Open Journal of Depression
2013. Vol.2, No.4, 72-81
Published Online November 2013 in SciRes (http://www.scirp.org/journal/ojd) http://dx.doi.org/10.4236/ojd.2013.24013
Open Access 72
Preterm Birth a Risk Factor for Postpartum Depression in
Pakistani Women*
Salima Sulaiman Gulamani1, Shahirose Sadrudin Premji2, Zeenatkhanu Kanji1,
Syed Iqbal Azam3
1School of Nursing and Midwifery, Aga Khan University, Karachi, Pakistan
2Faculty of Nursing, Department of Community Health Sciences, University of Calgary, Alberta, Canada
3Community Health Sciences Department, Aga Khan University, Karachi, Pakistan
Received August 16th, 2013; revised September 17th, 2013; accepted September 25th, 2013
Copyright © 2013 Salima Sulaiman Gulamani et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
A Pakistani cohort of 170 mothers of full-term infants and 34 mothers of preterm infants were screened at
6 weeks after delivery to compare the rate of PPD, and examine the contribution of parenting stress and
mother-infant interaction to PPD among mothers of preterm infants. Mothers completed the Edinburgh
postnatal depression scale, and a general questionnaire. Mothers of preterm infants also completed the
parental stress scale and parental bonding questionnaire. The rate of PPD was significantly higher with
the adjusted odds increasing by 2.68 (95% Confidence Interval 1.16 - 6.17, p = .015) in mothers of preterm in-
fants. Significantly more depressed mothers of preterm infants did not receive some level of support from
their husbands (p = .014), and had some level of difficulty feeding (p = .03) or identifying the amount to
feed their infant (p = .02). A large proportion of mothers reported no support from friends in rearing
children.
Keywords: Postpartum Depression; Preterm; Mother-Infant Interaction; Parental Stress; Developing
Countries
Introduction
Postpartum depression (PPD) is considered as a serious pub-
lic health problem due to its enduring impact on the mental
health of the mother (Hay, Pawlby, Waters, & Sharp, 2008) and
father (Goodman, 2004). In addition, it also affects family dy-
namics (Tammentie, Tarkka, Åstedt-Kurki, Paavilainen, &
Laippala, 2004) as well as all dimensions of child development
including physical, emotional, cognitive, language, social, and
attention (Black, Baqui, Zaman, Arifeen, & Black, 2009; Grace,
Evindar, & Stewart, 2003). Recent evidence indicates that the
level of PPD in low- and middle-income countries is higher
than the 10% to 15% prevalence estimated for high income
countries (Coast, Leone, Hirose, & Jones, 2012). The preva-
lence rate of PPD worldwide ranges from .5% to 60.8%, ex-
cluding Pakistan (Halbreich & Karkun, 2006). Amongst South
Asian countries, Pakistan has the highest prevalence of PPD
reported at 63.3% (Klainin & Arthur, 2009). The question re-
mains as to why Pakistani women have higher rates of PPD. In
2005, worldwide statistics indicated that 9.6% of all births were
preterm with Africa and Asia accounting for approximately
85% of these births. Pakistan has a preterm birth rate of 15.7%
(Lone, Qureshi, & Emmanuel, 2004). Consequently, an in-
terrelationship may exist between preterm birth and PPD in
Pakistani women.
Preterm Birth and Postpartum Depression
Adewuya, Fatoye, Ola, Ijaodola, and Ibigbami (2005) re-
ported that Nigerian mothers of preterm infants were 4 times
more likely to develop PPD than mothers of term infants. Me-
ta-analyses (e.g., Robertson, Grace, Wallington, & Stewart,
2004) examining risk factors of PPD consistently relate psy-
chosocial factors such as depression or anxiety during preg-
nancy, personal and family history of depression, lack of social
support, and stressful life events to PPD (Vigod, Villegas, Den-
nis, & Ross, 2010). None of these meta-analyses included pre-
term birth as a variable (Vigod et al.). Gulamani, Premji, Kanji,
& Azam (2013) indicate that culture influences mother-infant
interactions and determine social support rituals thus may indi-
rectly influence PPD. A qualitative synthesis (Vigod et al.) re-
vealed that studies did not consistently support an increased
risk of PPD in women with preterm infants. However, the au-
thors concluded that “mothers of preterm infants are at higher
risk of depression than mothers of term infants in the immediate
postpartum period” (p. 540).
