The number of deaths caused by child abuse is increasing, which is one of social concerns. The mental health of mothers might be related to child abuse. The aim of this study was to examine and compare the mental state of mothers in both the antepartum and postpartum period assessed by the Edinburgh Postnatal Depression Scale (EPDS) and Mother-Infant-Bonding-Scale (MIBS), and compare the results. Participants (n = 134) were recruited twice in antepartum medical checkups (20 to 36 weeks of gestation) and postpartum medical checkups (1 month after birth). Information on characteristics of participants was collected from medical records in both periods. Family function and ante-postpartum mental health were assessed by Family APGAR, EPDS, and MIBS. Antepartum depressive state was related to postpartum depressive state (p = 0.015), antepartum bonding was related to bonding in postpartum bonding (p = 0.0001), and antepartum bonding disorder was related to postpartum depressive state (relative risk = 11.7). Worries about costs and poor of family function were related to the mental health of mothers in both the antepartum and postpartum periods. Antepartum depressive state is an indicator of postpartum depression. We suggested that health professionals conduct an evaluation of mother’s mental health and related factors in the antepartum period. The present findings emphasize the importance of antepartum mental health as a predictor of postpartum depression and bonding disorder.
Recently, child abuse is one of social concerns. The prevalence handled by child consultation centers in Japan was 73,765 in 2013, which has been increasing each year. It has been reported that infants account for over 50% of all children who die as a result of abuse. Among the infants who died with abuse, many newborn babies were included [
Several studies indicated that postpartum mental health (anxiety of child-rearing, depressive state) might be related to child abuse [
Therefore, we examined the mental state in both of antepartum and postpartum in mothers assessed by the Edinburgh Postnatal Depression Scale (EPDS) and Mother- Infant-Bonding-Scale (MIBS), and compared the results.
This study was conducted at a university hospital located in an urban area in Japan. Mothers were surveyed twice, one during antepartum medical checkups (from 20 weeks of gestation to 36 weeks of gestation) and one during postpartum medical checkups (1month after birth). The participants were enrolled in this study based on the following criteria 1) age over 20 years, 2) without present or history of psychiatric diseases, and 3) permission of attending doctor. Out of 215 women who gave written informed consent to participate, 162 women (75.3%) completed the study. As the reasons of dropping out of the study were the NICU hospitalization of neonates and the changes in the birth institution or home address. Finally, we analyzed 134 participants who completely finished the study in both of antepartum and postpartum period. This study was approved by the Ethics Committee of the University of Tokyo.
This study was a longitudinal study which investigates the mental health and the bonding to the fetus or neonate of mothers in both of antepartum and postpartum. The mental state of mothers in this study means that it was assessed by EPDS and MIBS.
1) Characteristics of Participants
Information on characteristics of participants was collected from medical records in antepartum and postpartum. Information collected in the antepartum consisted of occupational status, marital status, parity, morning sickness, worries about costs. Information collected in the postpartum consisted of gestational week at the delivery, mode of delivery, obstetrical disorders during labor, baby’s weight and sex, APGAR score, umbilical blood pH, breast feeding and troubles with breast feeding.
2) Family Function
We examined Family APGAR score two times to evaluate the degree of the social support. The Family APGAR was introduced by Smilkstein in 1978 to assess satisfaction with social support from the family in adulthood, which was composed of five items measuring perceived family support in the domains of adaptation, partnership, growth, affection, and resolve. It was translated into Japanese by Nagamine [
3) Measurement of Mental Health
a) EPDS
EPDS is a self-reported questionnaire composed of 10 items scored on a four-point Likert scale (0 - 3) designed to assess antepartum and postpartum depression [
b) MIBS
MIBS was based on a study by Kumar and Marks [
4) Statistical analyses
SPSS Statistics 23 for Windows was used to analyze the descriptive statistics. Antepartum and postpartum scores were tested using the paired t-test and Fisher’s exact test. The dependent variables were postpartum EPDS score and Bonding score, and the independent variables were each score of antepartum and participants characteristics and Family APGAR score. The level of statistical significance was set to P < 0.05.
Mean ± SD or percent | |
---|---|
Age (years old) | 34 ± 4.2 |
Occupation | 58.9% |
Marital status | First 91% |
Second 4.4% | |
Not marriage 2.2% | |
Parity | Primipara 58.9% |
Multipara 38.8% | |
Morning sickness | 79.1% |
Worries of costs* | 11.1% |
Family APGAR in Antepartum (points) | 8.9 ± 1.5 |
Gestational weeks at delivery (weeks) | 40 ± 2.3 |
Vaginal delivery | 93.2% |
Caesarean section | 6.0% |
Abnormality in a delivery process | 71.6% |
Baby’s weight (lb) | 6.7 ± 0.9 |
Umbilical blood pH | 7.3 ± 0.1 |
Breast feeding only | 47.7% |
Combination feeding | 40.2% |
Bottle feeding only | 3.7% |
Troubles on breast feeding | 25.3% |
Family APGAR in postpartum (points) | 8.7 ± 1.6 |
*Delivery and baby care costs.
primipara and multipara were 58.9% and 38.8% respectively. Seventy-nine percent of the participants had morning sickness, and 11% were worries about delivery and baby care costs. The mean gestational week of pregnancy was 40 ± 2.3 weeks. The rates of vaginal delivery and caesarean section were 93.2%, and 6% respectively. Among the participants, 71.6% had an abnormality, for example, labor induction during the delivery process.
