postpartum depression among malay women from a rural area

ORIGINAL PAPER

Postpartum Depression Among Malay Women from aRural Area in Kedah, NorthWest of Peninsular Malaysia:Prevalence and Risk Factor

Rushidi WMWM*, Hayati MR**, Baizuri B**, Amir A***, Mahmood NM**** School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan,** Pendang Health Center, Pendang, Kedah, '*** School of Social Development, Universiti Utara Malaysia, 06010 Sintok, Kedah

Background: Community based epidemiological data on postpartum depressionin Malaysia is scarce.Aim: To determine the prevalence and risk factors for developing postpartumdepression among Malay women from a rural area in Kedah, North West ofPeninsular Malaysia.Method: We screened 185 women at 4-12 weeks postpartum attending theselected health centers using the Malay versions of Edinburgh PostnatalDepression Scale (EPDS) and Beck Depression Inventory II (BDI-11). Those scoring� 12 and / or � 9/10 on BDI-11 were interviewed using the Composite InternationalDiagnostic Interview (CIDI) and the 17-items Hamilton Rating Scale for Depression(HDRS-17). All diagnoses were based on the Tenth Edition of the InternationalClassification for Disease: Diagnostic Criteria for Research (ICD-I0: DCR-10).Results: The prevalence of postpartum depression was 21.08%. The conditionwas found to be significantly linked to polygamous marriages, high number oflife events and financial problems over the last one year prior to delivery, and lowscores on the Malay version of the MOS Social Support Survey and all itscomponents (overall support index, informational support, affectionate support/positive social interactions and instrumental support).Conclusions: Postpartum depression is indeed a reality among Malay women inrural areas In Kedah, North West of Peninsular Malaysia. These findings haveimplications for policies regarding maternal and childcare programs.

Key words: Postpartum depression, Malay women, community survey

Malaysian Journal of Psychiatry March 2005, Vol. 13, No. 1

Introduction

Postpartum depression affects approximately10-15 % of all mothers in Western societies (1, 2).Epidemiological inquiries elsewhere have reportedprevalence rates of 15.8% in Arab women (3), 34.7%in South Africa (4), 16% in Zimbabwean women (5),17% in Japanese women (6) and 23% in Indian

Correspondence:Dr. Wan Mohd. Rushidi Wan Mahmud, 213. Kilometer 7, Jalan

Kuala Kedah, 06600 Alor Setar, Kedah Darul Aman.([email protected] ;[email protected] )

women (7). Published reports on the epidemiologyofpostpartum depression among women in Malaysiaare scarce and overwhelmed by serious methodologicallimitations (8, 9). Among the limitations we includeutilization of non-validated instruments, no cleardefinition of the disorder and ignoring the influenceof ethnicity in this multiethnic and multiculturalsociety (8, 9). To the best of our knowledge, this isthe first community based inquiry into the prevalenceand risk factors for the development of postpartumdepression in Malaysia, which focuses solely on therural Malay population and uses validatedinstruments and clear definitions of the disorder.

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RUSHIDI WMWM et al

Method

SettingAccording to the Population and Housing Census2000 (10), the state of Kedah can be divided intourban and rural areas. Urban areas are defined asgazetted areas with their adjoining built-up areas,which have a combined population of 10,000 or moreat the time of the 2000 Population Census (10). Therespective districts are shown in Table 1. Pendangwas randomly chosen to represent the rural setting.One large (Pendang Health Centre) and 2 smaller(Sungai Tiang and Kubor Panjang ) health centerswhich provide maternal and child health care servicesfor the'majority ofthe population in the district, wereselected for the study. The annual delivery rates forthe state of Kedah and Pendang district are around29,000 and 1500 respectively (11).

Table 1: The division of the state of Kedah accordingto urban and rural areas (10)

Urban Rural

Kota Setar 1. Baling

Kuala Muda

2. Bandar Baharu

Kubang Pasu 3. Padang Terap

Kulim 4. Sik

5. Langkawi

5. Yan

6. Pendang

ParticipantsMalay women between 4-12 weeks postpartumattending the health centers between May andNovember 2002 were randomly (systematic randomsampling) selected for the study. 185 women werefinally recruited and provided informed consent toparticipate in the study.

DesignThe well established two-stage population surveywas utilized. The two phase design (a screeningquestionnaire followed by a diagnostic interview)offers an efficient mean of estimating prevalence of

the relevant psychopathology (12). Such approachhas been successfully utilized in internationalstudies in this area(2, 13, 14, 15, and 16). Furthermore,Ramli et al (17) also used the same method inlooking at general psychiatric morbidity amongMalaysian population.

Screening instrumentsTwo screening questionnaires namely the Malayversions of The Edinburgh Postnatal DepressionScale (18, 19) and Beck Depression Inventory II(BDI-II) (20) were used.

