https://orcid.org/0000-0002-7614-1729
Abstract
In Oman, the risk of maternal depression is not routinely screened for during pregnancy or after childbirth. This study aimed therefore to explore the prevalence of and the association between the risk of antenatal and postnatal depression among Omani mothers, as well as the sociodemographic characteristics of women with increased risk of antenatal depression. A longitudinal study was conducted among 263 Omani pregnant women who were screened for risk of antenatal and postnatal depression, using the Edinburg Postnatal Depression Scale (EPDS). A considerable rate of women had an increased risk of antenatal depression (22.4%), which slightly increased after childbirth. The majority of mothers who had increased risk of depression were housewives (61.0%), had low monthly income (62.7%), had higher education (54.2%), were living in simple family construction (55.9%), were physically inactive (86.4%), and were not using contraception before the current pregnancy (55.9%). Increased risk of antenatal depression was significantly and positively associated with risk of postnatal depression (P < 0.001). The findings of this study highlight the urgent need for standardization of depression screening of all pregnant women in the Sultanate. It also calls for a population-based study to investigate the prevalence of depression in pregnant women and the first year following childbirth.
Background
During pregnancy, maternal depression is regularly linked to long-term consequences for women, infants/children, and families (Abbasi et al., Citation2021). Antenatal depression refers to depression that occurs during pregnancy but before birth, and postnatal depression refers to depression that occurs following the birth of a child (Bauman et al., Citation2020). While the reported rates vary, postnatal depression was shown to be common among Middle Eastern mothers with a prevalence of 27% (Alshikh Ahmad et al., Citation2021), which is greater than other regions of the world (Alshikh Ahmad et al., Citation2021). In Oman, different studies identified similarly high levels of antenatal depression, 24.4%, among mothers (Al-Azri et al., Citation2016; Al Rawahi et al., Citation2020). Both studies used the Edinburgh Postnatal Depression Scale (EPDS) and concluded that without effective awareness initiatives, many women experiencing antenatal depression may not access the support they need. Research has shown that antenatal depression raises the likelihood of preeclampsia and surgical and instrumental deliveries, preterm births, suicidal ideation and thoughts, and postnatal depression (Gelabert et al., Citation2020; Islam et al., Citation2020; Zhang et al., Citation2022). Furthermore, pregnancy-related depression poses risks to mothers due to factors such as inadequate social support, financial stress, unstable living conditions, increased self-harm risk, bonding difficulties with the newborn, and potential neglect or abuse (Haque et al., Citation2015), highlighting the importance of awareness campaigns and accessible mental health resources for effective intervention. Antenatal depression, for example, might reduce participation in healthy antenatal care, such as diet, self-care, medical compliance, and social support, and increase participation in dangerous habits like alcohol, tobacco, and drug use (Rapoport, Citation2021).
The etiologies of depression disorders are complicated and multifactorial (Kiewa et al., Citation2022). High perceived stress and adverse life events, history of domestic violence or abuse, lack of partner or social support, unplanned or unwanted pregnancy, history of mental illness, past pregnancy loss, and present or past pregnancy complications were identified as the most predictive risk factors for antenatal depression (Biaggi et al., Citation2016). Low socioeconomic class, low self-esteem, younger age, having more children, and marital problems all further raise the risk (Ding et al., Citation2021). Furthermore, depression throughout pregnancy is a dependable and reliable predictor of postnatal depression. Most “postnatal” depressive episodes start antenatally (Creeley & Denton, Citation2019). As a result, early detection of depression and risk factors may serve as a protective factor against the development of postnatal depression.
Antenatal depression is one of the main reasons for maternal mortality and morbidity (McKee et al., Citation2020). However, the characteristics of women who are at risk for developing antenatal depression vary based on their context, and currently there is a dearth of Omani studies that explore the risk factors of developing depression symptoms among pregnant women.