The Psychosocial Model of Leigh and Milgrom (2008) used
to examine the interrelationship between preterm birth and PPD
relates adjustment difficulty to parenting role, such as parenting
stress, to PPD in a reciprocal way. Parenting stress reflects both
the parent’s ability to cope, based on their perception of re-
sources available to them, and their perceptions of the child,
*Declaration of conflicting interests: We declare we have no competing
interests.
Funding: The thesis work was funded by the Aga Khan University—Master
of Science in Nursing Student Thesis Budget.

S. S. GULAMANI ET AL.
Open Access 73
including the child’s characteristics and mother-infant interac-
tions (Leigh & Milgrom, 2008; Misri, Reebye, Milis, & Shah,
2006). Mother-infant interaction is “the influence by the infant
on the mother (infant attachment) and the influence by the
mother on the infant (maternal-infant bonding) during early
development” (Kashiwagi & Shirataki, 1995: p. 246). Predis-
posing factors such as low income, history of depression, his-
tory of abuse, young age, and less education have negative
implications for mother-infant interaction and parental
stress.
In this study, we determined whether there was a significant
difference in the rate of PPD between mothers of full-term in-
fants and mothers of preterm infants residing in Karachi,
Pakistan. We also examined the contribution of parenting
stress and mother-infant interaction to PPD among mothers
of preterm infants.
Methods
Design
Consecutive sampling was used for this cohort study to re-
cruit a fixed number of mothers who delivered full-term infants
(i.e., unexposed) and a fixed number of mothers who delivered
preterm infants (i.e., exposed) that met the eligibility criteria.
Although ultrasound in the first trimester is more sensitive in
estimating gestational age (Kalish et al., 2004), we used last
menstrual period as not all mothers had received an ultrasound
in the first trimester, but last menstrual period was consistently
recorded for all mothers. Preterm birth was defined as a baby
being born at less than 37 weeks gestational age, and full-term
birth was defined as a baby being born between 37 and 42
weeks completed gestational age. All mothers were screened
for the presence of PPD at four to six weeks after delivery and
completed a general questionnaire soliciting information about
characteristics of the sample (e.g., age, education, income),
patterns of routine life (e.g., infant feeding, work and sleep
patterns) and social life (e.g., support networks, marital rela-
tionship). Mothers of preterm infants also completed the paren-
tal stress scale and the parental bonding questionnaire at this
time.
Sample and Procedure
A total of 34 mothers of preterm infants and 170 mothers of
full-term infants participated in the study (Figure 1) if they: 1)
Figure 1.
Movement of mothers through the study.

S. S. GULAMANI ET AL.
Open Access 74
had a baby within the previous four to six weeks, 2) were be-
tween 18 to 40 years of age, 3) were able to speak Urdu or Eng-
lish, and 4) had not developed any complication during preg-
nancy (e.g. eclampsia) or after delivery (e.g. postpartum hem-
orrhage, sepsis). Mothers who had delivered twins or an infant
with abnormalities, or had a stillbirth were not eligible for this
study. A list was obtained of mothers who delivered at Aga
Khan Hospital for Women and Children (AKHWC), Karima-
bad and Garden (Karachi, Pakistan), between May 1, 2010 to
June 30, 2010. The nurse-in-charge approached mothers from
this list when they returned to the postnatal clinic, infant clinic,
or the vaccination room, and invited them to participate if they
met the inclusion criteria.
The sample size was calculated in order to achieve a power
of 80% with an anticipated relative risk of 3, ratio of preterm
and full-term mothers of 1:5, and level of significance of 5%.
We used a relative risk of 3 to ensure a conservative sample
size that could be achieved during the study period. A ratio of
1:5 was maintained as the prevalence of preterm infants was
very low. Furthermore, a 1:5 ratio allowed for precision in
sample size so that the rate of PPD could be measured accu-
rately (Rothman & Greenland, 1998).