1. Edinburgh Postnatal DepressionScale (EPDS)EPDS (21) is perhaps the most widelyused and internationally accepted scale formeasuring depressive symptomatology inthe postpartum period with excellentpsychometric properties in various clinicalpopulations (22). In the most recentreevaluation of the psychometricperformance of this instrument amongMalay women in Kedah, the optimumthreshold value for detecting postpartumdepression of varying severity was11.5 (cut off: 11/12) with the sensitivity,specificity and positive predictive valuesof 100%, 98.18 %, and respectively (19).

2. Beck Depression Inventory II (BDI - II)BDI is one of the most frequentlyadministered instruments in studies ofdepression. It is quick, easy to use and withestablished psychometric properties acrossa wide range of clinical and non-clinicalpopulations (23). BDI-II, first introducedin 1996, is the most recent version of theinstrument (23) that was upgraded in orderto make its symptoms content morereflective ofthe diagnostic criteria that aredescribed by the Diagnostic and StatisticalManual of Mental Disorders (24). Thepsychometric performance of this scale hasbeen evaluated among Malay postpartumwomen in Kedah (20). In the latter study, theoptimum threshold value for detectingpostpartum depression of varying severity inMalay women is 9.5 (cut off: 9/10) with thesensitivity, specificity and positive predictivevalues of 100%, 98.15% and 87.50%respectively (20).

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POSTPARTUM DEPRESSION AMONG MALAY WOMEN FROM •A RURAL AREA IN KEDAH, NORTHWEST OF PENINSULAR MALAYSIA: PREVALENCE AND RISK FACTORS

InterviewsAll potential cases (scoring e" 12 on EPDS and / ore" 9/10 on BDI-II) were interviewed using the. acomprehensive fully structured interview namelythe Composite International Diagnostic Interview(CIDI) (25) and the 17-items Hamilton Rating Scalefor Depression (HDRS-17) (26) either immediatelyor within a maximum of 1- 2 weeks from the date ofreceiving the completed questionnaire. To date, bothinstruments are among the best-validated measuresof depressive symptomatology and diagnosis incross-cultural research (22). All diagnoses were basedon the ICD-10 Diagnostic Criteria for Research(ICD-10:DCR-10) (27). The criteria for postpartumdepression at stage 2 of this study are listed in table 2.The latter is a combination of the criteria forpostpartum depression by Pitt (28) and the criteriafor depressive episodes in the ICD-10 DiagnosticCriteria for Research (ICD-10:DCR-10) (27).

Table 2: Criteria for postpartum depression

The subjects should describe depressivesymptoms.The symptoms should have developed sincedelivery and within six weeks postpartum.The symptoms should be unusual in theirexperience, and to some extent disablingThe subjects must fulfill the ICD-10:DCR-10

criteria for depressive episode

Assessment of risk factorsWe constructed a questionnaire for the assessmentof risk factors for postpartum depression, based onpreviously reported risk factors and factors identifiedas putative significance from a recent review ofthe Malaysian literatures on the disorder (2, 8, 9, 29).This questionnaire was administered to eachparticipant at the first assessment point (screeningphase). The questionnaire covered the followingareas:

Relevant basic socio-demographiccharacteristics and psychosocial variablesincluding past and family history ofpsychiatric disorder.

Obstetric history, number and gender ofchildren, history ofmiscarriages/ stillbirths,pregnancy and deliverycomplications; anddetails on the new born infants.

Stressful life events checklist which wasadopted from the items in the PostpartumDepression Predictors Inventory (30). Therespective events are financial problems,marital problems, death in the family,serious illness in the family, moving,unemployment and job change.

Assessment of the degree ofsoei al supportusing the Malay version of the MedicalOutcome Study (MOS) Social SupportSurvey (31). This self-administered scalehas dfsplayed good psychometricperformance in measuring social supportamong recently delivered Malay women(31) and has the ability to detect andmeasure all the main components of socialsupport that is crucial in child rearingnamely the affective/emotional,instrumental/tangible and informationalsupport (32).

Data analysesPostpartum depression as a diagnostic category(psychiatric case) was considered as the dependentvariable. Women with mild to moderate or moderateto severe depression were labeled as the depressedgroup (D). Those who scored < 12 on the EPDS andor < 10 on the BDI-II; and those who did not fulfillthe criteria for postpartum depression after thestructured interview were placed in the non-depressedgroup (ND). Results were considered statisticallysignificant if p d" 0.05. These data were analyzedusing the Statistical Package for the Social Sciences,version 10.0 (33) and Epi Info 2002 (34).

