Study design and participants
This cross-sectional correlation study was conducted to examine the relationship between prenatal care, depression, anxiety, stress and postpartum depression in women who have recently given birth. The research samples are women who gave birth 3 days ago (via vaginal delivery or cesarean section). The sample size included 186 women giving birth at Nik-nafs maternity ward in Rafsanjan. The inclusion criteria were: (1) mothers 18 years and older; (2) mothers with no known mental health problems or disorders; (3) Mothers without visual and auditory processing disorders. The exclusion criteria were: (1) the presence of gynecological diseases that affect the pregnancy status, the course of pregnancy and the health of mother and child, (2) termination of pregnancy due to premature premature rupture of membranes.
Sample Size and Samples
Based on studies by Izadirad et al. [21] To determine the association between health literacy and the Prenatal Care Adequacy Index (r = 0.244) with 99% confidence and 90% power, the sample size was assumed to be 140 individuals according to the following formula. Regarding the condition of the mothers and the possibility of non-response, 200 questionnaires were distributed.
$$\upomega =\frac{1}{2}\mathit{Ln}\frac{1+r}{1-r}$$
$$n=\frac{{\left({Z}_{1-\frac{\alpha }{2}}+{Z}_{1-\beta }\right)}^{2}}{{ (\omega)}^{2}}+3$$
Finally, 186 mothers completed the questionnaires.
Measurement
Demographic Information
Demographic information of participants included age, maternal body mass index (BMI), baby sex, type of delivery, previous delivery, number of deliveries, number of pregnancies, history of abortions, number of children, employment status, level education and income.
Edinburgh Postnatal Depression Scale (EPDS)
This 10-point self-rated measure is used to screen women for depressive symptoms during pregnancy and the postpartum period with scores from 0 to 3 (maximum EPDS score is 30). The cut-off remains at 13 or more, suggesting prenatal depressive symptoms. This questionnaire was adapted from Cox et al. [22]and has been used in various countries to study postpartum depression [23]. Montazer et al. [24] used it in Iran and the internal correlation coefficient was 0.80 [24]. In the present study, the reliability of the EPDS scale using Cronbach’s alpha coefficient was 0.79 and 0.76 at 3 days and 6 months after delivery, respectively.
Depression, Anxiety, Stress Scale (DASS-21)
The Depression, Anxiety, and Stress Scale (DASS-21), developed by Lovibond and Lovibond in 1995, was designed to assess the psychological constructs of depression, anxiety, and stress [25]. The scale consists of 21 items, including seven items for each of the three subscales depression (7 items), anxiety (7 items), and stress (7 items) on a four-point Likert scale (never/low/medium/high). The lowest score is zero and the highest score is three. The total score results from the sum of the scores of the associated items. The total score of the subscales should be doubled. Zakeri et al. [26] In Iran, the Iranian version of DASS-21 reported a Cronbach alpha coefficient of 0.81, 0.74, and 0.78 for depression, anxiety, and stress, respectively [26]. In the present study, the reliability of the DASS-21 scale using Cronbach’s alpha coefficient was 0.75 and 0.80, respectively, for anxiety and stress 3 days after delivery. In addition, the reliability of the DASS-21 scale 6 months after delivery was 0.93 and 0.79 for anxiety and stress, respectively. In the present study, we used two subscales of anxiety and stress.
Prenatal Care Quality Questionnaire (QPCQ)
This questionnaire was adapted from Sword et al. developed and validated. [27] in an Australian context to measure the quality of prenatal care. QPCQ has 46 items with six subscales, including (1) Information Sharing: Focus on how prenatal care providers answer questions, keep information confidential, and ensure women understand the reasons for testing (9 items), (2) Proactive Guidance: Women should get enough information to make decisions (11 items), (3) Sufficient time: the time that prenatal care providers spend (5 items), (4) Availability: the availability of the healthcare provider (4 items), (5) Availability: the availability of clinic/office staff or antenatal caregivers on 5 items; and (6) support and respect: respect and support from antenatal caregivers on 12 items. The items are on a five-point Likert scale (from totally disagree = 1 to totally agree = 5). Items 8, 15, 23, 28 and 40 are scored inversely. The overall score of QPCQ (46 questions) ranges from 46 to 230, with a higher score reflecting a higher quality of prenatal care. The QPCQ is a valid and reliable measure of the overall quality of prenatal care [27]. In the present study, the validity of this questionnaire was determined using face and content validities. We used internal consistency and test-retest for the QPCQ to assess reliability. Internal consistency was good (α = 0.94) and the intraclass correlation coefficient was 0.47 [28].
Data collection and statistical analysis
Referring to the research settings, the researcher began sampling at Niknaf’s maternity ward after receiving the necessary approval. Therefore, the demographic information form, the QPCQ, EPDS, and DASS-21 questionnaire (anxiety and stress subscales) were distributed among the appropriate samples, who answered the questionnaires in the presence of the researcher (face-to-face). In addition, the EPDS and DASS-21 were completed and evaluated 6 months after delivery. EPDS and DASS-21 were evaluated using a telephone interview 6 months after delivery. Over a period of 5 months (October 2019 to February 2020), 200 questionnaires were distributed and 186 copies returned (response rate: 93%). Finally, 186 samples were included in the study. No questionnaires were excluded from the study. The data were then analyzed using SPSS 22 and a significance level of 0.05 was considered. Descriptive statistics (frequency, percentage, mean and standard deviation) were used to describe the information. Pearson’s correlation coefficients were used to determine the relationship between the study’s quantitative variables. The Independent ttest, Mann-Whitney U, ANOVA, and Kruskal-Wallis tests (accounting for normality of the data) were used to determine the PPD according to the qualitative variables of the study. When the variable was normally distributed, an independent t-test was used to compare PPD according to two groups and an ANOVA test was used to compare PPD according to three or more groups. When the variable was not normally distributed, the Mann-Whitney U test was used to compare PPD after two groups and the Kruskal-Wallis test was used to compare PPD after three or more groups. Multivariate linear regression was used to identify the PPD determinants. We used multiple linear regression to estimate the relationship between the independent variables of the present study and the dependent variable of PPD (post-delivery and 6 months post-delivery). A significance level of 0.05 was assumed.
