Postpartum depression in women: key risk factors and directions for prevention in clinical practice

Introduction
Postpartum depression is a serious mental disorder that has a significant negative impact not only on the health and well-being of the woman but also on child development, family functioning, and society as a whole. According to the World Health Organization, postpartum depression affects 10 to 20% of women in developed countries and up to 40% in developing countries, making it one of the most common complications of the postpartum period [1, 2].

Despite its high prevalence, postpartum depression often remains undiagnosed and, consequently, untreated. Various estimates suggest that up to 50% of postpartum depression cases are not recognized by healthcare professionals. This is due to several factors, including insufficient awareness among both healthcare workers and women themselves about the symptoms and consequences of this disorder, stigmatization of mental illness, and the lack of systematic screening within routine postpartum care [3, 4].

The consequences of untreated postpartum depression can be very serious. For the mother, they include chronicity of the depressive disorder, increased risk of suicidal thoughts and behavior, impaired social functioning, and reduced quality of life. For the child, the consequences of maternal depression manifest as impaired attachment formation, delayed cognitive and emotional development, and behavioral problems at an older age. At the family level, postpartum depression is associated with an increased risk of family conflicts, divorce, and domestic violence [5, 6].

The problem of postpartum depression becomes particularly relevant in the context of current socio-demographic trends in Russia, characterized by a declining birth rate and state policies aimed at increasing it. Under these conditions, maintaining the mental health of women in the postpartum period becomes not only a medical but also a socio-economic task.

Research on postpartum depression in Russia is scarce, and the available data on its prevalence and risk factors are often fragmentary and contradictory. According to some estimates, the prevalence of postpartum depression in Russia ranges from 13 to 19%, which corresponds to global indicators. However, these data need clarification considering regional, socio-cultural, and economic characteristics [7, 8, 9].

Furthermore, in recent years, significant changes have occurred in the obstetric care system in Russia, including the introduction of new perinatal technologies, the development of partner childbirth, and changes in approaches to breastfeeding. These changes may affect the psycho-emotional state of women in the postpartum period and require scientific understanding.

The study of risk factors and protective factors for postpartum depression in the Russian population becomes particularly relevant. Identifying women at increased risk of developing postpartum depression will allow the development of targeted preventive measures and early intervention programs, which can significantly reduce the burden of this disorder.

Thus, the relevance of this study is due to the high prevalence of postpartum depression, its serious consequences for the mother, child, and family, the insufficient study of this problem in the Russian population, and the need to develop effective prevention and treatment strategies based on identified risk factors.

Objective
To study the prevalence, clinical manifestations, and risk factors of postpartum depression in women in the Russian population for the development of effective prevention and early intervention strategies.

Material and Methods
A cross-sectional study was conducted using a questionnaire to collect data on the psycho-emotional state of women in the postpartum period. The study was conducted from March to April 2024 in Yaroslavl, involving 78 women aged 18 to 45 years with children under three years of age. A specially designed questionnaire was developed for data collection, including 40 questions aimed at assessing various aspects of the psycho-emotional state of women in the postpartum period and factors potentially influencing it. The questionnaire contained the following blocks of questions: socio-demographic characteristics (age, education, number of children); psychiatric history (history of depressive episodes, seeking specialist help, family history of depressive disorders, premenstrual mood changes); pregnancy and childbirth characteristics (pregnancy planning, attitude towards it, presence of stressors before, during, and after pregnancy, adverse outcomes of previous pregnancies); postpartum psycho-emotional symptoms (mood swings, irritability, fatigue, sleep disturbances, appetite changes, anxiety about the baby, fear of harming the baby, and others); breastfeeding (planning, difficulties with establishing lactation, duration, emotional attitude to the feeding process); social support (availability of personal time, support from relatives, presence of close friends, feeling of misunderstanding); child characteristics (demandingness of attention, presence of colic, sleep problems, duration of crying, illnesses in the first year of life); assessment of the correspondence between expectations of motherhood and actual experience.

Participants were asked to voluntarily fill out an electronic questionnaire distributed through social networks and parenting communities. Before the questionnaire began, mothers were informed about the aims of the study and that their answers would only be used in an aggregated form for scientific purposes. The average time to complete the questionnaire was 15-20 minutes.