Ethical Considerations
Ethical approval for this study was obtained from the Ethical
Research Committee of the Aga Khan University. The re-
searcher or research assistant obtained informed consent prior
to enrolment of women in the study.
Instruments
PPD was measured with the Edinburgh postnatal depression
scale (EPDS), a ten item self-report scale that screens for the
presence of symptoms of PPD (i.e., not a diagnostic instrument)
(Cox, Holden, & Sagovsky, 1987). EPDS is a reliable and valid
instrument with a sensitivity of 85%, and specificity of 77%
(Cox et al., 1987). Extensively used in developing countries,
and translated into several languages, including Urdu (Husain
et al., 2006), the EPDS has been validated with a Pakistani
population (Rahman, Iqbal, Lovel, & Shah, 2005). The most
common cut-off of greater-than or equal to 12 was used to in-
dicate a positive screen for depressive illnesses.
Mother-infant interaction was measured with a 25 item pa-
rental bonding questionnaire (PBQ) based on the mother’s
self-report of characterization of their infant and mother-infant
relationship and scored on a five-point Likert scale, with a re-
verse sequencing for items related to favorable aspect of the
interaction (Brockington et al., 2001). The 25 items were de-
rived from principle component analysis of 84 items, which
resulted in four scales ranging in sensitivity from .93 to .28
(Brockington et al., Brockington, Fraser, & Wilson, 2006). The
PBQ has been validated with Professor Lynne Murray’s Global
Rating Scale (Murray & Cooper, 1997), and by interviewing 51
mothers using an interview guide for pregnancy related disor-
ders (Brockington et al., 2001, 2006). In a Dutch sample, the
PBQ had high internal consistency for the total PBQ (Cron-
bach’s alpha .87) when compared to the Maternal Postpartum
Attachment Scale (.75) and Mother-to-Infant Bonding Scale
(.67) at 8 and 12 weeks postpartum (Van Bussel, Spitz, & De-
myttenaere, 2010). Strong correlation was evident between
scales of PBQ and Maternal Postpartum Attachment Scale and
Mother-to-Infant Bonding (van Bussel et al., 2010). PBQ is
used as a global measure of quality of mother-infant interaction,
with a cut-off of 31 and above indicating clinically severe mo-
ther-infant interaction difficulties; whereas lower scores denote
good bonding (Loh, 2005). The PBQ is best used with the
EPDS, particularly when assessing the extent of the difficulties
of the relationship between the mother and child (Klier &
Muzik, 2004). Cultural appropriateness of the Urdu version of
the PBQ (back translated to ensure language equivalency) was
established by piloting the instrument on 10 mothers who came
to the postnatal clinic at Aga Khan University Obstetrics and
Gynecology clinic. Two items, number 22 and 24, were found
to be confusing for the mothers. Mothers had difficulty under-
standing the Urdu word used for “confident” (i.e., “yaqini
kafiayat”) in item 22; the word was therefore replaced with
“Aitimad”. In item 24, the Urdu term used for hurting (i.e.,
“ghira hua”) was replaced with “uljha hua” for a similar reason.
The Parental Stress Scale (PSS), a self-report scale with 18
items scored on a five point scale was used to measure parental
stress. The PSS has an internal reliability of .83 and test-retest
reliability of .81, and has been found to correlate with the Per-
ceived Stress Scale (r = .41) and the Parenting Stress Index (r
= .75) (Berry & Jones, 1995). Higher scores on the scale are
indicative of greater stress. A Chinese version of the PSS has
been validated on Chinese parents (Cheung, 2000). The tool
was translated into Urdu, and then back translated into English
to assure quality data. As with the Urdu version of the PBQ, the
Urdu version of the PSS was also pilot tested; however no
changes were required.
A two-part questionnaire elicited information to develop the
profile of the family: Part A focused specifically on the demo-
graphic characteristics of the mother, father, and infants; Part B
assessed the medical history, feeding practice and concerns
related to feeding, infant’s and mother’s sleep patterns, moth-
er’s social life (i.e., history of abuse of any form), and support
systems, and dysfunctional relationships in the household (e.g.,
husband and/or mother-in-law).
