Postpartum Depression and Anxiety among Lebanese Women: Correlates and Scales Psychometric Properties
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Sample Size Calculation
2.3. Survey Details
- -
- We used the Edinburgh Postnatal Depression Scale (EPDS) to screen for the possible presence of postpartum depression. It is the standardized tool used postnatally to quantify the severity and establish an estimation of postpartum depression [33]. EPDS is a valid 10-question scale that is valuable for identifying the potential risk of depression following childbirth and an effective screening tool that demonstrates sensitivity and high reliability. Regarding the scoring of the EDPS questionnaire, the following is used: answers are scored on a scale from 0 (not at all) to 3 (as much as I ever did). Therefore, the total score ranges from 0 to 30, with a score of 11 or more deemed positive for postpartum depression. On the total EPDS score, the threshold value ≥11 is deemed a relevant diagnostic criterion in order to diagnose appropriately postnatal depression during the post-delivery time range of 4–6 weeks [33].
- -
- The Lebanese Insomnia Scale (LIS), which is a validated scale for assessing insomnia in Lebanon [34], is composed of 18 items used to screen for the diagnosis of insomnia based on several validated and universally applicable self-report scales. It aims to provide a valid, standardized and reliable reflection of sleep quality. Answers are scored according to a scale (1 = never and 5 = always); greater scores designate worse insomnia. Cronbach’s alpha value for this scale was 0.732.
- -
- We also included the “Presumptive Stressful Life Events Scale” (PSLES) to evaluate whether there was one of several stressful life events that may have happened to the mother up to 12 months before giving birth to her newborn. This scale was constructed and standardized for two periods: the previous one year and over her lifetime. The scale events are divided into 9 categories: family and social, work, financial, marital and sexual, health, bereavement, education, legal and, finally, courtship and cohabitation. Each category has a series of events, where the mother should respond with a “yes” if the event occurred during the last year or/and during her lifetime. Cronbach’s alpha value for this scale was excellent (0.967).
- -
- This questionnaire also contained the “Perinatal Anxiety Screening Scale” (PASS) to detect the severity of perinatal anxiety. The PASS is a trustworthy 31-item self-reported questionnaire for postpartum and antenatal women to screen for anxiety. It distinguishes between high and low anxiety disorder risk by measuring specific anxiety symptoms. The mother scores these symptoms by indicating their frequency over the last month. The scale is as follows: 0 (not at all), 1 (sometimes), 2 (often) and 3 (always). Scores between 0 and 20 indicate the absence of anxiety symptoms, scores between 21 and 41 indicate mild-to-moderate symptoms, and scores between 42 and 93 indicate severe symptoms. High and low anxiety disorder risks were separated with a cut-off score of 26.
