Running Head: INTEGRATIVE REVIEW

An Integrative Review

Lillian Facka

Bon Secours Memorial College of Nursing

Arlene Holowaychuk MSN, RN

Nursing Research - NUR 4122

April 3, 2018

“I have neither given nor received aid, other than acknowledged, on this assignment or test, no

have I seen anyone else do so.”

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Abstract

The purpose of this paper is to examine the significance of depression history in a pregnant

mother in regards to the probability of developing postpartum depression (PPD). PPD is a state

of depression experienced after childbirth that may last anywhere from six weeks to one year.

Interventions for PPD are not utilized until PPD is diagnosed. Search methods include Academic

Search Complete and EBSCO’s Nursing Reference Center. Designs consisted of longitudinal

studies with self-reported questionnaires. These studies resulted in mothers with a history of

depression being at greater risk for developing PPD compared to those who did not have a

history of depression. Due to large participant drop out and self-reported data, limitations

included small cohorts and response bias. PPD affects the recovery of the mother after birth as

well as the development of the infant, implying that medical practice needs greater interventions

for prevention. Breastfeeding the infant as well as increased responsibility for the pediatrician in

the maternal assessment process are recommendations for future research.

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Postpartum depression (PPD) is a state of depression experienced by mothers after

childbirth. The World Health Organization states that an onset of PPD symptoms begin at six

weeks (Silverman et al., 2017). In addition to this time frame, depressive symptoms must

interfere with the daily functioning of the mother (McCall-Hosenfield et al., 2016). While PPD

is recognized as the most common complication of childbearing (McCall-Hosenfield et al.,

2016), less than half of PPD cases are recognized in a clinical setting (Fiala et al., 2017). Some

reports indicate that a history of depression is the most indicative factor for developing PPD,

however there are other characteristics that must be explored in order to make this definitive

ruling. The purpose of this integrative review is to organize research data from multiple sources

pertaining to the researcher’s PICO question, are women with depression prior to pregnancy

more prone to PPD than women who do not have history of depression. It is important that

researchers explore this topic in order to develop assessment tools that would analyze the

trajectory of depressive symptoms related to personal health history and instill new roles of

responsibility for pediatricians(McCall-Hosenfield et al., 2016). These tools would generate

positive health outcomes for mother and infant. The researcher’s personal and family health

history inspired her to investigate this topic further.

Design Methods

The research design is an integrative review. Search engines Academic Search Complete

and EBSCO’s Nursing Reference Center were databases used to obtain data regarding PPD.

Words searched were ‘postpartum’, ‘depression’, ‘PPD’, ‘PPD trajectories’, ‘depressive

symptoms’, ‘instability of mood’, ‘delivery risk factors’, ‘depressive episodes’, ‘PPD

probability’, ‘PPD symptomatology’, and ‘depression severity’. Academic Search Complete

generated a total of 1,964 articles while EBSCO’s Nursing Reference Center generated 156
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articles. Search limitations included quantitative, peer-reviewed studies written in English. It was

imperative these studies were published within the last five years for relevancy. The five articles

included in this research used data ranging from 2016 to 2018, meeting the qualifications for this

integrative review. Further inclusion criteria was comprised of women with and without a

personal history of depression, psychosocial stressors for pregnant women, and pregnant women

from various socioeconomic backgrounds. All five articles were quantitative studies that directly

relate to the PICO question.

Findings and Results

The findings and results produced from the five chosen articles produce a strong evidence

supporting women with a history of depression prior to pregnancy are likely to develop PPD

(Fiala, Švancara, Klánová, & Kašpárek, 2017; McCall-Hosenfeld et al., 2016; Silverman et al.,

2017; Lau, Htun, & Kwong 2018; Chen et al., 2016). A summary of the articles may be found in

Table 1. The researcher assembled the review based on risk factors for developing PPD.

Risk Factors

All five quantitative studies used in this review examined the risk factors for PPD. Fiala

et al., (2017) conducted a longitudinal study distributed questionnaires to 3,233 pregnant women

with a mean age of 25.6 years in age six months after delivery. Out of the 3,233, 12.8% exhibited

signs of depression prior to childbirth. Six weeks postpartum. 10.1% (N=327) had signs of

depression, 55 of which had been depressed during both the prenatal and postpartum period

(Fiala et al., 2017). Out of this cohort, determined risk factors for PPD included personal history

of depression (N=167), family history of depression on the pregnant mother’s maternal side

(N=553) or paternal (N=154), unintentional pregnancy (N=1,566), feelings of unhappiness about

being pregnant (N=164), and mothers living alone (N=88) McCall-Hosenfield et al., 2016
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Trajectories of depression symptoms were measured by McCall-Hosenfeld, J et al,.