Results

A total of 189 women between 4 to 12 weekspostpartum were initially recruited in the study.Twowomen were excluded at stage 1 (due to non residencystatus). From the 187 women recruited at stage 1, 71women scored either 10 or above on the Malayversion of Beck Depression Inventory II (BDI-II),and/or 12 and above on the Malay version of theEdinburgh Postnatal Depression Scale (EPDS). Theywere then included in stage 2 of the study andinterviewed using the fully structured interview(CIDI). 41 women were classified as depressed onCIDI but two of them were excluded because theonset oftheir depression was judged to be before their

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RUSHIDI WMWM el al

current deliveries. Therefore from the 185 womenwho were finally recruited in the study, only 39women fulfilled the criteria forpostpartum depressiongiving a prevalence rate of 21.08%. Majority ofthem were in the mildly depressed group (n=37;94.87%) and only 2 (5.13%) were in the moderatedepressed group.

The median age of the participating women was30.00 years (inter-quartile range = 25.50-33.00).62.16% (115%) of them were educated up to at least11 years of school education. All the women in thissample population were married and 5 of them wereinvolved in polygamous marriages. The medianduration of marriage was 6 years (inter-quartilerange =3-10). Majority of the women were full timehousewives (77.84%) and all their husbands werein active employment. The median total householdincome was RM 650; inter-quartile range = 500-1125). A significant proportion of families wasearning d" RM 500 (N=69; 37.30%).

In terms of the number of children, the median(including the current delivery) for this sample

population was 3 (inter-quartile range = 2-4). 30women had history of previous miscarriages andonly 41 of the participants planned their latestpregnancies. Majority of the deliveries were hospitaldeliveries (n=174; 94.05%) and 85.06% of the latterwere spontaneous vaginal deliveries. 98 (52.98%) ofthe babies were males and all of the women weresatisfied with the sex of their babies. About 66.49%of the women were fully breast feeding their infants

Univariate analyses were conducted for all thevariables among rural women. Summaries of theresults • are shown in Table 3 (a-h). Postpartumdepression as a diagnostic category was used as thedependent variable (0 =not depressed; 1= depressed).Detailed analyses of the results revealed no significantassociations between demographic, obstetrics,neonatal or psychosocial factors apart from thefollowing variables namely polygamous marriages,high number of life events and financial problemsover the last one yearprior to delivery and low scoresin all the components of the MOS Social SupportSurvey (overall support index, informational support,affectionate support/positive social interactions andinstrumental support) (p �" 0.05).

Table 3 (a): Non parametric analyses: socio-demographic characteristics among rural women andpostpartum depression

Variables Median 25th centile 50th centile Mann Whitney P values

U : 2 tailedAge (years)Depressed 29 25 33 2632.00 0.468Non depressed 30 26 33.25Duration of marriage (years)Depressed 41 32 49 2716.00 0.658Non depressed 38 32 46.25Total household income (RM)Depressed 600 500 800 2580.50 0.368

Non depressed 700 500 1225

Table 3 (b): Statistical analyses (chi-squares): socio-demographic characteristics among rural women andpostpartum depression

Variables Depressed Non depressed Chi squares P values

Educational level

0: none / primary / SRP1: SPM / MCE2 : higher

1716

6

536528

0.759 0.684

Polygamous marriages

Yes 3 2 4.679 0.031

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POSTPARTUM DEPRESSION AMONG MALAY WOMEN FROM A RURAL AREA IN KEDAH, NORTHWEST OF PENINSULAR MALAYSIA: PREVALENCE AND RISK FACTORS

Variables

Depressed Non depressed Chi squares P values

No 36 • 144

Past history of medical / surgical / psychiatric illnessYes 4 11 Fisher's exact 0.525No 35 135Family history of psychiatric illnessYes 1

0

Fisher's exact 0.211No 38

146

Women's employment status

Housewives 34 110 2.500 0.114Outside employment 5 36 Husband's employment status

Government 7 34 0.722 0.697Private 12 47Self employed 20 65

Table 3 (c): Non parametric analyses: obstetric factors among rural women and postpartum depression

Variables Median 25'h centile 50'h centile Mann Whitney P valuesU : 2 tailed

Duration after deliveryDepressed 41 32 49 2526.00 0.279Non depressed 38 32 46.25Duration of last childbirth (years)

Depressed

3

0 4 1219.50 0.299

Non depressed

2

1 4Number of children

Depressed

2

1 5 1230.00 0.317Non depressed

2

2 3.25

Table 3 (d): Statistical analyses (chi-squares): obstetric factors among rural women andpostpartum depression


History of previous miscarriage

Yes 5 25 0.419 0.517No 34 121Medical / surgical / psychiatric problems during pregnancyYes 3 16 0.356 0.551

No 36 130Nature of mothers

First time mothers 10 28 0.788 0.375Not first time mother 29 118

Planning of pregnancy

Yes 27 117 2.122 0.145

No 12 29


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Place'of deliveryHospital 39 135 Fisher's exact 0.124Outside hospital 0 11Spontaneous vaginal deliveries

