Risk of Postpartum Depression: The Considerable Role of Maternal Health Status and Lifestyle

Women’s health issues are complex and require collaborative efforts to unravel some of these complexities. This study aims to identify the incidence risk of Postpartum Depression (PPD) in a national sample of women in Saudi Arabia and the relationship with several health status, lifestyle, and sociodemographic factors. A cross-sectional study with an online questionnaire format assessed the risk of postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) and included several questions on postpartum health status and lifestyle factors. Of the 550 women who responded to the survey 75% scored within range of risk for PPD (≥12). We found significant associations between family income, younger baby age, birth difficulty, having family support, level of physical activity, and the risk for PPD (p < 0.05). Urgent attention and resources should be directed towards screening and treatment for PPD in the healthcare system. The development of programs for awareness, education, and support of postpartum mothers in the Kingdom of Saudi Arabia is also required.


Introduction
The World Health Organization (WHO) prioritizes a healthy diet, that is, nutrition, weight management, physical activity, planned pregnancy, and physical, mental, and psychosocial health for women of reproductive age [1][2][3][4][5]. (Women's health issues are complex, and collaborative efforts are required to unravel some of these complexities in order to support women through their reproductive experiences, to enhance health and well-being, and to ensure better maternal outcomes [6][7][8][9]. Postpartum depression (PPD) is a common issue among childbearing women, as up to one in seven women will experience PPD [8,10,11]. PPD may develop within the first few weeks after a child's birth and can seriously impact women's health and well-being if left unrecognized and untreated [6]. PPD may also have a significant impact on women's ability to bond with their babies, breastfeed or care for them, or care for themselves and their families [6,8,11].
Common symptoms of PPD include lack of interest or enjoyment, loss of appetite or ability to sleep, anxiety, racing or scary thoughts, difficulty concentrating or in decisionmaking, feelings of guilt or worthlessness, self-blame, excessive irritability, anger or agitation, crying, sadness or misery, fear of not being a good enough mother or of being left alone with the baby, or thoughts of harming the baby or self-harm [6,10,11]. If these symptoms persist longer than two weeks after delivery, professional help may be required, and recovery is possible with proper treatment and support [6,[9][10][11]. PPD can affect all women, support women in achieving more positive postpartum experiences and to raise awareness and draw attention to the importance of maternal mental health and well-being.

Study Design and Sample Size Calculation
We conducted a cross-sectional survey using an online questionnaire format. Responses were collected from a national sample of mothers living in Saudi Arabia from April to September 2021. A priori sample size calculation was conducted using OpenEpi.com. Based on the total Saudi female population in 2020 [36] and setting the confidence level at 95%, the margin of error at 5%, and the anticipated frequency at 50%, the estimated sample size was 385 respondents.

Study Respondents and Recruitment
The inclusion criteria were female adults (18-50 years old) within 1 year postpartum and residing in Saudi Arabia, regardless of nationality. Respondents who did not meet these criteria were excluded. The online survey was delivered using Survey Monkey (Palo Alto, CA, USA). A thorough description of the study detailing the study protocol and respondents' rights was provided at the outset of the online survey. All respondents were given the option to provide digital informed consent to participate by clicking yes or no before answering the survey questions. All respondents were free to end their participation at any point during the survey. The questionnaire was disseminated via social media platforms (e.g., Twitter v.8.89, WhatsApp v. 2.21.8.12, and e-mail) and required approximately 10 min to complete.

Study Instrument
The online questionnaire consisted of several items on sociodemographic, health status, and lifestyle indicators. Data related to age, gender, marital status, nationality, region, educational level, employment status, body mass index (BMI), income level, postpartum months, type of birth experience, breastfeeding status, pregnancy and birth issues, family support, smoking status, physical activity, history of mental illness, history of chronic illness, and recent use of antibiotics were collected. In addition, the Edinburgh postnatal Depression Scale (EPDS) screening tool for identifying depression was included in the survey. The survey was developed and reviewed by a group of healthcare professionals and piloted on a small group from the public before full release, as part of a series of projects by our research team [37,38].

Edinburgh Postnatal Depression Scale (EPDS)
The EPDS is a 10-item self-reported scale that assesses common symptoms of depression scored on a four-point scale (0-3), with total scores ranging from 0 to 30 [39]. The EPDS is a validated screening tool for PPD that has been translated into over 18 languages, including Arabic [40,41]. The Arabic version of the EPDS has a Cronbach's alpha of 0.84, indicating good internal consistency. A value ≥ 12 has been shown to indicate good sensitivity and specificity in Arabic-speaking cultures [40][41][42]. Therefore, we considered the risk of PPD to be present in scores of 12 or higher on the EPDS scale [39,42].