(2016). A sample of 2,802 women pregnant with their first baby completed telephone surveys

measuring depression during the third trimester ( McCall-Hosenfeld et al,. 2016). The Edinburgh

Postnatal Depression Scale (EPDS) was used to assess depression reported by the pregnant

women. Subjects that had a history of depression at a 7.9 times higher odds of developing PPD.

Mothers with a history of depression, inadequate social support, and unattached marital status

had a higher probability of belonging to a trajectory of higher depression.

In Sweden, 4,397 cases of PPD were diagnosed among women with and without a history

of depression (Silverman et al., 2017). PPD risk decreased at the second postpartum month and

slowly for the remaining ten months of the year. When comparing women with a history of

depression alongside women without a history, women with a history of depression had an

increased risk for PPD. Mothers aging 15-19 years old had a lower risk of developing PPD than

mothers who are 30-39 years old.

A three-wave prospective longitudinal design was used for 361 women in their second

trimester, third trimester, and six weeks postpartum (Lau, Y. et al., 2018). To measure

depression, the Edinburgh Postnatal Depression Scale (EPDS) was used to evaluate depressive

symptoms. Mild to moderate depression from the second trimester registered as 34.6%, third

trimester 10%, and six months postpartum 13.3%. Occurrence of severe depression in the second

trimester was 9.4%, third trimester 2.5%, and postpartum 1.4%. Antenatal depressive symptoms

were seen as a direct indication for later depressive symptoms in the postpartum period.

Complications during pregnancy may cause instability in the mother’s mood, resulting in

anxiety and depression (Chen, J. et al., 2016). These complications including stillbirth or fetal

mortality, pregnancy at a later age, and a scarred uterus. A cohort of 197 pregnant women
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experiencing complications who were in their second trimester was used for this study. The

Edinburgh Postnatal Depression Scale was used for assessment and risk factor assessment 7 days

postpartum, 42 days postpartum, and 3 months postpartum. Women with an EPS score of great

than or equal to thirteen were considered to have significant depressive symptoms. Those

experiencing depressive symptoms (N=10) were 30.5 years of age. This study resulted in no

significant post labor depressive symptoms.

Discussion/Implications

The research article produced results that determine a history of depression is an indicator

for developing PPD, supporting the PICO question. Not all results were numerically significant,

all articles suggested earlier interventions for mothers who had a history of depression prior to

pregnancy. Fiala et al., (2017), suggests that postpartum mothers are at a greater risk for

developing PPD six months after giving birth. Breastfeeding is suggested as a “protective

mechanism”; the research stating that breastfeeding would hinder the development of PPD. This

is a resource that is readily available to new mothers that may help with hormonal imbalances.

However, the healthcare community needs to intervene earlier with interventions prior to birth.

Lau, Y. et al., (2018) suggests that PPD is experienced during the second trimester; it is

recommended that healthcare providers monitor for PPD beginning at the second trimester.

McCall-Hosenfeld, J. et al., (2016), advocates for in-home medical check ups to reduce risk of

PPD development. In addition to in-home visits, researchers are calling for pediatricians to be the

forefront of screening new mothers for PPD, in agreeance with the American Academy of

Pediatrics. The recommendation to practice is evidenced by the premature end of the mother’s

interaction with their obstetrician at six weeks postpartum.

Limitations and Conclusion

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While evidence produced in this study is compelling and catalyzes the need for earlier

medical interventions, there were several limitations met in this process. The longitudinal cohort

study conducted by Fiala, et al., (2017), used a self-reported questionnaires with a high volume

of questions. The high volume was correlated to the high number of participants dropping out of

the study. McCall-Hosenfeld, J. et al., (2016), reported response bias as a limitation. Researchers

of this study related this bias to middle class people are more likely to participate in surveys

compared to those of a lower socioeconomic class, further questioning the validity of this study it

is not ethnically diverse. Silverman, M. E. et al., (2017), recommend that future studies should

consider other components of the childbearing experience related to PPD such as

neuroimmunological mechanisms and fluctuations in reproductive hormone levels. This study

continues on to state that the link between depression history and PPD is underestimated; this

may be linked to the increased awareness of PPD in 2018. Lau, Y. et al., (2018) recognized that

depressive symptoms were self-reported. Women who had a history of depression were not

included in this study, making it difficult to determine if depressive symptoms were present prior

to pregnancy. Lastly, Chen, J. et al., (2016), no postpartum mother met the criteria for depressive

symptoms. This indicates a larger sample size is needed to adequately perform this study with

greatly representation for the depressed postpartum cohort.