2.4. Forward and Back Translation
2.5. Statistical Analysis
3. Results
3.1. Sociodemographic Characteristics of the Participants
3.2. Principal Component Analysis
3.3. Bivariate Analysis
3.3.1. Bivariate Analysis Associated with Postpartum Depression and Anxiety
3.3.2. Bivariate Analysis Associated with Postpartum Anxiety
3.4. Multivariable Analysis
4. Discussion
4.1. Validation of Both Scales:
4.2. Factors Associated with Depression
4.3. Factors Associated with Anxiety
4.4. Implications for Psychiatric Practice
4.5. Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Variable | N (%) |
---|---|
Sex of the baby Male Female | 152 (51.7%) 142 (48.3%) |
Mother’s educational level Illiterate/primary Complementary Secondary University | 18 (6.1%) 14 (4.7%) 40 (13.6%) 223 (75.6%) |
Monthly income | |
No income <USD 1000 USD 1000–2000 >USD 2000 | 53 (18.8%) 42 (14.9%) 143 (50.7%) 44 (15.6%) |
Insurance type No insurance Private insurance NSSF Private and NSSF Army COOP | 29 (10.2%) 56 (19.7%) 116 (40.8%) 49 (17.3%) 22 (7.7%) 12 (4.2%) |
Governorate | |
Beirut | 32 (10.9%) |
Mount Lebanon | 104 (35.5%) |
North | 44 (15.0%) |
South | 109 (37.2%) |
Bekaa | 4 (1.4%) |
Mean ± SD | |
Mother’s age at delivery (years) | 29.53 ± 5.18 |
Father’s age at delivery (years) | 34.32 ± 5.87 |
Postpartum depression | 10.90 ± 6.17 |
Postpartum anxiety Postpartum insomnia Stress: previous year score Stress: lifetime score | 27.76 ± 13.23 47.88 ± 10.11 5.22 ± 8.06 2.86 ± 5.21 |
Model 1: Factor Analysis of the Edinburgh Postnatal Depression Scale (EPDS) | |||||
---|---|---|---|---|---|
Factor | Items | Factor 1 | Factor 2 | Factor 3 | Factor 4 |
I have been able to laugh and see the funny side of things | EPDS 1 | 0.869 | |||
I have looked forward with enjoyment to things | EPDS 2 | 0.795 | |||
I have blamed myself unnecessarily when things went wrong | EPDS 3 | 0.896 | |||
I have been anxious or worried for no good reason | EPDS 4 | 0.780 | |||
I have felt scared or panicky for no very good reason | EPDS 5 | 0.708 | |||
Things have been getting on top of me | EPDS 6 | 0.884 | |||
I have been so unhappy that I have had difficulty sleeping | EPDS 7 | 0.729 | |||
I have felt sad or miserable | EPDS 8 | 0.735 | |||
I have been so unhappy that I have been crying. | EPDS 9 | 0.759 | |||
The thought of harming myself has occurred to me | EPDS 10 | 0.467 | |||
Cronbach’s alpha | |||||
Percentage of variances explained | 48.84 | 13.67 | |||
Model 2: Factor Analysis of the Perinatal Anxiety Screening Scale (PASS) | |||||
Factor | Items | Factor 1 | Factor 2 | Factor 3 | Factor 4 |
Worry about the baby/pregnancy | PASS 1 | 0.922 | |||
