Physical illness and depression are very common after childbirth, and become more frequent with the passage of time. These are the startling conclusions of two papers in this issue of the journal.
Stephanie Brown and Judith Lumley (pages 1194–1201) performed a population survey of over two thousand women in Victoria who had given birth six months previously, followed by a more detailed telephone survey of a smaller group of these women. Six months after birth the prevalence of physical discomforts was astonishing: seven in ten women suffered excessive tiredness, half of the women experienced backache, one quarter of the women still had perineal pain and one quarter reported sexual difficulties. Depression was measured by a reliable and valid psychometric instrument, the Edinburgh Postnatal Depression Scale; six months after childbirth one in six women suffered clinical depression. There was an association between depression and physical discomforts, and the subsequent telephone survey showed a linear trend between the prevalence of physical symptoms and the degree of depression. Marie-Josephe Saurel-Cubizolles and her colleagues (pages 1202–1209) conducted a similar survey five months after childbirth in over one thousand women in France and Italy, where the prevalence of physical symptoms was again very high: more than half of the women complained of excessive tiredness, half suffered backache, one in three reported undue anxiety and one in six lack of sexual desire. Furthermore when the survey was repeated one year after childbirth the prevalence of these symptoms had increased, contrary to current beliefs. The authors did not estimate the prevalence of depression by a formal scale, but noted that one fifth of the women complained of tearfulness and depression five months after childbirth, increasing to one third at one year.
The strengths of these studies are their attempts to eliminate bias and their results being able to be made general. Although the response rate to the questionnaire survey in Victoria was low, the characteristics of the nonresponders were similar to the responders, such that significant response bias is unlikely. The surveys in France and Italy were based in maternity hospitals, but the authors took care to include both urban and rural hospitals in their study. The results of these studies therefore carry conviction, and are consistent with other investigations showing a high prevalence of physical ill-health and depression after childbirth. The results of the surveys in France and Italy are remarkably similar, despite differences in cultural beliefs, social organisation and obstetric services. One major finding in this study is that postnatal ill-health increases rather that decreases with the passage of time.
Forman Nielsen and colleagues (pages 1210–1217) investigated postnatal depression from a different point of view, by attempting to predict the disorder from psychosocial, antenatal and perinatal factors. The authors studied over six thousand women and from multiple regression analysis identified the factors which were independently associated with postnatal depression. From the magnitudes of the regression coefficients a risk index was constructed, which performed moderately well in the prediction of postnatal depression, the sensitivity being 79% and specificity 50%. From this information the likelihood ratio of a positive test is 1–6 and of a negative test 0.4. This implies that the risk index is unlikely to be universally useful, but the general information that severe psychological distress and social isolation in late pregnancy are associated with postnatal depression is important.
We must conclude from these studies that more should be done to identify and treat postnatal physical illness and depression. The burden of this must fall on primary care, in the United Kingdom, general practitioners, midwives and health visitors. In other parts of the world obstetricians are involved with the primary care of women, and will therefore have the responsibility for treating postnatal illness. Brown and Lumley suggest that in women who suffer postnatal depression disclosure of physical symptoms should be sought; and in women with physical symptoms several months after delivery a diagnosis of depression should be considered; this is especially true in women with psychological distress or social isolation in late pregnancy.