Data Analysis
Data was analyzed using Statistical Packages for the Social
Sciences (SPSS) version 17.0. Descriptive statistics were used
to compare the characteristics of groups: mothers of full-term
infants and preterm infants, full-term and preterm infants, de-
pressed and not depressed mothers of preterm infants. Chi
square or the Fisher’s exact test was used for categorical data.
An independent sample t test was used for continuous variable.
The Mann Whitney U test was used for ordinal level data or
when assumptions of independent samples t-test were violated.
A Chi square test was used to determine the differences in the
rate of PPD between mothers of full-term infants and mothers
of preterm infants. We used logistic regression modeling to
determine the odds of PPD in mothers of preterm infants com-
pared to full-term infants. A Fisher exact test was used to de-
termine the relationship between parental stress and PPD
among mothers of preterm infants.
Results
Two hundred and fourteen (214) mothers returned to the
center for follow-up care between four to six weeks after birth.
Two mothers had delivered twins, one mother had an abnormal
child, and four infants were accompanied by their father, aunt
or grandmother and were not with their mothers, and were

S. S. GULAMANI ET AL.
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therefore excluded from the study. Two hundred and eleven
(211) mothers met the inclusion criteria, but two mothers of
full-term infants and five mothers of preterm infants refused to
participate in the study (see Figure 1).
As can be seen in Table 1, the median gestational age of in-
fants in the full-term group was 39 weeks, while in the preterm
group it was 36 weeks, and the majority of infants in both
groups were greater-than or equal to 2.5 kilograms. Also, a
significantly higher representation of low birth weight infants
was noted in the preterm infant group (p = .00). No group dif-
ferences were noted in gender, education level, ethnicity, work-
ing status, planned pregnancy, relationship difficulties with
both husband and mother-in-law, domestic violence, support
systems, and friends support. However, a significant difference
in the mean ages of mothers was observed between the two
groups (p = .03). Proportionately, there were more mothers in
the full-term infant group, as compared to the preterm infant
group who were primiparous (p = .03). Proportionately, more
mothers in the preterm infant group compared to full-term in-
fant group indicated that their infants woke up for no reason;
this difference was significant (p = .01).
Mothers of preterm infants showed a higher rate of PPD
(35.3%) than mothers of full-term infants (15.3%). A Chi
square test revealed a significant difference in the rate of PPD
between the mothers of full-term and preterm infants (p = .01).
However, since significant differences were apparent in pre-
disposing factors such as mother’s age, number of children,
birth weight, and infant’s unexplained waking in the night uni-
variate logistic regression analysis was undertaken. Birth status
(i.e., full-term versus preterm birth) (p < .01) and number of
children (p = .028) were significant predictors of PPD in uni-
variate analysis (see Table 2). Mothers of preterm infants had
higher odds of depression (adjusted odds ratio = 2.68, 95%
Confidence Interval (CI) 1.16 - 6.17, p = .015) when compared
to mothers who delivered full-term infants after controlling for
number of children in the model.
As can be seen in Table 3, when the characteristics of pre-
term mothers are compared by depression status, there were no
differences in socio-demographic, obstetric, or health history
variables. No differences were found in the majority of social
variables, including relationship with husband and mother-in-
law, domestic violence (physical and verbal abuse), social sup-
port from mother-in-law, social support from friends, and fam-
ily type. However, proportionately, more mothers of preterm
infants in the not depressed group reported that their husbands
always supported them in caring for their child (p = .03).
As can be seen in Table 4, there were no differences ob-
served between the characteristics of preterm infants of de-
pressed mothers versus those of not depressed mothers, such as
gender, birth weight, and reasons for waking up in the night.
Although there was no significant difference with regards to
difficulty in identifying infant’s hunger, mothers of preterm
infants who were depressed, experienced more difficulty in
feeding their infants (p = .03), as well as difficulty in identify-
ing the amount of milk to feed their infants (p = .02).