Hospital 33 115 Fisher's exact 0.122

Outside 0 11Types of deliveries

Spontaneous vaginal 33 126 0.07 0.788Instrumental/caesarian 6 20Hospital deliveries only

Spontaneous vaginal 33 115 0.01 0.930

Instrumental/caesarian 6 20Satisfied with the type of delivery

Yes 38 146 Fisher's exact 0.211No 1 0Satisfied with place of deliveryYes 38 146 Fisher's exact 0.211No 1 0

Table 3 (e): Statistical analyses (chi-squares): infant related variables among rural women andpostpartum depression

Variables Depressed Non depressed Chi squares P valuesSex of the baby

Male 18 80 0.922 0.337

Female 21 66Satisfied the sex of the baby

Yes 39 146 No statistic was computed

No 0 0Breast feedingFully 23 100 1.25 0.263

Mixed / bottle feeding 16 46

Table 3 (f): Non parametric analyses: number of lite events among rural women and postpartum depression

Variables

Median 25th centile 50 th centile Mann Whitney P valueU : 2 tailed

No of life eventsDepressed

2

1 3 2662.00 0.006Non depressed

1

0 2

8


Table 3 (g): Statistical analyses (chi-squares): stressful life events among rural women andpostpartum depression

Variables Depressed Non depressed Chi squares P valuesFinancial problems

YesNo

2910

6086

13.641 <0.001

Marital problems

YesNo

1524

43103

1.161 0.281

Death of a close family member

YesNo

1128

28118

1.508 0.220

Serious illness in the family

YesNo

831

21125

0.875 0.350

Moving

YesNo

633

14132

1.072 0.300

Unemployment

YesNo

534

9137

1.949 0.163

Changing jobs

YesNo

534

12134

0.781 0.377

Table 3 (h): Non parametric analyses: measures of social support among rural women andpostpartum depression

Variables Median 25th centile 50' h centile Mann Whitney

U : 2 tailed

P values

No of close friends or relativesDepressed 3 2 4 2844.00 0.992

Non depressed 3 5 4Overall support index

Depressed 67 60 74 1933.50 0.002

Non depressed 75.5 66 86Emotional support

Depressed 37 30 41 2029.50 0.006

Non depressed 42.5 33.75 50Affectionate/positive social interaction

Depressed 16 14 18 2075.50 0.009


Instrumental/tangible

Depressed 15 12 17 2069.00 0.008


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Discussion

Giving birth is a momentous event and generallyconsidered . to be one of the happiest times in awoman's life. "Months of preparation, delivery, anddays of care in the hospital transcend into a new pageof life for the woman and her family. However, whatfollows for some mothers is not the textbook of joyof motherhood, but an unprepared torrent ofdespair"(35). This unexpected and unanticipated downwardemotional spiral is known as postpartum depression,defined symbolically by one observer as "the thiefthat steals motherhood" (36).

Evidence is accumulating that this disorder iscommon and blights the lives of many families. It"predisposes the women to depressive disorders inlater life, takes a toll on the quality of mother'srelationships, especially with her husband or partner"(37). Moreover it is associated with disturbances inmother — infant interactions, which in turn have anadverse impact on the course of the child's cognitiveand emotional development (38).

Accurate estimates of the risk and risk factorspostpartum depression are thus critical for thescientific and clinical understanding of postpartumdepression as well as for planning mental healthservices for the child bearing women and their families(2). Although the last two decades have witnessedgrowing interests both from medical and laypopulation this disorder, arguably is still laggingbehind the more "mainstream" psychiatric diagnoses(39). Furthermore, despite the progress which hasbeen made, it is extremely difficult to reliably predictwho will and will not experience the disorder giventhe multiplicity and complexity of interacting factorsinvolved (40).

In Malaysia, clinical study on postpartumdepression was almost non-existent prior to the pastdecade (8). Previous evidence that the disorder existsin this country, came from descriptions inanthropological studies (41, 42, 43). However, it isstill generally believed that the disorder is rareparticularly among the Malays (43). Key factorssuch as their strong positive and relaxed attitudestowards pregnancy and motherhood, overwhelmingfamily support during the postpartum period andstrict adherence to the traditional taboos orprohibitions following delivery are thought to beprotective against postpartum depression (43).

The clinical study by Kick Kit and colleagues(44) provided the first empirical evidence to thispresumed low rate of postpartum depression amongMalaysian women. Their documented prevalencerate of3 .9% was far lower than the figures of 10 -15%documented in many Western studies (1, 2, 45, 46).Recent studies in other Malaysian settings however,provide contrasting figures. Higher rates have beenconsistently recorded varying from 9% to 37.7% (47,48, 49., 50, 51, 52, 53, 54 and 55). Rushidi (8,9) arguesthat all these results should be considered in the lightof a few serious methodological limitations. Failureto define the term postpartum depression and usingnon-validated self rated instruments are two mostfundamental flaws evident in the majority (if not all)of these studies. Moreover, most studies fail toappreciate or acknowledge the possible contributionof culture and ethnicity in their findings. Hence it isnot surprising that not only did the rates differmarkedly between them, data on the various putativerisk factors is also inconsistent and contradictory(8, 9).