The mean weight of the newborns was 6.7 ± 0.9 lb. Concerning on breastfeeding, breastfeeding only, combination of breastfeeding and bottle-feeding, were 47.7%, 40.2%, respectively. Trouble with breastfeeding was found in 25.3% of the participants had.
Family APGAR score which measured the family function in the antepartum period was 8.9 ± 1.5 points, while that in the postpartum was 8.7 ± 1.6 points (
1) Depressive state: An antepartum depressive state (EPDS score more than 9 point) was 14.1% (19/134), while postpartum depressive state was 17.9% (24/134). The mean EPDS score in the antepartum and postpartum periods were 4 ± 3.8 points and 4.9 ± 3.8 points, respectively. There were significant differences in depressive points assessed by EPDS between the antepartum and postpartum periods (p = 0.015) (
2) Bonding disorder: We judged not antepartum bonding disorder was 41.7% (56/ 134), and not postpartum bonding disorder was 28.3% (38/134). The mean ± standard deviation MIBS score was 2.4 ± 2.4 points in the antepartum period and 1.5 ± 2 points in the postpartum period. There were significant differences in bonding points assessed by MIBS between the antepartum and postpartum periods (p = 0.00) (
antepartum | postpartum | p-value | |
---|---|---|---|
EPDS | 4 ± 3.8 | 4.9 ± 3.8 | 0.015 |
MIBS | 2.4 ± 2.4 | 1.5 ± 2 | 0.000 |
:lack of affection | 1.6 ± 1.9 | 0.8 ± 1.3 | 0.000 |
:anger & rejection | 0.8 ± 1.0 | 0.7 ± 1.0 | 0.3 |
Paired t-test.
Postpartum EPDS | Odds ratio | ||||
---|---|---|---|---|---|
Over 9 points | Under 8 points | 95%CI | |||
Antepartum EPDS | Over 9 points | 12* | 7 | 14.7 (4.9 - 44.5) | |
Under 8 points | 12 | 103 | reference | ||
*Fisher’s exact test p = 0.00.
Depression state | Bonding disorder | |||||||
---|---|---|---|---|---|---|---|---|
Antepartum | Postpartum | Antepartum | Postpartum | |||||
OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | |
Age | 1.2 (1 - 1.6) | 0.23 | 1 (0.9 - 1.1) | 0.93 | 1.1 (1 - 1.3) | 0.61 | 1 (1 - 1.1) | 0.41 |
Parity | 0.08 (0.01 - 0.6) | 0.52 | 1 (0.5 - 1.8) | 0.90 | 1 (0.4 - 2.8) | 0.09 | 0.6 (0.4 - 1.0) | 0.07 |
Morning sickness | 3.7 (0.1 - 143.8) | 0.87 | 1.2 (0.4 - 4) | 0.73 | 0.1 (0.02 - 0.8) | 0.03 | 1.4 (0.6 - 3.2) | 0.49 |
Worries of costs* | 46 (3.7 - 566.6) | 0.00 | 3.7 (1.2 - 11.6) | 0.02 | 4.4 (0.4 - 46.2) | 0.01 | 2.1 (0.6 - 7.0) | 0.21 |
Family APGAR in Antepartum (points) | 0.7 (0.2 - 2.2) | 0.04 | 0.8 (0.2 - 3.1) | 0.68 | 0.8 (0.4 - 1.7) | 0.00 | 0.6 (0.5 - 0.9) | 0.003 |
Abnormality in a delivery process | 3.8 (0.3 - 43.3) | 0.73 | 1.4 (0.5 - 4.0) | 0.56 | 2.6 (0.7 - 9.4) | 0.44 | 1.6 (0.7 - 3.6) | 0.23 |
Baby’s weight (lb) | 0.2 (0.01 - 1.7) | 0.93 | 1.8 (0.7 - 4.6) | 0.25 | 0.6 (0.2 - 1.9) | 0.91 | 1.9 (0.9 - 4.1) | 0.11 |
Umbilical blood pH | 0.00 (0.0 - 2280) | 0.49 | 7.4 (0.01 - 4477.9) | 0.54 | 0.01 (0.0 - 12.9) | 0.86 | 0.1 (0 - 15.1) | 0.41 |
Breast feeding only | 0.47 (0.2 - 1.3) | 0.15 | 0.5 (0.2 - 1.5) | 0.24 | 0.73 (0.4 - 1.3) | 0.3 | 0.46 (0.2 - 1) | 0.04 |
Troubles on breast feeding | 4.7 (0.4 - 54.3) | 0.09 | 1.1 (0.4 - 3.2) | 0.81 | 0.7 (0.2 - 2.6) | 0.03 | 2.1 (0.9 - 4.9) | 0.08 |
Family APGAR in postpartum (points) | 2.8 (0.9 - 9.1) | 0.00 | 0.8 (0.6 - 1) | 0.04 | 2.4 (1.2 - 4.9) | 0.01 | 0.2 (0.1 - 0.7) | 0.00 |
*Delivery and baby care cost.