Results from this integrative review call for early medical interventions for mothers with

a history of depression. While mothers may be at risk for developing PPD as a result of

psychosocial stressors, maternal age, or maternal complications, studies prove that a history of

depression is the most accurate indicator for develop of PPD. Implementation of postpartum

depression prevention should begin during the second trimester and followed up by the infant’s

pediatrician in addition to the mother’s obstetrician.

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References

Chen, J., Cai, Y., Liu, Y., Qian, J., Ling, Q., Zhang, W., Luo, J., Chen, Y., & Shi, S. (2016).

Factors associated with significant anxiety and depressive symptoms in pregnant women

with a history of complications. Shanghai Archives of Psychiatry 28(5). doi:

http://dx.doi.org/10.11919/j.issn.1002-0829.216035

Fiala, A., Švancara, J., Klánová, J., & Kašpárek, T. (2017). Sociodemographic and delivery

risk factors for developing postpartum depression in a sample of 3233 mothers from the

Czech ELSPAC study. BMC Psychiatry, 17(104), 1-10. doi:10.1186/s12888-017-1261-y

Lau, Y., Htun, T., & Kwong, H. (2018). Sociodemographic, obstetric characteristics, antenatal

morbidities, and perinatal depressive symptoms: a three wave prospective study. Plos

One, 13 (2). doi: 10.1317/journal.pone.0188365

McCall-Hosenfeld, J., Phiri, K., Schaefer, E., Zhu, J., & Kjerulff, K. (2016). Trajectories of

depressive symptoms throughout the peri- and postpartum period: results form the first

baby study. Journal of Women’s Health, 17. doi:10.1089/jwh.2015.5310

Silverman, M. E., Reichenberg, A., Savitz, D. A., Cnattingius, S., Lichtenstein, P., Hultman, C.

M., . . . Sandin, S. (2017). The risk factors for postpartum depression: A population-based

study. Depression and Anxiety,34(2), 178-187. doi:10.1002/da.22597

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Table 1: Quantitative Article Evaluation

Reference (APA) Fiala, A., Švancara, J., Klánová, J., & Kašpárek, T. (2017).
Sociodemographic and delivery risk factors for developing
postpartum depression in a sample of 3233 mothers from the
Czech ELSPAC study. BMC Psychiatry, 17(104), 1-10.
doi:10.1186/s12888-017-1261-y

Author One author works as a psychiatrist at the University Hospital in

(Year)/Qualifications Brno and currently a post-graduate psychiatry student. One author
is a data analyst at the Institute of Biostatistics and Analyses at the
Research Center for Toxic Compounds in the Environment and is
also an MSc and PhD candidate at Masaryk University with six
years of experience in healthcare data analysis. Another other is a
professor at Masaryk University and the director of Research
Centre for Toxic Compounds in the Environment. The last author
is a professor of psychiatry at Masaryk University in Brno, head
of the Department of Psychiatry in Brno, and vice director of
research at the University Hospital Brno-Bohunice.

Introduction/ Introduction Less than half of postpartum depression cases are

Background/Problem recognized in the medical profession. It has been concluded that
Statement there is a need for further, advanced research to determine at risk
populations, improve detection, and implement evidence-based
treatment.
Background Postpartum depression is considered a serious
medical condition that leads to negative parenting practices,
breastfeeding problems, and impaired child development.
Previous studies have indicated that 10-20% of women experience
a depressive episode. However, these studies used a limited
number of participants, resulting in varying outcomes.
Problem Statement Examine depressive signs in a representative
sample observed prospectively via the data collected in a
longitudinal study and to identify sociodemographic and delivery
risk factors.

Conceptual/ The article does not clearly state a theoretical framework.