Appraisal on the methodology

This study was purposely designed to avoid or atleast minimize the limitations and methodologicalflaws observed from previous local research in thisarea. Firstly, this study specifically focused on theMalays, the largest ethnic group in Malaysia (55 %of the overall population). Apart from avoiding thecomplex issue ofmultiracial and multicultural effectson postpartum depression, such approach wasdeemed suitable as the Malay's postpartum culturalproscriptions are already well in place (41, 42, 43, 56)compared to other main ethnic groups such as theChinese and the Indians.

The use of properly validated instrument wasanother notable improvement. All self-ratedinstruments used in this study (EPDS, BDI-II, andMOS Social Support Survey) were properly subjectedto rigorous validation process among Malaypostpartum women from the same target population.These instruments have also demonstrated theirworthiness in postpartum research. MOS SocialSupport Survey for example, was successfully usedamong patients with chronic illness includingdepression (57) and postpartum Chinese women(35). BDI on the other hand, has proven itseffectiveness in various postpartum studies (35, 58).However, perhaps this is the first time that the latestversion ofthe instrument (BDI-II) is found to be valid

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among postpartum women (20). As for EPDS, thegrowing popularity of its use has clearly beendemonstrated world wide (21). In Malaysia, thisinstrument has been validated twice, both amongmixed Malaysian population (18) and specificallyamong the Malays (19).

The well established two-stage population surveyapproach provided an added strength to this study.It is widely known that full diagnostic interview byclinicians are often too expensive and time consumingto justify their use in the general population orepidemiological surveys where the great majority ofthe participants will not show any signs onpsychopathology (12). Hence the two phase design(a screening questionnaire followed by a diagnosticinterview) offers a useful alternative and an efficientmean of estimating prevalence of the relevantpsychopathology (12).

The double screening strategy using the Malayversions of EPDS and BDI-II in the first stage of thesurvey was another asset to the study. This strategyof simultaneous administration of two or morescreening measures as a double or triple test hasalready been widely adopted in various branches ofmedicine, but yet it has not readily taken up inpsychological research even though such approachhas the ability to substantially improve identificationof depression among postpartum women (35).

Finally this study also delineated clear diagnosticcriteria for postpartum depression by taking intoconsideration suggestions from various internationalstudies (28, 40, 59) and recommendations from theTenth International Classification of Disease (ICD-10: DCR 10) (27) and Fourth Edition ofthe Diagnosticand Statistical Manual (DSM-IV) (24).

Rates of postpartum depression

39 women from the 185 recruited for this study,fulfilled the designated criteria for postpartumdepression giving a prevalence rate of 21.08%. Thisrate was in stark contrast to the very low figure of3.9% found in Seremban,Negeri Sembilan (44) (Malays= 3%; Indians = 8.5% and Chinese = 0%) and higherthan the figures of 16.6% recorded in Sungai Petani,Kedah (47), 11% in Penang (49) , 9.8% in Bachok,Kelantan (50) and 16.4% in Kuala Lumpur (52). Itwas more in concert with the higher rates of 26.7%,20.6% and 26.6%, documented in Kulim, Kedah

(48), Kota Bharu, Kelantan (51) and Kuala Lumpur(53) but notably lower than the 33.4% recorded inthe previous study conducted in the same state usingnon validated EPDS with lower cut-off score (54).The overall rate of 21.08% was also higher than theaverage prevalence of 13% documented by O'Haraand Swain (2) based on their meta-analysis of nearly59 studies on postpartum depression. However it iscomparable to the prevalence rates of 16% inZimbabwean women (5), 17% in Japanese women(6) and 23% in Indian women (7). What is clear is thatthe rate ofpostpartum depression among rural Malaywomen in Malaysia is certainly not as low as previouslypredicted or anticipated (41, 43, 44).

Risk factors of postpartum depression

Postpartum depression results from complexinteractions between biological, psychological andsocio-cultural factors (35, 40). Understanding thesefactors and their influences is crucial to help developappropriate screening and assessment methods aswell as identify women and families most at risk ofdeveloping significant problems in the postpartumperiod. Moreover the prevalence of postpartumdepression can also be lowered by modifying the riskfactors, perhaps through individual! group treatmentor preventative interventions, which target thesespecific factors (35, 40, 60, 61).