Fear that harm will come to the baby | PASS 2 | 0.880 | |||
A sense of dread that something bad is going to happen | PASS 3 | 0.661 | |||
Worry about many things | PASS 4 | 0.768 | |||
Worry about the future | PASS 5 | 0.489 | |||
Feeling overwhelmed | PASS 6 | 0.587 | |||
Really strong fears about thing (needles, blood, birth, pain, etc) | PASS 7 | 0.431 | |||
Sudden rushes of extreme fear or discomfort | PASS 8 | 0.607 | |||
Repetitive thoughts that are difficult to stop or control | PASS 9 | 0.496 | |||
Difficulty sleeping even when I have the chance to sleep | PASS 10 | 0.300 | |||
Having to do things in a certain way or order | PASS 11 | 0.714 | |||
Wanting things to be perfect | PASS 12 | 0.887 | |||
Needing to be in control of things | PASS 13 | 0.787 | |||
Difficulty stopping checking or doing things over and over | PASS 14 | 0.790 | |||
Feeling jumpy or easily startled | PASS 15 | 0.631 | |||
Concerns about repeated thoughts | PASS 16 | 0.516 | |||
Being ‘on guard’ or needing to watch out for things | PASS 17 | 0.471 | |||
Upset about repeated memories, dreams or nightmares | PASS 18 | 0.722 | |||
Worry that I will embarrass myself in front of others | PASS 19 | 0.804 | |||
Fear that others will judge me negatively | PASS 20 | 0.498 | |||
Feeling really uneasy in crowds | PASS 21 | 0.743 | |||
Avoiding social activities because I might be nervous | PASS 22 | 0.795 | |||
Avoiding things which concern me | PASS 23 | 0.540 | |||
Feeling detached like you’re watching yourself in a movie | PASS 24 | 0.779 | |||
Losing track of time and can’t remember what happened | PASS 25 | 0.677 | |||
Difficulty adjusting to recent changes | PASS 26 | 0.786 | |||
Anxiety getting in the way of being able to do things | PASS 27 | 0.712 | |||
Racing thoughts making it hard to concentrate | PASS 28 | 0.547 | |||
Fear of losing control | PASS 29 | 0.452 | |||
Feeling panicky | PASS 30 | 0.636 | |||
Feeling agitated | PASS 31 | 0.711 | |||
Cronbach’s alpha | |||||
Percentage of variances explained | 32.22 | 9.57 | 6.58 | 4.96 |
Depression | Anxiety | |
---|---|---|
0 | 6 (2.0%) | 1 (0.4%) |
1 | 8 (2.7%) | 1 (0.4%) |
2 | 13 (4.4%) | 0 (0%) |
3 | 13 (4.4%) | 1 (0.4%) |
4 | 14 (4.8%) | 1 (0.4%) |
5 | 19 (6.5%) | 2 (0.7%) |
6 | 12 (4.1%) | 0 (0%) |
7 | 12 (4.1%) | 8 (2.8%) |
8 | 15 (5.1%) | 7 (2.5%) |
9 | 14 (4.8%) | 5 (1.8%) |
10 | 16 (5.5%) | 3 (1.1%) |
11 | 14 (4.8%) | 4 (1.4%) |
12 | 16 (5.5%) | 3 (1.1%) |
13 | 19 (6.5%) | 3 (1.1%) |
14 | 13 (4.4%) | 5 (1.8%) |
15 | 12 (4.1%) | 13 (4.6%) |
16 | 16 (5.5%) | 4 (1.4%) |
17 | 10 (3.4%) | 8 (2.8%) |
18 | 15 (5.1%) | 8 (2.8%) |
19 | 9 (3.1%) | 4 (1.4%) |
20 | 12 (4.1%) | 11 (3.9%) |
21 | 2 (0.7%) | 6 (2.1%) |
22 | 5 (1.7%) | 5 (1.8%) |
23 | 4 (1.4%) | 9 (3.2%) |
24 | 2 (0.7%) | 10 (3.5%) |
25 | 1 (0.3%) | 2 (0.7%) |
26 | 0 (0%) | 4 (1.4%) |
27 | 0 (0%) | 6 (2.1%) |
28 | 1 (0.3%) | 14 (4.9%) |
29 | 2 (0.7%) | |
