food and sleeping area of postpartum mothers would be separated from the rest of the family from the first day of childbirth.

Table: 26 Distribution of the respondents according to their knowledge and uses of family planning methods n = 400 Knowledge about family Frequency Percent planning methods Yes 242 60.5 No 158 39.5 If yes, main source of knowledge Husband 119 49.2 LHV / LHW 89 36.8 Family 17 7.0 Friends 12 5.0 Media 3 1.2 BHU / FPC 2 0.8 Total 242 100.0 Ever use one of these methods for birth control None 246 61.5 Condom 83 20.7 Withdraw 37 9.2 Pills / Injection 20 5.0 Female sterilization 7 1.8 IUD 7 1.8 Male sterilization 0 0.0

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If no, reason behind this No need yet 85 34.6 Husband dislikes 76 30.8 Fear of side effect 61 24.8 Family restrictions 15 6.1 Religious factor 9 3.7 Total 246 100.0

Knowledge and source of knowledge about family planning methods: The health status of Pakistani women can improve by reducing the number of children that a woman has. There is an intense need to check the gap between women's reproductive intentions and their behavior regarding family planning methods. It is very important for healthy mothers and their children, because a healthy mother is able to care for her children in a better way. The table shows that the majority 60.5 percent of women had the knowledge about family planning, but 39.5 percent had no information. The study suggested that improving the reproductive health of women should be priority of Pakistan and contraceptives is an essential part of it. Among the mothers who had the knowledge from different sources, 49.2 percent got the information from their husbands, 36.8 percent of them got the information from LHV/LHW. LHV/LHW was found to be the second highest source of information because family planning centers are established to provide awareness and services in rural areas of Pakistan. Remaining, 7.0, 5.0, 1.2 and 0.8 percent of the respondent’s main source of information was family, friends, media and BHU, respectively. Ever use of methods for birth control: Contraceptive prevalence rate (CPR) is 35.4 percent (est. 2012-2013) in Pakistan, which is considered to be lower than other South Asian countries (CIA World Fact Book, 2016). A number of causes such as lack of awareness, misconception of side effects, traditional beliefs and unavailability of services are the factors contributing to the low prevalence rate of contraceptive methods. Data shows that the majority 61.5 percent of respondents didn’t use any method of birth control. Among the users of birth control methods, 20.7 percent of the respondents used condom, which is the highest figure of birth control methods. 9.2 percent of respondents used the method of withdraw. While, 5.0, 1.8, 1.8 and 0 percent of respondents used pills/injection, female sterilization, IUD, and male sterilization, respectively. Practices of

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male sterilization are rare in rural Pakistan as the present study indicates. It has been reported that the uses of birth control methods have increased than the past situation. Now, the rural women are aware about the methods and its importance for better health status. Different campaigns are launched by government and NGOs, but most of the women reported that they could not avail due to the traditional and family restriction. Many factors such as history of abortion, short birth interval, prenatal mortality and non use of birth control methods are maternal risks leads to PPD. Furthermore, in developing countries, poor health of women is related to the socioeconomic status, women's education and empowerment. Reasons of not using: The majority 34.6 of the respondents reported that they did not use a birth control method because of no need yet. 30.8 percent of respondent’s husbands disliked to use any type of birth control methods. However, 24.8, 6.1, 3.7 percent of the respondents were not used due to fear of side effect, family restrictions and religious factor, respectively. Batool (2010) also pointed out in the same line, such as husband dislikes, fear of side effect, family restrictions and religious factor were the main causes behind the not using contraceptives.

Table: 27 Distribution of the respondents according to their usage of non-food items n = 400 To great extent To some extent Not at all Statements Freq. % Freq. % Freq. % Non-food items 159 39.8 154 38.5 87 21.7 (uncooked rice, gachi) Huka / Cigarette 4 1.0 18 4.5 378 94.5 Pan / Naswar 4 1.0 11 2.8 385 96.2 Ghutka 2 0.5 14 3.5 384 96.0 Sleeping pills 2 0.5 3 0.8 395 98.7 Heroin - - 1 0.3 399 99.7

The table shows that most of the respondents take non-food items such as gachi, ice and uncooked rice to a great extent (39.8 percent) and to a some extent (38.5 percent), even some of them take koila.

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Table: 28 Distribution of the respondents according to their husband’s violent attitude n = 400 To great extent To some extent Not at all Statements Freq. % Freq. % Freq. %

Abusing 62 15.5 93 23.2 245 61.3 Teasing / Taunting 71 17.7 170 42.5 159 39.8 Slapping 39 9.8 49 12.2 312 78.0 Beating 28 7.0 21 5.2 351 87.8

Husband’s violent attitude: The responsibility of a husband is not only to provide the basic facilities to his wife, but also be responsible to provide love, affection and care. The best husband is one who does not misuse of his authority and strength. Allah says: "O you who believe! You are forbidden to inherit women against their will, and you should not treat them with harshness, that you may take away part of the Mahr (dowry, bridal-money given by the husband to his wife at the time of marriage) you have given them, unless they commit open illegal sexual intercourse. “And reside with them respectably. If you hate them, it is possible that you hate a thing and Allah gets through it a big deal of goodness" (Al-Quran-Al-Nisa’ 4:19). Violence is not only involving physical harm or force, but also includes sexual violence, emotional violence, psychological violence, spiritual violence and verbal abuse. Domestic violence against women exists all over the world, but the situation is worse in developing countries. In Pakistan, gender base violence is committed due to devaluation of women’s life, defined activities and low social status. Abusing and teasing/taunting are to be considered as verbal violence. As table shown in the distribution of verbal violence, 15.5 percent of the respondents faced violence to a great extent in terms of abusing, 23.2 percent of their husbands used different abusive words to some extent and 61.3 percent never faced abusive words. In terms of teasing/taunting, 17.7 and 42.5 percent of women claimed to a great extent and to some extent, and 39.8 of them never faced taunting or teasing behavior of their husbands. In terms of physical violence, 9.8 percent of the respondent’s husband slapped them to a great extent and 12.2 percent of them to some extent. The majority of them, 78.0 percent never faced slaps. 7.0 percent of the respondents were beaten by their husbands to a great extent, 5.2 percent were beaten to some extent. Majority, 87.8 percent

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of women never faced beating. Husbands violence in the form of either physical or verbal has adverse effect on women psychological and physical health. The main reason of the abusive behavior of intimate partner was unemployment and drug addiction. 44.0 percent reported verbal or physical abuse. Among them, 81.0 percent were unemployed and 72.0 percent of the cases were drug users (Ghajati et al., 2015). A study conducted by Dennis & Simone (2013) in British Columbia, Canada. Women were screened for postpartum depressive symptoms to determine the contribution of intimate partner’ violence and substance use (personal or partner) by using the Edinburgh Postnatal Depression Scale (EPDS). The study found that women are more likely to develop the PPD who experience current or past interpersonal violence and personal or partner use of substance. From the sample, 26 percent were diagnosed of PPD, and 7 percent of intimate partner’ violence. Mothers who faced intimate partner violence also had a positive PPD (Kornfeld, et al., 2012). About 1/3 of the sample were teenagers. The evidence of the results showed that one out of four women had the symptoms of PPD. Among them, one out of fourteen were depressed due to partner violence. In addition, mothers who faced domestic violence were twice as likely to have PPD. Evidence supported that depressed mother has negative effects on children (Grens, 2012). Domestic violence during pregnancy is found as a strong contributory factor of postpartum depression in a sample of Chinese women (Zhang et al., 2011).

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Table: 29 Distribution of the respondents according to their stressful life events n = 400 Yes No Statements Freq. % Freq. %

Financial problems 221 55.2 179 44.8 Mother-in-law’ desire to be pregnant in the first 156 39.0 244 61.0 year of marriage Husband’ desire to be pregnant in the first year of 133 33.2 267 66.8 marriage In-laws home environment 131 32.8 269 67.2 Health problems 96 24.0 304 76.0 Change home 95 23.8 305 76.2 Death of any relatives 78 19.5 322 80.5 Relationship changing 69 17.2 331 82.8

Stressful life events: Depression is the most common psychological disorder during the postpartum period. The stressful life events have the potential to change the lifestyle of an individual, particularly of women during pregnancy. Pregnancy might be a stressful period for mothers, some of them can experience highly stressful event in that period, such as financial strain, death of a loved one or chronic health issues. All of these may contribute to the development of PPD. Data shows that the majority 55.2 percent of the participant’s stressful events were related to financial problems. With low levels of monthly family income, the women’s personal needs cannot be fulfilled. They have not proper nutritional food which required for their reproductive health. In the present study, other reported stressful life events included: mother-in-law had a desire to be pregnant in the first year of marriage (39.0 percent); husband had a desire to be pregnant in the first year of marriage (33.2 percent); in-laws home environment (32.8 percent); faced health problems (24.0 percent); change home (23.8 percent); death of any relative (19.5 percent) and relationship changing (17.5 percent). Another study concluded in the same line as the stressful life events during pregnancy contribute to develop PPD. The most common incidence was: changing home (32 percent), personal illness or someone who very closely (27.2 percent), financial problems as trouble in paying bills (23 percent), and death of a loved one (21.2 percent) (Qobadi et al., 2016). Mukherjee (2016) found that the majority 64 percent of the respondents were in low-stress class; and the prevalence of PPD occurs due to the stressful life events such as severe illness (77

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percent) and death of a family member or close relation (63 percent). There is a strong relationship between frequency and intensity of stressful life events and the occurrence of mood disorder. Evidence supported that stressful life events such as in-laws home environment, relationship changing and divorce showed the higher association with PPD (Jafarpour et al., 2007). Soumyadeep et al. (2017) found that approximately 10 to 20 percent of mothers suffer from PPD, and antenatal stressful life event was found to be the main predictors of PPD.

Table: 30 Distribution of the respondents according to their social support n = 400 To great extent To some extent Not at all Statements Freq. % Freq. % Freq. % Husband supports me a 146 36.5 196 49.0 58 14.5 lot Conflict with my 56 14.0 210 52.5 134 33.5 husband Feeling control by 64 16.0 212 53.0 124 31.0 husband Family is always there 74 18.5 246 61.5 80 20.0 for me Friends supported me 85 21.2 243 60.8 72 18.0 In-laws, mother-in-law 65 16.3 214 53.5 121 30.2 supported me

Social support: Social support is an effective aspect of maternal and child care. In rural areas of Pakistan, culture has adverse effect in all the relationships and interpersonal interactions. The role of husband, family and social structure are important for mother in the antenatal and postpartum period. Social support is also affected by the misconception of health care practices. A strong and supportive relationship is helpful to change the maternal depressive mood. The table depicts that almost half percent of the respondents reported that their husbands support them a lot to some extent; and 36.5 percent to a great extent. Almost 53 percent of the respondents said that there is a conflict with their husband and feelings control by their husbands to some extent. Almost 61.0 percent of the respondents had felt that family is always there for them and friends supporting them to some extent. Data shows that the majority (53.5 percent) of the women had the support of their mother-in-law/in-laws in care their children to some extent.

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Table: 31 Distribution of the respondents according to share their feelings when depressed n = 400 Share feelings to anyone Frequency Percent when depressed Husband 118 29.5 Mother 113 28.2 Sister 68 17.0 Mother-in-law 23 5.8 Friends 11 2.2 None 67 16.8 Feelings after share Relaxed 160 40.0 Normal 158 39.5 Depressed 15 3.8 Not applicable 67 16.7

Feeling’s shared: The table indicates that the most of the respondents, 29.5 percent had shared their feelings with husband. 28.2, 17.0, 5.8 and 2.7 percent of them had shared their feelings with mother, sister, mother-in-law and friends, respectively. While, 16.8 percent of them did not share their feelings to anyone when depressed. Feelings after share: Most (40.0 percent) of the participants felt relaxed after share their feelings. 39.5 percent of mothers remain normal after share their feelings. 3.8 percent of them remain depressed even they share their feelings.

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Table: 32 Distribution of the respondents according to their getting help when depressed during pre-post period n = 400 Getting help when Frequency Percent depressed Yes 34 8.5 No 366 91.5 If yes, where did visit Doctor 12 35.2 LHV / LHW 9 26.7 Peer 7 20.6 Traditional healer 4 11.7 Psychiatrist 2 5.8 Total 34 100.0

Getting help when depressed: The table emphasizes that the majority 91.5 percent of the respondents did not get help when depressed. While, a negligible proportion of the sample gets the help when depressed during pregnancy or after birth of a baby. It means that a small proportion of the participants had awareness and wants to keep in touch with the health care providers, both professionals or traditional practitioners. If yes, where did visit: Among the all who made the visit for a consult, the majority 35.2 percent of the respondents had visited doctors for treatment. 26.7, 20.6, 11.7 and 5.8 percent of them getting help from LHV/LHW, peer, traditional healer and psychiatrist, respectively. Rural women have often lacked access to attain medical facilities and psychological treatment, increasing their risk of depressive symptoms leads to PPD. But these factors are important factors of access to both mother and child health care.

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4.4.1 Summary: Attitude and Factors of Postpartum Depression Gender of the newborn is a central issue for the mothers with relation to PPD. In Pakistan, the couple is expected to bear a son for the continuity of descent, because baby boy is to be considered as an asset of the family. The study found that almost half percent of the respondents were faced pressure for the birth of a baby boy, where, the most of the mothers were pressurized by their husband and mother-in-law. The distribution of the respondents according to their life as a mother indicates that the mother’s life was good, fair and poor with the percentages of 43.5, 44.0 and 12.5, respectively. The majority 47.3 percent of respondents care their babies in fair means and most, 90 percent of mothers had attachment in terms of either good or fair with their babies. Good and fair attachment with their husband was found to be 36.8 and 45.5 percent, respectively. Mothers viewed that they are depressed when they didn’t fulfill the desire expectations of motherhood defined by the society. Social taboos are also having a negative effect on the mother’s life, as they experienced these taboos happily or unhappily. Most of the mothers were experienced taboos such as compel to eat specific things during pregnancy; were not allowed to meet with that woman whose baby is expired during pregnancy or after birth; forced to eat butter (ghee) in the last month of pregnancy to increase the chances of normal delivery and stay at home for forty days after the baby is born; didn't keep newborn's clothes beyond forty days; put the iron (knife) and matches nearby the newborn or lock to his/her bed (caught/charpai); hear about their hair will begin falling when baby starts talking. Other’s attitude towards mothers illustrated that most of the husband’s and LHV/LHW’s attitude was good and mother-in-law’s attitude was harsh or normal. The distribution of verbal or physical violence found that mothers faced abusing (38.8 percent); teasing/taunting (40.3 percent), slapping (22.1 percent); and beating (12.3 percent). The most of the reported stressful life events were financial problems (55.3 percent); mother- in-law and husband had a desire to be pregnant in the first year of marriage (39.0 percent and 33.3 percent, respectively); in-laws home environment (32.8 percent); health problems (24.0 percent); change home (23.8 percent); death of love on (19.5 percent) and relationship changing (17.5 percent). The study analyzed that almost 86 percent of the respondents had a support of their husband to a some or great extent; almost 53 percent had a conflict with their husband or husband control their feelings; almost 61.0 percent felt that family and friends had always supported them to some extent; and 53.5 percent had a support of their mother-in-law/in-laws in the care of their children to some extent.

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4.5 Psychological and physical problems Table: 33 Distribution of the respondents according to their problems experienced before marriage n = 400 To a great extent To some extent Not at all Statements Freq. % Freq. % Freq. %

Headache 47 11.8 59 14.8 294 73.5 Stomach ache 24 6.0 48 12.0 328 82.0 Blood pressure 18 4.5 18 4.5 364 91.0 Sleeping disorder 4 1.0 14 3.5 382 95.5 Eating disorder 5 1.3 27 6.8 368 92.0 Anxiety 15 3.8 52 13.0 333 83.2

Issues before marriage: Table 33 shows that 73.5 and 82.0 percent of the respondents had not headache and stomach ache at all before their marriage. The majority 91.0, 95.5 and 92.0 percent of the sample had not the problems of blood pressure, sleeping disorder and eating disorder. Also, the majority 83.2 percent of them had not felt anxiety before marriage.

Table: 34 Distribution of the respondent’s feelings and experiences during their pregnancy n = 400 To a great extent To some extent Not at all Statements Freq. % Freq. % Freq. %

Crying 29 7.2 107 26.8 264 66.0 Sleeping disorder 116 29.0 114 28.5 170 42.5 Eating disorder 69 17.3 178 44.5 153 38.2 Anxiety 216 54.0 99 24.8 85 21.2 Shame or guilt 32 8.0 35 8.8 333 83.2 Irritation 214 53.5 98 24.5 88 22.0 Feeling tired 174 43.5 160 40.0 66 16.5 Perform activity slowly 98 24.5 194 48.5 108 27.0 The future may desperate 69 17.3 109 27.2 222 55.5

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Feelings and experience during pregnancy: Data shows that 7.2 and 26.8 of the respondents had experienced of crying episode to a great extent and some extent during pregnancy. Sleeping and eating disorder are most common among women during pregnancy. The greater incidence of sleeping and eating disorders contribute the antenatal depression, may elevate the risks of PPD. Almost 58 percent of the respondents had experienced the sleeping disorder (29.0 percent to a great extent; 28.5 percent to some extent) and 61.0 percent of them had experienced the eating disorder (17.3 percent to a great extent; 44.5 percent to some extent) during pregnancy. While, 42.5 and 38.2 percent of them had not experienced the sleeping and eating disorder at all. The majority, 54.0 percent of the respondents had felt anxiety to a great extent; and 24.8 percent to some extent during pregnancy. The majority, 83.2 percent of the respondents did not feel shame or guilt when knew about their pregnancy. In this table, the majority, 53.5 and 43.5 percent of the respondents had felt irritation and tiredness to a great extent; and 24.5 and 40.0 percent to some extent during pregnancy. 24.5 and 48.5 percent of women were performed their domestic work slowly to a great and some extent. About 17. 3 and 27.2 percent of the sample showed that their future may desperately to a great and some extent. It may also occur due to the maternal pregnancy related complications and low level of social support. Mood disorder, anxiety and depression are common among pregnant women, such as 1 out of 5 and 1 out of 8 participants were faced high stress and emotional stress; might help to identify the risk of PPD. Furthermore, the better antenatal health care has a negative effect on PPD. PPD might be decreased with increasing self-efficacy and socioeconomic autonomy (Mukherjee, 2016).

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Table: 35 Distribution of the respondent according to their feelings and experiences within the first two weeks after delivery n = 400 To a great extent To some extent Not at all Statements Freq. % Freq. % Freq. % Crying 18 4.5 102 25.5 280 70.0 Sleeping disorder 65 16.2 159 39.8 176 44.0 Eating disorder 53 13.2 168 42.0 179 44.8 Anxiety 163 40.8 127 31.7 110 27.5 Irritation 147 36.8 141 35.2 112 28.0 Feeling tired 155 38.7 150 37.5 95 23.8 The future may desperate 42 10.5 113 28.2 245 61.3 Think about suicide 20 5.0 45 11.2 335 83.8

Feelings and experience within the first two weeks after delivery: Table 35 indicates the female’s feelings and experiences within the first two weeks after delivery. Data shows that 4.5 and 25.5 of the respondents had experienced of crying episode to a great and some extent. Sleeping and eating disorder are common among women either during pregnancy or after delivery. The continuity of sleeping and eating disorder may enlarge the risks of PPD. These are known to be the symptoms of PPD, if it has gradual incidence. The results highlight that almost 55.0 percent of the respondents had experienced the sleeping disorder (16.2 percent to a great extent; 39.8 percent to some extent) and an eating disorder (13.2 percent to a great extent; 42.0 percent to some extent) within the first two weeks after delivery. The majority, 40.8 percent of the respondents had felt anxiety to a great extent; and 31.7 percent to some extent within the first two weeks after childbirth. The majority, 36.8 and 38.7 percent of the respondents had felt irritation and tiredness to a great extent; and 35.2 and 37.5 percent to some extent within the first two weeks after childbirth. Negative thinking such as the future may desperate and think about suicide occurs due to anxiety and stress, may increase the risks of PPD among women. 10.5 and 28.2 percent of the sample thought that their future may desperately to a great extent and some extent. It may also occur due to the maternal health complications and low level of social support. Some of them thought about suicide when cannot compete with these

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issues. The present study depicts that 5.0 and 11.2 percent of the participants thought about suicisde to a great extent and some extent, respectively.

Table: 36 Distribution of the respondents according to their problems faced by them in the postpartum period n = 400 To a great extent To some extent Not at all Statements Freq. % Freq. % Freq. % Menstruation problem 65 16.2 111 27.8 224 56.0 Weight loss 44 11.0 44 11.0 312 78.0 Weight gain 69 17.3 50 12.5 281 70.2 Body image change 56 14.0 80 20.0 264 66.0 Loss of energy 98 24.5 152 38.0 150 37.5 Perform activity slowly 60 15.0 191 47.8 149 37.2 Marital life disturb 89 22.2 168 42.0 143 35.8

Problems in the postpartum period: Most of the health issues occur after a childbirth, such as weight gain/loss and menstruation problem. Data shows that 16.2 and 27.8 percent of the respondents had faced the menstruation problem to a great and some extent, and 56.0 of them had not faced the menstruation problem at all after the delivery of last childbirth. 22.0 percent of the mothers had lost their weight to a great and some extent with equal percentages; and 78.0 percent did not lose their weight. 17.3 and 12.5 percent of the participant’s weight is gained to a great and some extent, respectively. While, 70.2 percent of the respondent’s weight is not gained after the last baby birth. Almost 1/3 proportion of the sample’ body image changed either to a great extent (14.0 percent) and some extent (20.0 percent). Mothers are more prone to develop the anxiety and stress when their weight is gained or body image change. Pregnancy and childbirth have a negative effect on women’ life, they can not take proper food that is necessary for their reproductive process. Due to this, they lose their energy and cannot perform domestic work properly. Women feel more depression when cannot maintain the balance in daily routine activities during the postpartum period. Results explain that the majority, 47.8 and 38.0 percent of women performed activities slowly and loss their energy after delivery to some extent. Although, 24.5 and 15.0 percent of the participants were loss their energy and perform activities slowly to a great extent. Mothers reported that they are responsible to prepare food and care their children, husband and elder ones; even they did

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it’s hardly because of their weak health status. Their marital life also disturbs due to the cultural restrictions. Mother, she has most need of attention of her husband during pregnancy or after childbirth, but the traditional families did not allow the spouses (Sullivan, 1953). As the results show in this table, the majority 42.0 percent of the respondent’s marital life disturbed after delivery of last child to some extent and 22.2 percent to a great extent. Participants were of the view that not only the family restrictions create hurdles in their marital relations; but also, their self-emotional behavior creates the contradictions. In addition, maternal body, including the reproductive organs, hormone levels and uterus size proceed to a non-pregnant state. They are avoided to attach with their husband (Whiffen and Susan, 1998).