Internationally, research concerning risk factorshas been affected by variability between studies interms of the classification and definition ofpostpartum depression, timing of measurement andfollow-up, type of assessment used, size of thesample and method of recruitment (60). There arealso major differences reported in subject popula-tions including parity, education, marital status, age,socio-economic level , ethnicity, cultural values andso on which often makes it difficult to generalizedthe results from these research groups to otherpopulations (2, 60).

Similar situation exists in Malaysia, complicatedfurther by its multiethnic and multicultural population.Available data is both inconsistent and unreliable (8).So far, the two most consistent factors are maritaldisharmony and low socioeconomic status (47, 48,50). Other possible factors include not breast-feeding(50), using traditional medication, depression in latepregnancy and earlypostpartum; and worrying aboutthe baby (51), partner working outstation, first time

RUSHIDI WMWM et al

and young mothers (48), and less socialization (47).Additionally, performing the traditional massagemay be protective against postpartum depression(51) whereas women with emergency deliveries areat higher risks than non emergency deliveries (55)

According to the results ofthe univariate analysesin this study, a recently delivered rural Malay womanis more likely to be depressed if she is involved in apolygamous marriage, experienced high number oflife events over the last one year prior to deliveryespecially in the form of financial problems. Worststill if she has poor social support as evidenced byher low scores on the overall support index and all theother components of the MOS Social Support Survey(emotional support, affectionate support/positivesocial interactions and instrumental/tangiblesupport). The significance of all the variables will beappraised in turn in the following sections.

Polygamous marriages and postpartum depression

Polygamy is one of the most sensitive and anxietyprovoking issue among Malay women in Malaysia(43). Although the figure for polygamous marriagesis still relatively small accounting for only 15 out of1000 Muslim men (62), it causes a lot of tension andconflict among those who are involved (43, 62, 63).Majority of Malay women are predictably opposedto such marriages (43). Hence, in order to protectwomen from being abused or married for the sake offun and convenience, the permission for polygamousmarriages must be obtained from the religiousauthorities in order to ensure the applicants have themeans of supporting his wive(s) (42, 62, 63).Nonetheless, in certain states such as Kedah andKelantan, their closeness to the border (Thailand)offers an unpreventable alternative. If the court orreligious authorities reject a man's application forpolygamy in Kedah for example, he can simply go tothe neighboring country to get married. He will thenbe legally married in the eyes of Islam, although themarriage is not registered under the Malaysian law(63). Such phenomenon may bring about numerousproblems later on since the marriage is not recognizedin Malaysia (43, 63).

Zaleha (62) in her analyses of polygamousmarriages in Kedah, Perlis and Pulau Pinang, revealsthat most men who practice polygamy in Kedah onlyhave two wives. A largerproportion ofthe applicationscame from urban settings. More worryingly however,the majority of these men tend to favor their second

wives and frequently ignore or neglect their financial/social obligations and liabilities towards their firstwives. Yet, most affected women prefer to suffer insilence for various reasons. Among them are lack ofconfidence in the relevant authorities and lack ofenforcement/implementation of the existing laws bythese agencies (62).

• Although only 5 women (2.70%) were involvedin polygamous marriages in this study, they werefound to be more vulnerable to develop postpartumdepression (3 of these women were in the depressedgroup). Locally, only one study has investigated thisphenomenon. Rushidi, Shakinah and Jamil (50) foundthat 5 (2.9%) of their participants were involved inpolygamous marriages. Contrary to their expectation,the women's partners were mainly from the lowerincome group. Some of them did not just haveone, but two or three wives at the same time.Two women from this group were grand-multiparaand full time housewives relying solely on theincome of their husbands who unfortunately wereearning less than RM 300 per month ... Despitethese facts, they did not find any significantrelationship between polygamous marriages andpostpartum depression (50).

Worldwide, data on this phenomenon isunderstandably scarce and limited to Islamic nationsor those with similar background. Fisch (64) in theirstudy in Israel did not find statistically significantassociation between the types of marriages andpostpartum depression. Contradictory results werehowever recorded in the United Arab Emirates (3).In discussing their findings, the authors proposedthat the impact of polygamy (whether being the firstor second wives) was more related to the pivotalfactor of marital problems (3). Unfortunately, theetiological significance ofthe association between thelatter and depression still remains debatable (65).There is evidence that marital dissatisfaction isprobably (a) causally related to the onset andmaintenance of depression (b) associated with thecourse ofthe disorder once it exists (e.g. increase riskof relapse) (c) associated with poor prognosis toexisting treatment ofdepression, or (d) a consequenceof the depression (66). Among the proposedexplanations for this relationship include reductionin social support, increase stress due to maritaldiscord which leads to depression, power differencesof men and women in marriage or even the possibilityof involvement of a third variable (e.g. personalityfactors) (65). None however has been comprehensive.