Statistical Analysis
The statistical analysis was performed using IBM SPSS (version 28.0.1.0). In the datacleaning process, no missing data related to the study's main variables were identified. Data were presented as the mean (M) and standard deviation (SD) for continuous variables and as frequencies and percentages for categorical variables. Frequency distribution was used to determine the percentages of those at risk of PPD across various sociodemographic and general health variables.
Chi-square and Fisher's exact tests were conducted to evaluate the association between demographic variables and the risk of PPD. Fisher's or chi-square tests were used in the case of 2 × 2 contingency tables, while Pearson's likelihood ratio was used for larger tables. Simple and multivariate logistic regression was used to assess health status, lifestyle, and sociodemographic variables as predictors of risk of PPD. Several variables were recoded into binary categories to reduce the likelihood of multicollinearity. Those that were difficult to categorize into two were converted into dummy variables. Only variables that returned significant results as PPD predictors from the simple regression were further entered into multivariate logistic regression.

Ethics Approval and Consent to Participate
The study was conducted in accordance with the guidelines proposed in the Declaration of Helsinki and all relevant local and international ethical guidelines and regulations. The study was reviewed and approved by the Unit of Biomedical Ethics Research Committee, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (Registration Number: HA-02-J-008, Reference No 84-21). The study protocol, procedures, and respondents' rights were explained at the beginning of the online survey. All respondents to the survey were given the option to provide digital informed consent to participate by clicking yes/no before answering the survey questions. All respondents were free to end their participation at any point during the survey.

Participant Characteristics
In total 550 mothers responded to the questionnaire and were included in the analysis. Most respondents (97%) were 20-39 years old (M = 29, SD = 5.4). Almost all respondents (98%) were married, while 513 (93%) were Saudi. Around two-thirds of mothers (69%) reported having a bachelor's degree and nearly 29% were not working or unemployed. Around half of the respondents (48%) had a monthly family income ranging from SAR 7000 to SAR 15,000. Almost one-third of the respondents were from the Mecca region (30%), while other areas were represented by fewer than 15 respondents. A total of 133 respondents (24%) had only one child, most (46%) had two children, and 30% had three or more children (Table 1). Two-thirds of respondents (67%) had babies aged 6 months or younger (M = 5, SD = 3.9). Most (93%) were not pregnant at the time of the survey. A high percentage (75%) had vaginal births, while about 45% reported having difficulties during their last birth (regardless of birth mode). About half (52%) were consistently breastfeeding, while the rest varied from those who used to breastfeed but stopped to those who were inconsistently breastfeeding and those who had never breastfed (12%, 23% and 13%, respectively). More than half (54%) were receiving constant family support, while the rest were roughly divided between those whose family support was inconsistent and those who were not receiving family support at all (Table 1).
A high percentage of respondents (80%) were either within the range of normal or overweight BMI; the rest were considered obese. Around 40% were not performing any form of physical activity, although more than half (56%) had a suitable space at home to do so. Only 13% were going to the gym regularly, while around 60% were not going at all. Smoking was reported by 6.5% of respondents, and most (91%) had not used antibiotics while pregnant. About 11.5% were struggling with at least one chronic health issue. The most frequent health issues reported were diabetes, gastrointestinal, and mental health issues (Table 1).

EDPS Scores
Of the 550 respondents, almost three-quarters (75%) scored 12 or higher on the EPDS, indicating a risk of PPD. The average EPDS score was 14, which was above the cut-off point of 12.

Sociodemographic Factors and Risk of PPD
Family income and area of residence were significantly correlated with the risk of PPD (p value < 0.001 and 0.002, respectively). This significance was reflected in the proportion of women with high EPDS scores across income levels. For income levels less than SAR 10,000, the proportion ranged between 83-88%, for higher income levels, the proportion ranged from 48% to 77%. In Dammam, Buraidah, Medina, and Abha, the proportion of women at high risk of PPD was over 80%, while in Riyadh and Mecca, it was closer to 60% ( Table 2).