Theoretical
Framework
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Design/Research Design, Research Methods, Data Collection Tools: Data from

Methods/Sample/ the Czech European Longitudinal Study of Pregnancy and
Setting/Ethical Childhood (ELSPAC), a longitudinal cohort study designed to
Considerations/ investigate the effects of biological, psychosocial, economic, and
Major Variable environmental factors on pregnancy, delivery, and subsequent
Studied/ child development. Also used were questionnaires evaluating the
Measurement women prenatal, six weeks postpartum, and six months
Tool/Data Collection postpartum. In addition, the Edinburgh Depression Scale, a self-
Tool/Data Analysis reporting questionnaire measuring a scale of one to ten, was used.
Ten indicated no sadness or feelings of being miserable while two
indicated feeling sad and miserable quite often.
Sample: The initial sample size in 1991 from 2011 was 7,589.
However, only 3,233 participants completed three parts of the
survey, making the total sample size 3,233 mothers with births
between April 1st, 1991 and June 30th, 1992 and the data
collection period ending in 2011.
Setting: Czech Republic (Brno and Znojmo)
Ethical Considerations: The ELSPAC study ethics committee
promoted the international legal and ethics framework of the study
design. Informed consent was sought from all study participants
from each data collection; consent was an integral part of each
questionnaire.
Major Variables Studied: Personal history with depression,
family history with depression, was the pregnancy intentional, is
mother primiparous or multiparous, the gender of the child,
gestational maturity, method of delivery, were newborns
transferred to the ICU, was the child breastfed or formula fed,
mother’s age, mother’s highest level of education, does mother
live alone or with a partner.
Data Analysis: Factors influencing maternal depression were
analyzed using logistic regression.
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Findings/Results Questionnaires were completed six months after delivery by 3,233

mothers with the mean age of 25.6 years.
36.1% (N=1,167) had only a primary education
43.9% (N=1,420) had only finished high school
18.8% (N= 609) were university graduates
49.5% were multiparous
48.9% were primiparous
51.9% born male
48.0% born female
Before childbirth 12.8% had signs of depression
Six weeks postpartum 11.8% (N=380) had signs of depression; of
the 380, 130 mothers were also depressed during the prenatal
period.
Six months postpartum 10.1% (N=327) had signs of depression,
55 of which had been depressed during the prenatal period and six
weeks postpartum
Risk Factors:
Personal history of depression (N=167)
Family history of depression on expectant mother’s maternal side
(N=553); paternal (N=154)
Unintentional pregnancy (N=1566)
Feelings of unhappiness about being pregnant (N=164)
Mother’s living alone (N=88)

Discussion/ Limited financial means for raising an infant indicates a high

Implications amount of stress for the mother, which can lead to depression.
Unintentional pregnancy is a risk factor for six weeks postpartum,
but no association with six months postpartum. If the mother felt
unhappy about being pregnant, the risk of developing PPD was
much higher, the study suggests this is a stronger stressor than
unplanned pregnancy. Mothers without a partner were also high
risk for PPD during six week postpartum. In this particular study,
artificial feeding techniques suggested a higher risk for
developing PPD six months postpartum. It also suggests that
depressive symptoms affect milk supply. Breastfeeding should be
viewed as a protective mechanism for inhibiting development of
PPD.
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Limitations/ There was a large drop out rate of participants, correlated to the
Conclusions high number of questions on the questionnaire. Some questions
also had methodological issues. EPDS considered a suboptimal
tool for detecting depressive symptoms and should not replace a
systematic clinical interview. Researchers concluded that a
depressive mood is the most important sign of a depressive
syndrome. Personal history of previous depressive episodes and
mothers who experience significant psychosocial stressors are also
a sign.

Appraisal/Worth to -Research supports the PICO question

practice -Affirms that mothers with a history of depression are at risk for
developing postpartum depression
-Includes risk factors that, in conjunction with history, may
increase risk of developing postpartum depression
-Discussion and implications should include an action plan for
nursing practice
-Further research should include questionnaires that are less
daunting in regards to amount of questions to ensure retention of
all subjects.