In Oman, due to a lack of comprehensive screening for the risk of maternal depression, antenatal depression continues to be undetected and untreated. Incorporation of a standardized measure into routine screening using, for example, the self-administered EPDS could assist in the detection of antenatal depression, thus providing a better opportunity for support. Undiagnosed and untreated depression during pregnancy can have long-term consequences for the mother, children, and families (ACOG, Citation2018). To identify, assess, and manage antenatal depression, doctors, nurses, and the multidisciplinary team encountering pregnant women need to be knowledgeable about the characteristics of women suffering from antenatal depression. Thus, this study aimed to explore the prevalence of and the association between the risk of antenatal and postnatal depression among Omani mothers, as well as the sociodemographic characteristics of women with an increased risk of antenatal depression.
Research Questions
What is the prevalence of antenatal depression risk among Omani mothers, and how does it compare to the prevalence of postnatal depression risk?
What characterizes women with increased risk of antenatal depression?
Materials and Methods
Study Design
In this longitudinal, descriptive study, pregnant women were screened for risk of antenatal depression in their third trimester. Utilizing the EPDS for screening, we followed the participants over time (between June and November 2021) to assess potential links between antenatal depression risk and birth outcomes. The study employed a prospective design, collecting real-time data from electronic health-care records. Longitudinal studies, while valuable for revealing cause-and-effect relationships in real-time, require significant time, resources, and commitment due to the extended follow-up period involved (Caruana et al., Citation2015).
Study Settings
The selection of the study settings was strategic, aiming to cover a wide area of the Al Dahira Governorate. Thus, one of the hospitals was chosen because of its central location (Yanqul Hospital). The only available polyclinic, located in the eastern part of the Governorate, was also selected (Ibri Polyclinic), and one of the 15 existing health centers was chosen (Al Ainain health center) because of its geographical location, being in the middle between the hospital and the polyclinic and thus covering citizens in this area as well. The Ibri Polyclinic is a health-care facility that offers a wide range of general and specialized medical services to patients on an outpatient basis and operates independently from the hospitals in the governorate.
Wilayat of Ibri is the largest state in Al Dahira Governorate in terms of area and population. It is also classified as one of the states with the largest populations at the level of sultanate with an estimated population of more than 116,000 people, and the total number of registered pregnant women in 2020 was 4,725 women according to 2021 statistics (A. Al-Ghafery, personal communication, June 1, 2021). In addition to the convenient selection of Ibri Wilayat, our objective was to select one of the largest cities to serve as a representative sample of a diverse population, thereby enhancing the generalizability of our research findings.
Sample
Participating women were selected through invitation by midwives based on their gestational age, during their attendance for antenatal health-care routine checkups. Women were screened for their eligibility, i.e., meeting the inclusion criteria: Omani pregnant women in the third trimester (30–41 weeks), 18 years or older, living in Ibri Wilayat and visiting one of the selected settings, who were able to speak and read Arabic, did not have any medical illness (healthy uncomplicated pregnancy), and did not have any psychiatric diagnosis before pregnancy. Women with intellectual disability or cognitive problems (e.g., neurological disorders), those who had any communication barrier (speaking or hearing problems), and those who had a medical condition (diabetes mellitus, hypertension, COVID-19) were excluded from the study. Conditions like diabetes, hypertension, and COVID-19 can directly impact a person’s mental health and increase the risk of depression (Saqib et al., Citation2023). By excluding participants with these medical conditions, the researchers aimed to isolate the factors specifically associated with antenatal depression risk, rather than having the results confounded by the effects of other medical issues.
Sample Size and Sampling
Based on a total population of 4,725 pregnant women attending health-care centers in Ibri annually, a 5% measuring error, and an estimated prevalence of 25% (based on previous evidence), applying an online calculation (Calculator.net 2022) led to a sample size of 272 women.
All available women fulfilling the inclusion criteria were invited to participate in the study. A non-probability sampling technique was used to screen 263 mothers in the antenatal and postnatal periods. Thus, the response rate was 96.7%, which is considered to be high.