Table: 37 Distribution of the respondents according to their health status since the last two years n = 400 To a great extent To some extent Not at all Statements Freq. % Freq. % Freq. %

Fever 63 15.8 116 29.0 221 55.2 Cholera 41 10.2 75 18.8 284 71.0 Blood pressure 15 3.8 55 13.7 330 82.5 Chronic pain 110 27.5 60 15.0 230 57.5 Diarrhea 13 3.3 34 8.5 353 88.2 Diabetes 14 3.5 50 12.5 336 84.0 Anemia 79 19.8 136 34.0 185 46.2

Health status since the last two years: Women with poor health status are more prone to develop the PPD. The majority 55.2 percent of respondents had not fever since the last two years. Almost 15.8 and 29.0 percent of the sample had suffered from fever to a great and some extent respectively. 71.0 percent of mothers had not the problem of cholera, 10.3 and 18.8 percent of the women had the problem of cholera to a great and some extent. Blood pressure is another health issue affects the women’s life. It creates the hurdles in performing the daily routine activities. 82.5 percent of mothers had not the problem of blood pressure, while, 3.8 and 13.7 percent of the sample reported the blood pressure (high or low) to a great and some extent. In the present study, majority of the mothers had the problem of blood pressure (high/low) during pregnancy and in the

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postpartum period. It indicates that women are more likely to have the problem of blood pressure (high/low) before and after childbirth rather than to a normal routine life. Chronic pain is also common for women due to the pregnancy and childbirth complications. Data shows that 57.5 percent of participants were not suffering from chronic pain. 27.5 and 15.0 percent of respondents had chronic pain to a great and some extent. If add up the findings, almost 43 percent of the mothers suffered from chronic pain. The majority 88.2, 84.0, 71.3 percent of the respondents had not faced the health issue of diarrhea, diabetes respectively. Whereas, the majority 54 percent of them had faced the problem of anemia (to a great extent and some extent)

Table: 38 Distribution of the respondents according to the availability of health care facilities n = 400 To a great extent To some extent Not at all Statements Freq. % Freq. % Freq. %

Emergency aid available 35 8.8 106 26.5 259 64.7 Patients are admitted at 38 9.5 157 39.3 205 51.2 BHU Proper supply of 31 7.8 182 45.5 187 46.7 medicine Multivitamins are 34 8.5 187 46.8 179 44.7 provided Family planning services 98 24.5 157 39.3 145 36.2 are provided Diagnostic tests are 26 6.5 108 27.0 266 66.5 available and free Vaccination is provided 160 40.0 176 44.0 64 16.0 at the time Sanitation services are 13 3.3 153 38.2 234 58.5 available Privacy is maintained 15 3.8 123 30.7 262 65.5

Health care facilities: The data show that majority 64.7 percent of the respondent’s views were that the emergency aid is not available in their area. While, 8.8 and 26.5 percent of the sample have the facility of emergency aid to a great extent and some extent in their area. Almost half percent of participants have not the facility of basic health units, where the patients are admitted, but 9.5 and 39.3 percent have the facility of basic health units to a great extent and some extent. The majority, 46.7 percent of the mothers did not get the proper supply of medicine. Furthermore, 7.8 and 45.5 percent of women get the

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proper supply of medicine.The majority 46.8 percent of mothers reported that multivitamins are provided to some extent by the LHW/LHV during pregnancy and after childbirth. 8.5 percent of them receive to a great extent, while, multivitamins are not provided to 44.7 percent of the sample. Most 39.3 percent of the women reported that the family planning services are provided to some extent and 24.5 percent to a great extent. Family planning services are not provided to 36.2 percent of the participants. The results illustrate that diagnostic tests are not available and free to the majority 66.5 percent of the respondents, but 6.5 and 27.0 percent of the respondents reported that the diagnostic tests are available and free to a great and some extent in their own or nearby areas. About 44.0 and 40.0 percent of the sample reported that the vaccination is provided at a time in the BHU, dispensary and FMC to some and a great extent. 16.0 percent of respondents did not have the facility of vaccine. Sanitation services are not available in the BHU, dispensary and FMC to the majority of the respondents as 58.5 percent of the sample were responded. 38.2 percent have the facility of sanitation services to some extent. While a negligible proportion, 3.3 percent have the facility of sanitation services to a great extent. Privacy is also not maintained to the mothers, as the majority 65.5 percent of mothers were not satisfied at all about the privacy in the centers/hospitals. The staff and doctors did not care about the self-respect and self-efficacy of the mothers. 30.7 percent of the respondents were satisfied to some extent about the provided privacy from the center. While, a small proportion, 3.8 were satisfied to a great extent.

4.5.1 Summary: Psychological and Physical Problems The study identified that most of the respondents had experienced eating disorder (61%), sleeping disorder (58 percent) and crying episode (34 percent). The feelings of women during pregnancy were tired (83 percent), irritation (78 percent), and anxiety (79 percent). The majority of the respondents had experienced of sleeping and eating disorder (55 percent) and crying episode (30 percent). The study also narrated that most of the women felt tired (76 percent), irritation (72 percent) and anxiety (41 percent) within the first two weeks following childbirth. According to the results most of women experienced the problems of crying, sleeping or eating disorder; and felt irritation, anxiety and tiredness to a great or some extent during pregnancy and within the fifteen days after delivery. PPD occurs when these symptoms are severe and last for more than two weeks, it may occur any time within the first year of childbirth. Health issues in the postpartum period

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demonstrated that of most the mothers had faced menstruation problem, loss their energy, weight gain or loss (to a great and some extent).

Table: 39 Distribution of the respondents according to their behavior and healthy appearance n = 400 Behavior Frequency Percent

Good 192 48.0 Normal 158 39.5 Bad 50 12.5 Healthier appearance Good 110 27.5 Normal 209 52.2 Bad (pale) 81 20.3

Behavior and healthier appearance of the mothers were examined by the researcher’s self- observation. It was observed when the responses were collected from the mothers during field research. The study shows that almost half percent of the respondent’s behavior was good. 39.5 and 12.5 percent of mothers have a normal and bad behavior with the researcher. Almost half percent of the mother’s health was normal, 27.5 percent have good health and 20.3 percent of the respondent’s health was bad (pale).

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Table: 40 Distribution of the respondents according to the prevalence of PPD n = 400 Prevalence of PPD Frequency Percent

Not depressed 157 39.2 Moderately depressed 80 20.0 Severely depressed 163 40.8

Prevalence of PPD: Data shows that 40.8 percent of the women had severe depressive symptoms in the postpartum period. The depressive symptoms of mothers were screened by using the EPDS (Edinburgh Postnatal Depression Score). 20.0 percent of mothers had moderate depressive symptoms, while, 39.2 percent of them were not depressed in their postpartum period. Others found that the prevalence rate of PPD was 14.8 percent among women (Qobadi, 2016); and 54.9 percent of mothers had mild PPD and 42.1 percent had moderate PPD (Mazaheri et al., 2014). Several studies found that mothers may experience PPD (8 percent –15 percent of mothers experience) or can occur by 4–6 weeks after childbirth, if the baby blues (80 percent – 85 percent of mothers experience) continue for longer 14 days (Kathree & Petersen, 2012; Ginsburg et al., 2012; Haga et al., 2012; Logsdon, 2012; Wade et al., 2012; Appolonio & Fingerhut, 2008; Xie et al., 2009; Ugarriza et al., 2007).

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Chapter 5 BI-VARIATE ANALYSIS: Exploring Relations

Bivariate analysis is a statistical method used to explore the relationship between two variables in order to test the hypothesis of an association. The main purpose of the bivariate analysis is to define the nature of the problem; identify the type and direction of the relationship; determine the significance of the relationship; and identify the strength of the relationship. The relationship/association between the dependent variable (postpartum depression) and independent variables: socio-demographic variables (age and education of the respondents, age at marriage, family income, number of children and health problems); cultural variables (family type, knowledge about PPD, attitude towards health facilities, antenatal and postnatal services, social expectations and social taboos) were carried out. The relationship/association between the dependent variable (postpartum depression) and independent variables: psychological variables (interpersonal relationships, antenatal depression, stressful life events, social support and violence) and obstetric variables (type of delivery, number of pregnancies, abortions, live and dead births, pregnancy and labor complications, breastfeeding, unplanned/unwanted pregnancy, infant health problems and Pre-eclampsia (like high BP; proteinuria) was also carried out. The related tables of all these variables are given below in this chapter with test values (chi-square and gamma) and level of significance with interpretation.

5.1 Testing of Hypothesis: Exploring Relationship 5.1.1 Dependent or response variable Testing of hypothesis are developed to explore the influence/effects of independent variables (socio-demographic, cultural, psychological and obstetric) on the dependent variable (postpartum depression). Postpartum Depression Postpartum depression is taken as dependent variable and, is measured in the aspects of the prevalence of postpartum depression. Prevalence of postpartum depression among women is measured through EPDS, and results are categorized into three levels. • Not depressed • Moderately/minor depressed • Severely/major depressed

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5.2 Socio-demographic Variables Age and Postpartum Depression Hypothesis 1: Higher the age of the respondents, lower the prevalence of postpartum depression Table: 41 Association between age of the respondents and symptoms of postpartum depression Prevalence of PPD Age of the respondents Total 36 & its 15 - 20 21 – 25 26 - 30 31 - 35 above Not depressed 7 35 53 54 8 157 4.5% 22.3% 33.8% 34.4% 5.1% 100.0% Moderately 14 19 29 13 5 80 depressed 17.5% 23.8% 36.3% 16.3% 6.3% 100.0% Severely depressed 29 34 86 9 5 163 17.8% 20.9% 52.8% 5.5% 3.1% 100.0% 50 88 168 76 18 400 Total 12.5% 22.0% 42.0% 19.0% 4.5% 100.0% Chi-square: 58.149 Sig. Level: 0.000 Gamma: -0.314 Sig. Level: .000

This table indicates the relationship between age of the respondents and the prevalence of PPD. Chi-square value (58.149) shows a strong significant relationship (P=0.000) between the variables. The value of gamma (-0.314) indicates a strong negative relationship between both variables, as the mother’s ages increases the symptoms of depressive disorder in the postpartum period are decreasing. The result depicts that mothers of younger ages had significantly higher rates of depression than older mothers. The prevalence of PPD was significantly higher in women aged 26 to 30 years, aged 21 to 25 years and aged 15 to 20 years than those mothers who belong to the age category of 31 to 35 and 36 and it’s above. It is concluded that the depression rate were not higher among older women aged 31 years and it’s above. Negron et al. (2013) concluded that women aged 20 to 24 years experienced more PPD, as compared to women of 35 years or older. Depression can affect mothers of any age group, but the young mothers are more vulnerable of being depressed during the postpartum period (Silverman et al., 2017; Edwards et al., 2012).

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Education and Postpartum Depression Hypothesis 2: Higher the education of the respondents, lower the prevalence of postpartum depression; lowers the educational attainments, higher the prevalence of postpartum depression Education is a continual process of gaining knowledge or skills. Getting an education is a basic social right of an individual as a member of society. Education is beneficial for all and has an adverse positive effect in our life, in order to alleviate the most of the challenges. Nelson Mandela says, “Education is the most powerful weapon which one can use to change the world” (USAID, 2013). The World Bank (2011) stated that “for every 1 percent increase in the proportion of women in secondary education, a countries annual per capita income growth rate increased by 0.3 percent”. The associative factors of female education are included; health improvement, lower fertility, lower maternal and child mortality, participation in economic activities, maintain a domestic role and safety of younger from different social evils. Table: 42 Association between education of the respondents and prevalence of postpartum depression Prevalence of PPD Education of the respondents Total

Illiterate 1 – 5 6 – 10 11 & its above Not depressed 46 37 47 27 157 29.3% 23.6% 29.9% 17.2% 100.0% Moderately 31 23 18 8 80 depressed 38.8% 28.8% 22.5% 10.0% 100.0% Severely depressed 115 25 16 7 163 70.6% 15.3% 9.8% 4.3% 100.0% 192 85 81 42 400 Total 48.0% 21.3% 20.3% 10.5% 100.0% Chi-square: 64.273 Sig. Level: 0.000 Gamma: -0.496 Sig. Level: 0.000

Chi-square value (64.273) shows a highly significant association between education of the respondents and the prevalence of postpartum depression. The gamma value (-0.496) confirm a strong negative relationship between the variables. Data explained that 28.8 percent illiterate respondents had severe postpartum depression. As the educational level increased the prevalence of postpartum depression decreased. It means that women had lower symptoms of postpartum depression were holding more number of schoolings. The enrollment of girls in school is seen to be low due to cultural, economic and social

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constraints. In rural Pakistan, there are a number of reasons behind the low level of female education. Girls are required to maintain their domestic chores and look after their siblings and elder ones rather than to attain an education. In another way, parents didn’t allow their daughters to go outside the home due to their honor and safety. Cultural factors have led to the pressure to remain women uneducated, their ability to tackle for issues extremely affected them (Ronaq, 2014). Women throughout Pakistan face a number of challenges such as illiterate and unemployment, (McCarthy, 2011). In the South Asian region, younger women with low level of education and economic status have poor health status (WHO, 2014). Results demonstrated that as the educational level of women increases, the prevalence of PPD decrease; it means that the educated women has more knowledge about depressive symptoms of PPD. Theoretical model explained that women with a better understanding about their emotional distress, they can adopt preventive measures of depressive symptoms. But society places a woman in such specific condition which create a contradiction to continue self-efficacy (Beck, 2002). To attain self-efficacy is only possible when women achieve a higher level of education. As Fathi et al. (2017) found a strong relationship between self-efficacy and level of education. Whereas, uneducated women are known to be associated with a number of factors such as short birth interval, number of children, lack of nutritional and health awareness.

Family Income and Postpartum Depression Hypothesis 3: Higher the family income of the respondents, lower the prevalence of postpartum depression Family income regulates the status of an individual, which influences living style, education and health. Income is defined as the total earning/money received by an individual/individual from all resources, including their own activities. Rural family income is mainly derived from farm, livestock and non-farm resources. Whereas, the poverty is closely related to the land distribution, which is highly unequal and skewed. Most of the families depend on the agriculture sector, but they could not fulfill their basic needs due to lower productivity (Khan et al., 2011). Other contributory factors are unemployment, illiteracy and family size. Rural women tend to suffer more problems than men. Their low socioeconomic status contributes to poor health status.

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Table: 43 Association between family income of the respondents and prevalence of postpartum depression Prevalence of PPD Family income Total Up to 20000 20001 - 30000 30001 – 40001 or above 40000

Not depressed 80 14 19 44 157 51.0% 8.9% 12.1% 28.0% 100.0% Moderately 43 7 13 17 80 depressed 53.8% 8.8% 16.3% 21.3% 100.0% Severely depressed 105 35 12 11 163 64.4% 21.5% 7.4% 6.7% 100.0% 228 56 44 72 400 Total 57.0% 14.0% 11.0% 18.0% 100.0% Chi-square: 38.540 Sig. Level: 0.000 Gamma: -0.269 Sig. Level: 0.000

Chi-square value (38.540) shows a highly significant association between family income of the respondents and the prevalence of postpartum depression. The gamma value (- 0.269) indicates a strong negative relationship between the variables. It is viewed that as the family income increased the prevalence of postpartum depression is decreased; means women had lower symptoms of postpartum depression with higher monthly income. The study depicts that 26.2 percent of the respondents had severe postpartum depression who were from the lower socioeconomic background. Postpartum Depression Theory explained that women of low socioeconomic status are on the higher risks of PPD (Beck, 2002). Poor women are known to be associated with a number of factors such as inadequate diet both in quality and quantity, short birth interval, number of children, lack of nutritional and health awareness. All these factors elevate the risks of low mood, anxiety and stress among pregnant women, leads to the PPD. Also, the rural women have often lacked access to attain medical facilities and psychological treatment, increasing their risk of depressive symptoms in the postpartum period. PPD can affect women in any population, but low income and minority mothers face a number of barriers, that make them more vulnerable (Hansotte et al., 2017; Edwards et al., 2012). By another, limited social support, stressful life events and financial instability may increase the risks of higher prevalence of PPD (Maternal and Child Health Bureau, 2013; Pearlstein et al., 2009).

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Family members and Postpartum Depression Hypothesis 4: Higher the total number of family members of the respondents, higher the prevalence of postpartum depression Table: 44 Association between family members of the respondents and prevalence of postpartum depression Prevalence of PPD Number of family members Total > 3 4 – 5 6 – 7 8 – 9

Not depressed 8 48 35 25 41 5.1% 30.6% 22.3% 15.9% 26.1% Moderately 5 9 26 20 20 depressed 6.3% 11.3% 32.5% 25.0% 25.0% Severely depressed 13 19 36 35 60 8.0% 11.7% 22.1% 21.5% 36.8% 26 76 97 80 121 Total 6.5% 19.0% 24.3% 20.0% 30.3% Chi-square: 28.478 Sig. Level: 0.000 Gamma: 0.185 Sig. Level: 0.003

Chi-square value (28.478) shows a significant association (P = 0.000) between the variables. The value of gamma (0.185) indicates a positive relationship between the total number of family members and the prevalence of PPD of the respondents. It means that more the number of family members is a cause of severe PP. It is clearly identified that families with low income and number of members are massive deprived of food and education. Consequently, how they utilize their income on health. If add up the findings, almost half percent of the respondent’s family members consist of more than 8 members. It exemplifies the high ratio of family members in rural areas of Pakistan. Mother and infant needs more nutritional food than other family members, but mothers remain unhealthy because they could not maintain their diet. Most of the pregnancy and childbirth related complications occurred because of poor diet and a deficiency of iron and vitamins (Batool, 2010). The higher incidence of these complications raises the risks in the development of PPD.

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Health Problems Since the Last Two Years and Postpartum Depression Hypothesis 5: Higher the health problems of the respondents since the last two years, higher the prevalence of postpartum depression Health is defined by WHO, as “a state of complete physical, mental and social well- being” (WHO, 2005). Health is also defined as the absence of any disease or injury that allows an individual to cope with all requirements of daily life (Sartorius, 2006). In Pakistan, women’s health issues remain unnoticed with the other social and cultural responsibilities. Currently, women constitute about 51 percent of the total population of Pakistan; most of them resides in poor rural areas, where no basic health facilities are available. Women are four times as likely to suffer from anemia and malnutrition than men (Asian Development Bank, 2009). Additionally, women are at higher risks of communicable diseases due to poverty, unhygienic food, lack of awareness and education and access to good health facilities. Table: 45 Association between health problems of the respondents since the last two years and prevalence of postpartum depression Prevalence of PPD Health Problems Total Low Medium High Not depressed 111 37 9 157 70.7% 23.6% 5.7% 100.0% Moderately 39 31 10 80 depressed 48.8% 38.8% 12.5% 100.0% Severely depressed 80 50 33 163 49.1% 30.7% 20.2% 100.0% 230 118 52 400 Total 57.5% 29.5% 13.0% 100.0% Chi-square: 25.079 Sig. Level: 0.000 Gamma: 0.325 Sig. Level: 0.000

The value of chi-square (25.079) and gamma (0.325) shows a strong positive relationship between the health problems since the last two years and the prevalence of PPD among women. Women who suffer from different health problems to a great or some extent were more likely to be more depressed than those who have good health. The most reported diseases were chronic pain, fever, cholera and anemia among women since the last two years. With poor health status women felt more anxiety and stress throughout their life. The condition is most severe during pregnancy with the other pregnancy related complications that have a significant effect on their psychological health status. Mostly,

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low mood, anxiety, stress, depression and other mental illness are unaccounted for women. These are the risk factors to enhance the depression in the postpartum period of women. Additionally, the lower age at marriage, short birth intervals, untrained staff lead to complications during pregnancy and afterwards is the significant factors of morbidity and mortality among women. The main cause behind the poor health status of women is lack of awareness and education, poverty, patriarchal system and lack of health facilities in their own or nearby their areas (Batool, 2010). Inability to attain the provided health facilities also a strong indicator of health issues. Mothers felt more depression when the male dominant society did not allow them to attain medical help during pregnancy and the postpartum period. In other side, some of them refused to visit to male physician, where the female doctors remain deficient. The study mentioned that respiratory problem, tuberculosis, anemia, hepatitis, chronic illness, diabetes and hypertension are the most common health issue among rural women that have led to a high rate of maternal mortality. The concept of deliveries at home is an important reason of health complications (Ronaq, 2014).

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5.3 Obstetric Variables Number of Pregnancy and Postpartum Depression Hypothesis 6: Higher the number of pregnancies of the respondents, higher the prevalence of postpartum depression Table: 46 Association between the number of pregnancies and the prevalence of postpartum depression Prevalence of PPD Number of pregnancies Total

None One - two Three - four Five or above Not depressed 30 65 24 38 157 19.1% 41.4% 15.3% 24.2% 100.0% Moderately 24 28 10 18 80 depressed 30.0% 35.0% 12.5% 22.5% 100.0% Severely depressed 26 46 39 52 163 16.0% 28.2% 23.9% 31.9% 100.0% 80 139 73 108 400 Total 20.0% 34.8% 18.3% 27.0% 100.0% Chi-square: 16.986 Sig. Level: 0.009 Gamma: 0.141 Sig. Level: 0.022

The value of chi-square (16.986) shows a relationship between the variables. The value of gamma (0.141) identifies a positive relationship between the number of pregnancy and prevalence of PPD among women. Results of chi-square and gamma indicates that those women who have number of pregnancies are more likely to develop the PPD than those who have less number of pregnancies. Most of the maternity issues are related to the pregnancy complications, miscarriage, abortion or dead births. Multiple pregnancies and complications are more prone to experience the problems of abortion, hemorrhage, difficulty in breastfeeding or still births. In addition, the percentage is even higher for those mothers who have inadequate support in caring for the baby. Theory supported that these are the strongest predictive factors that place a mother on higher risks of stress, anxiety and depression in both the antenatal and postpartum period (Beck, 2002). Pregnant women are expected to be a happy time following of their childbirth, but most of them experienced low mood, sadness, anxiety and severe mood swings afterward a childbirth (PubMed Health, 2016).

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Number of Abortions and Postpartum Depression Hypothesis 7: Higher the number of abortions of the respondents, higher the prevalence of postpartum depression An abortion is a process of ending a pregnancy by taking medication or a minor surgical procedure. Almost one in three women has an abortion in their lifetime. In Pakistan, the decline in birth rate is slower than in other Asian countries. The prevalence of contraceptive method is very low in Pakistan, estimated at 35 percent in 2012–2013 (The Times of Islamabad, 2016). It resulted in, the rates of unwanted/unintended pregnancy, induced abortion and unplanned births are very high, specifically in rural areas. The provision of family planning methods is critical, it enables women to have a number of children more than they desire. To save the life of a woman and to assist her essential treatment, abortion is legally allowed in early pregnancy in Pakistan. Given a lack of knowledge, most of the women has an experienced of unsafe abortion. An unsafe abortion has led to a high rate of complications such as excess bleeding, anemia, reproductive issues and maternal deaths (Batool, 2010). Table: 47 Association between number of abortions of the respondents and prevalence of postpartum depression Prevalence of PPD Number of abortions None One Two or above Total Not depressed 118 32 7 157 75.2% 20.4% 4.5% 100.0% Moderately 61 14 5 80 depressed 76.3% 17.5% 6.3% 100.0% Severely depressed 102 38 23 163 62.6% 23.3% 14.1% 100.0% 281 84 35 400 Total 70.3% 21.0% 8.8% 100.0% Chi-square: 12.454 Sig. Level: 0.014 Gamma: 0.238 Sig. Level: 0.005

The relationship between abortion and PPD is explored. Value of chi-square (12.454) shows a relationship at the 1 percent level of significance. The value of gamma (0.238) indicates a strong positive relationship between the number of abortions and prevalence of PPD of the respondents. The results found that the symptoms of PPD were higher for those women who faced abortions. In Pakistan, the procedure of safe abortion is limited and access to adequate services is problematic, and often a cause of stress, anxiety for

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women. Most of rural women are compelling to choose traditional methods or visit to Dai (TBA).

Planned Birth of a Baby and Postpartum Depression Hypothesis 8: An association between planned birth of a baby of the respondents and prevalence of postpartum depression In Pakistan, the decline in fertility rate is seen to be slow as compared with other South Asian countries. The trend of decrease in fertility rate has been slow, as the total fertility rate declined from 6.0 children per women in the 1980s to 3.8 in 2010-2012 (Sathar, et al., 2014; NIPS & ICF International, 2013). The high level of unintended pregnancies and less contraceptive use are the indicators to induce high fertility rate in Pakistan. It may increase the incidence of low mood, anxiety and stress during pregnancy. Unintended pregnancy or unplanned birth of a baby has an adverse effect on maternal psychological and physical health, increased the risks of PPD. Table: 48 Association between planned birth of a baby of the respondents and prevalence of postpartum depression Prevalence of PPD Planned birth of baby Total Yes No Not depressed 92 65 157 58.6% 41.4% 100.0% Moderately 53 27 80 depressed 66.3% 33.8% 100.0% Severely depressed 53 110 163 32.5% 67.5% 100.0% 198 202 400 Total 49.5% 50.5% 100.0% Chi-square: 32.989 Sig. Level: 0.000 Gamma: 0.378 Sig. Level: 0.000

The study identified a strong relationship between the unplanned birth of a baby and the incidence of PPD (chi square, 32.989). The value of gamma (0.378) concluded that PPD is more likely to develop among mothers with unplanned and unwanted births than among mothers with intended births. Nakku et al. (2006) has generally found the association between unplanned pregnancies and PPD, as women had a higher likelihood of PPD who experienced unplanned pregnancies. In contradiction with the present study, Abbasi et al. (2013) concluded that pregnancy related depression was found to be the

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strongest predictor of PPD rather than unplanned pregnancy. The significancy of the independent and dependent variable is also supported by the theoretical perspective. As Beck (2002) in the postpartum depression theory analyzed that the symptoms of PPD among mothers may occur due to unplanned/unintended pregnancies.