Reference (APA) McCall-Hosenfeld, J., Phiri, K., Schaefer, E., Zhu, J., & Kjerulff,
K. (2016). Trajectories of depressive symptoms throughout the
peri- and postpartum period: results form the first baby study.
Journal of Women’s Health, 17. doi:10.1089/jwh.2015.5310

Author Several authors are affiliated with the departments of Medicine

(Year)/Qualifications and Public Health Sciences and the Pennsylvania State University
College of Medicine, both certified medical doctors. Another
author possess and MD certification and is affiliated with the
Williamsport Family Medicine Residency Program. The last
author possesses a doctorate and is affiliated with the department
of Obstetrics and Gynecology at the Pennsylvania State University
College of Medicine.
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Introduction/ Introduction Postpartum depression (PPD) is recognized at the

Background/Problem most common complication of childbearing, affecting ~13%-
Statement ~14%. To be classified as PPD, symptoms of major depression
emerge during the peripartum period through four weeks
postpartum, must be present for at least two weeks, and must
interfere with the mother’s everyday functional living. Healthcare
providers must be cognizant of patterns of depression that can
occur in the postpartum time frame.
Background The course of PPD is not well understood. We
analyze trajectories of depression and key risk factors associated
with these trajectories in the postpartum period.
Problem Statement The purpose of this study is to examine the
role of these various risk factors play in the trajectory of PPD.

Conceptual/ The article does not clearly state the use of theoretical framework
Theoretical
Framework

Design/Research Women planning to give birth in Pennsylvania were recruited

Methods/Sample/ from different hospitals to participate in the study. Enrollment was
Setting/Ethical focused on including mothers from varying socioeconomic
Considerations/ backgrounds. Brochures and flyers with detailed study material
Major Variable were placed in obstetricians offices, hospitals, and community
Studied/ health centers. Criteria for the sample included nulliparity, English
Measurement or Spanish speaking, ages 18-35 years old at the time of
Tool/Data Collection enrollment. All participants agreed to be interviewed once before
Tool/Data Analysis delivery during the third trimester, and several times post delivery.
Interviews were conducted by trained interviewers via telephone.
The study examines data from the third trimester (baseline) and at
1, 6, and 12 months postpartum. The study was reviewed and
approved by the Pennsylvania State University College of
Medicine Institutional Review Board. Depressive symptoms were
measured variable using the Edinburgh Postnatal Depression
Scores (EPDS). Variables also included age, race, education,
poverty status, and types of insurance. Participants were instructed
to answer each question based on how they felt within the
previous seven days. Each answer was scored on a scale of 0-3,
with a score of 3 indicating the most severe depression symptoms.
Social support was measured using five questions from the
Medical Outcomes Study-Social Support Survey (MOS-SSS)
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encompassing emotional, informational, tangible, and affectionate

support, and positive social interaction.

Findings/Results Younger women less than or equal to 20 years old had higher
EPDS indicating greater depression at baseline, six months, and
twelve months than older woman. Women who were not living
with their partner or who were unattached also reported higher
EPDS than those who were living with their partner. Women with
low social support scale results had significantly higher EPDS. A
history of anxiety or depression had higher EPDS scores than
those women who did not have a history. Women with a history of
anxiety or depression had 7.9 times higher odds of developing
PPD. Higher social support scores were associated with lower
odds to depression trajectories. A mother with all three risk factors
(history of anxiety or depression, inadequate social support, and
unattached marital status) had a higher probability of belonging to
a trajectory of higher depression.

Discussion/ Nondepressed women accounted for 85.2% of the participants,

Implications signifying that depression was not an emerging problem for the
large majority of first-time mothers. Women with a history of
anxiety or depression, single marital status, and inadequate social
support had the highest likelihood of belonging to trajectories
representing the most depressed groups. Risk factors for
predicting PPD are similar to the risk factors of those who are
depressed before delivery. Researchers identified key factors that
clinicians might use to help them determine the risk for both
higher levels of PPD and emerging depression in the postpartum
period. The inclusion of several time points postpartum was a
strength of this study, allowing the data to represent worsening
depression. The methodology of trajectory analysis has not been
commonly used to examine patterns of PPD, possesses the
capability to identify, rather than assume, distinctive trajectory
groups, the ability to estimate the proportions in each trajectory
group membership to key covariates.
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Limitations/ Participant response bias posed a limitation, related to education

Conclusions and higher SES scores. The researchers suggest that middle class
people are more likely to participate in surveys and studies than
individuals with a lower SES. Inability to fully discriminate
between broad range of racial and ethnic categories, due to small
cell sizes among non-white participants. Data may not be
generalized to cohorts that are more racially and ethnically
diverse. Low rate of PPD may be related to method of data
collection via telephone interview; participants may have
minimized their depression symptoms for social desirability.
Future longitudinal studies should include delivery complications
as a likely predictor of PPD.

