Postpartum Depression and Anxiety among Lebanese women: correlates and scales validation

Background The last study conducted in Lebanon about postpartum depression dates back to 2014, whereas no studies have been conducted to assess postpartum anxiety (PPA). The shortage of research in this field and the potential opportunities to provide different aspects of postpartum care that respond to women's needs require a deeper understanding of the various problems faced by postpartum women. The study objectives were to delineate some factors associated with postnatal depression and anxiety among a sample of Lebanese women 4-6 weeks after delivery and validate the Edinburgh Postnatal Depression Scale (EPDS) and Perinatal Anxiety Screening Scale (PASS) in Arabic language in that sample. Methods This cross-sectional study, carried out between July 2018 and March 2019, enrolled 295 participants who came for a postnatal checkup to four clinics. Results Higher postpartum anxiety (Beta=0.25), higher insomnia (Beta=0.11) and having complications during delivery (Beta=1.81) were associated with higher postpartum depression. Higher postpartum depression score (Beta=1.38) and a premature baby birth compared to those born at term with normal weight (Beta=4.25) were associated with higher postpartum anxiety. The factor analysis for the EPDS and the PASS scales was run over the whole sample. The EPDS and PASS scales items converged over a solution of three and seven factors that had an Eigenvalue over 1 respectively, explaining a total of 64.73% and 65.12% of the variance respectively. High Cronbach’s alpha values were found for the EPDS (0.826) and PASS (0.920) scales. Conclusion Depression and anxiety prevalence rates in the Lebanese population is higher compared to other countries which may in part be due to differences of regional, social, and environmental culture. Different etiological factors could contribute to both depression and anxiety in the postpartum period, which could adversely affect both the mother and the infant.

Higher postpartum depression score (Beta=1.38) and a premature baby birth compared to those born at term with normal weight (Beta=4.25) were associated with higher postpartum anxiety. The factor analysis for the EPDS and the PASS scales was run over the whole sample. The EPDS and PASS scales items converged over a solution of three and seven factors that had an Eigenvalue over 1 respectively, explaining a total of 64.73% and 65.12% of the variance respectively. High Cronbach's alpha values were found for the EPDS (0.826) and PASS (0.920) scales.
Conclusion Depression and anxiety prevalence rates in the Lebanese population is higher compared to other countries which may in part be due to differences of regional, social, and environmental culture. Different etiological factors could contribute to both depression and anxiety in the postpartum period, which could adversely affect both the mother and the infant.

Background
Childbirth causes an important change in the mother's physiology; which may induce in her an onset of psychopathological symptoms that differ in intensity and frequency 1,2 . More particularly, these psychopathological symptoms include various forms of anxiety and depression. In addition to that, short/long-term impacts on the mother's as well as the child's wellbeing are detected 3 .
Sometimes, serious problems can arise, causing real harm to the mother's post-partum psychological stability 4 . These cases include a short lasting condition on commonly known as baby blues. It features mild symptoms such as: anxiety, mood swings, amplified emotional reactivity, with a minimal impact on functioning 4 . Baby blues were reported in 15-85% of women within the first 10 days after birth, with a peak incidence of the fifth day 5 . Although baby blues' postpartum occurrence is common and transient, generally not requiring intervention, the relevance of its recognition should be noted as it is postulated as a risk factor for subsequent postpartum depression (PPD) 6 .
The most statistically and clinically relevant psychological complication, related to giving birth to children is PPD 7 . About 10-15% of women giving birth may develop PPD, with different population groups and geographical locations variability 7 . The psychiatric literature reference, known as DSM-5, states that the "Postpartum Onset" (a class of: Major Depressive Disorder) is characterized by symptoms appearing during 4-6 weeks after delivery 8 . More specifically, postpartum depression symptoms include: disturbances in appetite and sleep, energy loss, sensation of guilt, diminished attentiveness, as well as plausible suicidal thoughts 8 . Diagnosis of PPD is considered a challenge since changes in sleep patterns and appetite, moreover excessive fatigue are routine changes women go through after giving birth 9 .
Previously established results, based on population based studies, demonstrated the following significant risk factors of PPD (in prenatal, perinatal and postnatal phases): (a) patient history of depression 10−12 ; (b) psycho-social factors (such marital problems, decreased social support and negative life) 12,13 ; (c) socio-economic factors (such as unemployment, poverty 10,13 and low education level 10,13 ); (d) medical factors, including complications in delivery and pregnancy 10,11 , substance (alcohol/nicotine) abuse while pregnant 10 , poor sleep 12,13 , post-delivery wound discomfort and drastic maternity blues 12 ; (e) factors related to child (such as the sex of the baby, difficulties in breastfeeding and undesired pregnancy) 10 .
Perinatal anxiety states anxiety experienced all through pregnancy (antenatal) and/or postpartum period (12 months after birth) 14 . Perinatal anxiety has been recognized as a solid leading indicator of postpartum depression 15  screens for a wide range of anxiety disorders as well as some common perinatal-specific fears. It is a valid and useful tool for identifying pregnant women and new mothers with problematic anxiety. This scale was also validated in other languages 29,30 but not Arabic.
The last study conducted in Lebanon about postpartum depression dates back to 2014 31 , whereas no studies have been conducted to assess postpartum anxiety (PPA). Postpartum morbidities in Lebanon have never been thoroughly investigated. The shortage of research in this field and the potential opportunities to provide different aspects of postpartum care that respond to women's needs require a deeper understanding of the various problems faced by postpartum women. This study's main objective is to delineate some of the factors connected to postnatal depression and anxiety, as well as to linguistically validate in Arabic language the EPDS and PASS scales; among the sample of Lebanese women 4-6 weeks after delivery.