Pregnancy Complications and Postpartum Depression Hypothesis 9: Higher the pregnancy complications of the respondents, higher the prevalence of postpartum depression Pregnant women are more prone to complications or suffering from any illness which has an adverse effect on childbirth. Most of the problems exist because of lack of knowledge or attitude and practices regarding obstetric health care. The low quality of antenatal and postnatal care is another strong predictor of poor health status of women. The pregnancy related complications are including unwanted pregnancy, frequent or high-risk pregnancies, unsafe abortion, injuries due to abortion and lack of access to family planning services. All these complications not only have the effects on mother’s physical health, but also generate the psychological issues. Table: 49 Association between pregnancy complications of the respondents and prevalence of postpartum depression Prevalence of PPD Pregnancy complications Total Low Medium High Not depressed 69 64 24 157 43.9% 40.8% 15.3% 100.0% Moderately 16 53 11 80 depressed 20.0% 66.3% 13.8% 100.0% Severely depressed 30 98 35 163 18.4% 60.1% 21.5% 100.0% Total 115 215 70 400 28.8% 53.8% 17.5% 100.0% Chi-square: 31.848 Sig. Level: 0.000 Gamma: 0.316 Sig. Level: 0.000

The value of chi-square (31.848) and gamma (0.316) shows a strong and positive association between the complications during pregnancy and the prevalence of PPD of the respondents. It is evident from the results that women who faced pregnancy related complications were more likely to be depressed in the postpartum period than those who did not face. It indicates high and medium complications during pregnancy caused severe

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or moderate PPD among women. In the present study, the univariate analysis found the most common pregnancy related complications such as anemia (59.5 percent); vomiting/nausea (48.2 percent); abdominal pain (42.8 percent); high blood pressure (35.0 percent); stomachache (33.8 percent); headache (33.2 percent); low blood pressure (27.5 percent); and body swelling and vaginal bleeding (19.0 percent). Pregnancy related complications have the impact on maternal life, such as stress, anxiety, hypertension and negative thinking are the psychological complications may occur during pregnancy, which ultimately increase the risks of PPD (Field, 2017). Mothers are vulnerable to develop the depression during the postpartum period due to the hormonal changes of pregnancy, even mothers have not a previous history of depression (O’Hara, 2009). Sundaram et al. (2014) analyzed the PPD symptoms and PPD diagnosis by measuring a number of variables such as antenatal and postpartum morbidity, socio-demographic variables and birth outcomes. A car accident, kidney/bladder infection, preterm labor, nausea, vaginal bleeding and being on bed rest were associated with PPD symptoms.

Delivery Complications and Postpartum Depression Hypothesis 10: Higher the complications of the respondents during delivery, higher the prevalence of postpartum depression The combinations of medical and social factors are complex in determining the maternal mortality. Social, economic and cultural factors play a vital role in maternal mortality than the medical ones. Mothers who lived in rural areas are more prone to face these problems as compared to women who lived in urban areas due to inadequate health facilities. The most serious health problem for women are major complications during pregnancy and delivery which caused millions of deaths every year. Pakistan’s rank is the third highest in the world with the number of maternal deaths; and the condition is worse in rural areas due to lack of resources even for those who want to seek treatment (Ronaq, 2014).

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Table: 50 Association between complications of the respondents during delivery and prevalence of postpartum depression Prevalence of PPD Complications during delivery Total Low Medium High Not depressed 99 46 12 157 63.1% 29.3% 7.6% 100.0% Moderately 46 26 8 80 depressed 57.5% 32.5% 10.0% 100.0% Severely depressed 65 82 16 163 39.9% 50.3% 9.8% 100.0% Total 210 154 36 400 52.5% 38.5% 9.0% 100.0% Chi-square: 19.293 Sig. Level: 0.001 Gamma: 0.286 Sig. Level: 0.000

This table indicates the relationship between the complications of the respondents during delivery and the prevalence of PPD. Chi-square value (19.293) shows a significant relationship (P=0.001) and the value of gamma (0.286) specify a positive association between the both variables. It indicates high and medium complications during delivery caused severe or moderate PPD among women. According to the results, the most reported complications were: water bag broke (37.5 percent); postpartum hemorrhage (28.8 percent); difficult labor (23.2 percent); high blood pressure (17 percent); early childbirth (12.8 percent); low blood pressure (12.2 percent). The study stated that the postpartum hemorrhage, difficult labor, high or low blood pressure and early child birth are frequently associated with postpartum depression. These complications may consider a strong predictor of postpartum depression because a newly mother can’t enjoy the motherhood activities after experiencing such complications (Field, 2017; Mazaheri et al., 2014; Rouhi et al., 2012). Others mentioned that the postpartum depression is a clinical depression that occurs within the first year after childbirth (Dennis et al., 2012; O’Hara, 2009). Most of the respondents reported that they visited doctors during the antenatal care, but their deliveries are assisted by TBAs. The untrained TBAs are not able to identify the complications early during childbirth, which can cause maternal or infant death. The lack of proper psychological and physical services induce the depressive disorders among women, especially after delivery of a baby (Ronaq, 2014).

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Infant Health Problems and Postpartum Depression Hypothesis 11: Higher the infant health problems during pregnancy, including late neonatal care of the respondents, higher the prevalence of postpartum depression The infant morbidity and mortality rate are the most complex indicator of societal health and well-being. As a general rule and mother health status/complications have an adverse effect on children’s health. In another way, child health complications directly affect the mother's psychological health status. In developing countries, the incidence of anemia and folic and iron deficiency is present in most of the women that are transferred to children, which ultimately caused of health complications (Batool, 2010). It resulted in, the most frequent infant health complications are fever, pale skin and stomachache. Table: 51: Association between infant health problems during pregnancy, including late neonatal care of the respondents and prevalence of postpartum depression Prevalence of PPD Child Health Complications Total Low Medium High Not depressed 99 33 25 157 63.1% 21.0% 15.9% 100.0% Moderately 34 29 17 80 depressed 42.5% 36.3% 21.3% 100.0% Severely depressed 73 56 34 163 44.8% 34.4% 20.9% 100.0% Total 206 118 76 400 51.5% 29.5% 19.0% 100.0% Chi-square: 14.415 Sig. Level: 0.006 Gamma: 0.206 Sig. Level: 0.004

The value of chi-square (14.415) shows a relationship between the variables. Gamma (0.206) indicates a positive relationship between the infant health problems and the prevalence of maternal’ PPD. It depicts that mothers were more depressed in their postpartum period whose infant raise with health complications. It means the chances of postpartum depression are more likely to high with poorer health status of the baby (during pregnancy or late neonatal period). The reported problems during pregnancy were low birth weight, short breath, premature birth, water shortage, heartbeat problem, and the baby’s movements stopped at the time of birth. The problems of neonatal period were a problem in sucking, pale skin, stomachache, hand and feet cold, and congenital problem.

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PPD has a negative effect on the mother infant relationship and maternal role in the early postpartum period (Stapleton et al., 2012; Leahy-Warren et al., 2011). Theory explained that child care anxiety occurs due to the poor health status of infant (Beck, 2002). Interpersonal theory supported that the condition is worse when women attain insufficient support in caring for their children (Sullivan, 1953). Not only the infant health complications caused PPD among women, the study found the impact of PPD on infant (physical health, sleeping hours and weight loss) and well-being. Gress-Smith et al. (2012) concluded that mothers with higher depressive symptoms gained low birth weight babies. Postpartum support may contribute to improving maternal and infant well-being by helping women transition into motherhood (Stapleton et al., 2012).

5.4 Cultural Variables Family Type and Postpartum Depression Hypothesis 12: An association between family type and prevalence of postpartum depression Table: 52 Association between family type and prevalence of postpartum depression Prevalence of PPD Family type Total Nuclear Joint Extended Not depressed 81 71 5 157 51.6% 45.2% 3.2% 100.0% Moderately 25 50 5 80 depressed 31.3% 62.5% 6.3% 100.0% Severely depressed 44 111 8 163 27.0% 68.1% 4.9% 100.0% 150 232 18 400 Total 37.5% 58.0% 4.5% 100.0% Chi-square: 22.718 Sig. Level: 0.000 Gamma: 0.342 Sig. Level: 0.000

This table indicates the relationship between respondent’s family type and the prevalence of postpartum depression. The value of chi-square (22.718) shows a significant association (P = 0.000) and gamma value (0.342) confirms a strong positive relationship between respondent’s family type and PPD. Respondents who lived in a joint or extended family system were on the higher risks of developing PPD than those who lived in a nuclear family system. In joint family system, mother-in-law plays an important role in mother’s personal life experiences and daily routine activities. Mothers can’t take diet

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without the permission of their mother-in-law or elder one, even can’t care their baby. Furthermore, the husband shows emotional distress for their wife due to family pressure. All these factors are highly significant with low mood, mood swings, sadness and anxiety, which may highlight as a strong predictor of PPD. A factor that has a more important role to predict PPD is the one that extended family system (Abdollahi et al., 2014). Another Rahman et al. (2003) stated that mothers living in nuclear families have lower symptoms of PPD as compared to those who lived in extended families. When we talk about domestic work, the variation in responses is based on the local nature of women’s work and family type. In the UK Asian groups, women felt unhappy within an extended family system having too much burden of domestic work. Also, in Uganda, they felt unhappy because of heavy physical labor, and felt happy when get support. Furthermore, they felt happy when get relief from this burden (Oates et al., 2004).

Sex of Baby and Postpartum Depression Hypothesis 13: An association between sex of baby and prevalence of postpartum depression Table: 53 An association between sex of baby and prevalence of postpartum depression Prevalence of PPD Sex of baby Total Boy Girl Not depressed 110 47 157 70.1% 29.9% 100.0% Moderately 38 42 80 depressed 47.5% 52.5% 100.0% Severely depressed 70 93 163 42.9% 57.1% 100.0% 218 182 400 Total 54.5% 45.5% 100.0% Chi-square: 25.694 Sig. Level: 0.000 Gamma: 0.393 Sig. Level: 0.000

The value of chi-square (25.694) shows a significant association (P = 0.000) between the variables, and the gamma value (0.393) proves a strong positive relationship between baby girl and PPD. It is concluded that mothers were on the higher risks of depressive disorders in their postpartum period who delivered a baby girl. Women who gave birth to a baby girl are more likely to develop PPD, has an adverse effect on mother child

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interaction (de Tychey, et al., 2008). Theoretical model suggested that the undesired sex of a baby has a negative effect on attachment patterns of mother and infant in relation to their emotional association (Whiffen and Susan, 1998).

Pressure to Bear Baby Boy and Postpartum Depression Hypothesis 14: An association between pressure to bear baby boy and prevalence of postpartum depression The gender of a newly born baby has an impact on the quality of life of the mother such as mental health, social functioning, emotional role and general health. In most of cases, rural families have certain expectations to deliver a baby boy imposed by cultural and social beliefs. Women feel anxiety, stress during their pregnancy because of prolonged pressure for a birth of a baby boy. Table: 54 Association between pressure to bear baby boy and prevalence of postpartum depression Prevalence of PPD Pressure for birth of baby boy Total Yes No Not depressed 52 105 157 33.1% 66.9% 100.0% Moderately 33 47 80 depressed 41.3% 58.8% 100.0% Severely depressed 107 56 163 65.6% 34.4% 100.0% 192 208 400 Total 48.0% 52.0% 100.0% Chi-square: 35.716 Sig. Level: 0.000 Gamma: -0.465 Sig. Level: 0.000

The value of chi-square (35.716) and gamma statistics (0.465) confirmed the existence of and positive relationship between the predicting and response variable. The association demonstrates that those women who pressurized to bear a baby boy were more likely to be more depressed in the postpartum period than those who were not pressurized. In Pakistan, the mothers live in a specific culture, where the greater value is placed on son's birth. Women faced cultural pressure to bear a baby boy, but they are more likely to enhance the PPD, if they give birth to a baby girl. Theoretical perspective supported that lack of social, economic and emotional support make the mother more vulnerable (Beck, 2002; Sullivan, 1953). A number of studies mentioned that a baby’s sex played a role in a

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mother’s life, as well as play a significant role to increase or decrease the chances of PPD. In china, women are more prone to PPD who gave birth a baby girl (Babysugar, 2008). In contrast to other studies, the women of French community didn’t face the pressure to deliver a baby boy; and women who delivered a boy are more likely to develop PPD and reduce quality of life (de Tychey, et al., 2008).

Social Taboos and Postpartum Depression Hypothesis 15: An association between social taboos and prevalence of postpartum depression Taboos, is a practice prohibited or restricted by social or religious customs. A taboo is a form of negative norm means a strict prohibition of behavior or association with a particular person, things or place. There are some taboos in the world, about what a person eats or drink or perform some practices. For instance, society holds the pressure to perform these specified practices; and the violator of the taboo may exempt from the group or society. In Pakistan, conservative traditions of rural areas put the pressure on women to spend their lives in their homes to fulfill domestic chores. The extremely narrow approach to women and gender discrimination are the hurdles for women to get proper medication. Women are not allowed to visit a doctor for treatment or even by other women. Women are required to eat specific foods and there are restrictions to perform some practices during pregnancy and within the forty days subsequently childbirth. Table: 55 Association between Stereotype and prevalence of postpartum depression Prevalence of PPD Social taboos Total Low Medium High Not depressed 41 62 54 157 26.1% 39.5% 34.4% 100.0% Moderately 23 38 19 80 depressed 28.8% 47.5% 23.8% 100.0% Severely depressed 27 66 70 163 16.6% 40.5% 42.9% 100.0% Total 91 166 143 400 22.8% 41.5% 35.8% 100.0% Chi-square: 11.339 Sig. Level: 0.023 Gamma: 0.150 Sig. Level: 0.031

The value of chi-square (11.339) shows a relationship between independent and dependent variables at the significance level of (P=0.023). The value of gamma (0.150)

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found a positive relationship between social taboos and the probability of occurrence of PPD among respondents. It is analyzed that women who experience social taboos or compel to perform specific practices were more likely to develop PPD, than those who don’t have restrictions at all. In the postpartum period, mothers have to follow specific rules for food, hygiene, breastfeeding maintenance, sexual activity and care for newborn. Theories recommended that traditional families place the women in such conditions which create a contradiction to continue the normal routines of everyday life (Beck, 2002; Sullivan, 1953). In the present study, the most frequent restrictions were, women did not allow to go outside home at sunset during pregnancy or within the forty days of childbirth or meet a woman whose baby is expired during pregnancy. In addition, they are required to eat specific things; put an iron nearby newborn and didn't keep newborn's clothes beyond the forty days. Also, families have a strong myth when a baby starts talking the hair of mother will begin falling. All these practices can increase the level of anxiety and stress among mothers during pregnancy and in the postpartum period (Staneva et al., 2015). If a mother experiences such practices, she is known to be as a “perfect mother”; if avoided, she is known to be as a “deviant”. Though, this process didn’t match her personal feelings, and the feelings of distress hsa a negative effect on women (Hilten, 2015). Strict social taboos did not allow women to visit male doctors. Generally, husbands didn’t visit to doctors to discuss their wife’s health issues or family planning methods (McCarthy, 2011). Grigoriadis et al. (2009) concluded that appropriate postpartum practices and support are protective measures against PPD. The aim of traditional practices is to help mothers in the recovery during the confinement period (pregnancy and childbirth), in China, Japan, Malaysia and Taiwan, (Grigoriadis et al., 2009; Cheng et al., 2006). Although, the American postpartum mother left without support from their families, friends or professionals (Ugarriza et al., 2007).

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Health Facilities and Postpartum Depression Hypothesis 16: Higher the provision of health facilities to the respondents, lower the prevalence of postpartum depression The provision of health services is necessary to improve the health quality and well-being of women through the lifespan, especially in their antenatal and postpartum period. In the world, millions of women are dying every year because of unavailability and lack access to health facilities; and those which are available in low quality. The state’s responsibility is to provide medical facilities to both maternal and infant. Health care providers are trained to provide health facilities, according to the unique needs of patients. These services include gynecological care, family planning, pregnancy related care and prenatal care. In Pakistan, basic health units, dispensaries and family planning centers are established to assist the pregnancy related services and essential health screening, but these centers did not provide better medical services and a safe environment. Mothers are more vulnerable due to unhygienic conditions of these centers. Table: 56 Association between health facilities to the respondents and prevalence of postpartum depression Prevalence of PPD Health Facilities Total Low Medium High Not depressed 70 60 27 157 44.6% 38.2% 17.2% 100.0% Moderately 21 42 17 80 depressed 26.3% 52.5% 21.3% 100.0% Severely depressed 70 75 18 163 42.9% 46.0% 11.0% 100.0% Total 161 177 62 400 40.3% 44.3% 15.5% 100.0% Chi-square: 11.647 Sig. Level: 0.020 Gamma: -0.032 Sig. Level: 0.654 The value of chi-square (11.647) shows a relationship between the variables. The value of gamma (-0.032) indicates a negative relationship between the health facilities and the prevalence of PPD among women. The study depicts that woman who attains basic health facilities were less likely to be depressed in the postpartum period than those women who have not attained these facilities. Women feel anxiety and stress when they have not access to health care facilities. The condition is worse for those women who are not allowed by their husband or other family members for checkup during pregnancy. Due to diverse geographical, cultural and domestic unrest, many Pakistani women face hurdles in

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their access to health care. These problems are highly prevailed in rural areas, where the travel is often a major challenge in accessing health care. As a result, Pakistan’s rank is the third highest in the world with the number of maternal deaths (Ronaq, 2014; GHETS, 2013). Additionally, culturally driven gender discrimination creates the barriers to health care access for women.

5.5 Psychosocial Variables Attitude and Postpartum Depression Hypothesis 17: Association between attitude of husband, in-laws and doctors towards respondents and prevalence of postpartum depression Table: 57 Association between attitude of husband, in-laws and doctors towards respondents and prevalence of postpartum depression Prevalence of PPD Attitude Total Harsh Normal Good Not depressed 9 41 107 157 5.7% 26.1% 68.2% 100.0% Moderately 15 7 58 80 depressed 18.8% 8.8% 72.5% 100.0% Severely depressed 49 56 58 163 30.1% 34.4% 35.6% 100.0% Total 73 104 223 400 18.3% 26.0% 55.8% 100.0% Chi-square: 59.734 Sig. Level: 0.000 Gamma: -0.455 Sig. Level: 0.000

The value of chi-square (59.734) indicates the existence of an association between the attitude and the incidence of depression in the postpartum period; whereas, the gamma value (-0.455) verify a strong negative relationship. It means that those women who faced negative attitude were more likely to be more depressed in the postpartum period than those who faced positive attitude. The behavior of health care providers plays an important role to minimize or maximize the depressive symptoms. As the American mothers reported that they feel frustration and humiliation when interact with their physicians; and the Australian and Canadian mothers describe that their physicians are preferred to prescribe medications in order to deal with PPD rather than offering counseling (Logsdon et al., 2012; Sword et al., 2008).

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Violence and Postpartum Depression Hypothesis 18: Higher the violence of the respondents, higher the prevalence of postpartum depression Violence describes as a violation of human rights, such as physical, psychological, emotional, sexual and financial abuse, or a loss of dignity and respect. WHO (2002) defined violence as "the intentional use of physical force, power or threatened against oneself or another person, a group or community; have a higher cause of injury, death, psychological harm, or deprivation." Frustration, aggression, exposure to violent media and tends to see other’s action as hostile or violence (in the home, neighborhood or other people) are the causes of violent behavior of someone (American Psychological Association, 2017). Others, Carpenter and Nevin (2010) illustrated that poverty, low level of education and family instability are the social factors that may cause of anti-social behavior and violence. Table: 58 Association between violence and prevalence of postpartum depression Prevalence of PPD Violence Total Low Medium High Not depressed 115 36 6 157 73.2% 22.9% 3.8% 100.0% Moderately 54 19 7 80 depressed 67.5% 23.8% 8.8% 100.0% Severely depressed 61 44 58 163 37.4% 27.0% 35.6% 100.0% Total 230 99 71 400 57.5% 24.8% 17.8% 100.0% Chi-square: 70.177 Sig. Level: 0.000 Gamma: 0.538 Sig. Level: 0.000

The value of chi-square (70.177) shows a significant relationship (P=0.000) between the variables. The value of gamma (0.538) indicates a strong positive relationship between the violence and the prevalence of PPD of the respondents. It means that those women who faced violence either physical or psychological to a great or some extent were more likely to be more depressed during the postpartum period than those who didn’t face at all. Domestic violence is a common practice in Pakistan. Male dominant culture of society does not support women to raise their voice against it. Domestic violence is considered a chief cause of women’s physical and psychological complications (Ronaq, 2014). The present study analyzed the verbal violence (teasing and taunting) as well as

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physical violence (slapping and beating) by the intimate partner. The study explains that 38.8 percent of the respondents faced violence in terms of abusing to a great or some extent; 40.2 percent of women claimed about teasing/taunting to a great extent or some extent. As regards physical violence, 22.1 percent of the respondent’s husband slapped them to a great or some extent; and 123 percent of the respondents were beaten by their husbands to a great or some extent. Majority, 87.8 percent of women never faced beating. The results of the bivariate analysis supported that husband’s violence in the form of either verbal or physical has adverse effect on women psychological and physical health. As women who faced verbal or physical violence by their husbands, have the symptoms of PPD in terms of moderate and severe. Dennis & Simone (2013) concluded that 26 percent were diagnosed of PPD, and most of them reported intimate partner violence; mothers who faced intimate partner violence also had a positive PPD (Kornfeld et al., 2012). It is illustrated that mothers who faced domestic violence were twice as likely to have a PPD (Grens, 2012); violence during pregnancy are found to be a strong predictor of postpartum depression in a sample of Chinese women (Zhang et al., 2011).

Stressful Life Events and Postpartum Depression Hypothesis 19: Higher the history of stressful life events of the respondents, higher the prevalence of postpartum depression Stress is defined as an interruption in a peaceful life. Everyone wants to feel safe and secure and live happily without any disruption. But some experience different incidents in their lives tend to cause stress. The most notorious causes of stress are death of loved one, loss of job, the care of children or elders, poverty and violence. These are known as stressful life events, one can completely devastating emotionally by these factors. Depression is a mental illness which highly influenced by stressful life events. Women with a pregnancy and childbirth complications are more likely to have depression. Furthermore, the occurrence of the most potentially stressful events during pregnancy proved to be a strong risk factor for PPD.

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Table: 59 Association between history of stressful life events and prevalence of postpartum depression Prevalence of PPD Stressful life events Total Low Medium High Not depressed 95 51 11 157 60.5% 32.5% 7.0% 100.0% Moderately 37 38 5 80 depressed 46.3% 47.5% 6.3% 100.0% Severely depressed 36 60 67 163 22.1% 36.8% 41.1% 100.0% Total 168 149 83 400 42.0% 37.3% 20.8% 100.0% Chi-square: 86.706 Sig. Level: 0.000 Gamma: 0.568 Sig. Level: 0.000

The value of chi-square (86.706) and gamma statistics (0.568) confirmed the existence of and positive relationship between the predicting and response variable. It means that the most stressful life events are a cause of PPD severe. In addition, mother with lower incidence of stressful life events, were not depressed during the postpartum period. In the present study, the reported stressful life events were as financial problems (55.2 percent); mother-in-law had a desire to be pregnant in the first year of marriage (39.0 percent); husband had a desire to be pregnant in the first year of marriage (33.3 percent); in-laws home environment (32.8 percent); health problems (24.0 percent); change home (23.8 percent); death of love on (19.5 percent) and relationship changing (17.5 percent). A number of studies reported the strong association between frequency and intensity of stressful life events and the probability of occurring of PPD. Women who were screened for antenatal depression and experienced four stressor categories such as financial, traumatic, and emotionally and partner related had the higher depressive symptoms during the postpartum period (Soumyadeep et al., 2017). Qobadi (2016) study the effects of stressful life events during pregnancy on the probability of PPD and concluded that mothers who experienced financial problems, high trauma and emotional issues had the highest score of PPD. Evidence also supported by the theoretical model, as theory illustrates that there is a strong positive association between stressful life (self-crises) event and the development of PPD among women (Beck, 2002). The risk factors in postpartum depression are a previous history of depression, family history of depression,

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stress or history of abuse. Mother of low self-confidence and low socioeconomic status may have higher chances to elevate the PPD (Bogdanovska, 2016). The significant predictors of event were in-laws home environment, arguments with spouse, hurdles to attain an education, relationship changing, divorce and sleeping disorder. Whereas, stressful life events such as in-laws home environment (p=0.001), relationship changing (p=0.017), divorce (p=0.026), sleeping disorder (p=0.049) and loan (p=0.037) showed the higher association with PPD (Jafarpour et al, 2007).