Health Status, Lifestyle Factors, and Risk of PPD
There was a significant association between baby age and risk of PPD (p < 0.001). Respondents with babies under 6 months of age had a higher risk of PPD (80%) compared to those who gave birth over 7 months ago (61%). There was also a significant association between birth difficulty and a higher risk of PPD (p < 0.001). This significance was reflected in the percentage of respondents with higher scores on the EPDS across the five levels of difficulty of easy/very easy birth experience (over 50%), moderate/difficult experience (over 70%), and very difficult experience (83%). Not receiving family support was significantly associated with a higher risk of PPD (p < 0.001). Those who received inconsistent family support were at a higher risk of PPD than those who had consistent or no support (87% compared with 69-73%, respectively) ( Table 2).
Those who were more physically active had a higher risk of PPD than those who were inconsistent or not physically active (87% compared to 68-70%, respectively, and this was statistically significant, (p < 0.001). We found similar results for going to the gym: a high percentage of respondents who either went to the gym regularly or sometimes had a higher risk for PPD. However, we found that those who had a suitable space at home in which to perform physical activity had significantly less risk (p < 0.05) of PPD compared to those who did not (PPD risk was 70% and 79%, respectively) ( Table 2).
None of the chronic health issues (mental health issues, diabetes, high blood pressure, heart disease, respiratory allergies, osteoporosis, blood diseases, food allergies, gastrointestinal issues and others including Hashimoto's disease, thyroid inactivity, stress/tension, rheumatism, sinus sensitivity, lactose sensitivity, or chronic muscle pains) were significantly associated with a higher risk of PPD (p > 0.05). Despite a lack of statistical significance, we noted that the proportion of women at risk of PPD among those suffering from health issues was higher than the proportion who were not. However, there was a significant association between being at risk of PPD and suffering from at least one of the diseases put under 'other' (p < 0.05). People suffering from these diseases had a higher risk of PPD than others (33% compared to 7.5%, respectively) ( Table 2).

Predictors of the Risk of PPD Development
In the simple binary logistic regression (univariate analysis), several variables were significantly associated with the risk of PPD (p < 0.05). The number of children and birth difficulty were not statistically significant (p > 0.05 for the models or the B-coefficient of the independent variables). These two variables were therefore not entered into the further multivariate analysis (Table 3). In the multivariate binary logistic regression, we found lower income, receiving some support, inconsistent physical activity, and going to the gym (sometimes) significantly influenced the risk of PPD (p < 0.05). These factors returned a positive effect except for Physical Activity (Sometimes). The odds > 1 indicate that the chance of developing PPD was greater than not (e.g., in the case of lower income, the chance of PPD was three times greater than not). For Physical Activity (Sometimes), the odds were 0.417 (less than 1), which means that there was a 41.7% risk for PPD (Table 3).

