This will be a prospective study. It will be conducted at a single center in the maternity ward of the hospital. All the ethical issues will be taken into consideration and approval will be taken from the research ethics committee. All the study participants will be informed about the purpose of the study, and the risks and benefits of participating in the study. Proper written informed consent will be taken from all the participants. All the women who are admitted to the maternity ward during the study period will be included in the study.
Women who do not give informed consent or those who are critically ill will not be included in the study. The study period for recruiting patients in the study will be two years. The maximum follow up time for all the participants will be six months. A research assistant will approach all the participants on the second postpartum day (before discharge from the hospital), obtain informed consent and fill in the interviewer-based structured questionnaire prepared for this study. Similar interviews will be taken at 1, 2, 4 and 6 weeks and at 6 months postpartum.
All the study participants will be called in the outpatient clinics at these specific time intervals and will be interviewed again by the research assistant. Questionnaire The questionnaire will have different parts. The demographics section will include the following variables: age of the mother, age of father, marital status, ethnicity, number of previous children and their age and sex, planned or unplanned pregnancy, employment status of mother and father, average monthly income of the family, number of dependent members.
The section on risk factors will include the number of previous pregnancies and their details; details and complications of this pregnancy; gender of the child; past medical history of the mother; past psychiatric history of the mother; history of PPD in previous pregnancies; major events in life; premorbid personality; history of hormone related mood disturbances; mood instability on taking oral contraceptives; depression or anxiety during this pregnancy; social support (psychological, financial and functional). The questionnaire will also include Edinburgh Postnatal Depression Scale (EPDS).
It is a self-reported screening tool used for postpartum depression. It has ten items related to the symptoms of patients in the past one week and each response is given a score from 0-3, 0 marking the absence of symptom whereas 3 meaning that the symptom is present most of the times. Therefore, the maximum score on the scale is 30; the higher the score, the higher is the risk of postnatal depression. A cutoff of 10 will be taken and patients having a score of 10 or more on EPDS will be categorized as the high risk group. The diagnosis of PPD will also be made on the basis of DSM-IV criteria.
DSM-IV criteria categorizes PPD as a depressive disorder with depressive symptoms lasting for more than two weeks and occurring within four weeks of delivery. The symptoms include loss of interest in daily activities, low mood, feelings of guilt and hopelessness, suicidal ideations and social and functional impairment. Statistical Analysis All the data collected will be organized and the data will be entered in SPSS for data analysis. Multiple statistical tests will be done to determine the significance of various factors.
The patients will be categorized into two groups based on the scores of EPDS: high risk and low risk group. Chi squared test will be done for categorical variables and student t-test will be done for continuous variables. A p-value of <0. 05 will be considered to be statistically significant. Based on the monthly income and dependent family members, the participants will be divided into three socioeconomic groups: lower, middle and upper class. A chi-squared test will be done to find if there is significant difference in the socioeconomic status of high risk and low risk group.
Similarly, chi-squared test will be done to determine significant difference between the socioeconomic status of patients diagnosed as having PPD or not based on DSM-IV criteria. Multivariate analysis will also be done to control for other confounding factors or risk factors of PPD included in the questionnaire and to find the association between PPD and socioeconomic status exclusively. Strengths It will be a prospective study and will determine an association between socioeconomic status and PPD. Other risk factors of PP can also be determined.
All the risk factors which have been identified till date have been included in the questionnaire. All the confounding factors will be excluded so the results obtained from this study will be reliable. Limitations There are also a few limitations of the study. The follow up time period should have been one year to make it a stronger and reliable study. Blinding has not been done so interviewer bias can affect the reliability of the results. It is a single center study and patients only from maternity ward will be included.
It would have been better to conduct this study at multiple centers so that the results obtained can be generalized to the whole population and are not limited to a particular group of people. Patients should also be included from outpatient clinics to increase the sample size. Another limitation is the variability and less reliability of the patients’ obstetric history and mood symptomatology. Therefore, initial interview of the patients can be taken in the second or third trimester to increase the reliability of history. Implications
The findings of this study will have wide variety of implications. The results will identify the disease burden and prevalence of PPD in our population. This will raise our suspicion of the diagnosis in patients presenting with such symptoms in the maternity wards and clinics. This will reduce the number of women who are underdiagnosed and undertreated for PPD. Secondly, it will also clarify the association between socioeconomic status and PPD. Thus, mothers of low socioeconomic status can be frequently screened for PPD if they have a higher risk. References
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