The PSS data were skewed; the median was 41 for mothers
of preterm infants in the depressed group, and 34 for mothers of
preterm infants in the not depressed group. Since data were
skewed, PSS scores above the 50th percentile were categorized
as high parental stress, and scores below the 50th percentile
were categorized as low parental stress. Of the 12 mothers of
preterm infants who were depressed, 5 showed low parental
stress and 7 showed high parental stress; whereas of the 22
mothers of preterm infants who were not depressed, 14 showed
low parental stress and 7 showed high parental stress. A Fisher
exact test was used to determine the relationship between pa-
rental stress and PPD among mothers of preterm infants. No
significant difference was found between depressed and not
depressed mothers in the proportion of mothers who showed
low versus high parental stress. At 95% CI, there is 87.42%
likelihood that there is no difference in the parental stress be-
tween depressed and not depressed mothers. Hence, the data
suggest that there is no relationship between parental stress and
PPD.
The PBQ data were skewed; the median was 3.5 for mothers
of preterm infants in the not depressed group and 3.5 for de-
pressed group of preterm infants. Scores on the PBQ ranged
from 0 to 18, which indicated that none of the mothers of pre-
term infants were found to have bonding difficulty. Given the
distribution of data, no statistical test was undertaken to test the
hypothesis that there is no relationship between mother-infant
interaction and PPD.
Discussion
In this study, a significant difference (p = .01) was found in
the rate of PPD between Pakistani mothers of full-term and
preterm infants: 15.3% versus 35.3%, respectively. Other stud-
ies (Logsdon & Usui, 2001; Madu & Roos, 2006) also identi-
fied a significant difference in the rate of PPD between mothers
of full-term and preterm infants. We found that mothers of
preterm infants had an adjusted odds ratio of 2.68 (95% CI 1.16 -
6.17, p = .015) of developing PPD compared to mothers of
full-term infants after controlling for group differences (e.g.,
number of children) through logistic regression modeling.
However, significant differences were apparent in predisposing
factors such as age, number of children, birth weight, and in-
fant’s unexplained waking in the night. Furthermore, infants in
the preterm group were between 32 weeks and 36 weeks gesta-
tion and only of slighter lower birth weight. In two American
studies (Brandon et al., 2011; Voegtline & Stifter, 2010), care
of late preterm infants has been associated with greater emo-
tional distress, parental stress and anxiety when compared to
the care of full-term infants. The high infant mortality rate as-
sociated with preterm birth and low birth weight, combined
with limited community resources to support Pakistani mothers
of preterm mothers in caring for their infants may also explain
the high rates of PPD among mothers of preterm infants.
The findings of the current study imply that Pakistani moth-
ers of preterm infants may be at a high risk for developing PPD.
Moreover, mothers who are experiencing preterm birth for the
second time have a higher chance of developing PPD (Allen,
2004). Early interventions could be planned that focus on edu-
cating mothers and fathers about the preterm infant’s behavioral
cues and feeding readiness, as well as nutritional requirements
to promote growth and development. Using evidence to inform
parents about best practices for feeding their preterm infants
and providing accurate information about infants’ development
may increase mothers’ knowledge about infant behavioral cues
(Maguire, Bruil, Wit, & Walther, 2007), and may decrease de-
pressive symptoms (Veddovi, Kenny, Gibson, Bowen, & Starte,
2001).
The current study found no significant difference between
depressed and not depressed mothers of preterm infants in the

S. S. GULAMANI ET AL.
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Table 1.
Full-term and preterm infants’ characteristics and socio-demographic, obstetric and health history, and social characteristics of mothers of full-term
and preterm infants.
