# Postpartum depression and its correlates: a cross-sectional study in southeast Iran | BMC Women’s Health

### 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.