Instruments
Edinburgh Postnatal Depression Scale
The Arabic version of the self-administered EPDS was used as a screening tool to assess the risk of both antenatal and postnatal depression (Cox et al., Citation1987; Zubaran et al., Citation2010). The EPDS's effectiveness in identifying postnatal risk has been evaluated in two notable studies conducted by Cox in 1987 and 1996. The internal reliability in the current study was tested using Cronbach alpha (α = 0.811), which constitutes a very good reliability. The EPDS consists of ten items, with response options including “as much as always,” “not quite so much,” “definitely not so much,” and “not at all.” The responses were graded 3–0 and the total score was 0–30. According to the cut-off points in the EPDS, scoring 0–9 was considered low risk, 10–12 moderate risk, and 13–30 had increased risk of antenatal depression (Cox et al., Citation1987).
Demographical Data Sheet
The participating mothers’ sociodemographic data and health-related factors were recorded in a separate section along with the EPDS questionnaire. Data included mothers’ age, height, prepregnancy and current weight, physical activity (Yes/No), parity status (primi/multi-para), number of pregnancies, gestational age, experience of miscarriage (number if several), planned/unplanned pregnancy, contraception use and type, medication (if on regular use)/type, educational level, employment status, accommodation status, household’s monthly income, number of children (boys/girls), and presence of supportive members such as family, close friends, siblings, etc. (Yes/No). These variables were selected based on a comprehensive literature review and were deemed to be crucial as they provide insights into the diverse socioeconomic, health-related, and personal circumstances that can impact pregnancy experiences, maternal well-being, and child development.
Data Collection Procedure
Two assistants (registered midwives, one from each health-care center) received training on how to recruit participants, assess them for eligibility, and fill out the surveys. Data was collected via self-reported surveys and the antenatal data (green card) registry.
The EPDS questionnaire was administered twice; when women visited the clinics for antenatal care (during their third trimester, i.e. between gestational weeks 28 and 40), and then again when they came for the postnatal follow-up visit (usually between weeks two and six postnatal). All parts of the instrument were self-administered. The researcher was available at all times to answer the midwives’ questions and the midwives were available for the participating women to answer their queries.
Ethical Considerations
Ethical approval was obtained from the Sultan Qaboos University Hospital Ethics Committee (REF. NO. SQU-EC/434/2021) and the Ministry of Health in Oman (MH/DGHS/DG/2123111067) before data collection. Following a detailed explanation of the study, participants who agreed to take part were provided with written information. Once any questions were addressed, those willing to actively participate were asked to sign an informed-consent form. They were assured that they could refuse to answer or withdraw from the study at any time without any explanation and with no consequence for the care provided to them.
As an ethical consideration and based on the total EPDS score, participants scoring above 13 were to be contacted by the midwife for a referral to a psychiatrist. However, none of the mothers in our study scored 13 or higher, resulting in no need for midwife intervention.
Data Analysis
Descriptive and inferential analyses using the statistical software SPSS (version 23) were carried out. Descriptive statistics were used to describe the participants’ characteristics and the prevalence of antenatal and postnatal depression risk. Categorical variables were described using frequencies and percentages, whereas the continuous variables were expressed through mean and standard deviation. Bivariate analysis was conducted to identify antenatal depression risk (independent variable) and its association with postnatal depression risk using paired samples t-tests.
Results
Sample Characteristics
The participating mothers’ mean age was 30.92 (SD= 5.45), ranging from 19 to 46 years. The mean prepregnancy BMI was 25.98 (SD = 5.52), while the mean BMI during pregnancy (third trimester) increased to 29.43 (SD = 5.26). The majority of the women had higher education (n = 148, 56.3%). More than half of the women were housewives (54%). The monthly income for the majority of the women was between 500–1,000 OMR (55.9%). Furthermore, around half of the women were living in shared traditional houses with other relatives, 49.8%. A total of 81.0% were not practicing any physical activity except for household work ().