30 | 4 (1.4%) | |
31 | 13 (4.6%) | |
32 | 13 (4.6%) | |
33 | 9 (3.2%) | |
34 | 9 (3.2%) | |
35 | 8 (2.8%) | |
36 | 13 (4.6%) | |
37 | 4 (1.4%) | |
38 | 5 (1.8%) | |
39 | 7 (2.5%) | |
41 | 13 (4.6%) | |
42 | 9 (3.2%) | |
43 | 4 (1.4%) | |
44 | 6 (2.1%) | |
46 | 4 (1.4%) | |
48 | 1 (0.4%) | |
49 | 2 (0.7%) | |
51 | 1 (0.4%) | |
54 | 2 (0.7%) | |
56 | 1 (0.4%) | |
57 | 1 (0.4%) | |
59 | 1 (0.4%) | |
67 | 2 (0.7%) | |
71 | 2 (0.7%) | |
81 | 1 (0.4%) |
Variable | Depression Score | p-Value | Anxiety Score | p-Value |
---|---|---|---|---|
Governorate | 0.374 | 0.003 | ||
Beirut | 11.53 ± 6.77 | 31.44 ± 13.87 | ||
Mount Lebanon | 10.16 ± 6.55 | 24.54 ± 14.19 | ||
North | 11.07 ± 5.55 | 26.09 ± 12.90 | ||
South | 11.49 ± 5.77 | 30.85 ± 11.38 | ||
Bekaa | 7.25 ± 7.22 | 33.25 ± 5.25 | ||
Mother’s education level | 0.014 | 0.048 | ||
Illiterate/primary | 13.55 ± 3.07 | 34.65 ± 4.86 | ||
Complementary | 13.85 ± 6.02 | 26.85 ± 10.70 | ||
Secondary | 9.17 ± 6.18 | 27.72 ± 14.40 | ||
University | 10.80 ± 6.26 | 27.43 ± 13.52 | ||
Insurance type | 0.073 | 0.859 | ||
No insurance | 8.76 ± 5.77 | 26.28 ± 13.17 | ||
Private insurance | 9.80 ± 5.53 | 27.19 ± 15.06 | ||
NSSF | 12.08 ± 5.95 | 27.75 ± 11.49 | ||
Private and NSSF | 11.00 ± 7.44 | 28.91 ± 15.55 | ||
Army | 9.86 ± 6.24 | 29.41 ± 12.79 | ||
COOP | 10.58 ± 5.55 | 31.45 ± 13.27 | ||
Number of deliveries | <0.001 | 0.192 | ||
First child | 9.29 ± 6.25 | 26.52 ± 13.84 | ||
Second child | 11.47 ± 5.48 | 27.96 ± 12.42 | ||
Third child or more | 12.84 ± 6.21 | 30.02 ± 12.94 | ||
Gestational week | 0.152 | 0.057 | ||
Premature birth | 11.48 ± 7.08 | 32.50 ± 14.41 | ||
At term but weighed less than normal | 9.10 ± 5.37 | 26.11 ± 11.29 | ||
At term with normal weight | 11.04 ± 6.16 | 27.02 ± 13.37 | ||
Satisfied with the sex of the baby | 0.01 | 0.153 | ||
No | 13.77 ± 8.18 | 35.89 ± 17.60 | ||
Yes | 10.72 ± 6.07 | 27.49 ± 13.14 | ||
Do not know | 18.00 ± 3.39 | 32.80 ± 2.95 | ||
Delivery mode | 0.252 | 0.006 | ||
Normal delivery | 10.02 ± 5.64 | 24.48 ± 11.68 | ||
Normal delivery with help during delivery | 11.05 ± 5.16 | 28.68 ± 14.36 | ||
Cesarian section | 11.31 ± 6.55 | 29.81 ± 13.61 | ||
Sex of the baby | 0.102 | 0.02 | ||
Male | 11.44 ± 6.44 | 29.64 ± 13.53 | ||
Female | 10.26 ± 5.82 | 26.01 ± 12.67 | ||
Admission to NICU | 0.057 | 0.004 | ||
No | 10.56 ± 6.06 | 26.77 ± 13.36 | ||
Yes | 12.37 ± 6.59 | 32.63 ± 11.68 | ||
Baby woke up at night | <0.001 | <0.001 | ||
1–2 times | 9.17 ± 6.14 | 24.08 ± 14.52 | ||
3–5 times | 10.95 ± 5.85 | 28.46 ± 11.68 | ||
>5 times | 14.04 ± 5.56 | 34.43 ± 12.05 | ||
Baby eats regularly | <0.001 | 0.001 | ||
No | 13.47 ± 6.12 | 32.76 ± 11.94 | ||
Yes | 10.22 ± 5.99 | 26.33 ± 13.52 | ||
Baby had health problems | 0.013 | 0.029 | ||
No | 10.43 ± 5.86 | 27.05 ± 12.34 | ||
Yes | 14.13 ± 7.44 | 35.14 ± 18.57 | ||
Complications during pregnancy | 0.005 | 0.003 | ||