Term Group Preterm Group
Characteri stics n = 170 n = 34 p value
Infants
Demographic
Median (Range) Median (Range)
Gestational Age (in Weeks) 39 (37 to 42) 36 (32 to 36)
n (%) n (%)
Weight
*0.00†
<2.5 Kg 15 (9) 12 (35)
>2.5 Kg 152 (91) 22 (65)
Gender 0.61~
Baby Boy 73 (42.9) 13 (38.2)
Baby Girl 97 (57.1) 21 (61.8)
Behavior
Reason for Waking up in the Night 0.01*†
Hungry 153 (90) 24 (70.6)
No Reason 6 (3.5) 5 (14.7)
Does Not Wakeup 8 (4.7) 2 (5.9)
Others 3 (1.8) 3 (8.8)
Mothers
Socio-Demographic
Mean (SD) Mean (SD)
Age 26.02 (4.09) 27.67 (3.81) 0.03*^
n (%) n (%)
Education Level 0.95~
Graduate and Above 99 (58.2) 20 (58.8)
Others 71 (41.8) 14 (41.2)
Ethnicity 0.90~
Muhajir 93 (54.7) 19 (55.9)
Others 77 (45.3) 15 (44.1)
Working Status 0.72†
Yes 12 (7.1) 3 (8.8)
No 158 (92.9) 31 (91.2)
Obstetric & Health History
Number of Children 0.03*α
One 86 (50.6) 11 (32.4)
Two 52 (30.6) 12 (35.2)
Three and More 32 (18.8) 11 (32.4)
Planned Pregnancy 0.84~
Yes 117 (68.8) 24 (70.6)
No 53 (31.2) 10 (29.4)
Past Psychiatric Illness NA
Yes 3 (1.8) 0
No 167 (98.2) 34 (100)
Social
Relationship Difficulties
With Husband 0.19†
Yes 3 (1.8) 2 (5.9)
No 167 (98.2) 32 (94.1)
With Mother-in-Law 0.41†
Yes 2 (1.2) 1 (3.1)
No 168 (98.8) 31 (96.9)
Domestic Violence
Punched, Kicked or Hit >0.99†

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Continued
Never 166 (97.6) 33 (97.1)
Sometimes to Always 4 (2.4) 1 (2.9)
Bad language >0.99†
Never 166 (97.6) 33 (97.1)
Sometimes to Always 4 (2.4) 1 (2.9)
Support System
Husband Support 0.24α
Never 5 (2.9) 1 (2.9)
Sometimes 22 (12.9) 7 (20.6)
Often 21 (12.4) 5 (14.7)
Always 122 (71.8) 21 (61.8)
Mother-In-Law 0.37α
Never 41 (24.1) 7 (20.6)
Sometimes 7 (4.1) 3 (8.8)
Often 15 (8.8) 7 (20.6)
Always 107 (63) 17 (50)
Friends Support 0.20α
Never 144 (84.7) 26 (76.5)
Sometimes 6 (3.5) 1 (2.9)
Often 6 (3.5) 1 (2.9)
Always 14 (8.2) 6 (17.6)
SD = Standard deviation; NA = not applicable; > = greater than. *Significant p value. ^Independent samples t Test. ~: Pearson chi square. †Fishers Exact Test. α: Mann
Whitney U Test.
Table 2.
Univariate logistic regression analysis.
Characteri stics Odds
Ratio 95% Confidence Interval p Value
Mother’s Age
(in Years) 1.032 0.95 - 1.12 0.475
Reason for Night
Waking 0.91 0.19 - 4.48 0.909
Birth Weight 1.43 0.53 - 3.85 0.481
Birth Status
(Term/Preterm) 3.02 1.33 - 6.85 0.008*
Children
1 1.00
2 2.74 1.12 - 6.74 0.028*
3 1.98 0.85 - 4.62 0.113
*Significant p value.
proportion of mothers who showed low versus high parental
stress. Studies (Davis, Edwards, Mohay, & Wollin, 2003; Olaf-
sen et al., 2008) have reported higher levels of parental stress in
mothers of preterm infants. However, these studies did not
compare parental stress between mothers of preterm infants
who were depressed versus those who were not depressed. Ad-
ditionally, methodological heterogeneity exists between these
studies and the current study. For instance, the current study
used a parental stress scale to measure stress, whereas other
studies used the parental stress index (Olafsen et al.) or the
depression anxiety stress scale (Davis et al., 2003). In the cur-
rent study, mothers were recruited from outpatient clinics while
other studies recruited mothers of infants in the neonatal inten-
sive care unit (Davis et al., 2003), or post hospital discharge
(Olafsen et al.).