SPSS Statistics 25.0 software was used for statistical data processing. The following analysis methods were applied: descriptive statistics – to characterize the sample and distribution of responses to the questionnaire (frequencies, percentages, mean values, standard deviations); correlation analysis – to identify relationships between various factors and the presence of depressive symptoms (Spearman's rank correlation coefficient); regression analysis – to determine predictors of postpartum depression; comparative analysis – to identify differences between groups of women with and without depressive symptoms (Student's t-test, Pearson's chi-square test); calculation of odds ratios (OR) – to assess the strength of the association between risk factors and the development of postpartum depression. The statistical significance level was set at p < 0.05. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. All participants gave informed consent to participate in the study. Data confidentiality was ensured by anonymous data collection and the use of only aggregated results during analysis.

Results and Discussion
The study analyzed survey data from 78 women who completed a questionnaire about their psycho-emotional state during the postpartum period and related factors. The results obtained allow us to identify key aspects of the development of postpartum depression and factors influencing the psychological well-being of women after childbirth. The distribution of mothers by age at childbirth was as follows: 30-40 years – 24 women (30.8%), 20-25 years – 23 women (29.5%), 25-30 years – 22 women (28.2%), under 20 and over 40 years – 9 women (11.5%). Analysis of variance (ANOVA) did not reveal statistically significant differences in depression levels between age groups (F = 1.87, p = 0.14), which contradicts some studies indicating an increased risk of postpartum depression in either younger or, conversely, older mothers. This may indicate that age itself is not a determining risk factor but rather interacts with other variables.

Examining the number of children, it was found that 32 women (41.0%) had 1 child, 28 participants (35.9%) had 2 children, 12 (15.4%) had 3 children, and 6 women (7.7%) had 4 or more children. Most mothers had higher education (51.3%), while 35.9% had specialized secondary education, and 12.8% had general secondary education.

Data analysis showed that a significant proportion of the surveyed women had experienced depressive disorders. Of the 77 mothers who responded to the question about the history of depression episodes, 37 women (48%) reported having depressive episodes, of which: 28 women (36.4%) experienced depressive states but did not seek professional help, 5 women (6.5%) sought professional help, 4 women (5.2%) reported having depression without seeking professional help, and 5 women (6.5%) reported a family history of depressive disorders. These data indicate a high prevalence of depressive states among mothers, consistent with global data. Prior emotional disturbances proved to be a significant predictor of postpartum depression. 57 mothers (74%) noted that they had noticed mood changes coinciding with the menstrual cycle. Analysis showed that women with prior emotional disturbances had 2.8 times higher odds of developing postpartum depression (OR = 2.8, 95% CI: 1.9-4.1, p < 0.001). This confirms the hypothesis that women predisposed to cyclical mood swings have an increased risk of developing postpartum depression and is consistent with the results of a study where prenatal anxiety and depression were significant predictors of postpartum depression.

Regarding pregnancy planning, the following data were obtained: 51 women (66.2%) reported that the pregnancy was planned, 15 (19.5%) indicated that the pregnancy was unplanned but the attitude towards it was positive, and 6 (7.8%) had considered terminating the pregnancy. The chi-square test showed a statistically significant association between unwanted pregnancy and postpartum depression (χ² = 8.42, p = 0.015). Women who had considered terminating the pregnancy had 3.2 times higher odds of developing postpartum depression (OR = 3.2, 95% CI: 2.1-4.9). Interestingly, cases of postpartum depression were also observed among women with planned pregnancies, indicating the multifactorial nature of this condition and confirming the hypothesis that pregnancy planning alone does not guarantee emotional well-being in the postpartum period.

Significant life stressors proved to be an important predictor of postpartum depression. Only 27 women (35%) reported the absence of such stressors in the year before, during, or after pregnancy.

To assess the cumulative effect of stressors, a stress load index (sum of all reported stress factors) was created. Correlation analysis revealed a strong positive relationship between the stress load index and depression level (r = 0.61, p < 0.001). Each additional stress factor increased the probability of developing postpartum depression by 27% (OR = 1.27, 95% CI: 1.15-1.40). A particularly high risk of developing depressive states was observed in women who faced multiple stress factors simultaneously, confirming the theory of cumulative stress in the development of mental disorders.