Appraisal/Worth to Findings highlight a need for further awareness of risk factors

practice that may predispose women to become depressed during the
postpartum period and the implementation of early intervention
strategies. Support of in-home visits in an effort to reduce
postpartum depression in first time mothers. Physicians to be
aware of key predictors; these women should be screened multiple
parts of the year. Early termination of the mother’s interaction
with obstetrician at six weeks may, which may be too early to
detect emerging depression. Researchers calling for pediatricians
to be the forefront of screening new mothers for depression, in
agreeance with the American Academy of Pediatrics. Goal of this
greater awareness would be to produce appropriate, targeted, early
clinical interventions for women with multiple risk factors for
PPD.

Reference (APA) Silverman, M. E., Reichenberg, A., Savitz, D. A., Cnattingius, S.,
Lichtenstein, P., Hultman, C. M., . . . Sandin, S. (2017). The risk
factors for postpartum depression: A population-based study.
Depression and Anxiety,34(2), 178-187. doi:10.1002/da.22597

Author All seven of the authors who conducted this research possess a
(Year)/Qualifications doctoral degree, deeming them experts in their field of study and
further qualifying them to conduct this research. One out of the
seven authors possess medical doctor credentialing from the
Karolinska Institutet in Stockholm, Sweden. Other authors are
associated with Icahn Medical School at Mount Sinai, the
department of epidemiology at Brown University, the department
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of obstetrics and gynecology at Brown University, and school of

medical sciences at Orebro University in Orebro, Sweden.

Introduction/ Introduction Reports suggest that PPD is associated with a

Background/Problem history of depression. Additional factors associated with PDD are
Statement age, demographic characteristics, pregnancy complications, and
obstetric factors. Research methods, such as use of clinical rather
than epidemiologic samples, are prone to recall bias, and lack
clinical specificity. This leads to poor estimation of PPD cases.
Background PPD can result in negative personal and child
developmental outcomes. Previous studies have no examined how
maternal depression history interacts with known risk factors.
Problem Statement This study is aimed to determine the extent to
which a history of depression contributes to the risk of clinically
recognized PPD.

Conceptual/ The article does not clearly state the use of theoretical framework
Theoretical
Framework

Design/Research Data was obtained from the Swedish Medical Birth Register. The
Methods/Sample/ cohort included women who delivered from January 1, 1997 to
Setting/Ethical December 31, 2008. Information was included on the women’s
Considerations/ first childbirth during data collection period to avoid confusion.
Major Variable The setting for this study is Sweden. The protocol was approved
Studied/ by the Icahn School of Medicine at Mount Sinai’s Program for the
Measurement Protection of Human Subjects, the Swedish National Board of
Tool/Data Collection Health and Welfare, and the Ethical Review Board at Karolinska
Tool/Data Analysis Institutet, Stockholm. Variables examined were history of
depression, year of delivery, maternal age at delivery, cohabitation
with the father of the infant, hypertensive diseases, diabetic
diseases, prolonged labor, mode of delivery, gestational age, birth
weight for gestational age, congenital malformation, and sphincter
rupture. Data analysis tools included the use of incidence rate
ratios from Poisson regression models and Kaplan-Meier
techniques. 707,701 women with a live singleton birth between
1997 and 2008.
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Findings/Results Within the first year after delivery, there were 4,397 cases of PPD
among women with and without a history of depression. Rates
dropped dramatically after one week and one month postpartum.
Risk of PPD decreased at the second postpartum month and
continued to decrease slowly for the remaining ten postpartum
months. Compared with women without a depression history,
there was a statistically increased risk for PPD in women with a
history of depression. For women with a history of depression
aging 15 to 19 years old, there was a lower risk for developing
PPD. Mothers aging 30 to 39 years old had a significantly higher
risk.

Discussion/ A highly increased risk for PPD in women with a history of

Implications depression compared to women without a history of depression.
Depressive symptoms after pregnancy exist along a continuum of
severity rather than as an all or none phenomenon, and the vast
majority of studies exploring PPD risk have relied on symptom
based measures that are prone to producing higher prevalence
estimates. This is due to the inability to differentiate between
clinically significant symptoms of depression and postpartum
discomforts such as sleep disturbances, changes in appetite,
decreased energy, and concentration difficulty.