Understanding the mothers’ experience of having a preterm
infant becomes important to provide context to this finding of
no significant difference in parental stress in mothers of pre-
term mothers who were depressed compared to those who were
not depressed. In the current study, mothers of preterm infants
also did not experience any bonding difficulty. One possible
explanation for the finding may be that Pakistani mothers are
not sufficiently engaged with their infants, as the primary care
giver is usually the mother-in-law or other family elder. Alter-
nately, Feeley, Gottlieb, and Zelkowitz (2005) have indicated
that mothers with a higher education level show more sensitive
responses towards their preterm infants. A majority of mothers
who delivered preterm infants were baccalaureate or graduate
prepared, therefore, the mothers may have been able to interact
effectively and establish good bonding with their preterm in-
fants; hence did not experience parental stress.
The lack of mother-infant bonding difficulties may also be
related to the performance of the tool, as the psychometric
properties of the Urdu version of the PBQ have not been exam-
ined. A German study was unable to confirm the original 4
factor structure when testing the psychometric properties of the
German version of the PBQ (Reck et al., 2006). Reck et al.’s
findings suggest that one general factor, that is impaired bond-
ing, explained 23.9% of the total variance; the internal consis-
tency being .85. Additionally, a 16-item version of the PBQ
was proposed, as 9 items had no meaningful loading on im-
paired bonding. In Reck et al.’s study the EPDS score was cor-
related with the PBQ score (r = .43, p < .001). Furthermore,
15% of variance in the scores was shown to be related to the
joint variance of the two instruments (Reck et al.). The lower
rates of bonding impairment in their study, when compared to
Brockington et al. (2001), were attributed to differences in
sample (Reck et al.). Similar to Reck et al. we recruited a com-
munity sample.
In our study, depressed mothers of preterm infants reported
receiving significantly less support from their husbands. The

S. S. GULAMANI ET AL.
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Table 3.
Characteristics or preterm mothers by depression status.
Depression Status
Depressed Not Depressed
Characteri stic
n = 12 n = 22
p Value
Socio-Demographic
Median (Range) Median (Range)
Mothers’ Age 27 (13) 27 (14) 0.72^
n n
Mothers’ Education >0.99†
Graduate and Above 7 13
Others 5 9
Mothers’ Ethnicity 0.83~
Muhajir 7 12
Others 5 10
Mothers’ Working Status >0.99†
Yes 1 2
No 11 20
Obstetric & Health History
Number of Children 0.66α
One 4 7
Two 5 7
Three and More 3 8
Planned Pregnancy 0.27†
Yes 7 17
No 5 5
Past Psychiatric Illness NA
Yes 0 0
No 12 22
Social
Relationship Difficulties
With Husband 0.12†
Yes 2 0
No 10 22
With Mother-In-Law 0.33†
Yes 2 0
No 10 22
Domestic Violence
Punched, Kicked, or Hit 0.35†
Never 11 22
Sometimes 1 0
Bad Language 0.35†
Never 11 22
Sometimes 1 0
Support System
Husband Support 0.03*^
Never 1 0
Sometimes 5 2
Often 1 4
Always 5 16
Mother-in-Law 0.13^
Never 3 4
Sometimes 3 0
Often 2 5
Always 4 13
Friends’ Support 0.90^
Never 9 17
Sometimes 0 1
Often 1 0
Always 2 4
Family Type >0.99†
Nuclear 3 5
Extended 9 17
> = greater than. ^Mann Whitney U Test. †Fishers Exact Test. ~: Pearson chi square. *Significant p value.

S. S. GULAMANI ET AL.
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Table 4.
Distribution of infants’ characteristics of preterm infants group by depression status.