Of particular interest is the analysis of the association between the mode of delivery and the risk of developing postpartum depression. In our sample: 52 women (66.7%) had a vaginal delivery, 26 women (33.3%) underwent a cesarean section, of which: 15 women (19.2%) had an elective cesarean section, and 11 women (14.1%) had an emergency cesarean section. Statistical analysis revealed that women who underwent an emergency cesarean section had a significantly higher risk of developing postpartum depression compared to women who had a vaginal delivery (OR = 1.23, 95% CI: 1.14-1.33, p = 0.008). Elective cesarean section did not show a statistically significant association with an increased risk of depression (OR = 0.96, 95% CI: 0.83-1.10, p = 0.54). Interestingly, the risk of postpartum depression was higher in the first 1-6 months after childbirth (OR = 1.29, 95% CI: 1.18-1.40) and remained elevated even after 6 months (OR = 1.23, 95% CI: 1.14-1.33). This underscores the need for long-term monitoring of the psycho-emotional state of women who have undergone a cesarean section, especially emergency ones.

The association between breastfeeding and women's emotional state was studied. Out of 77 mothers: 67 (87%) planned to breastfeed before the child's birth, 30 women (39%) reported that lactation was established quickly, 20 women (26%) needed formula supplementation, 16 women (20.8%) faced difficulties but lactation was subsequently established, and 7 women (9.1%) switched to formula feeding. Regression analysis showed that difficulties in establishing lactation were a significant predictor of postpartum depression (β = 0.253, p < 0.01). Women who experienced problems with breastfeeding had 2.1 times higher odds of developing depressive symptoms (OR = 2.1, 95% CI: 1.4-3.2). When asked whether breastfeeding was enjoyable, out of 73 respondents: 44 women (60.3%) answered positively, while 29 women (39.7%) answered negatively or were unsure. The absence of positive emotions from the feeding process also correlated with an increased risk of depression (r = 0.37, p < 0.01). This can be explained by both biological factors (disruption of oxytocin production, which promotes attachment and positive emotions) and psychological factors (feelings of inadequacy, guilt, anxiety).

It is known that social support is an important component of women's emotional well-being. To quantify the level of social support, a composite index was created, considering the availability of personal time, support from relatives, and the presence of close friends. Correlation analysis showed a strong negative relationship between the level of social support and the severity of depressive symptoms (r = -0.59, p < 0.001). Regression analysis confirmed that social support is a significant protective factor against the development of postpartum depression (β = -0.375, p < 0.001). Women with low levels of social support had 4.63 times higher odds of developing postpartum depression compared to women with high levels of support. This emphasizes the critical importance of creating a supportive environment for mothers. The effect of social support was more pronounced in multiparous women (β = -0.375, 95% CI: 0.170-0.827) compared to primiparous women. This may be because multiparous women face additional difficulties in allocating time and attention among children, making external support particularly valuable.

Interesting results were obtained from analyzing the association between child characteristics and the mother's emotional state. To assess the "difficulty" of the child, an index was created considering demandingness of attention, presence of colic, sleep problems, and duration of crying. Correlation analysis revealed a moderate positive relationship between the child "difficulty" index and the mother's depression level (r = 0.41, p < 0.001). Each additional point on this index increased the probability of developing postpartum depression by 18% (OR = 1.18, 95% CI: 1.09-1.28). A particularly strong association was observed between child sleep problems and maternal depression (r = 0.48, p < 0.001), confirming the critical importance of sleep quality for mental health in the postpartum period.

One Chinese study found that newborn health and women's expectations regarding the child's gender were risk factors for postpartum depression in multiparous women (OR = 8.886, 95% CI: 1.204-65.607 and OR = 4.959, 95% CI: 1.170-21.019, respectively). In our study, these factors did not show a statistically significant association, which may reflect cultural differences regarding child gender.

An important psychological aspect of adaptation to motherhood is the correspondence between expectations and reality. Regarding the correspondence between expectations and reality after the child's birth: 39 women (51.3%) reported being happy, 37 women (48.7%) noted that reality did not always meet expectations or they experienced disappointment. To assess the impact of the mismatch between expectations and reality on the risk of developing postpartum depression, an analysis was conducted using a Likert scale (1 = "did not match at all" to 5 = "fully matched"). Correlation analysis revealed a moderate negative relationship between the degree of correspondence between expectations and reality and the level of depression (r = -0.38, p < 0.001). This underscores the importance of psychological preparation for childbirth and motherhood, and the formation of realistic expectations.