Table 1. Sociodemographic characteristics of the participants (N = 263).
The Prevalence of Antenatal and Postnatal Depression Risk
Results demonstrated that the mean antenatal depression risk score was 8.87 (SD= 5.14). Conversely, the postnatal depression risk mean score slightly increased to 9.17 (SD= 4.99). Upon categorizing the antenatal and postnatal depression risk scores, the corresponding prevalence rates are presented in . Specifically, 22.4% (n = 59) of women had an increased risk of antenatal depression, while 25.9% (n = 68) reported an increased risk of postnatal depression. A statistically significant and moderately positive relationship between antenatal and postnatal depression risk was observed (Pearson correlation coefficient = 0.52, P < 0.001).
Table 2. Antenatal and postnatal depression among Omani women according to the Edinberg Postnatal Depression Scale (EPDS).
Association Between Characteristics of Mothers and Levels of Antenatal Depression Risk
The result showed that none of the variables had a significant association with the antenatal depression risk categories. However, there was a statistical indication when it comes to family construction (P = 0.07) and contraception use (P = 0.07). For more details, see .
Table 3. Participant characteristics in relation to antenatal depression risk (low, moderate, and increased risk) according to EPDS. Values are presented as column percentages.
As shown in , there were no statistically significant differences in sociodemographic characteristics among mothers classified as low risk, moderate risk, and those experiencing an increased risk of depression. The highest prevalence of respective characteristics under respective depression categories has been highlighted. The results showed that the mean age for low-risk mothers is 31 (SD = 5.7), at moderate risk (M = 30, SD= 5.3) and for mothers who had an increased risk of depression (M = 30, SD = 4.8), whereas the mean parity remained the same in all depression categories 2 (SD = 2). The mean BMI prepregnancy and current BMI show overweight among all categories (> 23.9). Furthermore, the mean gravida was the same across all depression categories, 3 (SD = 2), as well as the mean for the number of abortions in all categories M = 1 (SD= 0). Moreover, the result shows that 45.8% of the total number of mothers who were at moderate risk of depression were housewives, while the percentage increased to 61.0% among mothers who had an increased risk of depression. With regard to the monthly income, among those at moderate risk of depression, 49.2% earn 500–1,000 OMR/month. Similarly, among mothers who had an increased risk of depression, the majority (62.7%) had a monthly income of 500–1,000 OMR/month, which is much higher than those with lower monthly income (< 500 OMR/month). The results also show that, among mothers who were at moderate risk of depression, 61.0% had a higher educational level, and 54.2% of the mothers with increased risk of depression had higher education. When comparing the accommodation among mothers at moderate risk of depression, it was shown that 49.2% of them lived either in a new house or in a traditional shared house. Among mothers who had an increased risk of depression, the distribution was 42.4% and 54.2% for new houses and traditional shared houses, respectively, with no significant differences between the groups.
A disparity in the distribution of the family construction was found. Although not significant, it was statistically indicated (P = 0.071) that most mothers with low risk for depression lived in nuclear families (60.0%). Similarly, 55.9% of mothers with an increased risk of depression lived in simple family construction, while 57.6% of the mothers at moderate risk of depression lived in compound families. The majority of mothers (83.1%) who were at moderate risk of developing depression and 86.4% of those who were at increased risk of depression were not conducting any physical activities except for household work. Among the group of mothers at moderate risk of developing depression, 74.6% of them had planned pregnancies, while 25.4% of total mothers who had an increased risk of depression did not plan their pregnancies. Similarly, of those at moderate risk of developing depression, 76.3% and 55.9% of those who had an increased risk of depression were not using contraception before the current pregnancy. For more details, see .
Discussion
The study aimed to explore the prevalence of and the association between antenatal and postnatal depression risk among Omani mothers, as well as the characteristics of women with an increased risk of antenatal depression. The main findings of the study were the high prevalence of antenatal depression risk (22.4%) and postnatal depression risk (25.9%) among the participants, and the significant association between antenatal depression and postnatal depression risk (P < 0.01).