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Life-events, childbirth and postpartum depression

Childbirth in itself is a major event or life transition.Accumulation of additional stress at this time mayplace women at greaterrisks ofdeveloping depressivesymptoms (60). Many events such as poor maritalrelationships, housing and financial difficulties,unemployment, and bereavement, have beenassociated with increase vulnerability to develop.depression among postpartum women, yet someauthors argue that the significance of such events isnormally dependent on the woman' s perception andappraisal of the events (67, 68). Additionally, theeffects tend to be greater among women with multiplestressors and limited support (35, 40, 60, 69).

In this study, financial problems emerged as themost frequent life event experienced by the depressedparticipants (n=29) and as a significant predictorafter multivariate analyses. Unfortunately, it is quitedifficult to compare the above findings to existinglocal studies since none has explored the phenomenonin such details. Involvements of certain individualevents were however documented such as theassociations between postpartum depression andmarital problems related to financial difficulties (50)and to marital disharmony (47, 48).

More globally, there is satisfactory evidencelinking postpartum depression with stress andincrease in recent negative life events (45, 70, 71, 72).Stressful events occurring during pregnancy orfollowing birth appear to increase the risk ofpostpartum illness (40, 60, 73). Stressful life eventis also one of the strongest predictors of postpartumdepression in their meta-analysis (2). Although allthe life-events in question occurred before delivery,yet they were significant risk factors for postpartumdepression (2). Further confirmatory evidence camefrom the two meta-analyses by Beck (29, 74). In herlatest work, the effect size of life stress was found tobe moderate with r values ranging from 0.38 to 0.40(29). In another review, stressful life event is describedas ofthe confirmed risk factors, with agreement fromrandomized controlled trials or approximately 75%of well designed cohort studies (60).

In a survey in North Carolina, United States,participating women were asked to select 13 majorlife events occurring during the year before theirdeliveries (75). The four highest reported life eventsin descending order were moving to a new address(38%), arguing more often with husbands/partners

(31%), close family members was sick and had to goto hospital (29%) and having a lot of bills that theycould not pay (26%). Losing their job even thoughthey wanted to continue working and their partnerslosing their jobs came seventh (11%) and tenth (10%)respectively.

They also found that the occurrence ofsix or morepotentially stressful events during the last 12 monthsbefore delivery proved to be a strong independentrisk factor for postpartum depression. Mothers whoreported losing their jobs (even though they wantedto continue working) or reported being overwhelmedwith bills to pay has a two fold risk of postpartumdepression compared to mothers who did notexperience these economic adversities (75).Conversely, Lu (76) in a study involving 85 Taiwanesehomemakers, demonstrated that although the lattergroup seemed to lead relatively uneventful lives with,one life event occurring in the space of one year,such low exposure can still result in considerabledistress. The author argued that because thehomemakers do not work outside the home andsome do not leave the home often, the life eventsthey do experience may have considerable impacton their emotional health (76).

Social support and postpartum depression

In the area ofchildbirth, good social support is linkedto good adaptation to parenthood and positivemother-infant interactions (77). The provision ofsupport/aid by partners, family, friends, neighborsand so on, helps to reduce the parenting stress andassists the new parents to become more competentin childrearing (78). Logsdon and Davis (79), in theirreview ofsocial and professional support for pregnantand parenting women, believe that receiving adequatesocial support in the early parenting period isassociated with greater satisfaction with the maritalrelationship, better maternal and child interactions,less maternal alcohol and drug use, higher rate ofobtaining timely infant immunizations, fewerunintentional infant injuries and child abuse.

There are three crucial categories of support inthe area of child rearing: (a) instrumental/tangiblesupport (b) informational support, and (c) emotional/affectionate support (32). Instrumental support refersto direct help in housekeeping or child care and itincludes providing the mothers with help to lookafter the infant/ child and performing the householdtasks. Informational support meanwhile, consists of

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tasks. Informational support meanwhile, consists ofproviding information that a mother can use withtasks of infant/child care, self-care and personal andenvironmental problems. Finally, emotional supportimplies understanding how difficult childrearing issympathizing with the parents and offering themwords of encouragement.

In this study, the assessment of the content ofsocial support was made using the Malay version ofthe MOS Social SuppOrt Survey (31). It is a brief,multidimensional, self-administered scale, initiallydeveloped for patients with chronic illnesses includingdepression (57). Recently the instrument has beentranslated, validated and used successfully amongpostpartum Chinese women in Hong Kong (35).Looking at the results of the univariate analyses,clearly the scores on the overall support index and allcomponents of MOS social support survey were allassociated with postpartum depression among ruralMalay women. Those with low scores on all thecomponents and the overall support index were morelikely to be affected by the disorder compared tothose with higher scores.