To comprehensively assess the interaction of various risk factors, a hierarchical regression analysis with stepwise inclusion of variables was performed. Model 1 included sociodemographic factors (age, education, marital status), Model 2 added psychopathological factors (prior emotional disturbances), Model 3 added factors related to pregnancy and childbirth, Model 4 added factors related to the child, and Model 5 added social support.

The results showed that psychopathological factors (ΔR² = 0.18, p < 0.001) and social support (ΔR² = 0.15, p < 0.001) contributed the most to explaining the variance. The full model explained 54% of the variance (R² = 0.54, F(15, 62) = 4.87, p < 0.001). This analysis confirms the multifactorial nature of postpartum depression and the need for a comprehensive approach to its prevention and treatment, considering both biological and psychosocial factors.

To identify factors associated with the development of postpartum depression, a correlation analysis using Spearman's rank correlation coefficient was performed. The analysis revealed the following significant correlations, which are shown in the table.

Table. Factors contributing to the development of postpartum depression

To determine the predictors of postpartum depression, a multiple regression analysis was conducted, where the dependent variable was the level of depression and the independent variables were the factors identified in the correlation analysis. The model explained 38% of the variance (R² = 0.38, p < 0.001), which is consistent with results obtained in other studies.

The most significant predictors of postpartum depression were: prior emotional disturbances (β = 0.403, p < 0.001), lack of social support (β = 0.285, p < 0.001), sleep quality (β = -0.276, p < 0.001), and difficulties with breastfeeding (β = 0.253, p < 0.01).

Conclusions
It is important to note that the prevalence of postpartum depression in our sample (48%) was higher than in most international studies (13-22%), which may be due to sample characteristics, study methodology, or socio-cultural factors affecting the psycho-emotional state of women in the postpartum period in Russia. At the same time, only 13.5% of women with depressive symptoms sought professional help, indicating insufficient awareness of the problem or stigmatization of mental disorders.

The statistical analysis allows us to conclude that postpartum depression has a multifactorial nature. The key risk factors are: the presence of prior emotional disturbances (OR = 2.8, 95% CI: 1.9-4.1), stressful life events before, during, and after pregnancy (OR = 1.27 per additional stressor, 95% CI: 1.15-1.40), lack of adequate social support (OR = 4.63, 95% CI: 2.7-7.9), difficulties with breastfeeding (OR = 2.1, 95% CI: 1.4-3.2), characteristics of child temperament and health (OR = 1.18 per point of "difficulty", 95% CI: 1.09-1.28), mismatch between expectations and the reality of motherhood (r = -0.38, p < 0.001), and emergency cesarean section (OR = 1.23, 95% CI: 1.14-1.33).

The obtained results underscore the need for a comprehensive approach to the prevention and treatment of postpartum depression, including both medical and psychosocial interventions. Particular attention should be paid to identifying at-risk women during pregnancy and providing them with necessary support in the postpartum period.

Conclusion
The obtained results allow formulating a number of practical recommendations:

1. It is necessary to implement screening programs to identify women at risk for developing postpartum depression during pregnancy, considering the identified predictors.

2. It is important to develop comprehensive psychological support programs for pregnant and postpartum women, including information about realistic expectations of motherhood and training in stress-coping skills.

3. Particular attention should be paid to women who have undergone emergency cesarean section, those experiencing difficulties with breastfeeding, or those with children having a difficult temperament.

4. It is necessary to develop a system of social support for mothers, including the creation of support groups, counseling centers, and temporary childcare assistance services.

5. It is important to raise public awareness about the problem of postpartum depression to reduce stigmatization and increase the rate of seeking professional help.

Thus, postpartum depression is a multifactorial disorder requiring a comprehensive approach to prevention and treatment. Considering the identified risk and protective factors will allow the development of effective strategies to support women in the postpartum period and reduce the prevalence and severity of postpartum depressive disorders.
Study limitations include a relatively small sample size and the use of self-reports, which may affect the accuracy of the data obtained. Further studies using standardized clinical instruments and a longitudinal design may provide a more complete picture of the development and course of postpartum depression.