The study showed that the prevalence of antenatal depression risk among pregnant women in this study is 22.4%. The result is similar to the reported prevalence in Omani populations (24.0% and 24.4% in respective studies) (Al-Azri et al., Citation2016; Al Rawahi et al., Citation2020), and in a Spanish population (21.4%) (Míguez & Vázquez, Citation2021a). On the contrary, the antenatal depression risk in our population was higher than the reported antenatal depression among pregnant women in both high-income and low-income countries such as India (17.74%) and Sri Lanka (12.95%) (Mahendran et al., Citation2019), Ireland (15.8%) (Jairaj et al., Citation2019), and Australia (6.2%) (Ogbo et al., Citation2018), and slightly higher than other Middle Eastern countries such as Qatar (20.9%) (Naja et al., Citation2021) and Kuwait (20.1%) (Pampaka et al., Citation2018). A possible explanation of the high prevalence observed in the current study could be the employment status (61.0% are housewives) and the educational level within our sample (54.2% have higher education). As per data from the Ministry of Labor in Oman (MoL, Citation2020), a substantial percentage (56.6%) of Omani women are actively seeking employment (NCSI, Citation2021), suggesting that the composition of our study sample may be influenced by circumstances leading to their unemployment status. While we failed to identify a significant association between our sample’s employment status and their risk of perinatal depression, there is existing evidence that links unemployment with depression (Chen et al., Citation2019; Koh et al., Citation2019; Míguez & Vázquez, Citation2021b; Yin et al., Citation2021). In addition, unplanned pregnancy was common in 25.4% of the sample in the current study, which might explain the high prevalence of antenatal depression risk, similar to previous studies (Duko et al., Citation2019; Míguez & Vázquez, Citation2021b; Yin et al., Citation2021). A high number of physically inactive mothers (86.4%) in this study might also explain the high prevalence of antenatal depression risk. According to the Dunkel Schetter and Lobel’s model (Dunkel Schetter & Lobel, Citation2012), promoting a healthy lifestyle among women could enhance the improvement of health and generation of a better quality of life at any stage (prepregnancy, pregnancy and postnatal) (Dunkel Schetter & Lobel, Citation2012). Accordingly, midwives and other health-care providers need to incorporate health-promoting aspects in their daily work with pregnant women, especially those with or at risk for antenatal depression.
Another interesting finding is the high prevalence of postnatal depression risk among women in the current study (25.9%). The result is similar to the reported prevalence from a recently published Spanish study (21.4%) (Míguez & Vázquez, Citation2021a). However, the postnatal depression risk in our population was higher than the reported postnatal depression in, for example, Italy (19.9%) (Cena et al., Citation2021), Australia (3.3%) (Ogbo et al., Citation2018), and neighboring Middle Eastern countries such as Saudi Arabia (17.1%) (Alzahrani, Citation2019) and Kuwait (11.7%) (Pampaka et al., Citation2019). On the other hand, the reported prevalence in the current study is lower than the reported prevalence in, for example, Uganda (27.1%) (Atuhaire et al., Citation2021), Damascus (28.2%) (Roumieh et al., Citation2019), and Egypt (33.5%) (Ahmed et al., Citation2021).
Our study showed that the antenatal depression risk was significantly correlated with the postnatal depression risk. This finding is in line with several studies indicating that self-reported antenatal depressive symptoms strongly predict postnatal depressive symptoms (Dagher et al., Citation2021; Ogbo et al., Citation2018). Screening for possible depression and depressive symptoms, and early referral for expert assessment of at-risk women, might be useful methods for improving maternal mental health outcomes, according to our findings. There is also clear evidence that psychological interventions during the antenatal period could significantly affect antenatal and postnatal depression (Yasuma et al., Citation2020). In conclusion, the overall prevalence of antenatal depression risk among Omani women in this study was 22.4%, which is considered among the higher prevalences reported in international studies in both high- and low-income countries (Al-Abri et al., Citation2023). The prevalence in our population might be explained in light of the absence of routine screening for perinatal depression risk in antenatal care in Omani settings.