Limitations/ Findings show that PPD risk is associated with maternal age but
Conclusions also how the risk is modified by depression history. Future studies
should consider the possibility of neuroimmunological
mechanisms of PPD along with other biological aspects of
childbirth, such as fluctuations in reproductive hormone levels.
Strengths of this study include the use of a population-based
cohort with complete national coverage ascertaining clinically
significant instances of depression after childbirth. It is possible
that the association of depression history and PPD is
underestimated. The lower results of reported PPD may be linked
to increased awareness of PPD as well as improved strategies
aimed at identifying early maternal depression. Importance of
identifying depression after childbirth has gained considerable
attention.

Appraisal/Worth to This study examines PPD from a population based cohort to

practice increase clinical significance, making certain to address
limitations from previous PPD studies. Multiple variables we
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explored in this study, still proving that history of depression is the

most significant variable in the acquisition of PPD.

Reference (APA) Lau, Y., Htun, T., & Kwong, H. (2018). Sociodemographic,
obstetric characteristics, antenatal morbidities, and perinatal
depressive symptoms: a three wave prospective study. Plos One,
13 (2). doi: 10.1317/journal.pone.0188365

Author Two authors are associated with the Department of Alice Lee
(Year)/Qualifications Centre for Nursing Studies, Yong Loo Lin School of Medicine in
the National University of Singapore. Another author is associated
with the School of Health Sciences, Macao Polytechnic Institutes,
Macao Special Administrative Region of the People’s Republic of
China.

Introduction/ Introduction There are evident negative consequences linked to

Background/Problem perinatal depression that impacts new mothers and neonatal
Statement outcomes. Antenatal depressive symptoms are associated with an
increased risk of postnatal depressive symptoms. Antenatal
morbidities, such as gestational diabetes, pre-eclampsia, headache,
nausea, and vomiting, increase the risk for experiencing
depressive symptoms. Mothers and infants being cared for by the
NICU may have a higher risk for postnatal depressive symptoms.
Problem Statement The study is aimed at investigating the
pattern of perinatal depressive symptoms, determine the
relationships between sociodemographic characteristics, obstetric
factors, antenatal morbidities, postnatal conditions, and perinatal
depressive symptoms using SEM.

Conceptual/ Framework is not clearly stated

Theoretical
Framework
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Design/Research An approach using a longitudinal data set was used for this study.
Methods/Sample/ Structural equation modeling was used to identify potential risk
Setting/Ethical factors. Participants included perinatal women recruited from a
Considerations/ government hospital in Macau, the People’s Republic of China.
Major Variable Ethical approval that complied with the Declaration of Helsinki
Studied/ was obtained from the Macau Health Bureau. Non-probabilistic
Measurement convenience sampling was adopted. A sample size of 361 women
Tool/Data Collection were used to complete this study. A full explanation of the study
Tool/Data Analysis was given and written consent was obtained. Three sets of
questionnaires were developed to obtain data from the
participants. The first set of questionnaires recorded
sociodemographic and obstetric variables. The second set of
questionnaires recorded antenatal morbidities. The third set of
questionnaires consisted of postnatal conditions. EPDS was used
to assess the intensity of depression symptoms. A score greater
than nine indicated mild to moderate depression symptoms. A
score greater than fourteen indicated severe depression symptoms.

Findings/Results Prevalence rate for mild to moderate depression from the three
waves is as follows: 34.6%, 10%, 13.3%. Prevalence rate for
severe depression is as follows: 9.4%, 2.5%, 1.4%.

Discussion/ Findings indicated that depressive symptoms are experienced in

Implications the second trimester. This information is different from previous
studies, which describes the second trimester as a peaceful time
during pregnancy. Depressive symptoms during the second
trimester may be linked to the transition to parenthood. This
indicates that medical care providers should monitor for
depressive symptoms during the second trimester. Antenatal
depressive symptoms were found to be significant risk factors for
postnatal depression. Earlier antenatal depressive symptoms can
predict later depressive symptoms in the postpartum period.

Limitations/ Limitations included non-randomized sampling in one hospital,

Conclusions which could limit generalization of data. Depressive symptoms
were reported via self-reported screening tool, which is not the
gold standard of a structured psychiatric interview. Lastly, women
who had a history of depression were not included, unable to
determine whether or not depressive symptoms existed prior to
pregnancy.
By identifying the antenatal morbidities and postnatal conditions,
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health care professionals can ideally focus on early treatment and

management. This will minimize complications and potentially
lower the odds of perinatal depressive symptoms.