Social Support and Postpartum Depression Hypothesis 20: Higher the social support of the respondents, lower the prevalence of postpartum depression The term social support has been defined as “support accessible to an individual through social ties to other individuals, groups, and the larger community” (Simeone et al., 1979). Social support refers to the relationships or having a network of friends, family or other people, available in time of needs or crises to give physical, psychological and financial help. Social support is very important to sustain physical and mental health. It has a positive effect on health behavior as the supportive behavior’s predictive better health status (Reblin and Uchino, 2008; Ozbay et al., 2007). Social support enhances the quality of life by providing a positive self-image, and tiger against a stressful life event. Table 60: Association between social support and prevalence of postpartum depression Prevalence of PPD Social Support Total Low Medium High Not depressed 18 96 43 157 11.5% 61.1% 27.4% 100.0% Moderately 9 56 15 80 depressed 11.3% 70.0% 18.8% 100.0% Severely depressed 38 112 13 163 23.3% 68.7% 8.0% 100.0% Total 65 264 71 400 16.3% 66.0% 17.8% 100.0% Chi-square: 26.419 Sig. Level: 0.000 Gamma: -0.384 Sig. Level: 0.000

Motherhood is considered a joyful life event, but it may cause of emotional disorder for some women. Low social support can be associated with PPD and other related

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psychological issues. The value of chi-square (26.419) shows a significant association (P = 0.000) between social support and PPD among women. Gamma value (-0.384) indicates a strong negative relationship between these variables. The results describe that women are more prone at the risks of PPD who have low levels of social support. Additionally, women who have the support of their husbands or other family members for a great or some extent, were not depressed in the postpartum period. The results also supported by the theoretical model, the insufficient social support is identified as a strong positive predictor of the development of PPD; and a supportive relationship is helpful to change the maternal depressive mood (Beck, 2002; Sullivan, 1953). In Pakistan, social support is affected by the traditional cultural values and misconception of health care practices. A mother’s care is essential for her physical and psychological well-being. Women who attain professional help and have social support, tended to feel more relaxed and safety during the postpartum period (Corrigan et al., 2015). Others, concluded that social support of mothers in the child care was significant in adjusting to their new situation, and lack of social support was associated with PPD (Ugarriza et al., 2007). A number of studies have supported the magnitude of the effects of social support on PPD among women, an increased level of social support is highly associated with low level of PPD (Shapiro & Fraser, 2013; Brown et al., 2012; Kim et al., 2012; Chien et al., 2012; Edwards et al., 2012; Fowles et al., 2012; Quelopana, et at., 2011; Xie et al., 2009). Kanotra et al. (2007) illustrated that mothers need of help on breastfeed issues and social support in care of newborn, but the inconsistency and lack of appropriate social support caused of PPD. However, insufficient knowledge and untrained healthcare providers can create hurdles in the diagnosis and treatment of PPD (Logsdon et al., 2012; Gillibrand, 2012). Brown et al. (2012) found that the symptoms of depressive disorder were common among young mothers, but the higher positive social support score had an inverse relation with depressive symptoms. Other, Chojenta et al. (2012) reported the outcome variables of PPD among women of Australia, such as demographic, previous history of depression, stressful life events, and social support. The study indicates that lower positive social interaction and affectionate support were associated with PPD. In contrast to the above studies, Leahy-Warren et al. (2011) found no strong relationship between social support and PPD among women in Ireland; yet, they report an inverse relation between social structure and PPD.

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Experiences and Feelings during Pregnancy and Postpartum Depression Hypothesis 21: Association between experiences and feelings of the respondents during pregnancy and the prevalence of postpartum depression Women are at higher risk of anxiety, stress and depression at certain times such as puberty, menstruation period and during and after pregnancy. Hormonal changes unique to women may trigger the depressive symptoms in the postpartum period. When a woman got pregnant, levels of hormones (estrogen and progesterone) increase greatly. In order to physical changes, women felt restless, sadness, hopelessness or having feelings of guilt and worthy. They experienced crying a lot, having no energy, having trouble in decision making and eating and sleeping too little or too much. Table: 61 Association between experiences and feelings of the respondents during pregnancy and the prevalence of postpartum depression Prevalence of PPD Pregnancy experiences Total Low Medium High Not depressed 55 83 19 157 35.0% 52.9% 12.1% 100.0% Moderately 21 35 24 80 depressed 26.3% 43.8% 30.0% 100.0% Severely depressed 22 67 74 163 13.5% 41.1% 45.4% 100.0% Total 98 185 117 400 24.5% 46.3% 29.3% 100.0% Chi-square: 48.121 Sig. Level: 0.000 Gamma: 0.456 Sig. Level: 0.000

This table indicates the relationship between respondent’s feelings and experiences during pregnancy and the prevalence of postpartum depression. Chi-square value (48.121) shows a significant association (P = 0.000) between the variables. The gamma value (0.456) depicts a strong positive relationship between women’s experiences and feelings during pregnancy and PPD. Women who experienced the problems of crying, sleeping or eating disorder; and felt irritated, anxiety and tiredness to a great or some extent during pregnancy were depressed severely in the postpartum period than those women who didn’t experience. The univariate analysis of the present study describes that most of the respondents experienced eating disorder (61 percent), sleeping disorder (58 percent) and crying episode (34 percent). The frequency of the results indicates that women felt tired (83 percent), irritation (78 percent), and anxiety (79 percent) during pregnancy. The

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greater incidence of these problems contributes the antenatal depression, strongly associated with PPD. PPD might be decreased with self-efficacy, socioeconomic autonomy and better health care (Mukherjee, 2016). Theory proposed that baby blues or mild depressive symptoms (sadness, irritability, crying, poor concentration) are common due to hormonal changes and sleeping disorder, which may end up for a week or two. Furthermore, PPD occurs when these symptoms are severe and last for more than two weeks, it may occur any time within the first year of childbirth. Assessing a previous history of anxiety, stress or depressive symptoms are necessary in the antenatal period, because the previous history of depressive symptoms is a risk factor for PPD (Dennis et al., 2012; O’Hara, 2009; Beck, 2002). The most frequent symptoms of PPD can include change in appetite, feelings of guilt, and suicidal thoughts (Pearlstein et al., 2009).

Experiences and Feelings within the First Two Weeks after Delivery and Postpartum Depression Hypothesis 22: Association between experiences and feelings of the respondents within the first two weeks after delivery and the prevalence of postpartum depression Physical and emotional changes play a crucial role to develop the PPD among women. Physical change after a childbirth includes a dramatic drop in hormone (estrogen and progesterone) or in thyroid glands in maternal body. A sharp drop of these hormones can leave mothers feeling tired, crying episode, irritation and low mood. Emotional issues also contribute to PPD including sleep deprived, trouble in handling minor problems, inability to care for a newborn, loss of self-control or even think about suicide.

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Table: 62 Association between experiences and feelings of the respondents within the first two weeks after delivery and the prevalence of postpartum depression Prevalence of PPD Delivery experiences Total Low Medium High Not depressed 69 79 9 157 43.9% 50.3% 5.7% 100.0% Moderately 26 43 11 80 depressed 32.5% 53.8% 13.8% 100.0% Severely depressed 26 79 58 163 16.0% 48.5% 35.6% 100.0% Total 121 201 78 400 30.3% 50.3% 19.5% 100.0% Chi-square: 59.428 Sig. Level: 0.000 Gamma: 0.513 Sig. Level: 0.000

Chi-square value (59.428) shows a significant association (P = 0.000) between the variables. The gamma value (0.513) proves a strong positive relationship between women’s feelings and experiences within the first two weeks after delivery and PPD. Women who experienced problems such as crying, sleeping or eating disorder; and felt irritated, anxiety and tiredness to a great or some extent after delivery were depressed severely in the postpartum period than those women who didn’t experience. As the data shown in univariate analysis, most of the respondents experienced sleeping and eating disorder (55 percent) and crying episode (30 percent). The results also analyzed that women felt tired (76 percent), irritation (72 percent), and anxiety (41 percent) within the first two weeks after delivery. Theory of Postpartum Depression viewed that the continuity of these problems may elevate the risks of depression; and these are known to be the symptoms of PPD, if it has gradual incidence. Negative thinking including desperate and suicidal thought occurs due to child care anxiety, irritation and stress. It may happen due to the maternal health complications and low level of social support during pregnancy or in the postpartum period (Beck, 2002). The researcher found that change in appetite, anxious thought, loss of interest, poor concentration and worry about the future are the signs of PPD (Bogdanovska, 2016).

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Difficulty in Feeding and Postpartum Depression Hypothesis 23: An association between difficulty in feeding, and prevalence of postpartum depression Breastfeeding is good for mother and baby health. It provides all the vitamins and nutrient needs in the first six months of an infant’s life. But the socio-cultural and environmental challenges have an adverse effect on women’s physical and psychological health status. Number of pregnancies, number of children and long duration of breastfeeding creating the hardships for women; and women are more likely to depress within a first postpartum year. In Pakistan, the rural women are facing more problems than the urban women, where the women are responsible for unusual household responsibilities. Table: 63 Association between difficulty in breastfeeding and prevalence of postpartum depression Prevalence of PPD Difficulty in feeding Total Low Medium High Not depressed 54 38 24 116 46.6% 32.8% 20.7% 100.0% Moderately 34 24 8 66 depressed 51.5% 36.4% 12.1% 100.0% Severely depressed 82 26 18 126 65.1% 20.6% 14.3% 100.0% Total 170 88 50 308 55.2% 28.6% 16.2% 100.0% Chi-square: 11.255 Sig. Level: 0.024 Gamma: 0.230 Sig. Level: 0.006

Cross tabulation analysis identifies the significant relationship (P=0.024) between the dependent (incidence of PPD) and independent (breastfeeding) variables as shown the value of chi-square (11.255); and the value of gamma (0.230) indicates a positive relationship between these variables. It means that those women who faced difficulty in breastfeeding were more likely to be more depressed in their postpartum period than those who did not face. It is stated that women who didn’t breastfeed their baby or stopped early breastfeeding are at higher risks of PPD (Baby Center Medical Advisory Board, 2015). In addition, mothers who have problems in starting or continuing to breastfeed may increase the risks of PPD. Mothers cannot produce enough milk to feed their infant because of malnourished, lack of proper diet and short intervals between pregnancies (McCarthy, 2014).

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Physical Issues in the Postpartum Period and Postpartum Depression Hypothesis 24: Higher the physical issues in the postpartum period of the respondents, higher the prevalence of postpartum depression Afterward a childbirth, mothers faced a number of problems in the postpartum period, such as menstruation problem, weight gain or weight loss, loss of energy and change in body image. Reproductive health is the most serious problem in Pakistan that women face in their life. Women have not right to take decisions about their health, which highly affects their morbidity and mortality (Ronaq, 2014). Table: 64 Association between the physical issues in the postpartum period of the respondents and prevalence of postpartum depression Prevalence of PPD Physical issues Total Low Medium High 87 59 11 157 Not depressed 21.7% 14.7% 2.8% 39.2% Moderately 27 43 10 80 depressed 6.8% 10.8% 2.4% 20.0% 48 74 41 163 Severely depressed 12.0% 18.5% 10.3% 40.8% 162 176 62 400 Total 40.5% 44.0% 15.5% 100.0% Chi-square: 35.282 Sig. Level: 0.000 Gamma: 0.392 Sig. Level: 0.000

Results of chi-square (35.282) and gamma (0.392) indicates a strong positive association between the physical problems and the symptoms of depression in their postpartum period. It is stated that those women who have problems of menstruation, weight loss or gain and marital relations were more likely to develop the PPD than those who have not these problems. The study shows that most of the women have a menstrual problem to a great and some extent after marriage; even they did not face these problems before marriage, as were described in the above results. In order to weight gain women are more prone to the higher risks of PPD because their body image changed; and these results also concluded in the same line by Green et al. (2006). Another analyzed that weight gain and weight loss both conditions were seen as a source of unhappiness among women in Uganda, UK, Asia, France and USA (Oates et al., 2004).

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5.6 Effects of Postpartum Depression Postpartum Depression and Mother Life Hypothesis 25: There is an association between the postpartum depression and the mother’s life Postpartum depression considered as a dark secret of motherhood, which may reduce the quality of life. PPD does not affect just the mother, but also depressed mothers deliver depressed babies. A mother’s life is considered to be very difficult in treating with the everyday responsibilities and care for the baby. If these difficulties remain long, it can be highly affected the diet habit, care for baby, attachment to her child and husband (PubMed health, 2016). Table: 65 Association between the postpartum depression and mother’s life Mother’s Life Prevalence of PPD Total Not depressed Moderately Severely depressed depressed 10 11 66 87 Poor 11.5% 12.6% 75.9% 100.0% 57 39 74 170 Fair 33.5% 22.9% 43.5% 100.0% 90 30 23 143 Good 62.9% 21.0% 16.1% 100.0% 157 80 163 400 Total 39.3% 20.0% 40.8% 1 00.0% Chi-square: 90.087 Sig. Level: 0.000 Gamma: - 0.619 Sig. Level: 0.000

The value of chi-square (90.087) shows a strong relationship between the variables. The value of gamma (-0.619) indicates a strong negative relationship between the prevalence of PPD and the mother life’ experiences. Theory explained that low self-efficacy, low self-esteem, and perceived lack of knowledge about maternal health and child care are the risk factors of PPD (Beck, 2002). Also, good diet of mother based on the supply of food and maternal behavior towards eating habit; and the eating disorder is highly influenced by the low mood and anxiety. Conversely, proper availability of food items and inadequate supply of food were seen as a source of happiness and unhappiness respectively (Oates et al., 2004). Attachment theory supported that PPD is a distress for women because of having effects on mother and infant attachment (Whiffen & Susan, 1998). Particularly, infants are vulnerable due to impaired maternal-infant interactions

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have a negative impact on cognitive, emotional and behavioral outcomes (Baby Center Medical Advisory Board, 2015).

Postpartum Depression and Respondent's Behavior Hypothesis 26: An association between postpartum depression and respondent's behavior Table: 66 Association between postpartum depression and respondent's behavior Respondent’s Prevalence of PPD Total behavior Moderately Severely Not depressed depressed depressed Good 104 47 6 157 26.0% 11.7% 1.5% 39.2% Normal 36 35 9 80 9.0% 8.8% 2.2% 20.0% Bad 52 76 35 163 13.0% 19.0% 8.8% 40.8% 162 158 50 400 Total 40.8% 39.5% 12.5% 100.0% Chi-square: 45.988 Sig. Level: 0.000 Gamma: 0.476 Sig. Level: 0.000

Value of chi-square (45.988) and gamma (0.476) indicates a strong positive relationship between the incidence of PPD and behavior of the respondents. Data shows that women who have more depressive disorder in their postpartum period were more likely to behave negatively than of those women who were not depressed. Surely, low mood, mood swings, anxiety and anger are the symptoms of PPD (Beck’ theory, 1998); and these symptoms were observed among most of the respondents who showed bad behavior when the data was collected. It is viewed that mothers become more anger when asked them why you behave as unmannered, but some of them refuse to provide further information about their problems.

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Postpartum Depression and Respondent's Health Appearance Hypothesis 27: An association between postpartum depression and respondent's healthy appearance Table: 67 Association between postpartum depression and respondent's healthy appearance Respondent's Prevalence of PPD Total health appearance Moderately Severely Not depressed depressed depressed

Good 70 77 10 157 63.6% 36.8% 12.3% 39.2% Normal 21 45 14 80 19.1% 21.5% 17.3% 20.0% Bad 19 87 57 163 17.3% 41.6% 70.4% 40.8% 110 209 81 400 Total 100.0% 100.0% 100.0% 100.0% Chi-square: 64.860 Sig. Level: 0.000 Gamma: 0.559 Sig. Level: 0.000

Value of chi-square (64.860) shows a strong relationship, and the value of gamma (0.559) verifies a strong positive relationship between respondent's healthy appearance and the prevalence of PPD of the respondents. It means that those women who have good health were less likely to be depressed in the postpartum period than those who have bad health. It is viewed that depressive mothers have pale faces. These women have a number of other health issues such as anemia, chronic pain, body ache which deliberately affects their mental health status.

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5.7 Summary: Bivariate Analysis In bivariate analysis, the chi-square and gamma test were applied to check the relationship between independent and dependent variables. A number of risk factors that are taken as independent variables were socio-demographic, obstetric, cultural and psychological variables. Furthermore, the effect of PPD on the life of mothers was also checked. 5.7.1 Socio-demographic Variables and Prevalence of Postpartum Depression Age, education, family monthly income and total number of family members were the socio-demographic variables that show the association with the symptoms of PPD with the values of chi-square (58.149), (64.273), (38.540), (28.478), respectively. The gamma value indicates a strong negative relationship between age, education and family monthly income and the symptoms of PPD. It means that as the age, education, and family monthly income are increasing mothers reduced the risk of having symptoms of PPD. Furthermore, the gamma value shows a strong positive relationship between the total number of family members and prevalence of PPD. 5.7.2 Obstetric Variables and Prevalence of Postpartum Depression From obstetric factors, the present study found a relationship between umber of pregnancies, abortion, unplanned pregnancy, pregnancy and delivery complications, infant health complications and PPD. The value of chi-square (16.986) and (12.454) show a relationship between the number of pregnancies and PPD and the number of abortion and PPD, respectively. The value of gamma (0.141) and (0.238) indicates that as the number of pregnancies and abortions are increasing, mothers were on the higher risks of developing PPD. It highlights that mothers with multiple pregnancies and abortion are more prone to hemorrhage or still births. The value of chi-square (32.989) shows a strong relationship between the unplanned birth of a baby and the prevalence of PPD of the respondents; and the value of gamma (0.378) shows a strong positive relationship between these variables. The value of chi-square (31.848), (19.293) shows a strong positive relationship and (gamma value, 0.316; 0.286) between pregnancy and delivery complications and the symptoms of PPD. It depicts that a high and medium complication pregnancy and delivery caused severe or moderate PPD among women. The value of chi- square (14.415) and gamma (0.206) indicates a strong positive relationship between the infant health problems and the prevalence of maternal’ PPD. It means that the chances of postpartum depression are more likely to high with poorer health status of the baby

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(during pregnancy or late neonatal period). It is concluded that the postpartum hemorrhage, difficult labor, high or low blood pressure and early child birth are frequently associated with postpartum depression. Furthermore, the study concluded that these are the strongest obstetric factors that place a mother on higher risks of anxiety, stress and depression in antenatal and postpartum periods leads to the symptoms of PPD. Although, the number of children, pregnancies, deliveries, live and dead births, checkup during pregnancy, place of birth of a baby and type of delivery were not found to be significant in the bivariate analysis. 5.7.3 Cultural Variables and Prevalence of Postpartum Depression The value of chi-square and gamma show a significant association between family type (chi-square, 22.718; gamma, 0.342); the sex of the baby (chi-square, 25.694); social taboos (chi-square, 11.339; gamma, 0.150); utilization of health facilities (chi-square, 11.647; gamma, -0.032) and the prevalence of PPD. The association between family type and PPD depicts that mothers who lived in a joint family system were more prone to develop low mood, mood swings, sadness and anxiety due to mother-in-law and other family member’s behavior. The relationship between the sex of the baby and the prevalence of PPD means that those mothers were depressed who deliver baby girl. In addition, the probability of occurrence of PPD is increased when mothers experienced social taboos. The most common social taboos were not allowed to go outside the home at sunset time during pregnancy; to eat specific things during pregnancy; forced to eat butter (ghee) in the last month of pregnancy to increase the chances of normal delivery; mothers didn't keep newborn's clothes beyond forty days; put the iron (knife) and matches nearby the newborn or lock to his/her bed (caught/charpai); and they hear about their hair will begin falling when baby starts talking. 5.7.4 Psychosocial variables and Prevalence of Postpartum Depression The value of chi-square and gamma show a significant association between the attitude of husband, in-laws (chi-square, 59.734; gamma, -0.455); violence (chi-square, 70.177; gamma, 0.538); stressful life events (chi-square, 86.706; gamma, 0.568); social support (chi-square, 26.419; gamma, -0.384) and the prevalence of PPD. Negative attitude of husband, in-laws and violence of the husband may cause of low mood, anxiety and stress that leads to the symptoms of PPD. It may consider a chief cause of women’s psychological and physical complications. The chance of PPD was increased for those women who faced stressful life events such as financial problems, mother-in-law and husband had a desire to be pregnant in the first year of marriage, in-laws home

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environment, health problems, change home and death of love one. The study also found that mothers had symptoms of PPD who had lower levels of social support. Chi-square and gamma value verified a significant association between women’s experiences and feelings during pregnancy (chi-square, 48.121; gamma, (0.456); women’s feelings and experience within the first two weeks after delivery (chi-square, 59.428; gamma, 0.513) and the symptoms of PPD. The study identified that most of the respondents had experienced eating disorder, sleeping disorder, crying, tiredness, irritation and anxiety during pregnancy and within the first two weeks after delivery. The value of chi-square (11.255) exemplify a relationship between the difficulty in breastfeeding and the prevalence of PPD of the respondents. The value of gamma (0.230) indicates a negative relationship, means that those women who faced difficulty in feeding were more likely to be depressed than those who have not faced. 5.7.5 Life as a Mother and Prevalence of Postpartum Depression The value of chi-square (90.087) shows a strong relationship; and the value of gamma (- 0.619) indicates a strong negative relationship between the prevalence of PPD and the mother life’ experiences. The study concluded that mother’s life was good or fair who had lower symptoms of PPD. Mother’s life was poor when they didn’t care their baby properly due to low mood, stress and anxiety. In addition, these problems also cause poor attachment with their husband and baby.

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Chapter 6 MULTIVARIATE ANALYSIS Explores the relative importance of predicting variables in predicting response (postpartum depression) variable

6.1 Introduction Human behavior cannot be described or measured directly because of its complexity. The human characteristics should be described or measured by multiple factors to explain the relationship/association between a response variable and more than one explanatory variable (Batool, 2010). The multivariate analysis has been discussed in this chapter. The chapter describes the model for explaining the prevalence of postpartum depression within the socio-demographic, cultural, psychological and obstetric context. In social sciences, the studies used several methods to explain the association between dependent and more than one independent variable. Multivariate analysis is a type of statistical analysis in which a number of variables relate simultaneously to each other. It refers to the model where each decision, product or situation involves more than one variable. A multivariate analysis technique typically used for research and development; market and consumer research; process control and process optimization; and quality control or quality assurance of products. It contains multiple variables instead of one or two by using matrix algebra. The most frequent use of multivariate analysis is regression, variance, covariance and path analysis. Regression analysis is a form of statistical technique that estimates the relationship between one dependent variable (also known as response variable or measurement) and more than one independent variable (also called predictor or explanatory variables). Multiple linear regression is a widely used method to examine the significance of each of the values of the independent (predictor or explanatory) variables to the dependent (response) variable. Multiple linear regression is a collective name of the method and analysis of numerical data attempts for modeling the relationship between a response and two or more explanatory variables by fitting a linear equation in order to observe the data. Every value of the independent/explanatory variable is associated with a value of the dependent/response variable (Maki, et al., 1978).

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6.2 Multiple Linear Regression Model Multiple Linear Regression is the most common form of regression analysis, used to explore the relationship between one dependent variable from two or more independent variables. The term multiple regression analysis was first used by Pearson in 1908, to explain the maximum variation in the response variable by applying more than one predictor variable, called multiple linear regression analysis. It summarizes the strength of the linear relationships between each pair of response variables. The model for multiple linear regression is described as follows:

Y = α+ b1X1 + b2X2 + b3X3... + bnXn + e Explanation of the regression equation: Y = estimated dependent variable X = each independent variable c = constant (which includes the error term that indicates the proportion of unexplained variance in the dependent variables). b = regression coefficients (estimate the amount of change in the dependent for a unit change in the dependent variables). α = Intercept, (indicates the value of y when all the x values are zero).

6.3 Suitability of Multiple Linear Regression There is a need to check the suitability of techniques for the data before applying any method. It means that the data fulfill all the requirements of the application that is being selected. Before using the multiple linear regression analysis, it was assured that the data fulfill all assumptions required for the application of this technique. Multiple linear regression was used to measure unstandardized regression coefficient, standardized regression coefficient and coefficient of determination (R²). In the regression model, the coefficients were used to identify the importance of each of the variable in the relevance of the response variable. The level of postpartum depression is measured by using the Edinburgh Postpartum Depression Scale for mothers. Postpartum depression is categorized into three levels of not depressed, moderately depressed and severely depressed. Despite, the quantum of data, the ability to obtain a clear picture of responses and make an intellectual decision was a greater challenge for the researcher.