The limited literature on antenatal depression in Oman and the Middle East restricted a comparison of observations between our findings and these studies’ outcomes, creating a restrictive imposed reality on this study. During the research period, the research team implemented a nonprobability convenience sampling strategy to recruit participants who met the inclusion criteria. This sampling method was used to recruit a larger sample size in a short time and was considered feasible in terms of cost and time (Etikan et al., Citation2016). Convenience sampling, on the other hand, has a higher risk of selection bias than other quantitative sampling techniques (Polit & Beck, Citation2021), thus risking restricting the findings’ generalizability because the sample may not reflect the entire population. To overcome this limitation, the researchers requested a sample from three different settings to verify that the individuals were diverse. Furthermore, sample homogeneity was achieved by applying clear and distinct inclusion and exclusion criteria.
Implications for Practice
Early and accurate identification and effective intervention may prevent long-term consequences for childbearing women, their children, and families and reduce the burden of antenatal depression and postpartum depression risk for the individual, health system, and community at large. Implementation of a screening tool for antenatal depression risk is highly recommended and may contribute to the improvement of the quality of antenatal care. Therefore, a training programme for midwives on the use of the EPDS can be suggested at a policy level and may positively impact mothers’ health as well as newborns’ physical and mental health. In addition, the training of midwives may contribute to a healthy pregnancy without stress, depressive symptoms, or depression and might help in managing depression if it occurs.
Screening is essential for promoting emotional and physical well-being, and the mothers are in urgent need of support based on the high prevalence detected in the current study. Midwives can ask about emotions and provide cognitive and behavioral relaxation techniques to women early in pregnancy to prevent mental health disorders (depression, anxiety, etc.) and thus avoid adverse outcomes. Furthermore, with effective screening, follow up, and treatment of detected symptoms, as well as education and implementation of preventative strategies, a reduction of stress in pregnant women is an expected outcome.
Finally, and based on this study’s findings, merging a screening intervention into antenatal care in Oman will aid in the identification of pregnant women who are suffering from prenatal depression. In addition, referring these women to the nearest psychiatric unit for proper diagnosis and treatment will contribute to positive birth outcomes and a reduction in serious obstetric complications. Finally, the EPDS tool is recommended to be circulated among midwives and nurses to improve the current routines during the antenatal and postnatal periods, to promote and maintain the mothers’ mental well-being and to provide all mothers with the opportunity to initiate early breastfeeding and get adequate breastfeeding support, if necessary.
Conclusions
The current study showed a considerable rate of antenatal and postnatal depression risk. In addition, antenatal depression risk was found to be significantly associated with postnatal depression risk. Thus, screening for antenatal depression would allow for interventions with the aim of preventing depression from continuing postnatally. The results of this study call for the need to conduct a national, population-based study investigating the prevalence of depression and its determinants among pregnant women up to one year after childbirth. Furthermore, midwives and other health-care professionals delivering services to pregnant women need to be aware of how common antenatal depression could be during pregnancy. The specific characteristics associated with antenatal depression risk in this Omani population remain unknown based on the current data. Further research is needed to identify the key risk factors that could inform targeted interventions and support services for pregnant women in Oman.
Acknowledgements
Special thanks to all midwives at Ibri Health Clinics and Yanqul Hospital for their great attention to detailed, outstanding assessments, and valuable assistance in the data collection process. Thank you to Mr. Assad Rashid Al Ghafri, the head of medical statistics in the directorate of Al Dhahira region, for being supportive throughout this project. Thanks are due to all the mothers who participated in this study.
Disclosure Statement
The authors declare that they have no competing interests.
Data Availability Statement
The data sets generated and/or analyzed during the current study are available from the corresponding author (AK) upon reasonable request.
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