Discussion
We evaluated various health status, lifestyle, and sociodemographic factors in women and their potential relationship with the risk of PPD within 1 year postpartum. We found that a lower income, difficult birth experiences, lack of consistent family support, and levels of physical activity were significantly correlated with the risk of PPD. Our findings echo other Saudi studies, as 74% of our study sample scored over 14 on the EPDS [13,17]. This could be due to the circumstances of the COVID-19 pandemic, as our survey was conducted between April and November 2021 (during the height of the pandemic) and reflects the critical findings of Papworth et al. (2021) who found that 90% of mothers who had recently given birth felt isolated due to the COVID-19 restrictions, as well as several other international studies that showed that women during COVID-19 were more likely to present clinically significant levels of depressive and anxiety symptoms [7,9,15,33,34].
We found significant associations between the risks of PPD and age, level of education, employment, level of income, and area of residence. This is similar to the findings of previous studies and could be related to social and family dynamics, or the pressures of studying or working while pregnant or mothering [12,13,19,20], as well as the increase in these pressures during the pandemic [15]. This also echoes the findings of other international studies on the effects of the pandemic on maternal mental health [7,9,33]. Our regional findings were interesting, with PPD rates ranging from 57.1% to 89.5%, indicating that at least half of the mothers and a majority of the respondents from these cities may have been struggling with symptoms of depression at the time of the study [13,19,20].
There was a clear significance in the correlation between lower income and the risk of PPD in our study. Lower income could be a factor impacting the availability and accessibility of family support during the postpartum period, as well as access to needed resources to facilitate mothers' breastfeeding, recovery, and sustained well-being, including engagement in physical activity. Our findings also complement the current literature, as we found high risks of PPD when women were not receiving consistent family support or unemployed [7,9,[11][12][13][14]19,43]. We reason that the difference in depression rates among the three levels of family support is as follows: many of those receiving no family support may have become accustomed to this situation. However, many of those who were receiving consistent family support may have also been facing other forms of stress, such as overinvolvement of the family or difficulty in communicating or setting boundaries, especially during the pandemic.
Similar to previous studies, we found interesting variations in the risks of PPD in younger age mothers, first-time mothers, mothers with two children, and mothers with more than three children [11,12]. These findings could be related to the lack of experience and awareness of the pressures of motherhood in new and first-time mothers, a lack of social support and the increased amount of care, work and mothering required as the number of children increases [12,16,28] and could be explored further. We also found a significant association between baby age and the risk of PPD, as those with babies under 6 months of age had a higher risk of depression (80% vs. 61%) compared to women whose babies were older. These issues bear further scrutiny and exploration as to the type and amount of support required for a healthy and well postpartum period, which would reduce the risk of PPD.
Our findings for 45% of the study sample who reported difficulties with their last birth are concerning and could be attributed to the COVID-19 restrictions in place at the time, as well as systematic and cultural issues in maternity and obstetrics care [7,9,11,12,14,15,33]. We calculated that the odds of developing PPD after a difficult birth were 11 times higher, which was significant, with a probability of around 91.7%. We also reaffirm the findings linking postpartum medical complications (e.g., postpartum hemorrhage or infections) and difficulties in breastfeeding or childcare, which lead to stress, anxiety, poor sleep quality, fatigue, and increased incidence of PPD [12,14,17,18].
Our results linking physical activity and PPD were surprising and conflict with the currently accepted knowledge [22,23,27]. We found the highest levels of PPD in women who consistently engaged in some form of physical activity. A study from 2020 found little evidence for an association between physical activity and depressive symptoms and discussed the evidence of associations between diet, physical activity, and depression; however, they recommended further research on the relationship between physical activity, specific dietary components, and PPD [24]. In addition, we cannot overlook that the data collection for this study occurred during the COVID-19 pandemic, when severe restrictions were in effect, which may have impacted women's ability to engage in physical activity or go to the gym and may have confounded mental health issues.
Our study had several strengths as well as some limitations. Although this was a multi-region population-based study with a large sample size, our data were based on a cross-sectional design, and the non-probability convenience sampling method may have hindered the generalizability of the results to all mothers. In addition, our data were collected using electronic platforms and a self-reported questionnaire, which may also have caused selection bias and limitations in the generalizability of our findings. Future studies may consider other methods, such as prospective designs, in-person interviews, or other objective measures to circumvent such limitations.
This study investigated the role of several key maternal health status and lifestyle factors in the risk of developing PPD, yet the data were collected during the height of the COVID-19 pandemic. We did not have information related to the impact of the pandemic on the risk of PPD development among our study sample, as the study design was crosssectional, and we did not have baseline data for pre-pandemic levels of PPD risk. The pandemic may have played a major role in the risk of PPD found in this study. It was beyond the scope of this study to focus on and directly investigate the pre-pandemic levels of physical activity engaged in by our sample.

Study Implications and Recommendations
These issues require further research to link women's integrative and preventive health policies and programs in order to improve reproductive health and maternal mental health [1][2][3]6,8,9,11,12,16,28]. Attention from primary care providers and other healthcare professionals and policymakers working in the reproductive and maternal health fields is also required [21,34,35].
We strongly encourage increased national attention to the issue of maternal mental health and further research exploring the burden of perinatal mental health issues, such as PPD on the well-being of the mother, the baby, family unit, society, and economy. It may also be of value to consider studying the effects of lifestyle factors, such as diet, nutrition, physical activity, and family support, in the context of Saudi Arabia. In light of our intriguing findings on physical activity, further research on participation in physical activity, exercise, and the relationship with PPD risk among new mothers should also be conducted, as exercise has been previously shown to be a cost-effective treatment for improving mental health and well-being and mitigating PPD symptoms [22,23,26]. The impact of a difficult birth experience itself (birth trauma) and the potential emotional impact of the intention to breastfeed, breastfeeding success on perinatal mental health issues, and maternal wellness in general also need to be studied.

Conclusions
PPD risks were significantly associated with lower income levels, birth difficulty, younger baby age, lack of family support surrounding the mother, and levels of physical activity. PPD is a serious public health concern that has far-reaching consequences for the health and quality of life of the mother and child, as well as for the well-being of the family unit and society at large. Furthermore, it has serious economic implications that must be considered by policymakers. Urgent attention and resources should be directed towards screening and treating PPD in the healthcare system. The development of programs for the education and support of postpartum mothers in the Kingdom of Saudi Arabia is also required. Informed Consent Statement: Informed consent was obtained from all respondents involved in the study. Consent for publication was not required as no personal identifying information was involved.

Data Availability Statement:
The raw datasets generated and/or analyzed during the current study are not publicly available as other related research projects are still ongoing; however, they will be available from the corresponding author on reasonable request.