No | 10.19 ± 6.11 | 26.21 ± 12.46 | ||
Yes | 12.44 ± 6.11 | 31.36 ± 14.44 | ||
Hypotension during pregnancy | <0.001 | 0.029 | ||
No | 10.55 ± 6.21 | 27.27 ± 13.10 | ||
Yes | 15.33 ± 3.77 | 34.33 ± 14.26 | ||
Loss of consciousness during pregnancy | 0.018 | 0.074 | ||
No | 10.71 ± 6.17 | 27.50 ± 13.31 | ||
Yes | 16.28 ± 4.50 | 36.57 ± 7.81 | ||
Hospitalized during pregnancy | 0.022 | 0.005 | ||
No | 10.52 ± 6.01 | 26.87 ± 12.45 | ||
Yes | 12.64 ± 6.64 | 32.55 ± 15.39 | ||
Complications during delivery | 0.016 | 0.102 | ||
No | 10.47 ± 6.12 | 27.22 ± 13.41 | ||
Yes | 12.81 ± 6.17 | 30.68 ± 12.04 | ||
Anemia after delivery | 0.013 | 0.09 | ||
No | 10.58 ± 6.14 | 27.54 ± 12.97 | ||
Yes | 13.91 ± 5.80 | 32.55 ± 16.49 | ||
Technological help during delivery | 0.236 | 0.027 | ||
No | 11.08 ± 6.20 | 27.61 ± 13.56 | ||
Yes | 9.19 ± 6.05 | 32.71 ± 7.27 | ||
Previous abortions | 0.037 | 0.164 | ||
No | 10.49 ± 6.03 | 27.27 ± 12.49 | ||
Yes | 12.28 ± 6.50 | 19.86 ± 15.35 | ||
Planned pregnancy | 0.006 | 0.001 | ||
No | 12.07 ± 6.37 | 30.76 ± 12.73 | ||
Yes | 10.07 ± 5.89 | 25.68 ± 13.22 | ||
Happy with married life | 0.008 | 0.001 | ||
No | 13.65 ± 5.83 | 35.38 ± 13.63 | ||
Yes | 10.51 ± 6.08 | 27.01 ± 12.98 | ||
Alcohol during pregnancy | 0.065 | 0.106 | ||
No | 10.90 ± 6.14 | 27.36 ± 13.38 | ||
Yes | 13.93 ± 6.65 | 33.07 ± 10.65 | ||
Delivery period | 0.06 | <0.001 | ||
14 h | 8.90 ± 4.74 | 18.54 ± 10.07 | ||
20 h or more | 13.40 ± 4.34 | 35.86 ± 9.63 | ||
Less than 14 h | 9.75 ± 6.45 | 26.57 ± 14.08 |
Variable | Depression | Anxiety | ||
---|---|---|---|---|
r | p-Value | r | p-Value | |
Depression | 1 | - | 0.628 | <0.001 |
Anxiety | 0.628 | <0.001 | 1 | - |
Insomnia | 0.359 | <0.001 | 0.323 | <0.001 |
Stress during previous year | 0.037 | 0.532 | 0.058 | 0.331 |
Stress during lifetime | 0.028 | 0.636 | 0.013 | 0.833 |
Mother’s age at delivery | −0.09 | 0.124 | −0.086 | 0.148 |
Father’s age at delivery | −0.06 | 0.307 | −0.033 | 0.585 |
Number of previous abortions | 0.184 | 0.155 | 0.057 | 0.664 |
Number of cigarettes per day | −0.076 | 0.845 | 0.595 | 0.091 |
Number of waterpipes per week | 0.168 | 0.549 | 0.590 | 0.021 |
Model 1: Stepwise Linear Regression Taking the Postpartum Depression Score as the Dependent Variable without Taking the Postpartum Anxiety Score as an Independent Variable | ||||
---|---|---|---|---|
Variable | Unstandardized Beta | p-Value | 95% Confidence Interval | |
Postpartum insomnia score | 0.173 | <0.001 | 0.104 | 0.242 |
Hypotension during pregnancy (yes vs. no *) | 3.68 | 0.008 | 0.953 | 6.407 |
Third or more child vs. first * | 1.975 | 0.014 | 0.404 | 3.546 |
Baby woke up more than 5 times during the night vs. 1–2 times * | 1.942 | 0.035 | 0.137 | 3.747 |
* Reference group; Nagelkerke R2 for model 1 = 18.3% | ||||
Model 2: Stepwise Linear Regression Taking the Postpartum Anxiety Score as the Dependent Variable without Taking the Postpartum Depression Score as an Independent Variable | ||||