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6.3.1 Assumptions of Multiple Linear Regression Before applying an application, it is necessary for the analysis to ensure that the obtaining data fulfill all requirements of the assumptions. When these assumptions are not being met according to the criteria, the results may be unreliable. It resulted in, a Type I or Type II error occur, or the chance of over or under-estimation of significance. The importance of assumptions is described by Pedhazur (1997) as “Knowledge and understanding of the situations when violations of assumptions lead to serious biases, and when they are of little consequence, are essential to meaningful data analysis”. Some of the assumptions are described as follows: ➢ There is a need of linear relationship between the dependent variable and independent variables. ➢ Each variable and group must be from the population variance and multivariate normal population. ➢ For all groups, covariance matrix must be equal and in a linear way. ➢ In case of homogeneity of variance and linear, there should be no relationship between the predicted and residual values; where, the residual is shown the difference between the value predicted by the multiple linear regression models and observed value. ➢ The error between predicted and observed values should be normally distributed. The normality can be checked with a goodness of fit test. This can be tested by plotting residual values on a histogram with a fitted normal curve. ➢ There is no or little multicollinearity in the data, where multicollinearity exists when the independent/predictive variables are not highly correlated with each other. ➢ There is no or little auto-correlation in the data, where, the auto-correlation exists when the residual are not independent from each other. ➢ In case of homoscedasticity, the scatter plot is a good method to check homoscedasticity. It requires that the variance of error terms is similar across the predictive variables. ➢ The construction of the histogram is a good method to analyze either the data is from a multivariate normal population or not. A histogram is a diagram consists of the frequency of a variable by means of rectangles whose widths is equal to the class intervals, and whose area is proportional to the corresponding frequencies (Freedman, 1981).

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➢ The analysis of residual can expose problems in order to the use of linear regression. ➢ The construction of histogram and scattered plot confirmed that the data encounter the assumptions of multiple linear regression method of analysis. ➢ If the scatter plots of different variables did not show any association in dealing with residual, then the data fulfill all the requirements of the assumptions of homogeneity and linearity of variances of the variables. Furthermore, the data were analyzed after assure the assumptions of multiple linear regression analysis.

6.3.2 Purpose of Multivariate Analysis – Regression Analysis (Multiple linear regression) The purpose of multivariate analysis is to use a set of variables (columns) to predict another, and to explore which variables (columns) are important in the relationship. In the present study, the multivariate analysis is used for the identification of the importance of independent (explanatory) variables in explaining dependent (response) variables such as the prevalence of postpartum depression. The main purpose of regression is calculating the values of beta. In order to make the comparison of independent variables, the standardized regression coefficients are calculated by multiplying the regression coefficients which stem from the standard deviation of the relevant independent variables. For the regression equation, the standardized regression coefficients bear the standard unit of measurement, to compare the significance of two predictor variables in order to explain variance in the response variable. Regression analysis is a statistical technique to identify the relationships among variables. It is a best technique in order to determine the small set of explanatory variables in producing the highest value of R². A set of independent variables explained the value of R² that describes the proportion of the variance of Y. The multiple linear regression is used in order to measure coefficient (standardized regression coefficient, unstandardized regression coefficient, and coefficient of determination R²), and the estimation of standard error and the value of t. In the regression model, these three coefficients are used to check the relative importance of the predictor variable. Postpartum depression is measured by using the EPDS (Edinburg Postpartum Depression Scale) and to check the symptoms of PPD among women.

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For the present study, 3 regression models are developed to estimate the regression coefficients to view the relative importance and significance of predicting variables in explaining response variable. Model 1 and 2 are developed to see the relevance significance of contributory/explanatory variables on the response variable (Postpartum Depression). The independent contributory factors are presented in model 1. To see the effect of background variables, the model 2 is developed. By using the two models, the study identifies how the explanatory (independent) variables have the effects on the prevalence of PPD along with the background variables. So, the model 2 showed that the background variables provided empirical evidence of the relations between the background and dependent variables. Model 3 is developed to see the relevance significance of contributory/explanatory variables on the response variable (Mother’s life). In the models, all the significant and non-significant variables are included.

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6.4 Results and Discussion Model No. 1- Table: 68 Standardized regression coefficients, t values and level of significance of obstetric and psychosocial variables regressed on the prevalence of the postpartum depression *Dependent variable: Postpartum Depression Unstandardized Standardized Coefficients Coefficients Variables T Sig. B Std. Error Beta Obstetric Variables .045 .037 .054 1.230 .220 Number of pregnancy X1 Number of abortions X2 .142 .065 .100 2.187 .030 Difficulty in feeding X3 -.038 .051 -.032 -.746 .456 Planned birth of baby X4 -.177 .080 -.100 -2.223 .027 Pregnancy complications X5 .179 .061 .134 2.923 .004 Delivery complications X6 -.115 .062 -.085 -1.858 .064 Infant Health complications X7 .158 .052 .137 3.041 .003 Psychosocial Variables -.105 .050 -.090 -2.111 .036 Attitude X8 Violence X9 .152 .056 .135 2.694 .007 Stressful life events X10 .291 .061 .245 4.746 .000 Social support X11 -.305 .068 -.205 -4.460 .000 Experiences in the antenatal period .283 .065 .234 4.380 .000 X12 Experiences during the first two -.080 .075 -.063 -1.065 .288 weeks of postpartum period X13 Physical issues X14 .034 .063 .027 .533 .594 R2 .504

In the above table unstandardized regression coefficients, standardized regression coefficients of every predictive/explanatory variable are given along with t value, standard error and level of significance. Low mood, sadness, irritation, tiredness or fatigue, eating and sleeping disorder, poor concentration are the dimensions of the index as response variable (symptoms of postpartum depression). These are the depressive symptoms of PPD that were identified by Beck’ (2002) Postpartum Depression Theory. Obstetric complications such as number of pregnancy and abortions, difficulty in feeding, unplanned pregnancy, pregnancy, delivery and child health complications were the

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factors that are entered into a multiple linear regression model to explore the predictive variables that dispose women to PPD. Attitude (husband, mother-in-law, family members and doctors/LHW), violence, stressful life events, social support in antenatal and postpartum period, pregnancy and delivery experiences and physical issues were the socio-psychological variables that are entered into a multiple linear regression model to explore the predictive variable that cause to elevate the PPD among mothers. The significance of predictive variable is identified by using the regression coefficient beta (standardized coefficient). The higher value of regression shows the relative importance of each independent variable. The table indicates that the number of abortions increases the risks of developing PPD among women. The value of regression coefficients 0.100 means that as the number of abortions is increasing, mothers increased the risk of having symptoms of PPD by 0.100 units, significant at 0.030, level. The value of coefficient 0.100 indicates that an increase in planned pregnancy caused a reduction in women’s symptoms of PPD by 0.100 units, at the significance level of 0.027. Abbasi et al. (2013) mentioned that almost 32 percent of the pregnancies were unplanned and the PPD was less prevalent among women with planned pregnancies compared to women with unplanned pregnancies. It is evident from the results that pregnancy complications and infant health complications increase the risks of developing PPD moderately or severely. Beck’ theory supported that number of pregnancy and abortions, unintended birth of a baby, pregnancy complications and child care anxiety are the strongest contributory factors of PPD (Beck, 2002). As viewed in the regression model, pregnancy complications have a coefficient value 0.134 at 0.004 significance level; and child health complications have a coefficient value of 0.137 at 0.003 significance level. In psychological variables, negative attitude, violence, stressful life events, low social support has a positive association with the response variable. The value of regression coefficient 0.090 demonstrates that the harsh attitude of the husband, mother-in-law, family members, doctors and LHV/LHW increases the risks of developing PPD among the respondents, at the significance level of 0.03. Whereas, the attitude of the husband and mother-in-law were the strongest positive factors to raise the risks of depressive disorders. In the model, verbal or physical violence having the association with PPD by 0.135 units, significant at 0.007 level. The study highlighted that the stressful life events and low level of social support are the strongest predictors in increasing the prevalence of PPD. Among these factors, stressful life events have a coefficient of regression value

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0.245; and social support has a value of regression coefficients 0.205, at 0.000 level of significance. It means that stressful life events such as financial problems, having the pressure to conceive early after marriage and in-laws home environment; and low level of social support by husband, family and doctors in the antenatal and postpartum period caused an increase in women’s symptoms of PPD. Theory proposed that women are more likely to develop PPD who had already depressive disorders, history of antenatal depression, lower social support and experienced domestic abuse during pregnancy and afterward childbirth (Beck, 2002, Sullivan, 1953). Qobadi (2016) reveals that the overall prevalence of self-reported PPD was 14.8 percent; and mothers who experienced high relational problems with low financial had the highest likelihood of PPD as compared to those who experienced lower relational with high financial. Others found associative factors of PPD were the age group, lower social support, poverty, stress, addiction, and antenatal depression (Abbasi et al., 2013). Dindar & Erdogan (2007) reported the strongest risk factors of depression were previous psychiatric illness (odds ratio [OR] 15.95); abortion or loss of a baby (OR 7.49); smoking (OR 4.17); lower family income (OR 4.10); conflict with husband (OR 3.49); birth of a baby girl (OR 2.54); mother-in-law attitude (OR 2.53); and lower social support (OR 1.53). Experiences and feelings during pregnancy shows a significant impact with a regression coefficient value 0.234, at a significance level of 0.000. The pregnant women have greater risks of being depressed when there is a harsher attitude, violence, stressful life events and low social support. Furthermore, number of pregnancies, difficulty in feeding, delivery complications, experiences during the first two weeks of postpartum period and physical issues were found to be non-significant in the regression model. It means that these variables have not relative importance in the model, either these factors showed the association in bivariate analyses. Sundaram et al. (2014) analyzed that being in a car accident (odds ratio [OR], 1.65); kidney/bladder infection (OR, 1.59); preterm labor (OR, 1.54); nausea (OR, 1.50); vaginal bleeding (OR, 1.42); being on bed rest (OR, 1.34) was associated with PPD symptoms. Whereas, diabetes before pregnancy (odds ratio [OR], 5.65); blood transfusion (OR, 2.98); hypertension (OR, 1.94); nausea (OR, 1.80); vaginal bleeding (OR, 1.76), kidney/bladder infection (OR, 1.63); being on bed rest (OR, 1.56); preterm labor (OR, 1.51) was associated with PPD diagnosis. In the regression model, the value of R2 (0.50) demonstrated that explanatory variables show 50 percent variation in the symptoms of PPD. Zafar (1993) clarified that if the value

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of R2 is more than 0.40 percent in the model, the model is to be considered as a best fit model in the social sciences. This reflects that the predictive variables are appropriate and relevant in the regression model, for such a specific problem that is being studied (Batool, 2010). The value of R2 is shown that the predictor variables given in the model 1 is best suited to explain the response (PPD) variable.

The value of regression coefficients (beta) is described for explaining the symptoms of PPD as follows:

Fitted Model

Prevalence of PPD = 32.012 + .054X1+.100X2 -.032X3-.100X4+.134X5

-.085X6 +.137X7 - .090X8 +.135X9 +.245X10-.205X11+.234X12 -

.063X13 +.027X14

X1 is the number of pregnancies, X2 is the number of abortions, X3 is difficulty in feeding,

X4 is planned birth of a baby, X5 is pregnancy complications, X6 is delivery complications,

X7 is child health complications, X8 is an attitude, X9 is violence, X10 is stressful life events, X11 is social support, X12 is experiences in the antenatal period, X13 is experiences during the first two weeks of postpartum period and X14 is physical issues

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Model No. 2-

Table: 69 Standardized regression coefficients, t values and level of significance of socio-demographic and cultural variables regressed on the prevalence of the postpartum depression *Dependent variable: Postpartum Depression Unstandardized Standardized Coefficients Coefficients Variables T Sig. B Std. Error Beta Socio-demographic and cultural variables -.121 .034 -.138 -3.498 .001 Age of the respondents X1 Education of the respondents X2 -.120 .038 -.141 -3.169 .002 Family monthly income X3 -.170 .034 -.224 -5.068 .000 Family members X4 .071 .029 .101 2.464 .014 Family type X5 .285 .068 .178 4.198 .000 Mother life X6 -.347 .050 -.289 -6.921 .000 Health problems X7 .164 .048 .131 3.388 .001 Health facilities X8 .058 .051 .045 1.121 .263 Sex of baby X9 .314 .070 .175 4.502 .000 Pressure to bear a baby boy X10 .264 .069 .147 3.853 .000 Social taboos X11 .029 .045 .025 .651 .516 R2 .465

Age, education, family monthly income, family members, family type, mother’s life, health problems, health facilities, sex of the baby, pressure to bear a baby boy and stereotype were the socio-demographic and cultural factors that are entered into a multiple linear regression model to see the importance of background variables that dispose women to PPD in relations with contributory factors. It is evident from the table that higher age reduces the symptoms of PPD moderately or severely. The value of regression coefficients 0.138 means that as the age is increasing, mothers reduced the risk of having symptoms of PPD by 0.138 units, significant at 0.001, level. Muraca & Joseph (2014) concluded the results in contrast to the present study, as the prevalence of PPD was significantly higher among the older mothers aged 40 to 44 years than in younger women aged 30 to 35 years. The study stated that the higher educational level and family monthly income played an important role in reducing the

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prevalence of PPD. Among these factors’ education has a coefficient of regression value 0.141 and family income has a value of regression coefficients 0.224. These values indicate that an increase in year of schooling decrease in women’s symptoms at 0.002 significance level; and increase in family income caused a reduction in respondent’s symptoms of PPD by 0.224 units, significant at 0.000 level. The number of family members caused an increase in the prevalence of PPD among women. As shown in the regression model, the value of coefficient 0.101 demonstrates that as there are higher number of family members, respondents are more prone to the risks of developing PPD at significance level of 0.01. Poor life as a mother and poor health status of the respondents were also significantly associated with a slightly increased risk of PPD. The value of coefficient 0.289 indicates that the symptoms of PPD were significant at 0.000 level for those mothers who have a healthy diet, good attachment with their husband and baby, perform domestic work properly or care their baby in a better way. In the model, the impact of poor health status since the last two years on PPD is found to have the value of regression coefficient 0.131 at the 0.01 percent level of significance. The most frequent health issues among the respondents were chronic pain, fever, cholera, anemia and blood pressure. In cultural variables, family type (joint or extended), sex of baby girl and pressure for the birth of a baby boy have a positive relationship with the response variable. Furthermore, health facilities and social taboos were found to be non-significant means that these variables have not relative importance in the model. Either these factors showed the relationship in bivariate analyses. The result of the present study shows the association in the line of previous study’s results. As Abdollahi et al (2014) indicates that high score of PPD were significant with a lower family income, family structure (joint or extended), age at marriage, husband’s education, low general health status and diseases. Another Rahman et al. (2003) viewed that when compared mothers living in nuclear families, mothers belong to the extended families were at the higher risks of PPD. Attachment theory proposed that a mother’s life is considered to be very difficult in treating with the everyday responsibilities and care for the baby. If these difficulties do not last long, it may a huge effect on mother’s attachment to her child (Whiffen and Susan, 1998). Without treatment some mother’s thoughts of harming themselves and their baby or even becoming suicidal (Beck’ theory, 2002). So, there is a need to provide emotional and physical support for better mood swings and deep unhappiness (PubMed health, 2016). For the current study, all these variables are

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considered in the model to identify the relative importance of each variable excluding age at marriage and husband’s education; because these variables had not shown a significant association with PPD checked by cross tabulation. So, these variables were dropped from the regression model. In contrast to the above results, health facilities and stereotypes have not shown a significant effect on the prevalence of PPD among respondents. Fitness model is estimated by using the coefficient of determination (R2) in order to access the contribution of predictor variable in the variance of the response variable. This indicates that the predictor variables are appropriate and relevant in the model, for such a specific problem that is being studied (Batool, 2010). In the above table, the value of R2 (0.46) highlighted that independent variables showed 46 percent variation in the prevalence of PPD. It is concluded that the values of R2 is identified that the independent (background) variables given in the model 2 is best suited to explain the dependent PPD variable in relations with contributory factors (obstetric and socio-psychological variables).

The value of regression coefficients (beta) is described for explaining the prevalence of PPD as follows:

Fitted Model

Prevalence of PPD = 30.612 + -.138X1 -.141X2 -.224X3+.101X4 -.289X5 +.131X6

+.045X7 +.178X8 +.175X9 +.147X10 +.025X11

X1 is the age of the respondents, X2 is education of the respondents, X3 is family monthly income, X4 is family members, X5 is life as a mother, X6 is health status, X7 is health facilities, X8 family type, X9 is the sex of the baby, X10 is pressure for the birth of a baby boy and X11 is stereotypes.

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Model No. 3- Table: 70 Standardized regression coefficients, t values and level of significance of psychosocial and obstetric variables and postpartum score regressed on the mother’s life *Dependent Variable: Mother’s life Unstandardized Standardized Coefficients Coefficients Variables T Sig. B Std. Error Beta Psychosocial Variables .174 .046 .173 3.785 .000 Attitude X1 Violence X2 -.145 .051 -.150 -2.840 .005

Stressful life events X3 -.120 .057 -.118 -2.108 .036

Social support X4 .354 .063 .277 5.602 .000

Pregnancy experiences X5 .011 .047 .011 .235 .815

Delivery experiences X6 -.148 .067 -.137 -2.212 .028

Physical issues X7 .066 .056 .062 1.163 .246

Prevalence of PPD X8 -.117 .052 -.136 -2.247 .025 Obstetric Variables -.028 .033 -.039 -.838 .403 Number of pregnancies X9 Number of abortions X10 -.024 .058 -.020 -.415 .678

Difficulty in feeding X11 .050 .046 .050 1.099 .273

Planned birth of baby X12 .139 .073 .091 1.899 .050

Pregnancy complication X13 .017 .055 .015 .301 .764

Delivery complications X14 -.030 .055 -.026 -.547 .585

Infant health complications X15 .071 .029 .101 2.464 .014 R2 .462

In the above table regression coefficients (unstandardized/standardized) of every predictive variable are specified along with t value, standard error and level of significance. Care for baby, diet habit, perform domestic work, attachment with baby and husband are the dimensions of the index as response variable (mother’s life). These are the factors that depict the life of a mother. Mother life is determined in three categories of good, fair and poor. Attitude, violence, stressful life events, social support, pregnancy experiences, delivery experiences, physical issues, general health problems and prevalence of PPD were the socio-psychological variables that are entered into a multiple linear regression model to explore the predictive variables that affects mother’s life.

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Among the psychological factors, attitude has a coefficient of regression value 0.173 indicates that harsh attitude caused the poor life of a mother at significance level of 0.000. Husband violence (verbal or physical) has a value of regression coefficient 0.150 and stressful life events has a coefficient regression value 0.118. These values depict that an increase in violence caused a poor life of mothers at 0.005 significance level; and an increase in stressful life event also caused a poor life of mothers by 0.167 units, significant at 0.03 level. Higher social support caused an increase in the good life of women. As shown in the regression model, the value of coefficient 0.277 indicates that as there is a high level of social support, mothers spend their life more happily at significance level of 0.000. The data viewed that violence, stressful life event, harsh attitude and lower level of social support were significantly associated with a slightly increased risk of PPD. It means that violence and stressful life events are the strongest negative predictor for good or fair mother’s life; and attitude and social support are the strongest positive predictor for good or fair mother’s life. Theoretical model suggested that if a mother is satisfied with her life and not being depressed in the postpartum period, obviously she will fulfill all the responsibilities in a good way. On another side, a depressed mother can’t care their baby and feel burdened. They also delayed attachment with their infant and spouse afterward a childbirth (Beck, 2002; Whiffen and Susan, 1998; Sullivan, 1953). The coefficient value 0.137 shows that life was poor for those mothers’ who feels or experience such issue within the first two weeks after delivery at the significance level of 0.02. The most frequent problems were crying, sleeping and eating disorders, anxiety, irritation and felt tiredness. In the model, pregnancy experiences, general physical issues and health problems were not found to be significant to the poor mother’s life. Which demonstrated that these factors have not a relative importance in the regression model. The impact of PPD on the mother’s life is found to have the value of regression coefficient 0.136 at the 0.02 percent level of significance. Results supported that the planned birth of a baby reduces the chances of mothers to live being happy or led their life in a good or fairway as the value of regression coefficients 0.091 shows an association at the significance of 0.05, level. Also, the infant health complications played a significant role in a mother’s life. Motherhood is a great challenge for women mentally and physically. Mothers faced a more critical situation if experience low mood, mood swings, anxiety, irritation and sleeping and eating disorder. They have more chances to develop PPD if these problems

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exist long and remain untreated. Cheng et al. (2009) found that unwanted pregnancy and PPD have negative effects on to initiate maternal care and breastfeeding; they were less likely to initiate maternal care (OR 0.34, 95 percent CI 0.3-0.5); and breastfeed (OR 0.74, 95 percent CI 0.57-0.97). Mothers felt anxious when they could not perform daily activities due to the number of challenges. Most of them lose their energy because they have not proper food that is necessary for their reproductive process. It’s a duty for women to do all the domestic chores, care their children, husband and elder ones; even they did it’s hardly because of their poor health status. The studies concluded that not only the family restriction creates hurdles in the relations of spouses, but also the emotional behavior of newly mother creates the contradictions. Theory supported that women need more attention of her husband during pregnancy or after childbirth, but the traditional families did not allow their spouses. In addition, mothers are avoided to attach with their husband because the maternal body, including the reproductive organs and hormone levels are proceeding to a non-pregnant state (Whiffen and Susan, 1998; Sullivan, 1953). Oates et al (2004) stated that emotional attachment and difficulties in the care of the baby are the sources of unhappiness among women almost in all centers of these countries (France, Italy, Ireland, USA, Sweden, Austria, Portugal, Switzerland and Japan), except of Uganda and UK Asian group. Furthermore, obstetric complications such as number of pregnancy and abortions, difficulty in feeding, pregnancy and delivery complications have not shown a relative importance in the regression model. In the above table, the value of R2 (0.46) identifies that independent variables showed 46 percent variation in the mother’s life. The results of the R2 indicate that the explanatory variables mentioned in the model 3 is best suited to explain the response variable (mother’s life). The value of regression coefficients (beta) is described for explaining the mother’s life as follows: Fitted Model

Mother’s life =16.718 +.173X1 -.150X2 -.118X3 -.277X4 +.011X5 -.137X6 +.062X7

-.136X8 -.039X9 -.020X10 +.050X11 +.091X12 +.015X13 -.026X14

+.101X15

X1 is an attitude, X2 is violence, X3 is stressful life events, X4 is social support, X5 is pregnancy experiences, X6 is delivery experiences, X7 is physical issues, X8 is health problems, X9 is the prevalence of PPD, X10 is number of pregnancy, X11 is number of

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abortions, X12 is planned birth of baby, X13 is pregnancy complications, X14 is delivery complication and X15 is infant health complications.