Although anthropologists has suggested that thepresence of overwhelming support is among the keyfactors preventing the occurrence postpartumdepression among Malay women (41, 43), none ofthe previous clinical studies has ever explored thismatter in depth or used properly validated instrumentto measure the degree of social support among Malaypostpartum women. There may be some indirectevidence to suggest that inadequate support is a riskfactor. For example, marital disharmony (47, 48, 50),partner working outstation (48), or less socialization(47) have all been independently linked to the disorder.

In the international scene, the inverse linkedbetween social support and postpartum depressionhas been clearly demonstrated perinatal research (2,29, 79, 80). Hyun et al (78) demonstrated theimportance ofsuch support in three different culturesnamely Korea, Hong Kong and United States.Spangenberg and Pieters (81) and Cooper et al (4)also showed similar relationship among postpartumwomen in South Africa. This relationship has alsobeen recorded in studies involving predominantlyCaucasian women in the United States (69, 71, 82)and United Kingdom (70, 83); African Americanwomen in the United States (80, 84); Chinese womenin Taiwan (76) and Hong Kong (35), and Lebanesewomen in Lebanon (85).

O'Hara and Swain (2) in their meta-analysesindicate that social support is a strong negativepredictor of postpartum depression. Concurringly,in a systematic review ofpublished scientific literature,researchers observe that lack of social support is oneof the confirmed risk factors of postpartumdepression with agreement from approximately 75%of reported studies on the disorder (60). Finally, themost recent evidence came from Beck's latest meta-analyses (29). Using r as the effect size indicator (86),the relationship between postpartum depressionand social support is in the range of moderate effectsize (with mean r ranging from 0.36 to 0.41) (29).Such findings also confirmed the results ofher earliermeta-analyses (74).

Implications and Recommendation

Until recently, postpartum psychologicalwellbeing and mental health problems have receivedlittle attention from the Malaysian medicalprofession and the general public. Various factorsincluding misleading statistics as well as the lackof epidemiological data on the service needs of thepopulation are perhaps some of the contributoryfactors (8). In a way, this study managed to provideclear evidence that postpartum depression is indeeda reality at least among Malay women in Malaysia.Based on 21.08% prevalence rate and nearly 29,000deliveries per year, it is estimated that the state ofKedah alone will have nearly 6,113 women whoare affected with this disorder. Unfortunately, mostof these women escape medical attention andremain hidden in the community. The referral rateto specialized care is even lower based on the clinicalexperience of local psychiatrists (9).

Lack of proper primary care services, socialstigma of mental illness in the local population withassociated avoidance of help seeking behavior (87,88), somatic presentation ofdepression among Malaywomen (89), strong beliefs in the supernatural causesof mental illness in the Malay society (90) perhapsfurther aggravate the problem of under detection.Moreover, in the majority (if not all) of the womenin the study, depressive episode was their firstencounter with mental illness. Hence, the women andtheir families may have little knowledge ofdepressionand may misconstrue the mental illness asmaladjustment to sleep deprivation, childbearing andparenthood (35).

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In 1987, the Malaysian Ministry of Healthlaunched "The Safe Motherhood Initiative" (91) ina global effort to reduce the maternal mortality andmorbidity in Malaysia. The idea was to promotegreater emphasis on the M in Maternal and ChildHealth services. Unfortunately, since then the stresshas been solely concentrated on the physical, ratherthan the emotional and psychological wellbeing ofthe mother. Maybe, it is opportune time to reevaluatethe current system to incorporate the frequentlyneglected perinatal psychological needs.

The existing Maternal and Child Health servicein Malaysia is actually quite comprehensive. Duringthe postpartum period alone, the midwives orcommunity health nurses perform home visits on thefollowing days 0 (day of delivery— ifpatient deliversat home), 1, 2, 3, 4, 6, 8, 10 and 20. The infant willthen be followed up in the nearby health clinicsmonthly for the first 6 months, 2 monthly for the next6 months and 6 monthly in the subsequent monthsuntil he or she is 6 years old. The newly deliveredmother on the other hand, will be seen again at around6 weeks after delivery for her routine postpartumexamination.

In general, most of the psychological /psychiatricservices can actually be delivered in the communityusing the pre-existing resources. Such team willconsist of midwives, community health nurses,primary health care doctors, social workers,counselors, psychologists and psychiatrists. Indeedthese teams could even serve as models for other areaswithin the medical field. Moreover, postpartumdepression is actually an interesting model ofpsychological illness. Apart from providing an idealopportunity for prevention because the condition ispreceded by a clear market (birth), there is also adefined period of risk for onset, and the high-risk ofmothers can easily be identified (92). Finally, tomanage perinatal psychological problems well is toimprove the prognosis of the mother and reduce therisks for future ill health of the child. Ignoring themwould jeopardize both...(93).

Acknowledgement

We would like extend our gratitude to all thewomen who participated in this study and toKedah's State Director of Health, medical officersand staff from all the health centers for theircooperation and assistance.

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