Variable | Unstandardized Beta | p-Value | 95% Confidence Interval | |
Insomnia score | 0.290 | <0.001 | 0.131 | 0.449 |
Planned pregnancies (yes vs. no *) | −5.174 | 0.002 | −8.364 | −1.984 |
Baby ate regularly (yes vs. no *) | −4.657 | 0.012 | −8.273 | −1.041 |
Baby woke up more than 5 times per night compared with 1–2 times * | 4.295 | 0.033 | 0.341 | 8.250 |
* Reference group; Nagelkerke R2 for model 2 = 18.0% | ||||
Model 3: Stepwise Linear Regression Taking the Postpartum Depression Score as the Dependent Variable and Taking the Postpartum Anxiety Score as an Independent Variable | ||||
Variable | Unstandardized Beta | p-Value | 95% Confidence Interval | |
Postpartum anxiety score | 0.256 | <0.001 | 0.211 | 0.301 |
Postpartum insomnia score | 0.079 | 0.009 | 0.020 | 0.139 |
Third or more child vs. first * | 2.470 | 0.001 | 1.052 | 3.888 |
Hypotension during pregnancy (yes vs. no *) | 2.760 | 0.014 | 0.555 | 4.964 |
Second child vs. first * | 1.663 | 0.017 | 0.304 | 3.023 |
* Reference group; Nagelkerke R2 for model 3 = 46.6% | ||||
Model 4: Stepwise Linear Regression Taking the Postpartum Anxiety Score as the Dependent Variable and Taking the Postpartum Depression Score as an Independent Variable | ||||
Variable | Unstandardized Beta | p-Value | 95% Confidence Interval | |
Postpartum depression score | 1.33 | <0.001 | 1.116 | 1.543 |
Planned pregnancy (yes vs. no *) | −4.365 | 0.001 | −6.943 | −1.787 |
Baby ate regularly (yes vs. no *) | −3.639 | 0.015 | −6.564 | −0.713 |
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Hobeika, E.; Malaeb, D.; Obeid, S.; Salameh, P.; Hobeika, E.; Outayek, M.; Akel, M.; Kheir, N.; Sleiman, Z.; Barakat, H.; et al. Postpartum Depression and Anxiety among Lebanese Women: Correlates and Scales Psychometric Properties. Healthcare 2023, 11, 201. https://doi.org/10.3390/healthcare11020201
Hobeika E, Malaeb D, Obeid S, Salameh P, Hobeika E, Outayek M, Akel M, Kheir N, Sleiman Z, Barakat H, et al. Postpartum Depression and Anxiety among Lebanese Women: Correlates and Scales Psychometric Properties. Healthcare. 2023; 11(2):201. https://doi.org/10.3390/healthcare11020201
Chicago/Turabian StyleHobeika, Eva, Diana Malaeb, Sahar Obeid, Pascale Salameh, Elie Hobeika, Miguella Outayek, Marwan Akel, Nelly Kheir, Zaki Sleiman, Habib Barakat, and et al. 2023. "Postpartum Depression and Anxiety among Lebanese Women: Correlates and Scales Psychometric Properties" Healthcare 11, no. 2: 201. https://doi.org/10.3390/healthcare11020201
APA StyleHobeika, E., Malaeb, D., Obeid, S., Salameh, P., Hobeika, E., Outayek, M., Akel, M., Kheir, N., Sleiman, Z., Barakat, H., & Hallit, S. (2023). Postpartum Depression and Anxiety among Lebanese Women: Correlates and Scales Psychometric Properties. Healthcare, 11(2), 201. https://doi.org/10.3390/healthcare11020201