Appraisal/Worth to This study presents a different perspective on postpartum

practice depression, stating that if mothers experience depression
antenatally, they are likely to have postpartum depression. The
researchers advocate for early screening for depressive symptoms.

Reference (APA) Chen, J., Cai, Y., Liu, Y., Qian, J., Ling, Q., Zhang, W., Luo, J.,
Chen, Y., & Shi, S. (2016). Factors associated with significant
anxiety and depressive symptoms in pregnant women with a
history of complications. Shanghai Archives of Psychiatry 28(5).
doi: http://dx.doi.org/10.11919/j.issn.1002-0829.216035

Author One author is associated with the Shanghai Mental Health Center,
(Year)/Qualifications Shanghai Jiao Tong University School of Medicine in Shanghai,
China. Another author is a part of the International Peace
Maternity & Child Health Hospital Affiliated to Shanghai Jiao
Tong University School of Medicine in Shanghai China. The third
author is connected to the department of Biostatistics, School of
Public Health at Fundan University in Shaghai, China. The last
author is a part of the department of Psychiatry at the Huashan
Hospital of Fundan University.

Introduction/ Introduction Instability of mood during pregnancy can result in

Background/Problem anxiety and depression. Current high-risk pregnancy or history of
Statement complications increases the risk of negative mood symptoms such
as anxiety and depression.
Problem Statement This study aims to explore anxiety and
depression symptoms in ‘high-risk’ pregnant women in hopes of
providing obstetricians with useful information that can aid early
mental health interventions during this critical period.

Conceptual/ Not clearly stated

Theoretical
Framework
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Design/Research Participants in this study consisted of pregnant women who were

Methods/Sample/ registered at the International Peace Maternity and Child Health
Setting/Ethical Hospital in Shanghai from March 2014 to October 2014. Inclusion
Considerations/ criteria was pregnant women who are permanent residents of
Major Variable Shanghai, receiving regular obstetric examination in the chosen
Studied/ research hospital, having one or more criteria for “high-risk”
Measurement pregnancy, giving birth in the chosen research hospital, providing
Tool/Data Collection informed consent, being sixteen to twenty weeks pregnant. High
Tool/Data Analysis risk includes women who have a history of stillborn birth, history
of giving birth to a congenitally abnormal fetus, pregnancy at later
age, and scarred uterus. 195 cases were analyzed. Participants were
provided with written informed consent. Ethical approval was
granted by the IRB of Shanghai International Peace Maternity and
Child Health Hospital. Women filled out a general information
questionnaire, Hospital Anxiety and Depression Scale (HAD), Life
Event Scale (LES), and Eysenck Personality Questionnaire (EPQ).
The Edinburgh Depression Scale was used at seven days, 42 days,
and three months after labor.

Findings/Results Patients with an EPS score of greater than or equal to thirteen

were considered to have significant depressive symptoms. The
participants at baseline with significant depressive symptoms only
had the following characteristics: (n=10), mean age is 30.5.
Pregnant women with anxiety symptoms at baseline had higher
depression scores than those without anxiety and depression. No
significant post labor depressive symptoms.

Discussion/ Following up on health status in recent three months, quality of

Implications marital relationship, concerns about fetal health, attitude towards
pregnancy, and role of the husband at home post-birth were
associated with prominent anxiety and depressive symptoms. This
data further emphasizes the importance of social support and
relationships during the pregnancy period and how the strain in
that area of life is often associated with depressive symptoms.
These factors help in assessing and providing early intervention for
psychological issues affecting pregnant women. It is hoped in the
future that psychological assessment will be a regular part of check
ups for women while pregnant.
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Limitations/ In this study, no one reached criteria for depressive symptoms

Conclusions after postpartum. As a result, analysis was not performed on
depressive symptoms after childbirth. A larger sample size is
needed to further explore depressive symptoms experienced in the
postpartum period. Factors affecting the women’s emotions were
not found. The development and outcome of women’s symptoms
could not be analyzed.
This study indicates that anxiety and depressive symptoms are
more common in women with a history of complications or those
classified as “high-risk”. Concern for fetal health and interpersonal
relationships, especially marriage, are associated with anxiety and
depressive symptoms.

Appraisal/Worth to The results of this study can provide evidence for the screening of
practice pregnant women with anxiety and depression as well as content for
the design of psychological interventions.