“lack of affection” significantly decreased from antepartum to postpartum (p = 0.00). In “anger and rejection” which were no significant differences between antepartum and postpartum (p = 0.3) (
We examined the relationship between bonding disorder in antepartum and relation of the depressive state in postpartum. As a result, 23 of 96 mothers who had bonding disorder in antepartum had depressed mental state in postpartum. Mothers with an antepartum bonding disorder were 11.7 times more likely to have a postpartum depressive state than those without antepartum bonding disorder (
Postpartum Bonding Score | Odds ratio 95%CI | |||
---|---|---|---|---|
Over 1 points | Point 0 | |||
Antepartum Bonding Score | Over 1 points | 67* | 11 | 5.7 (2.5 - 13) |
Point 0 | 29 | 27 | reference |
*Fisher’s exact test p = 0.000.
Postpartum Depressive state | Odds ratio 95%CI | |||
---|---|---|---|---|
Over 1 points | Point 0 | |||
Antepartum Bonding Score | Over 1 points | 23* | 73 | 11.7 (1.5 - 89.7) |
Point 0 | 1 | 37 | reference |
*Fisher’s exact test p = 0.001.
This is the first study to demonstrate that depressive state and bonding disorders of mothers in antepartum period may be related to those in the postpartum period. Also, worries about costs and poor family function were causes of the mental stresses sustained from the antepartum period to the postpartum period in mothers. Furthermore, there was a correlation between bonding disorders in the antepartum period and depressive state in the postpartum period.
According to our results, mothers with a depressive state in the antepartum period sustained the depressive state in the postpartum period, with a relative risk ratio of 14.7 compared to mothers without depressive state in antepartum. It is suggested that antepartum depressive state may be a suitable factor for predicting postpartum depression [
There were significant differences in the bonding of mothers to their babies between the antepartum and postpartum periods. The negative feelings of mothers towards the fetus in the antepartum period diminished in the postpartum period. It is difficult for pregnant mothers to form strong bonding to their fetuses only by ultrasonographic imaging. However, once the babies are born and mothers can hold and nurse them, the mother’s negative feelings toward the baby reduce. MIBS was evaluated by two aspects, “lack of affection” and “anger and rejection”. “Lack of affection” improved in the postpartum period compared with the antepartum period, while “anger and rejection” did not improve in the postpartum period. Also, poor family function which exerts as a mental stress factor in both of the antepartum and postpartum periods contributes to sustained bonding disorders from antepartum to postpartum in mothers. The “anger and rejection” score of MIBS represents a direct risk factor for child abuse [
When postpartum depression was used as a dependent variable in the statistical analyses, a bonding disorder in the antepartum period was significantly associated with postpartum depression. Also, of the 38 participants without bonding disorder to the fetus in the antepartum period, only one showed a postpartum depressive state in the postpartum period. It is suggested that the bonding disorder of mothers in the antepartum period is a predictor of depressive state in the postpartum period. Health professionals should coordinate interventions to improve bonding of mothers to their babies from the antepartum period. The Siddiqui et al. demonstrated that fetus imaging through ultrasonography could be effective on the promoting of mother’s bonding to fetus. It was reported that the bonding of mothers to their fetus might precede the establishment of the mother and fetus (child) relationship [
We concluded that a depressive state and bonding disorders of mothers in the antepartum period are related to those in the postpartum period. Also, the bonding disorders in the antepartum period were associated with a postpartum depressive state. Worries about costs and poor of family function were related to the depressive state of mothers in both of the antepartum and postpartum. It is essential that the health professionals evaluate the mental health of mothers and the related factors in the antepartum period, and provide to improve their mental health. In antepartum, we emphasize the importance of antepartum mental health assessment as a predictor of postpartum depression and bonding disorder in mothers.
The limitations of this study were that the number of participants was small and the location of this study was limited to only one hospital. Therefore, it is necessary to conduct further investigation in multiple hospitals.
Regarding child abuse prevention, when “anger & rejection” was apparent feelings toward the baby during the antepartum period, continuous support is clearly needed. Because mothers who have negative feelings toward their fetus can easily become depressed in the postpartum period, intervention should be conducted to prevent child abuse.
We are very grateful to the participating in this study. This study was supported by Grant in-Aid for Young Scientists (B) in Japan.
We declare no conflicts of interest.
Sugishita, K., Kamibeppu, K. and Matsuo, H. (2016) The Inter Relationship of Mental State between Antepartum and Postpartum Assessed by Depression and Bonding Scales in Mothers. Health, 8, 1234-1243. http://dx.doi.org/10.4236/health.2016.812126