6.5 Summary: Multivariate Analysis For the present study, Model 1 and 2 are developed to see the relevance significance of contributory/explanatory variables on the response variable (Postpartum Depression). The independent contributory factors are presented in model 1. These were obstetric variables and psychosocial variables. To see the effect of background variables, the model 2 is developed. Because in the study, socio-demographic and cultural variables were considered as background variables. By using the two models, the study identifies how the explanatory (independent) variables have the effects on the prevalence of PPD along with the background variables. So, the model 2 shown that the background variables provided empirical evidence of the relations between the background and a dependent variable. The results identified that the number of abortions, planned birth of babies, pregnancy complications, and infant health complications were found to be significant in the regression model. Which highlighted that these were the obstetric variables that have a significant impact on the prevalence of PPD among mothers. In addition, the number of pregnancies, delivery complications were not found to be significant in the model. Form the psychosocial variables, harsh attitude of husband and in-laws, violence (verbal/physical), stressful life events, low level of social support, experiences and feelings during pregnancy have shown a relative importance in the model. Furthermore, age and education of the respondents, family monthly income, family type, health problems, sex of the baby (girl), pressure for the birth of the baby boy were the soci- cultural variables that found to be significant with PPD in the model. These were the variables that provided evidence of the relations between the background and a dependent variable. It means that not only the independent variables contribute to the development of PPD, but also there are some background variables which play an important role in the contribution of PPD. Here the explanation is made of the factors that are most likely to develop a causal chain between background variables and independent variables regressed on PPD. Education is the most important social factor. The knowledge about PPD based on the educational level of the respondents. Due to low levels of education and knowledge women are not aware about their mental health status, if they feel low mood, anxiety, stress during

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antenatal and postpartum period. Obviously, these are the strongest cause of postpartum depressive symptoms. Also, an uneducated woman didn’t know about their rights. It resulted in, they bear harsh attitude of husband, in-laws and also faced violence. Family monthly income is an important variable in the existence of any type of health problem. The expenditures of medication depend on family monthly income. Most of the obstetric complications occur when women have not enough money to utilize on her medication. Most of the complications such as stillbirth, hemorreoh and unsafe abortions occur, when they have not access to health care facilities due to low level of income. Also, home deliveries are higher in rural areas, because most of the families can’t bear the expenditures of hospitals. In addition, financial problem is found to be strongest variable of stressful life event in the model 1. Women are compelling to bear harsh attitude of mother-in-law and other family members of in-laws in the joint or extended family system. They create hurdles in all matters specifically maternal related practices. Most of the women depressed in their antenatal period when they have a pressure of the birth of the baby boy that leads to the PPD. It’s a cultural factor that puts the pressure on women to bear baby boy. It is concluded that both the obstetric and psychosocial variables are the contributory factors of PPD. The study also concluded that the effects of psychosocial factors are more likely to higher than the obstetric factors. As seen in the model 1, all the psychosocial factors shown a relative importance except the experiences within two weeks after delivery and physical issues. In addition, most of these factors are affected by the socio-cultural factors that are already discussed. Education, family income, family type and desire for the birth of baby boy may cause stressful life events (financial problem, health problem, in-laws home environment), utilization of health care services and treatment pattern that leads to PPD. Model 3 is developed to see the relevance significance of contributory/explanatory variables on the response variable (Mother’s life). In the model, harsh attitude of husband and in-laws, violence (verbal/physical), stressful life events, low level of social support, experiences/feelings during delivery and symptoms of PPD have a negative impact on the mother’s life. It is concluded that the planned birth of baby and infant health complications has shown a relative importance in the regression model. Obstetric complications such as number of pregnancy and abortions, difficulty in feeding, pregnancy and delivery complications have not shown a relative importance in the regression model.

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Chapter 7 QUALITATIVE ANALYSIS

Qualitative research is an exploratory research method used to gain an insight about behavior, beliefs, values and activities of a specific population. In qualitative analysis, focus group discussion was used. It is a useful tool permits the researcher to study the specific issue in depth and detail.

7.1 Focus Group Discussion Focus group discussion is a widely used technique for analyzing qualitative data. It is a process of discussion with a small group of people from similar background to develop the ideas and opinions about a specific subject. The group consists of 4 to 12 members (6- 8 preferred) selected from homogeneity criteria who participate in discussion for one to two hours (Quinn, 1990). The participants are guided by a trained moderator and facilitator. They are responsible to introduce the topics for discussion and assists the group members to participate in discussion amongst themselves (Moran, 1988). Focus groups should be carried out in order to assess obstacles for cultural or religious elements in their respective social context (Al-Busaidi, 2008). Focus group interview is used to deepen understanding of complex behavior; how a group of people feel and think about a certain issue; to identify the potential solution to a problem; and examine the resource allocation and strategic planning. It provides a wider range of detailed information and the opportunity to obtain clarification about individual or group feelings, views and opinions. The focus group is carried out by a moderator and one or more facilitator; to facilitate the group and to record the responses, opinions, interest, decisions and body language that people make in the social context. The role of the moderator is very important in the process of discussion. The moderator must have the ability to gain trust of the participants to collect maximum responses. Members of the focus group share their ideas in words; thus, it must be sure what a member means when using a common language. Sometimes same words have a diverse meaning in different cultures.

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7.2 Ethics of Focus Group Discussion There are some ethics for discussion as how to engage the participants and how to proceed and conduct a focus group discussion. Homogeneity is important, but participants should be allowed for divers and conflicting opinions. In addition to the idealistic responses, the participants should be anonymous to each other for independent responses. Typically, the discussion should be last between one and two hours. The questions should be kept in good order for the flow of responses at the selected time. Make sure that questions are understandable and applicable to all the participants and are helpful to encourage them for discussion. Also ensure the considering questions, contents, format and structure are appropriate for analysis. Before conducting the interview, the researcher makes sure that the questions are understandable by the participants. Informed the participants about the purpose of the group discussion; role of the participants; what is expected from them; and how long the discussion will last. The moderator describes the ground rule of the discussion and confirm that the privacy will retain.

7.3 Advantages of Focus Group Discussion There are a number of advantages of focus group discussion that should not be underestimated. It provides the opportunity for moderator to assemble the maximum and valuable information in a limited time and expenditure. The focus group offers the opportunity to obtain the missed and relevant data and the validity of quantitative findings (Jamieson & Williams, 2003). It's also helpful for the participants to produce additional information through discussion; and avoiding misconception or false information by check and balance on each other’s (Wilkinson, 1998b). The researcher can get maximum information through observing and non-verbal responses (body language or facial expressions).

7.4 Limitations of Focus Group Discussion It should not be assumed that the individuals in a focus group are expressing their own definitive individual view. They are speaking in a specific context, within a specific culture, and so sometimes it may be difficult for the researcher to clearly identify an individual message. This too is a potential limitation of focus groups. Although focus group research has many advantages, as with all research methods there are limitations. Some can be overcome by careful planning and moderating, but others are unavoidable

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and peculiar to this approach. The researcher, or moderator, for example, has less control over the data produced than in either quantitative studies or one-to-one interviewing (Morgan, 1988). The moderator has to allow participants to talk to each other, ask questions and express doubts and opinions, while having very little control over the interaction other than generally keeping participants focused on the topic. By its nature, focus group research is open ended and cannot be entirely predetermined. On a practical note, focus groups can be difficult to assemble. It may not be easy to get a representative sample and focus groups may discourage certain people from participating. For example, those who are not very articulate or confident, and those who have communication problems or special needs. The method of focus group discussion may also discourage some people from trusting others with sensitive or personal information. In such cases, personal interviews or the use of workbooks alongside focus groups may be a more suitable approach. Finally, focus groups are not fully confidential or anonymous, because the material is shared with the others in the group.

7.5 Selection of Participants and Location At the time of selection of the members, a number of questions arise. Who should participate in the discussion? How should the participants be involved in the discussion? How many groups of discussion are conducted? Which one should be invited firstly? Normally, 4 to 12 members are preferred for focus group, but the researcher can enhance the number of participants for maximum variation in responses. A room of any house is a suitable place to conduct the discussion. Before selecting the place, it was ensured that the place is neutral and accessible to every participant. Sitting arrangement was arranged around a table in U shape and all the members were in eye contacts with each other. Moderator herself selected an observable space to have an eye contact of all the participants.

7.6 Precession of Focus Group Discussion Precession of focus group discussion assists to understand the behavior and feeling of the participants. The facilitator was reached before the participants at the location and arrange the room. The seating arrangement was at one table in a U shape pattern; therefore, all the participants see one another. Firstly, facilitator received all the participants (mothers, having a baby under 1 years of age) with greetings and introduced all the participants

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with each other. A small talk was encouraged by the moderator before starting the formal discussion to create a friendly and comfortable environment.

7.7 Role of the Moderator Once the group discussion has been arranged, the role of the moderator is started. The focus group is carried out by a moderator with the assistance of the facilitator. The role of the moderator is essential for the focus group discussion. Being honest, the moderator must have the ability to gain trust of the participants rather than pressurizing the participants. He/she must have the ability to handle sensitive situation and avoid personal opinion and favoring specific participants. The moderator has the responsibility to anonymous data from the group. It is essential for the moderator to provide the equal time to each participant of the focus group and to avoid the dominance of one or two members. For the present study, the researcher acted herself as a moderator to attain the meaningful data. All these aspects were followed by the researcher in the process of discussion. She has the qualities of interpersonal skills and a good listener according to the demand of the focus group study.

7.8 Beginning the Focus Group Discussion Before starting the focus group discussion, some important points were described by the moderator. The purpose and ethics of the discussion were made clear to all the participants to understand the nature of the discussion. There will be equal opportunity for all the members and also permitted to give the opinions in favor or against the topic. This was necessary for the participants to express their views freely. They were informed some rules to keep in mind during discussions • This is merely a research study. • Speak all but one at a time. • Keep the time on track. • Try to keep the discussion on track. • Try to respond at all or most of the questions. • Avoid to reference of any person directly during conversation. • Your answers will be recorded on tape due to fear of missing the important points. • The session will continue about one and half hour to two hours without formal break.

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General to specific method was used to explore the views of the participants. The following some questions were asked during the discussion from the interviewers: 1. What are your views about postpartum depression among women? 2. In your opinion, how age, education, family income and type contributing to depression? 3. What are your views about the obstetric factors (pregnancies, abortion, births, unplanned pregnancy, types of birth); and antenatal and postpartum complications and care affecting postpartum depression? 4. How much contribution towards postpartum depression is made by stressful life events; social support; violence and son preference. 5. In your view, what are the most frequent symptoms of postpartum depression. Do you get help when facing these problems? 6. How does postpartum depression has an effect on the mother’s life? 7. What is your opinion about the role of family, BHUs and Government to eradicate the postpartum depression among mothers?

7.9 Conducting the Focus Group Discussion (Recording and Written Notes) The Focus group discussion was conducted by the moderator with the assistance of the facilitator. The two methods were used to record the responses, i.e. by taking notes and tape recording. The main purpose of using these tools is to collect maximum responses in their own languages or words without missing any concept. The moderator tries her best to make short notes without interrupting the continuing discussion. The tape recorder is an essential tool of the qualitative research method. In addition, it does not eradicate the importance of taking notes. Taking notes is helpful for the moderator to add up new questions during the interviewing process. The tape recorder was used to gather highest quality and to increase the accuracy of data. The tape recorder allows the researcher to be more concentrated to the participant. It was ensured by the facilitator the tape recorder is working properly by turning on and off. The tape recorder was kept on the appropriate place from where the views of all participants are recorded.

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7.10 Some Aspects to Improve the Quality of Data The following some steps were taken to engage the participant and to collect the valuable information from the interviewee. 1. The researcher herself acted as a moderator. 2. It was made sure that the selected place is neutral and reachable for all the participants (females). In addition, the selected places were comfortable and peaceful without interruption. 3. The seating arrangements were in the U shape around the table with equal distance. The reason was that the moderator, the facilitator and all the participants are able to keep eye contact with each other and listen to each other easily. 4. The accuracy of the tape recorder was checked through reversing to hear the tone of the voice. In addition, the participants were encouraged to improve their conversation. 5. The questions were set in sequence for a smooth discussion without interruption and try to keep on track. 6. Only open-ended questions were asked during the discussion, it permits the participants to a response from a variety of dimensions. The researcher was avoided to formulate the close ended questions because these questions against the ethics of qualitative studies. 7. A purposeful small talk was encouraged by the moderator before starting the formal discussion, to create a friendly and comfortable environment. 8. Clear explanation of the purpose of the study and the background knowledge was provided to all the participants to minimize the misconception and expectations. 9. Before starting the discussion, the participants were understood about the importance of their health, health care and services. 10. A strategy was developed to engage all the participants to convey their ideas and thoughts freely without hesitation. 11. The effort was made by the moderator to control the dominants and aggressive participants and encouraged the inarticulate or shy participants to contribute to the conversation. 12. In order to get the additional information, pause and probe methods were used. For example, by asking as would you describe further? Would you give more details? Can you give reference what you say? Please argue again, I did not understand?

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13. The tape recorder was turned off after the completion of discussion and said thanks to the participants. To get the satisfaction it was asked again if something is missing. When there was no response for further discussion, the moderator appreciated and thanked once again for cooperation.

7.11 Analysis of Focus Group Discussion The technique of content analysis is used to analyze the focus group discussion. The content analysis is defined as a research method for the systematic, objective, and quantitative description of the overt content of discussion" (Berlson, 1974). It allows the researcher to recover and examine the societal trend. Content analysis is a tool used to estimate the incidence of certain views or concepts within a text or set of texts. The text of the analysis may be described as article, chapters, books, interviews, newspaper headlines, conversation, discussion, essays, documents and any other way of communication. The process of content analysis is lengthy which may require to assure the all data and responses have done thoroughly. For the analysis, firstly, the moderator counts and examine the meanings, presence and association of such words and ideas. Afterward, the conclusions are made about the responses within the texts. The transcript reads out thoroughly, and makes the brief notes when found the most interesting, relevant and different type of information. Each item was categorized in the list for a description of what it is about; and distributed the list as major or minor categories for comparison and makes the differences. The data were organized through the process of cutting and pasting. Also, the abbreviated themes were written from the data. All the statements were arranged and filtered after examining each in detail. Establishing a data index and the process of labeling the various types of data was the first step of content analysis. Then, the data were classified in order to simplify the complexity of reality. Another moderator may have different opinions towards the data, so they were involved to code the data and to discuss and compare the results. Afterward the discussion a comprehensive summary was prepared. Also, the summary was compared with brief notes which were taken during the focus group discussion. Eight focus group discussions were arranged in eight union councils, two from each rural town of District Faisalabad. The total number of rural towns is four in District Faisalabad; namely, Jhumra, Jaranwala, Tandlianwala and Samundri.

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7.12 Results and Discussion 7.12.1 General Understanding about Postpartum Depression Postpartum depression is one of the most predominant psychological problem during a woman’s lifespan. Due to the high level of illiteracy and ignorance, women were unaware about their mental health conditions. The majority of the respondents were of the view that they don't know well about postpartum depression. Although, the quantitative result of the present study found that the most of the women had the symptoms of PPD, but they were unaware about their depressive disorder. When some participants were probed, one respondent said that “I feel anxiety and low mood after delivery of my last child, it means I suffer from postpartum depression. While, some participant had the opinion “mostly we have slept and eating disorder and felt fatigue after perform small activities”. A negligible proportion of participants clearly knew that what is postpartum depression. They had the correct information about PPD, because they visited doctors/psychologist for consulting their emotional health problems. Where, doctors diagnosed that they have the symptoms of PPD. It was analyzed that the majority of the participants had no knowledge and understanding about PPD. They attach a number of feelings and symptoms with PPD, but were unaware about the root cause of PPD. It was found that some of the mothers who were apparently depressed, anxious or worry were found to have moderate or severe PPD upon the scale of the EPDS. This is entirely due to mother’s low self-efficacy that changed their health behavior and plays an important role in developing PPD.

7.12.2 Importance of Education, Family Income and Family Type The majority, almost half of the participants were illiterate. Those who were illiterate, most of them had low levels of education (up to primary level). They reported numerous reasons, such as conservative socio-cultural setup, unawareness, inadequate resources and unavailability of educational institutions. Some of the participants were of the view that they had a lower opportunity to attain education than male in rural areas. Three women said that “traditional values is the main reason behind the female low literacy rate, where the cultural barriers compel them to get an education. One of them reported that “early age at marriage is a strong contributing factor of women’s lower literacy rate; because their parents preferred to marry their daughters over schooling. The majority of the participants in all FGD sees their role in the family as to bear and rear children, domestic

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chores and look after their elders. It was observed that some of the women were aware about the importance of education and understand that lack of knowledge about health- related information cause to maintain their health problems. Most of the participants were of the view that their families spend a large amount of income on food rather than on education and health. Five participants, two from an income category up to Rs. 10,000 and three from next higher income category said that “their joint family system is primarily impediment access to education. In the same way they can’t provide good education to their own children because of joint family system and low economic status. Our cultural norms and values shaped the family type that create contradiction to get an education as well as health care and services.

7.12.3 The Effect of the Obstetric Factors (pregnancy, abortion, birth, unplanned pregnancy, type of birth) and Antenatal and Postpartum Complications Obstetric factors are characterized as the maternal complications suffered by childbearing. The majority of the participants viewed that the obstetric complications occur due to the poor diet, unawareness about pregnancy and delivery related complications and unavailability of health care centers in their areas. Some of them reported that most of the complications exist because of birth at home in the absence of skilled birth attendants in rural areas. When some participants were probed, one of them said that ‘I want to go the hospital for childbirth, but my mother-in-law did not allow me and compel to assist my delivery at home by the untrained TBA (Dai). As a consequence, I delivered stillbirth because she can’t handle with high blood pressure”. Another participant was on the view that “obstructed labor cause maternal deaths. Most of the mother said that unintended/unwanted pregnancy was associated with increased risk of obstetric complications, may induce in developing the PPD. The importance of pregnancy placed women on the attention and care given throughout pregnancy; the number of antenatal visits depends on the pregnancy want ends. A large proportion of the participants were of the view that unsafe abortion incurs a high risk of complications such as chronic morbidity, hemorrhage and uterus infection. They argue that unsafe abortion tempted by untrained TBAs (Dai) is one of the major causes of maternal morbidity in rural areas. One of the mothers marked that low economic status unable them to pay for safe medical abortions. While, two of them replied that “we experience irregular menstruation after inducing abortion. Most mothers complained that they experience anemia, high or low blood pressure, vomiting, body swelling, difficult

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labor and postpartum hemorrhage. Almost half proportion of the participants reported abdominal pain. It is concluded that the identification of these complications was the potential risk factor of PPD. In short, it resulted in abortion, unintended pregnancy, complications during pregnancy and after childbirth is associated with moderate to severe PPD.

7.12.4 Contribution of Stressful Life Events, Social Support, Violence and Son Preference The most reported stressful life events among respondents were lower family income, in- laws home environment and health problems. Some said, “they feel depression and anxiety when pressurized by their husband or family to have a baby in the first year of marriage”. The presence of these symptoms (low mood, anxiety, stress) during pregnancy was the most robust predictor of PPD. Most of the participants were expressed that they can really overcome on all the motherhood related problems, if there is someone to support in a crisis situation when the support is really needed. Some of them said that “we feel more anxiety and stress when required to fulfill domestic chores with childcare responsibilities”. It was observed that mother who sought professional and family help with childcare responsibilities were less likely to have feelings of being depressed than those who did not seek help. Most of the mothers respond that they had been experiencing additional stress at the time of birth, when not supporting by their spouse. They stated that the husband is a primary supportive person, but the cultural values of our society didn’t allow their partner to assist them. It was also understandable by some mothers, “we need more emotional attachment of their husband during the antenatal and postnatal period”. Almost half of the respondents reported that their husband’s attitude is not good with them. Some of the participant’s husband used to inflict physical abuse. Even the behavior of husband and mother-in-law is too much changed when knows they deliver a baby girl. Two of them complained that “we are compelled to stay our mother’s house after the birth of a baby girl, also their husband didn’t visit here to see their daughters”.

7.12.5 Antenatal and Postpartum Care and Treatment Patterns The phenomenon of PPD was not understandable by most of the women because they had no proper education. It was recognized that rural women did not know about the symptoms and effects of postpartum depression. Though, the result of quantitative study

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indicates that most of mothers have the symptoms of depression on postpartum score, identified through EPDS. It was understandable by the majority of the respondents; the provision of antenatal and postnatal care and services is best for their good health. An increase visit at the antenatal care center increase the awareness of possible complications; may decrease the risk of PPD. Most were provided health care at BHUs or visited peers, hakim or traditional healer. Some of them have utilized the modern health facilities; even half of them reported the traditional birth at home. Five participants form the all the FGDs were revealed that “we can’t visit any health care professional or doctor without the permission of mother-in-law, even their husband allowed them. Utilization of maternal health care depends on the poor economic conditions and lack of availability of health care centers in rural areas of Faisalabad district. It was observed that the respondent’s feelings, expressions and views depict their socioeconomic deprivation.

7.12.6 Postpartum Depression and its Effects on Mother’s Life Although crying episode, anxiety, irritation, feeling tiredness and eating and sleeping disorder are observed more frequently in most of the postpartum mothers. Members also reported eating non-food items/pica (un-cooked rice and gachi) during their pregnancy. Two of them added an interesting thing that they eat coal (koala) because they listen that “the color of their new born will white if they eat coal during pregnancy. Likewise, these stereotypes are most common in rural area of Faisalabad. Motherhood is the most beautiful experience of a woman’s life. Most of the participants were expressed that they felt anxiety and stress when didn’t fulfill the desire expectations of motherhood. They were of the view that our cultural traditions led the requirements for mother to perform specific duties. Where, mother-in-law or sister-in law play an important role and put the pressure on them to have a particular behavior according to their desire. It was understandable by some of them, depressive symptoms may occur when there is a contradiction between the defined expectations of motherhood and their personal feelings and experiences. It was identified from all the FGD, typically, the majority of the participants were uneducated with lower economic status and unaware about the reasons and consequences of PPD. Actually, it was a matter of shame for them to discuss their personal problems with others. It is important to note that the discriminating attitude towards women affected the health of mothers’ emotionally and physically, along with elevating the risks of PPD. Most of them who understand the effect

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of PPD on mother’s life, were reported that the care of their baby is badly affected by PPD. Childcare anxiety occurs when a depressive mother can’t care their baby in a better way. When asked about their diet habit, they viewed that “we had no proper shelter and take a meal (chappati) twice a day hardly, and you asked about healthy and nutritional diet”. It was observed that most of the mothers have poor health status and can’t perform domestic work properly. The burden of work negatively effect on mother’s life along with the depressive symptoms in the postpartum period. When participants were probed, three of them expressed that “we are not only responsible to perform domestic chores, but also involved in livestock and agricultural activities. One mother of eight children said that “I am not only to prepare food and look after my children, but also look after my mother-in- law”. It was recognized that PPD has a negative effect on mother’s attachment with their baby and husband. A mother is more prone to elevate the risks of stress when her attachment needs are not being met by her partner. The attachment theory explains that when the husband and wife are securely attached to another, obviously they will support to each other. Difficulties occur when intimate partner is avoiding to attach that leads to the postpartum depression (Whiffen and Susan, 1998).

7.12.7 Role of Family, BHUs and Government to Eradicate the Postpartum Depression among Mothers Participants of all the FGD’s give some opinions to eradicate the symptoms of PPD. Their opinion about the role of family, BHUs/Government health institutions are described in forms of suggestions: ➢ There is a need to employ the gynecologist in rural areas. ➢ Number of LHW/LHV should be increased. ➢ Need for the mobilization of both male and female in using family planning methods. Because the number of mothers were of the view that their husband and family members didn’t allow them to use family planning methods. ➢ The antenatal and postpartum period is to be considered the most critical period for mothers, may elevate the risk of developing postpartum depressive symptoms. So there is a need for the counseling of husband, mother-in-law and other family member in terms of having supportive and positive behavior for mothers. ➢ Emergency facilities should be provided to mothers in both antenatal and postpartum periods.

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➢ Diagnostic tests and prescribed medicine should be free, there is an assurance of the availability of medicine at the dispensary and BHU. ➢ To provide nutritional food for the healthy mothers. ➢ An essential need to provide awareness about psychological related disorders. ➢ A need for the appointment of psychologist in government hospitals or related health institutions.

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Chapter 8 SUMMARY: FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

8.1 Main Findings The main findings, conclusion and recommendations of the present study are presented in this chapter. The main findings are presented in five categories, such as socio- demographic, obstetric, cultural and psychological variables and effect of PPD on the life of mothers for the suitability of the readers. Furthermore, the significance of the results has been related to the previous studies in the context of the theoretical perspectives.

8.1.1 Socio-demographic Variables 8.1.1.1 Age of the Respondents and Age at Marriage For the present study, respondents were selected under the age category of 15-49 (reproductive age) years. The result shows the distribution of respondent according to the age group as 42.0 percent belonged to age category 26-30 years, 22.0 percent belonged to 21-25, 19.0 percent belonged to 31-35 and 12.5 percent belonged to 15-20, while 4.5 percent belonged to 36 and its above years. The mean current age was 2.81 years with standard deviation 1.028 years. In bivariate analysis, the value of chi-square (58.149) shows a strong significant relationship (P=0.000) between the response and predictive variables. Gamma value (-0.314) indicates a strong negative relationship between these variables. It is evident from the multivariate analysis of the present study, the value of regression coefficients is 0.138; means as the age is increasing mothers reduced the risk of having symptoms of PPD by 0.138 units, significant at 0.001, level. It was found that mothers of older ages had significantly lower rates of depression than younger mothers; as the prevalence of PPD was significantly lower among mothers who belong to the age of 31 years or older than those who belong to the age group of 21 to 25 years and 15 to 20 years. Others, concluded the results in the same line, teenage mothers experienced more PPD, as compared to women of 35 years or older (Negron et al., 2013; Ashok, 2007). The results indicate that the early marriage is still applied in rural areas of Pakistan. The distribution of the respondents according to the age at marriage shows that a large proportion of females have been married at young ages (majority 54.5 percent got married in the age group of up to 20 years). The results of the bivariate analysis didn’t show the

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relationship between the dependent and independent variable. In contrast to the present study, Ashok (2007) showed a strong relationship between the early marriages and the depressive symptoms in the postpartum period as hypertension was found to be highly significant with teenage mother’s depressive disorders. Researchers identified that early marriages have a negative effect on their health due to the number of births, illiteracy, unawareness of childbearing process and lack of control over their own bodies (Batool, 2010; Beck, 2002).