Depression Status
Depressed Not Depressed
n = 12 n = 22
Characteri stics
n n
p value
Gender 0.73†
Baby Boy 4 9
Baby Girl 8 13
Birth Weight 0.27†
<2.5 Kg 6 6
2.5 Kg and Above 6 16
Reasons for Waking up in the Night 0.08†
Hungry 8 16
No Reason 4 3
Does Not Wakeup 0 1
Others 0 2
Feeding Practices
Difficulty in Feeding Infants *0.03α
Never 6 19
Sometimes 4 2
Often 2 1
Difficulty in Identifying Infants’ Hunger 0.08α
Never 7 19
Sometimes 4 2
Often 1 1
Difficulty in Identifying the Amount to Feed Infants *0.02α
Never 6 19
Sometimes 4 3
Often 2 0
Kg = Kilogram. †Fishers Exact Test. α: Mann Whitney U Test. *Significant p value.
importance the mother attached to the source of support and the
level of support apparent to her from this source, altered her
appraisal of the stressful situation (Logsdon & Usui, 2001). In
instances when a woman attaches more importance to support
from a specific source (such as her husband), and does not feel
she has received that support, the incidence of PPD is higher.
Furthermore, typical support systems will not meet her needs
(Logsdon & Usui, 2001). Hence, although involving the father
may be difficult in a male dominated society, which is charac-
teristic of Pakistan, attempts should be made to include them.
Regardless of depression status, mothers of preterm infants
indicated that they never utilized the support of friends. Ved-
dovi et al. (2001) found that mothers who mingled in social
gatherings showed less depressive symptoms. Hence, social
networking (in person and online) could support Pakistani
mothers of preterm infants by assisting them to manage the
challenges they are experiencing in caring for their preterm
infant. A buddy program, whereby mothers of preterm infants
support other mothers of preterm infants by sharing experiences
and helping to identify effective coping strategies, has been
shown to decrease depressive symptoms in mothers of preterm
infants (Preyde & Ardal, 2003). The AKHWC: Garden and
Karimabad could implement such a social networking strategy
or buddy program and evaluate its effectiveness.
The limitation of this study is that only those mothers who
returned to centers for follow-up care (i.e., postpartum or infant
care) were approached to participate in the study. They repre-
sent only 25.6% of mothers who delivered in the two centers.
This rate of postpartum care is lower than the reported rate of
40% in low- and middle-income countries (Matthews, Severin,
& Jelka, 2010). Furthermore, we did not measure all risk fac-
tors for depression, for instance depression and anxiety during
pregnancy, and life events. Although we examined previous
history of depression and social support, this was through ma-
ternal self-report which is subject to bias. Given the wide con-
fidence intervals in the adjusted odds ratio (95% CI 1.16 - 6.17)
these confounder may be distributed differently between the
groups.
Samples were recruited from two hospitals run by a private
organization, and were found to be homogenous in terms of
economic and educational background, as evident from the
demographic characteristics of the participants. One of the
drawbacks of using a homogenous sample is that the external
validity of the study is limited. The findings of this study may
not be applied to other settings such as government institutions,
where the income and education level of the mothers is signifi-
cantly different. In addition, the instruments used to measure
parenting stress and mother-infant interaction were not ade-
quately tested for their validity and reliability in the Pakistani
population. Lastly, given the small number of preterm infants,
our study did not have sufficient statistical power to make in-
ferences regarding the potential contribution of parenting stress

S. S. GULAMANI ET AL.
Open Access 80
to PPD among mothers of preterm infants.
The study findings suggest that Pakistani mothers of preterm
infants are at a higher risk for PPD as compared to mothers of
full-term infants who sought the services of the AKHWC, Ka-
rachi, Pakistan. Feeding challenges and the level of support
available to mothers of preterm infants who were depressed
versus those who were not depressed may partially explain the
findings. However, PPD in mothers caring for preterm infants
could not be explained with respect to parenting stress and
mother-infant interaction difficulties. Nurses need to be aware
that the preterm birth has the potential of increasing the risk of
PPD, and could plan care in ways that enhances maternal con-
fidence and competence for feeding preterm infants. As well,
nurses could promote involvement of the father in the care of
the preterm infant.
Acknowledgements
We wish to thank Dr. Tak Fung and M. Sarah Rose for their
support with the advanced statistical analysis and Jennifer Cark-
ner for providing technical assistance in the finalization of the
paper. We wish to thank the Pakistani women for participating
in the study. The thesis was awarded the Sigma Theta Tau In-
ternational Chapter Research Award, 2010.
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