8.1.1.2 Education of the Respondents The present study examines the effect of mother’s educational level on the prevalence of PPD. The distribution of the mothers, according to their education highlighted that almost half percent of the respondents were illiterate and only 10.5 percent had up to intermediate (12 years of schooling) and above level of education. In bivariate analysis, chi-square value (64.273) show a highly significant association between education of the respondents and the prevalence of PPD. The gamma value (-0.496) shows a strong negative relationship between the variables. Among the social factors, education has a value of regression coefficient 0.141; it means an increase in year of schooling decrease in women’s symptoms at 0.002 significance level. There are a number of cultural, economic and social reasons behind the low level of female education in the rural areas of Pakistan. The most associative factors are fulfilled domestic chores, look after their siblings and elders, financial restraints; and also, parents didn’t allow them to go outside the home due to honor and safety. Other studies also concluded the contribution of education in the prevalence of PPD. They found a strong correlation between the women’s personal education and PPD; the level of education is an important indicator to eradicate the symptoms of PPD (Mazaheri et al., 2014; Tannous et al., 2008; Serge et al., 2007).

8.1.1.3. Family Monthly Income The distribution of the respondents, according to their family monthly income determine that low socioeconomic status contribute to poor health status (psychological and physical). The results show that more than half, 57.0 percent of the respondent’s family monthly income was up to 20000 rupees, and 18.0 percent respondent’s family monthly income was 40000 and above. In bivariate analysis, the value of chi-square (38.540) shows a highly significant association; and the gamma value (-0.269) shows a strong

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negative relationship between family income of the respondents and the prevalence of PPD. A value of regression coefficients (0.224) indicates that an increase in family monthly income caused a reduction in mother’s symptoms of PPD by 0.224 units, significant at 0.000 level. Mothers face a number of barriers (inadequate diet in terms of quality and quantity, lacked access to attain medical facilities and psychological treatment) due to financial instability; associated with low mood, anxiety and stress among women, may elevate the risks of PPD (Health Resources and Services Administration, 2013; Edwards et al., 2012; Pearlstein et al., 2009; Beck, 2002). Another study found a significant correlation of variables related to PPD (P > 0.05), such as mothers’ education, personal and family financial status and unwanted pregnancy (Mazaheri et al., 2014).

8.1.1.4 Total Number of Family Members The present study depicts the high ratio of family members in rural areas of Pakistan. The distribution of the mothers, according to the number of family members shows that almost 1/3 part of the women had more than 10 family members. If add up the findings, half percent of the respondent’s family members consist of more than 8 members. Chi- square value (28.478) showed a significant association (P = 0.000), and the gamma value (0.185) indicates a positive relationship between the total number of family members and the prevalence of PPD. The multivariate analysis also supports the significance between the response and predictive variable. As shown in the regression model, the value of coefficient 0.101 shows that as there are higher number of family members, mothers are more prone to the risks of developing PPD at significance level of 0.01. It is evident from the results that the distribution of family income is highly affected by the total number of family members, as these families are compelled to live hands and mouth. Most of the mothers remain unhealthy because they could not maintain their diet and utilize their income on health. It resulted in, the pregnancy and childbearing related complications occurred leading to the symptoms of PPD.

8.1.1.5 Health Problems of the Respondents for the Last Two Years In Pakistan, women’s health problems remain unnoticed and untreated with the other social and cultural issues, specifically in rural areas. Most of women were at higher risks of communicable diseases due to unhygienic food, poverty, lack of awareness, low level of education and inability to attain good health facilities. The results of the present study

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identified that the most common health issues for the last two years among respondents were anemic (54 percent), fever (45 percent), chronic pain (42 percent), cholera (29 percent) and high or low blood pressure (17 percent). Bivariate results found a strong (chi-square value, 25.079) and a positive (gamma value, 0.325) relationship between the health problems for the last two years and the prevalence of PPD. In the regression model, the impact of poor health status since the last two years on PPD is found to have the value of regression coefficient 0.131 at the 0.01 percent level of significance. It connotes that mothers who suffer from different health problems to a great or some extent were more likely to be depressed than those who have a good health status. There are more chances of low mood, anxiety and stress throughout their life with poor health status. Mothers may diagnose of PPD if these symptoms occur during pregnancy or afterward childbirth.

8.1.2 Obstetric Variables 8.1.2.1 The Number of Children and History of Previous Pregnancy and Delivery According to the results, majority 39.0 percent of mothers had 1 – 2 number of children and 16.8 percent of them had 5 and more than 5 numbers of children. In the present study, the number of pregnancies shows high fertility trends in rural areas of Pakistan. As the data shows that more than 5 numbers of pregnancies were among 27.0 percent of the women. A young married woman had more chances to become pregnant due to the long reproductive period (15-49); and multiple pregnancies and abortions makes the condition worse. According to the results, almost 30 percent of the women had experienced abortion or miscarriage. Among all who experienced abortion, 79.0 percent of them had the experience of heavy blood loss and 21.0 percent had the experienced of light blood loss. Most respondents, 39.8 percent delivered 3 or more babies. But the present results indicate the lower number of children as almost 39 percent had 1-2 number of children. It means that women experienced stillbirths or their babies were dying as they delivered 3 or more babies. The present study also found a relationship between pregnancy, abortion and PPD. In bivariate analysis, the value of chi-square (16.986) and (12.454) showed a strong relationship between the number of pregnancies and PPD and the number of abortion and PPD respectively. The value of gamma (0.141) and (0.238) indicates a strong positive relationship between these problems and the prevalence of PPD among

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women. It highlights that mothers with multiple pregnancies and complications are more prone to experience the problems of abortion, hemorrhage or still births. These are the strong predictive factors that place a mother on higher risks of anxiety, stress and depression in antenatal and postpartum periods leads to the symptoms of PPD. In rural Pakistan, most of the mothers are forced to choose traditional methods or visit to Dai (TBA) for antenatal care and services. For the multivariate results, the value of regression coefficients 0.100 means that as the number of abortions is increasing, mothers increased the risk of having symptoms of PPD by 0.100 units, significant at 0.030, level. Most of the women had experienced of low mood, sadness and anxiety during pregnancy and afterward a childbirth (PubMed Health, 2106); and the pregnant women with number of children are more prone to elevate the PPD (Ghajati et al., 2015). For the present study, the number of children, deliveries, live and dead births were not found to be significant in the bivariate analysis; and the number of pregnancies has not effect on the response variable in terms of its variation.

8.1.2.2 Planned Birth of the Baby The phenomenon of unplanned pregnancies exists due to lack of knowledge and financial restraint; husband and family have religious objection and behavior regards family planning methods; and availability, inaccessibility, and poor quality of family planning services. The distribution of the mothers, according to the planned birth of baby shows that more than half percent of the respondent’s baby births was unplanned. The value of chi-square (32.989) shows a strong relationship, and the value of gamma (0.378) shows a strong positive relationship between the unplanned birth of a baby and the prevalence of PPD of the respondents. The value of regression coefficient 0.100 indicates that an increase in planned birth of a baby caused a reduction in women’s symptoms of PPD by 0.100 units, at the significance level of 0.027. Mazaheri et al. (2014) demonstrated that the predictor variables such as maternal education, maternal occupation, financial status, unintended pregnancy, type of delivery, miscarriage and undesired sex of a baby were significant with PPD; where, the unplanned pregnancy was a strong predictor than other variables (ß = 0.24). A number of studies also found a strong relationship between planned births and PPD; mothers with planned/intended births are less likely to elevate PPD (Cheng et al., 2009; Finer and Henshaw, 2006; Nakku et al,. 2006).

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8.1.2.3 Pregnancy Complications In the present study, the most of the pregnancy related complications of the respondents were: anemic (59.5 percent), vomiting/nausea (48.3 percent), abdominal pain (42.8 percent), high blood pressure (35.0 percent), stomach ache (33.8 percent), headache (33.3 percent), low blood pressure (27.5 percent), and body swelling and vaginal bleeding (19.0 percent). The value of chi-square (31.848) and gamma (0.316) shows a strong positive relationship between the complications during pregnancy and the symptoms of PPD of the respondents. Furthermore, pregnancy complications had a coefficient value 0.134 at 0.004 significance level. It is identified from the above results that high and medium complications during pregnancy caused severe or moderate PPD among women. It can be expressed that these problems have the impact on maternal life, including low mood, stress, anxiety, hypertension and negative thinking. Mostly, all of these psychological troubles occur during pregnancy, which ultimately increase the risks of PPD (O’Hara, 2009).

8.1.2.4 Checkup During Pregnancy The distribution of the respondents regarding checkup during last pregnancy depicts that the majority 43.5 percent of pregnant women did visit private hospitals; 30.0 percent of them did visit a government hospital; and 18.0 percent of them did not visit any health care center for checkups during last pregnancy. In rural Pakistan, women can’t maintain their health due to lack of knowledge, inadequate access and lack of health care centers and insufficient or untrained paramedical staff. In most of the cases, women are not allowed to go outside the home for checkups and treatment, even though the basic health units were available in their villages. Antenatal and postpartum period receives less attention from health care providers. In this sense, PPD remains untreated because of lack of knowledge among women, and largely neglected by a health care professional (Groh, 2013; Amnesty International, 2010; WHO, 2008). Checkup during pregnancy have not shown an association with PPD in the cross tabulation.

8.1.2.5 Place of Birth of Baby and Type of Delivery The majority 34.8 percent of the respondents delivered their last baby at home, 32.0 percent at private hospitals or clinic and 31.5 percent in government hospitals. The majority of the deliveries at home depicts the women’s miserable and helpless condition. Childbirth at home can cause a number of complications for both maternal and infant. It

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may raise the chances of postpartum hemorrhage, stillbirth, infant’s physical disability and maternal or infant death. A number of studies found that almost half percent of rural women delivered their last baby at home under unhygienic environment (Batool, 2010; Hakim and Zahir, 2001). The condition is worse in less developed areas of Pakistan, where, 77 percent of deliveries were occurring at home in the rural areas of district Thatta (Mirza, 2007). The study found that the majority, 65.8 of the respondents delivered their last baby in normal case, 32.8 percent with caesarean and 1.5 with assisted delivery type. Furthermore, the incidence of the symptoms of PPD did not occur due to the place of birth of a baby and type of delivery, that was checked through chi-square and gamma value.

8.1.2.6 Complications during Delivery The distribution of the women according to their complications during delivery were found as water bag broke (37.5 percent), postpartum hemorrhage (28.8 percent), difficult labor (23.3 percent), high blood pressure (17 percent), early childbirth (12.8 percent), and low blood pressure (12.3 percent). Delivery complications of the respondents have a significant association with the prevalence of PPD, as shown the value of chi-square (19.293) and gamma (0.286). It depicts a high and medium complication of delivery caused severe or moderate PPD among women. It means that the postpartum hemorrhage, difficult labor, high or low blood pressure and early child birth were frequently associated with postpartum depression. Postpartum depression occurs due to the lack of proper physical or psychological services, especially after delivery of a baby (Ronaq, 2014; Dennis et al., 2012; O’Hara, 2009). But in the present study, these problems have not a significant effect on the dependent variable in the regression model. In addition, rural mothers are more prone to face health problems as compared to urban women due to inadequate health facilities.

8.1.2.7 Infant Health Problems during Pregnancy and Late Neonatal Care The study depicts that child health complications during pregnancy and in neonatal period have a negative effect on psychological and physical health status of mothers. The most reported problems during pregnancy were low weight birth (30.5 percent), short breath (21.0 percent), premature (13.3 percent), water shortage (10.8 percent), heartbeat problem (8.3 percent), and the baby’s movements stopped at the time of birth (7.8 percent). The problems of neonatal period were a problem in sucking (28.3 percent), pale skin (25.5

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percent), stomach ache (20.8), hand and feet cold (9.8 percent), and congenital problem (6.0 percent). In bivariate analysis, the value of chi-square (14.415) and gamma (0.206) indicates a strong positive relationship between the infant health problems and the prevalence of maternal’ PPD. In regression model, child health complications have a coefficient value of 0.137 at 0.003 significance level. It means that the chances of postpartum depression are more likely to high with poorer health status of the baby (during pregnancy or late neonatal period). PPD has a negative effect on the mother infant relationship and maternal role in the early postpartum period (Leahy-Warren et al., 2011; Stapleton et al., 2012); also, the PPD have an impact on infant health (physical health, sleeping hours and weight gain) and well-being. Other, Gress-Smith et al. (2012) concluded that mothers with higher depressive symptoms had gained less weight child and their infant had more health problems.

8.1.3 Cultural Variables 8.1.3.1 Family Type The distribution of the respondents according to the family type indicates that 58.0 percent of the respondents belonged to joint family and 37.5 percent of them belonged to nuclear family. Chi-square value (22.718) shows a significant association (P = 0.000) between respondent’s family type and PPD. The gamma value (0.342) shows a strong positive relationship between these two variables. The value of the regression coefficient (0.178) indicates that women who lived in a joint or an extended family system were on the higher risks of developing PPD at 0.000 significance level, than those who lived in a nuclear family system. Mothers who lived in joint family system, reported that mother-in- law’s behavior and husbands’ emotional distress for their wife due to family pressure were highly significant with their low mood, mood swings, sadness and anxiety. These are the strongest predictor of PPD. A factor that has a more important role to predict PPD is the one that joint or extended family system (Abdollahi et al., 2014; Rahman et al., 2003).

8.1.3.2 Sex of the Baby Frequency distribution regarding the sex of the baby was 54.5 percent baby boy and 45.5 percent for baby girl. The bivariate analysis indicates the relationship between the sex of the baby and the prevalence of PPD as shown the value of chi-square (25.694) at the

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significance level of 0.000. The gamma value (0.393) also shown a strong positive relationship between baby girl and PPD. The coefficient value (0.175) demonstrated that mothers were on the higher risks of depressive disorders in their postpartum period who delivered a baby girl at 0.000 level of significance. In Pakistani culture, married couple are expected to have a son for the continuity of descent. Baby boy is considered as a source of income and family feel proud within relatives. Most of the mothers mentioned that to become a mother should be a happiest time of her life, but instead of joy she felt depressed at the birth of her daughter. Women faced serious problems in their marital life who cannot deliver a baby boy (Ho-Yen et al., 2007). The dissatisfaction in infant’s sex (birth of a baby girl) is not only a cause of PPD, but also the depressed mothers are more likely to arise depressed babies. Some of them reported that girls are burdened for them, when getting married the family property is transferred to another family in the form of dowry.

8.1.3.3 Pressure for the Birth of a Baby Boy The study found that almost half percent of the respondents faced pressure for the birth of a baby boy, where, the most of the mothers were pressurized by their husband and mother-in-law. Gender of the newborn is a central issue for the mothers with relation to PPD. In Pakistan, husband, mother-in-law and other family members considered that only the women are responsible for the birth of a baby girl. The attitude of husband and in- laws is changed when they knew she delivered a baby girl. In bivariate analysis, the value of chi-square (35.716) and gamma (-0.465) confirmed the existence of and negative relationship between the predicting and response variable. In the regression model, coefficient value 0.147 indicates that those women who pressurized for the birth of a baby boy were more likely to be depressed in the postpartum period than those who were not pressurized by 3.853 units, at 0.000 level of significance. In contrast to eastern societies, the western parents have a mixed gender preference (Mills & Begall, 2010; de Tychey, 2008).

8.1.3.4 Social Experiences and Social Taboos The distribution of the respondents regarding to their social experiences and social taboos was identified as follows: • The majority 32.8 percent of the respondents were not allowed to go outside the home at sunset time during pregnancy.

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• Almost half percent of women were experienced to eat specific things during pregnancy. About, 57 percent of women were not allowed to meet with that woman whose baby was expired during pregnancy or after birth. • About, 57.8 percent of mothers were of the view that all the negative signs (Nausea, ugly, faster heartbeat) mean it will be a girl and all the positive symbols (sweet tooth, beauty) point to a boy. OR look so huge! You have twins. • The most 50.5 percent of women were forced to eat butter (ghee) in the last month of pregnancy to increase the chances of normal delivery and stay at home for forty days after the baby is born, maybe something bad happens. • 45.3 percent of newborn babies were wrapped tightly to extend the child's arms and legs in length. • The majority 53.5 percent of mothers didn't keep newborn's clothes beyond forty days. • 40.8 percent experienced the greetings in the way of congratulations on just giving birth! Now quickly have another one. • The majority 74.0 percent of respondents put the iron (knife) and matches nearby the newborn or lock to his/her bed (caught/charpai). • The most 89.0 percent of the mothers were reported that they hear about their hair will begin falling when baby starts talking. In bivariate analysis, the value of chi-square (11.339) shows a relationship between social taboos and the probability of occurrence of PPD, at the significance level of (P=0.023). Where, the value of gamma (0.150) indicates a positive relationship between the dependent and independent variable. Mothers have to follow specific rules for food, hygiene, breastfeeding maintenance, sexual activity and care for newborn. All these practices can increase the level of low mood, anxiety and stress among mothers, if continued afterward childbirth may raise the risks of developing PPD (Staneva et al., 2015: Hilten, 2015). The theoretical model proposed that traditional societies place the women in such conditions which create a contradiction to continue the normal routines of everyday life (Beck, 2002). Leung et al. (2005) illustrated in the contrast of the present results, as some cultural and traditional practices in postpartum period played a crucial role in reducing stress among Chinese women.

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8.1.4.5 Health Care Facilities Frequency distribution regarding the less amount of utilization and availability of health care facilities were found as diagnostic tests are not available and free to the majority 66.5 percent of the respondents; the privacy is not maintained to the mothers (66 percent) emergency aid is not available in the respondent’s area (64.8 percent); have not the facility of basic health units where the patients are admitted (almost half percent); and did not get the proper supply of medicine (47 percent). The availability of the services was identified as multivitamins are provided to some extent by the LHW/LHV (46.8 percent); the family planning services are provided (64 percent); the vaccination is provided when needed (84 percent); and the facility of sanitation services is provided to some extent (36 percent). The value of chi-square (11.647) showed a strong relationship between the variables. The value of gamma (-0.032) indicates a negative relationship, means a woman who attains basic health facilities were less likely to be depressed in the postpartum period than those women who have not attained these facilities. In Pakistan, the most of the women face hurdles in access to health care due to diverse geographical, cultural and domestic unrest. These problems are highly prevailed in rural areas, where the travel is often a major challenge in accessing health care. As a result, Pakistan’s rank is the third highest in the world with the number of maternal deaths (Ronaq, 2014; GHETS, 2013).

8.1.4 Psychosocial Variables 8.1.4.1 Attitude The distribution of the family attitude towards mothers illustrated that the husband’s attitude was good for 73.5 percent; mother-in-law’s attitude was good for 46.0 percent and harsh attitude was about 17.0 percent; family members’ attitude was good for almost 53 percent; and LHW/LHV and doctors’ attitude was good for almost 62 percent of the respondents. The value of chi-square (59.734) and gamma (-0.455) found a strong and a negative relationship between the attitude and depressive symptoms of women in the postpartum period. The value of regression coefficient 0.090 demonstrated that the harsh attitude of the husband, mother-in-law, family members, doctors and LHV/LHW increases the risks of developing PPD among the respondents, at the significance level of 0.03. Furthermore, it was analyzed that the attitude of the husband and mother-in-law are the strongest positive factors to increase the risks of depressive disorders. Whereas, the most of the mothers were on the view that the behavior of health care providers plays an

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important role to minimize or maximize the depressive symptoms. As the American mothers reported that they feel frustration and humiliation when visit to doctors; and the Australian and Canadian mothers narrated that their physicians are preferred to prescribe medications in order to deal with PPD rather than offering counseling (Logsdon et al., 2012; Sword et al., 2008).

8.1.4.2 Violence The distribution of verbal or physical violence found that mothers faced abusing (38.8 percent); teasing/taunting (40.3 percent), slapping (22.1 percent); and beating (12.3 percent). In bivariate results, the value of chi-square (70.177) found a significant relationship (P=0.000) and the gamma value (0.538) established a strong positive relationship between the violence and PPD of the respondents. In the model, verbal or physical violence having the association with PPD by 0.135 units, significant at 0.007 level. Violence is not only involving physical harm or force, but also includes sexual, emotional, psychological and spiritual violence. It may consider a chief cause of women’s psychological and physical complications, as mothers who faced domestic violence were twice as likely to have symptoms of PPD (Ronaq, 2014; Grens, 2012; Kornfeld, et al., 2012; Grens, 2012; Zhang et al., 2011).

8.1.4.3 Stressful Life Events The most of the reported stressful life events were financial problems (55.3 percent); mother-in-law and husband had a desire to be pregnant in the first year of marriage (39.0 percent and 33.3 percent, respectively); in-laws home environment (32.8 percent); health problems (24.0 percent); change home (23.8 percent); death of love on (19.5 percent) and relationship changing (17.5 percent). Chi-square value (86.706) showed a strong significant association (P = 0.000) and a strong positive relationship (gamma value, 0.568) between stressful life events and the incidence of PPD. In the regression model, stressful life events is found to be the strongest predictor in increasing the prevalence of PPD. The predictor variable has a coefficient of regression value 0.245 at 0.000 level of significance. Others, recognized that almost 15-20 percent of mothers had postpartum depressive symptoms; among them, 46 percent were depressed because of stress and social support related factors. With these factors, antenatal depression, low mood, anxiety and childcare stress were the strongest predictors of PPD (Jafarpour et al. 2014; Leung et al., 2005).

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8.1.4.4 Social Support The study analyzed that almost 86 percent of the respondents had a support of their husband to a some or great extent; almost 53 percent had a conflict with their husband or husband control their feelings; almost 61.0 percent felt that family and friends had always supported them to some extent; and 53.5 percent had a support of their mother-in-law/in- laws in the care of their children to some extent. The value of chi-square (26.419) shows a significant association (P = 0.000) and the gamma value (-0.384) confirm a strong negative relationship between these variables. Social support has a value of regression coefficients 0.205, at 0.000 level of significance, means that women who had the social support, were not depressed in the PPD. A number of studies concluded that high levels of social support of mothers were significant in adjusting to their new situation, and lack of social support was associated with PPD. Also, mothers who attain professional help tended to feel more relaxed and safety during the PPD (Corrigan et al., 2015; Shapiro & Fraser, 2013; Brown et al., 2012; Kim et al., 2012; Chien et al., 2012; Edwards et al., 2012; Xie et al., 2009; Ugarriza et al., 2007).

8.1.4.5 Feelings and Experiences during Pregnancy The study identified that most of the respondents had experienced eating disorder (61%), sleeping disorder (58 percent) and crying episode (34 percent). The frequency distribution according to the feelings of women during pregnancy were tired (83 percent), irritation (78 percent), and anxiety (79 percent). Chi-square value (48.121) verified a significant association (P = 0.000) between women’s experiences and feelings during pregnancy and PPD; and the gamma value (0.456) confirmed a strong positive relationship. Experiences during pregnancy showed a significant impact on PPD with a regression coefficient value 0.234, at a significance level of 0.000. According to the results most of women experienced the problems of crying, sleeping or eating disorder; and felt irritation, anxiety and tiredness to a great or some extent during pregnancy. PPD occurs when these symptoms are severe and last for more than two weeks, it may occur any time within the first year of childbirth. A number of studies mentioned that the most frequent symptoms of PPD can include change in appetite, feelings of guilt, and suicidal thoughts (Dennis et al., 2012; O’Hara, 2009; Pearlstein et al., 2009).

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8.1.4.6 Feelings and Experiences within the First Two Weeks after Delivery The results indicate that the majority of the respondents had experienced sleeping and eating disorder (55 percent) and crying episode (30 percent). The study also narrated that most of the women felt tired (76 percent), irritation (72 percent) and anxiety (41 percent) within the first two weeks following childbirth. In bivariate analysis, chi-square value (59.428) make a significant association (P = 0.000); while, the gamma value (0.513) proves a strong positive relationship between women’s feelings and experience within the first two weeks after delivery and PPD. In another way, these issues did not confirm the impact in relations to PPD in the regression model. Change in appetite, anxious thought, loss of interest, poor concentration and worry about the future were the signs of PPD (Bogdanovska, 2016). In contrast to the above findings, frequently variables such as feeding, health of baby and baby crying were not contributing to irritation, negative feelings and frustration, yet the difficulty in feeding caused unhappiness (Oates et al., 2004).

8.1.4.7 Breastfeed to Last Baby and Facing Difficulty Breastfeeding have not only the effects on mother and infant, but also have a strong impact on the bonding between infant and mother. It may have a possible psychological connection with postpartum depression. The distribution of the mothers according to breastfeed to the last baby indicates that the majority 77.0 percent of the respondents were breastfed their last baby. Among them, almost 64 percent of the respondents were felt difficulty when breastfeeding. In the cross tabulation the value of chi-square (11.255) exemplify a relationship between the difficulty in breastfeeding and the prevalence of PPD of the respondents. The value of gamma (0.230) indicates a negative relationship between these variables. It means that those women who faced difficulty in feeding were more likely to be depressed than those who have not faced. A number of studies reveal the prevalence of PPD is at high risk with decreasing breastfeeding (Stuebe et al., 2012; Nishioka et al., 2012). In addition, women with difficulties in breastfeeding may have a higher incidence of depressive symptoms, should be screened for PPD.

8.1.4.8 Physical Issues in the Postpartum Period The distribution of the respondents according to their health issues in the postpartum period shows that almost 44 percent had faced menstruation problem (to a great and some extent); 22.0 percent of the mothers loss their weight (to a great and some extent) with

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equal percentages; almost 30 percent of them gained their weight (to a great or some extent); almost 1/3 proportion of the sample’ body image change either to a great extent (14.0 percent) and some extent (20.0 percent); 39 percent of the them were loss their energy and perform activities slowly to a great extent; and the majority 42.0 percent of the respondent’s marital life was disturbed after delivery of last child to some extent and 22.3 percent to a great extent. Theory concluded that a newly mother needs more attention of her husband, but the traditional families did not allow the spouses (Sullivan, 1953). In bivariate analysis, the value of chi-square (35.282) and gamma (0.392) point out a strong positive relationship between these variables, but these problems did not regress on PPD in the model.

8.1.5 Dependent Variables 8.1.5.1 Prevalence of PPD The depressive symptoms of mothers were screened by using the EPDS. The distribution of the mothers, according to the symptoms of PPD shows that 40.8 percent of the women had severe depressive symptoms; and 20.0 percent of mothers had moderate depressive symptoms. While, 39.3 percent of them were not depressed in their postpartum period. Several studies found that mothers may experience PPD (8 percent –15 percent) or can occur by 4–6 weeks after childbirth if the baby blues (80 percent –85 percent) continue for longer 14 days (Kathree & Petersen, 2012; Ginsburg et al., 2012; Haga et al., 2012; Logsdon, 2012; Wade et al., 2012; Appolonio & Fingerhut, 2008; Xie et al., 2009; Ugarriza et al., 2007). Oates et al (2004) described the postnatal depression as a common phenomenon following delivery. The concept about PND varies in different areas of the world, but close to the Western concept. Most of the ideas considered that PND occur due to family conflict, lack of social support, attachments with baby and intimate partner and sleeplessness.

8.1.5.2 Life as a Mother The distribution of the respondents according to their life as a mother indicates that the mother’s life was good, fair and poor with the percentages of 43.5, 44.0 and 12.5 respectively. Mothers viewed that they are depressed when they didn’t fulfill the desire expectations of motherhood defined by the society. The majority 47.3 percent of respondents care their babies in fair means, 31.8 percent in a good way and 21.0 percent

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in a poor way. Almost 90 percent of mothers had attachment in terms of either good or fair with their babies. The findings found that 36.8 and 45.5 percent of respondents had good and fair attachment with their husbands respectively; and 17.8 percent of respondents had poor attachment with their husbands. Theory mentioned that postpartum depression may occur when there is an inconsistency between society’s expectations of motherhood and mother’s personal feelings and experiences; and childcare anxiety occurs when mothers can’t care their babies in a better way (Beck, 2002; Sullivan, 1953). In addition, attachment theory proposed that a strong emotional association between infant and mother is helpful to decrease the depression among mother (Whiffen and Susan, 1998).

8.2 Conclusion Gender development plays an important role in the development of any country. In contrast, Pakistani women are only responsible for reproduction and caring children and other household chores. They did not allow to participate in the development process. Postpartum is the most neglected, abandoned and life-threatening phase for both mothers and babies; most complications and deaths occur during the postpartum period (WHO, 2013). Retrieval from childbirth and adaptation to maternity can take a long time. It is the time after birth in which the mother's body, including the reproductive organs, hormone levels and uterus size proceeds to a non-pregnant state. The postpartum is a period of vulnerability to psychological disturbance associated with childbirth, which encompasses several mood disorders. PPD is a major depressive episode start within 30 days after delivery, the frequency of mood disorder increases dramatically. Many women experienced minor symptoms of postpartum depression, but some others are susceptible when the symptoms are severe and have long period. Postpartum depression has devastating effects on mothers, infants and their families. Education is to be considered a most important factor for women through which a woman is enabled to stimulate and enhance their exposure about different life aspects. An educated woman can communicate properly and have an awareness about their health status and utilization of health care services. Long school distance, early marriages, low economic resources and traditional values are the main reasons behind the female low literacy rate. The majority of the female population was illiterate due to lack of facilities in rural areas. The study found that due to the high level of illiteracy and ignorance,

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women were unaware about their mental health conditions. It was analyzed that the majority of the participants had no knowledge and understanding about PPD. They attach a number of feelings and symptoms with PPD, but are unaware about the root cause of PPD. The majority, almost half of the participants were illiterate. Those who were illiterate, most of them had low levels of education (up to primary level). They reported numerous reasons, such as conservative socio-cultural setup, unawareness, inadequate resources and unavailability of educational institutions. Most mothers complained that they experience anemia, high or low blood pressure, vomiting, body swelling, difficult labor, postpartum hemorrhage. Almost half proportion of the participants reported abdominal pain. It is concluded that the identification of these complications was the potential risk factor of PPD. In short, it resulted in abortion, unintended pregnancy, complications during pregnancy and after childbirth is associated with moderate to severe PPD. The most reported stressful life events among respondents were lower family income, in-laws home environment and health problems. It was recognized that rural women did not know about the symptoms and effects of postpartum depression. Though, the result of quantitative study indicates that most of the mothers had the symptoms of depression on postpartum score that are identified through EPDS. Crying episode, anxiety, irritation, feeling tiredness and eating and sleeping disorder were observed more frequently in most of the postpartum mothers. It was identified from all the FGD, typically, the majority of the participants were uneducated with lower economic status and unaware about the reasons and consequences of PPD. The present study concluded that PPD has a negative effect on mother’s attachment with their baby and husband. A mother is more prone to have the risks of stress when her attachment needs are not being met by her partner. The attachment theory explains that when the husband and wife are securely attached to another, obviously they will support to each other. Difficulties occur when intimate partner is avoiding to attach that leads to the postpartum depression (Whiffen and Susan, 1998).

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8.3 Recommendations

8.2.1 At State Level ➢ Education is to be considered a most contributory factor for change. There is a need to design strategies and policies at the state level, to enhance the opportunities of education for women. It would helpful for women to have the knowledge about their rights and health related issues (physical or emotional); and can participate in socioeconomic and cultural decisions. Because most of the problems occur due to the socioeconomic and cultural constraints. ➢ The provision is to be made to aware people about the rights and needs of women, specifically in the antenatal and postpartum period. For that purpose, the awareness programs should be launched by state institutions. ➢ The government should appoint gynecologist at the BHU level for providing awareness about the antenatal and postpartum complications. ➢ Not only the gynecologist, but also the government should appoint a psychologist at hospitals for counseling and creating awareness about the antenatal and postpartum related psychological issues. ➢ Violence is a stronger predictor for the depressive symptoms in the antenatal and postpartum period, that has an adverse effect on mother-child health. There is an essential need to eradicate all the types of violence against women. Gender base workshops and seminars should be organized, where the awareness should be provided to the husband about the effects of violence on women. ➢ The provision of health services is necessary to improve the health quality and well- being of women through the lifespan, especially in their antenatal and postpartum period. ➢ The state’s responsibility is to provide medical facilities to both maternal and infant. Health care providers are trained to provide health facilities, according to the unique needs of mothers. These services include gynecological care, family planning, pregnancy related care and prenatal care. ➢ Family planning methods should be introduced in rural areas of Pakistan, and the couples should be mobilized to use of these methods. ➢ Government of Pakistan should launch campaigns for public health awareness about breastfeeding, the benefits of small family, antenatal and postpartum care and

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utilization of health facilities. Because these factors are found to be significant with the symptoms of PPD. ➢ There is a need of proper attention by government to highlight the issues such as family environment and restrictions regarding the utilization of health care facilities that cause the prevalence of PPD. Because most of the mothers getting depressed when there are cultural obstacles to attain health facilities. ➢ Most of the deliveries take place at home, in rural areas of Pakistan. Abortions and deliveries are treated by untrained TBA’s, may lead to hemorrhage, inflammatory diseases and menstruation problems. There are more chances of low mood, anxiety and stress among women. Government should focus on these issues in order to enhance the availability of BHU, dispensaries with trained medical staff.

8.2.2 At household and community level ➢ Parents should pay attention to their daughter’s education, personality development, overtake the social issues, provide them balance diet and avoid their early marriages. ➢ There is a dire need to eradicate the cultural constraints that didn’t allow women to go outside the home to attain health services. ➢ Local communities and non-government organizations should arrange awareness campaigns on both the psychological and physical issues with the collaboration of each other. ➢ There is an essential need for the counseling of husband to change their attitude towards their wives’ diet and proper checkup in the antenatal and postpartum period. ➢ It is recommended that LHW/LHV and other related officers provide the guideline to the rural people regarding the utilization of health care facilities. In addition, government should provide the basic infrastructure to have easy access to BHU.

8.2.3 At Personal/Individual Level ➢ It is an important social and religious responsibility of women to take care themselves. ➢ Women should visit to the doctors or at least discussed with LHW/LHV when they feel fatigue, weakness, anxiety, stress, shortness or rapid heartbeat, dizziness or loss of concentration. Because all are the strongest contributory factors of PPD, if these problems occur during pregnancy or after a childbirth.

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➢ Antenatal care is the basic right of women, routine checkups are necessary for women during pregnancy. Women should have proper antenatal and postpartum care. ➢ It is recommended that, for normal delivery about seven visits are necessary to aware about the health status of women in Pakistan. The number of visits can be increased depends on health status. ➢ In addition, women’s consultancy with a health care professional to obtain postpartum instructions is beneficial for them because women who attend prenatal and postnatal classes have better knowledge about their health.

8.4 Recommendations for Future Study ➢ Due to shortage of time and money, the research covered only one district of Punjab. The further study should be conducted that not only cover the other districts of Punjab, but also consider the all provinces of Pakistan. ➢ It is also recommended that a comparative study can be conducted, which made the comparison of Pakistan with not only developing countries but also with developed countries. It will helpful to identify the factors of postpartum depression and its effect on the mother’s life in the world scenario. ➢ The data were only conducted from the mother. It will helpful, if make sure the participation of psychologists, gynecologists and family members for the deepen insight of factors and effects of PPD. ➢ Mostly, the socioeconomic, psychosocial and cultural factors for postpartum depression were identified in the present study, because this study was a sociological study. It is suggested that the further study should be conducted that not only rely on psychosocial factors, but also consider to identify the biological factors of postpartum depression. It is helpful to find out, which type of factors makes the more contribution to develop the symptoms of postpartum depression. ➢ The researcher only used one scale to identify the symptoms of PPD, either the other related scales (Social support scale, adjustment scale) can be used for the effectiveness of the study.

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Appendix A

Interview Schedule

An Analytical Study of Contributory Factors of Postpartum Depression among Women in Punjab, Pakistan

Town------Union Council ------Date------Baby’s date of birth ------

To study the socio-economic and demographic characteristics of the respondents.

Socio-economic and demographic characteristics of the respondents 1.What is your age (years)? 1. 15 – 20 2. 21 – 25 3. 26 – 30 4. 31 – 35 5. 36 and above 2. What was your age at marriage (years)? 1. Up to 20 2. 21 – 25 3. 26 – 30 4. 31 – 35 5. 36 and above 3. What is your marital status? 1. Married 2. Widow 3. Divorced 4. Separated 4. What is your education? (Number of classes passed) 1. 0 2. 1 – 5 3.6 – 10 4. 11 and above 5.What is your husband’s age (years)? 1. Up to 25 2. 26 – 30 3. 31 – 35 4. 36 and above 6. What was your husband’s age at marriage (years)? 1. Up to 20 2. 21 – 25 3. 26 – 30 4. 31 – 35 5. 36 and above 7. What is your husband’s education? (Number of classes passed) 1. 0 2. 1 – 5 3. 6 – 10 4. 11 and above 8. What is your occupation? 1. Govt. employee 2. Private employee 3. Laborer 4. Livestock/agriculture 5. Housewife 6. Any other (specify) 9. What is your monthly income? 1. Up to 10000 2. 10001 – 20000 3. 20001 – 30000 4. 30001 and above 5. N/A 10. What is your husband’s occupation? 1. Agriculture 2. Non-agriculture 11. If non-agriculture, then: 1. Govt. employee 2. Private employee 3. Business 4. Laborer 5. Unemployed

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12. What is your husband’s monthly income? 1. Up to 10000 2. 10001 – 20000 3. 20001 – 30000 4. 30001 and above 5. N/A 13. What is your family monthly income? 1. Up to 20000 2. 20001 – 30000 3. 30001 – 40000 4. 40001 and above 14. What is your family type? 1. Nuclear 2. Joint 3. Extended 4. Any other _____ 15. Total number of family members 1. > 3 2. 4 – 5 3. 6 – 7 4. 8 – 9 5. 10 and above

Information on previous pregnancy/delivery 16. How many children have you had before? 1. None 2. 1 – 3 3. 4 – 6 4. 7 and above 17. Number of pregnancies 1. None 2. 1 – 3 3. 4 – 6 4. 7 and above 18. Number of abortions 1. None 2. 1 3. 2 and above 19. Have you any blood loss during an abortion 1. Yes 2. No 3. Not applicable 20. Number of deliveries 1. None 2. 1 – 3 3. 4 – 6 4. 7 and above 21. Number of live births 1. None 2. 1 – 3 3. 4 – 6 4. 7 and above 22. Number of dead births 1. None 2. 1 3. 2 and above

Information on last pregnancy/delivery (12-month baby) 23. What is sex of your baby? 1. Boy 2. Girl 24. What is the age of your baby (weeks)? 1. Up to 12 2. 13 – 24 3. 25 and above 25. Was your baby planned? 1. Yes 2. No 26. What were the complications did you face during pregnancy? Complications 1 2 Complications 1 2 Yes No Yes No Headache / Migraine Body swelling Stomachache Gestational diabetes Anemia Urinary problem High blood pressure Uterus stitches Low blood pressure Abdominal pain

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Proteinuria (abnormal Vaginal bleeding quantities of protein in the urine) Fibroid uterus (rasoli) Vomiting

27. Where did you visit for checkup/treatment during pregnancy? 1. Govt. hospital 2. Private hospital / Clinic 3. Basic health unit / 4. Dai (TBA) 5. None Family welfare center

28. Where was the birth of your baby? 1. Govt. hospital 2. Private hospital / Clinic 3. Basic health unit / 4. Home Family welfare center 29. If at home, who was attended your delivery? 1. Dai (TBA) 2. LHV 3. Nurse 4. Doctor 30. What was the type of your delivery? 1. Normal 2. Caesarean 3. Assisted delivery (pulling – artificial labor)

31. What were the complications that occurred during delivery? Complications 1 2 Complications 1 2 Yes No Yes No High blood pressure Baby movement stopped Low blood pressure Early delivery Body swelling Difficult labor Water bag broke Postpartum hemorrhage Baby was in an unusual position

32. What were the infant health problems during pregnancy and late neonatal care? Complications 1 2 Complications 1 2 Yes No Yes No Water shortage Congenital (physical Premature disability) Low weight Pale skin Heartbeat Stomachache Short breathing Hand, feet cold Baby movement stopped Problem in sucking

33. Do you breastfeed to your baby? 1. Yes 2. No 34. If yes, do you have difficulty in breastfeeding? 1. To a great extent 2. To some extent 3. Not at all

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To investigate the contributing factors in postpartum depression among respondents. Attitude and factors of postpartum depression

35. Knowledge and history of antenatal and postpartum depression Statements 1 2 Yes No Knowledge about postpartum depression You have antenatal depression Any family member has antenatal depression You have postpartum depression at any previous delivery Any family member has postpartum depression

36. What were yours and husband’s feelings when knew about pregnancy and after birth of baby? Statements 1 2 3 Happy Normal Unhappy Your feelings about pregnancy Husband’s feelings about pregnancy Your feelings after birth of baby Husband’s feelings after birth of baby

37. Did you have pressure for birth of baby boy? 1. Yes 2. No

38. If yes, then who pressurized? 1. Husband 2. Mother-in-law 3. Both of them

39. In your opinion, what is the main reason behind the desire for birth of baby boy? Statements 1 2 Yes No Family feel proud within relatives Boyis the earning hand Mother will be secured Girls are only shame for them Girls are burden for them

40. What is your husband, in-laws and doctor’s attitude towards you? Statements 1 2 3 Good Normal Harsh Husband Mother-in-law

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Other family members Doctors / LHW / LHV

41. Would you describe your attitude of the following? Statements 1 2 3 Good Fair Poor Life as a mother Caring for baby Diet habit Performing domestic work Attachment with baby Attachment with husband

42. There are some social expectations and social taboos for mother or infant, did you experience any type of these during pregnancy or after delivery? Statements 1 2 Yes No Don’t leave the house at sunset time during pregnancy. Drinking or eating specific things during my pregnancy will make my baby white (gora). Detachment with that woman whose baby is expired during pregnancy or after birth. During pregnancy, all the negative signs (Nausea, ugly, faster heartbeat) mean it will be a girl and all the positive symbols (sweet tooth, beauty) point to a boy. OR look so huge! You have twins. Eat butter (ghee) as much in the last month of pregnancy, it will make the baby easier to pass through when your water breaks. Stay at home for forty days after the baby is born, maybe something bad happens. Wrap your newborn baby tightly, your child's arms and legs will not extend in length Don't keep your newborn's clothes beyond forty days. It is bad luck and dangerous. Give them away or bury them. Congratulations on just giving birth! Now quickly have another one. Baby is also susceptible to black magic during the first 40 days, you should cover newborn with cloth and putting iron near the baby. My mother-in-law said that when my baby starts talking my hair will begin falling.

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43. Do you have knowledge about family planning methods? 1. Yes 2. No

44. If yes, what is the main source of knowledge? 1. Husband 2. Family 3. Friends 4. LHV / LHW 5. Basic health unit 6. Media 45. Did you ever use one of these methods for birth control? 1. None 2. Condom 3. Female Sterilization 4. Male Sterilization 5. IUD 6. Withdraw 7. Pills / Injections

46. If no, what is the main reason behind this? 1. Fear of side effect 2. Husband dislikes 3. Religious factor 4. Family restrictions 5. No need yet

47. Did you take addiction materials during pregnancy or after delivery? Statements 1 2 3 To a great extent To some extent Not at all Non-food items (gatchi, imli etc) Huka / Cigarette Ghutka Pan / Naswar Sleeping pills Heroin

48. Did your husband violence you? Violence 1 2 3 To a great To some extent Not at all extent Abusing Teasing/ Taunting Slapping Beating

49. Stressful life events in the last years? Stressful life events 1 2 Yes No Change home Relationship changing Husband desire is to be pregnant in the first year of marriage Mother-in-law desire is to be pregnant in the first year of marriage Financial problems

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In-laws home environment Death of any relatives Health problems 50. How did you feel about the social support you have? Statements 1 2 3 To a great extent To some extent Not at all Husband supports me a lot Conflict with my husband Feeling control by the husband Family is always there for me Friends supported me In-laws/mother-in-law supporting me in caring of children

51. Do you share your feelings to any one of the followings, when feel depressed or in tension during pregnancy or after delivery? 1. 2. Mother 3. Sister 4. Mother-in law Husban d 5. Friends 6. None 52. What do you feel after share your feelings? 1. Relaxed 2. Normal 3. Depressed 4. N/A 53. Did you get help for your depression during pregnancy or after delivery? 1. Yes 2. No 54. If yes, where did you visit? 1. Doctor 2. Psychiatrist 3. LHV / LHW 4. Peer 5. Traditional healer 6. Anyother 55. What did he/she suggest? ______

Psychological and physical problems

56. Did you experience the following problems before marriage? Statements 1 2 3 To a great extent To some extent Not at all Headache Stomachache Blood pressure Sleeping disorder Eating disorder Anxiety

57. What did you feel or experiences the following issues during pregnancy? Statements 1 2 3

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To a great extent To some extent Not at all Crying Sleeping disorder Eating disorder Anxiety Shame or guilt Irritation / Anger Feeling tired Perform activities slowly My future may desperate

58. What did you feel or experiences the following issues within the first two weeks after delivery? Statements 1 2 3 To a great To some extent Not at all extent Crying Sleeping disorder Eating disorder Anxiety Irritation / Anger Feeling tired My future may desperate Think about suicide

59. Did you experience the following problems after delivery? Statements 1 2 3 To a great extent To some extent Not at all Menstruation problem Weight loss Weight gain Body image change Loss of energy Perform activities slowly Marital life disturbed

60. The following issues relate to your health status, did you experience the following physical health problems for the last two years? Health Aspects 1 2 3 To a great extent To some extent Not at all Fever Cholera

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Blood pressure Chronic pain Diarrhea Diabetes Anemia 61. To what extent the health care services are provided to you and in your area by health care providers? Health care services 1 2 3 To a great extent To some extent Not at all Emergency aid is available Patients are admitted at BHU Proper supply of medicine Multivitamins are provided Family planning services are provided Diagnostic tests are available and free Vaccination is provided at a time Sanitation services are available Privacy is maintained

62. Researcher’s personal observation about respondent a- Behavior: 1-Good 2- Normal 3-Bad b- Health in appearance: 1- Good 2- Normal 3- Bad (pale)

Name of Interviewer: ______I assure you the information provided by you, will be kept confidential and will be used for research purposes only.Thanks. Allah Hafiz

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Appendix B

To check the level of postpartum depression among women Edinburgh Postnatal Depression Scale (EPDS): Edinburgh Postnatal Depression Scale is used to check the level of postpartum depression among women. As you have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt Inthepast 7 days, not just how you feel today. 1. I have been able to laugh and see the funny side of things. As much as I always could (Score of 0) Not quite so much now (Score of 1) Definitely not so much now (Score of 2) Not at all (Score of 3) 2. I have looked forward with enjoyment to things. As much as I ever did (Score of 0) Rather less than I used to (Score of 1) Definitely less than I used to (Score of 2) Hardly at all (Score of 3) 3. I have blamed myself unnecessarily when things went wrong. Yes, most of the time (Score of 3) Yes, some of the time (Score of 2) Not very often (Score of 1) No, never (Score of 0) 4. I have been anxious or worried for no good reason. No, not at all (Score of 0) Hardly ever (Score of 1) Yes, sometimes (Score of 2) Yes, very often (Score of 3) 5. I have felt scared or panicky for no very good reason. Yes, quite a lot (Score of 3) Yes, sometimes (Score of 2) No, not much (Score of 1) No, not at all (Score of 0) 6. Things have been getting on top of me. Yes, most of the time I haven’t been able to cope at all (Score of 3) Yes, sometimes I haven’t been coping as well as usual (Score of 2) No, most of the time I have coped quite well (Score of 1) No, I have been coping as well as ever (Score of 0) 7. I have been so unhappy that I have had difficulty sleeping. Yes, most of the time (Score of 3) Yes, sometimes (Score of 2)

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Not very often (Score of 1) No, not at all (Score of 0)

8. I have felt sad or miserable. Yes, most of the time (Score of 3) Yes, quite often (Score of 2) Not very often (Score of 1) No, not at all (Score of 0) 9. I have been so unhappy that I have been crying. Yes, most of the time (Score of 3) Yes, quite often (Score of 2) Only occasionally (Score of 1) No, never (Score of 0) 10. The thought of harming myself has occurred to me. Yes, quite often (Score of 3) Sometimes (Score of 2) Hardly ever (Score of 1) Never (Score of 0)

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