Study design
This cross-sectional study was carried out between July 2018 and March 2019. Participants were recruited from four gynecologists' clinics located in four different governorates in Lebanon. For the choice of participants, each Lebanese married woman, aged more than 18 years old, who came for a postnatal checkup to the clinic 4-6 weeks after delivery was asked if she would like to participate in this study and after her written consent she was considered as a participant. Patients excluded were women with physician's diagnosed mental illness or who refused to take part in the study.

Sample size calculation
The Epi info program was used to calculate the minimum sample size needed for our study, with an acceptable 5% margin of error and an expected 12.5% frequency of women with postpartum depression 7 for an estimate of 86000 births per year in Lebanon 32 , the results indicated that we need 168 participants to participate in the study.

Survey details
The survey was administered at the obstetrician's clinics in Arabic without the presence of a third party observant (e.g. husband, family member, etc.) and took approximately 25 minutes to be completed. The questionnaire was self-administered to the mother unless she was illiterate, in which case the investigator helped out by reading for her the questions.
The first part of the questionnaire consisted of the sociodemographic features including age, gender, and region, the level of education, professional status, insurance type as well as history of diseases and other questions that were linked to factors associated with postpartum depression and anxiety according to the literature review 10,11,13,33 .
The second part consisted of the scales used in the study as follows: -We used the Edinburgh Postnatal Depression Scale (EPDS) to screen for the possible presence of postpartum depression. It is the standardized tool used postnatally to quantify the severity and establish an estimation of postpartum depression 34 . EPDS is a valid 10-questions scale, valuable to identify potential risk of depression following childbirth, and an effective screening tool, demonstrating sensitivity and high reliability. Regarding the scoring of the EDPS questionnaire, the following is done: answers are scored on a scale, from 0 (not at all) to 3 (as much as I ever did). The total score therefore ranges from 0 to 30, with the score of 11 and more: deemed positive for postpartum depression. On the total EPDS score, the threshold value ≥11 is deemed a relevant -It includes as well the "Presumptive Stressful Life Events Scale" (PSLES) to evaluate if there is a number of stressful life events that may have happened to the mother up to 12 months before giving birth to her newborn. This scale is constructed and standardized for two time spaces; last one year and life time. The scale events are divided into 9 categories: family and social, work, financial, marital and sexual, health, bereavement, education, legal, and finally courtship and cohabitation. Each category has a series of events that he mother should respond by a "yes" if the event has occurred during the last year, or/and during her lifetime. The Cronbach alpha value for this scale was excellent (0.967).
-This questionnaire also contains the "Perinatal Anxiety Screening Scale" (PASS), to detect the severity of perinatal anxiety. The PASS is a trustworthy 31-item self-report questionnaire for postpartum and antenatal women to screen for anxiety. It distinguishes between high and low anxiety disorder risk by measuring specific anxiety symptoms. The mother scores these symptoms by indicating their frequency over the last month. The scales range between 0 (not at all), 1 (sometimes), 2 (often) and 3 (always). Scores between 0 and 20 indicate the absence of anxiety symptoms, scores between 21 and 41 indicate mild-to moderate symptoms, whereas scores between 42 and 93 indicate severe symptoms. High and low anxiety disorder risk are separated between the 26 cut-off score.

Forward and back translation
All scales were translated from English to Arabic through an initial translation and back translation process. A mental health specialist translated the English version into Arabic, then another expert translated the Arabic version back into English. Once the process was completed, the comparison of the two English versions showed no significant differences.

Statistical analysis
Statistical analysis was carried out using SPSS software version 23. For continuous quantitative variables, descriptive statistics mainly mean values and standard deviation (SD) were presented, whereas for nominal and ordinal variables frequencies and percentages were used. Using the Shapiro Wilk test, we checked the normality of distribution for all variables. The Student's t-test was conducted to observe differences between the means of two groups, whereas the ANOVA test was used to compare the means of three groups or more. Four stepwise linear regressions were conducted; the first two were conducted, taking the postpartum depression and anxiety scores as dependent variables but without taking them as independent variables in the models, whereas the other two included those variables as independent variables in each model respectively.
Two factor analyzes were launched to confirm the validity of the depression and anxiety questionnaire in the Lebanese population by using the main component analysis technique, with a promax rotation since the extracted factors were found to be significantly associated. The Kaiser-Meyer-Olkin measure of sampling adequacy and Bartlett's test of sphericity were ensured to be adequate. The retained number of factors matched to Eigenvalues higher than one. Moreover, Cronbach's alpha was recorded for reliability analysis for the total score and for subscale factors. Significance was defined as a p-value less than 0.05.

Sociodemographic characteristics of the participants
Out of 350 women approached, 295 (84.28%) of them accepted to participate in this study. The results of the sociodemographic characteristics of the participants are summarized in Table 1. The results showed that the mean age of the mothers at delivery was 29.53 ± 5.18 years, with 75.6% having a university level of education, 50.7% having a monthly income between 1000-2000 USD,

Principal component analysis
Out of all the items of EPDS scale, none of the items was removed. All items could be extracted from the list, since no items over-correlated to each other (r > 0.9), had a low loading on factors (< 0.3) or because of a low communality (< 0.3). The factor analysis for the EPDS and the PASS scales was run over the whole sample (Total n = 295). The EPDS scale items converged over a solution of three factors that had an Eigenvalue over 1, whereas the PASS converged over a total of 7 factors, explaining a total of 64.73% and 65.12% of the variance respectively. A Kaiser-Meyer-Olkin measure of sampling adequacy of 0.816 was found for the EPDS scale and 0.878 for the PASS scale respectively, with a significant Bartlett's test of sphericity (p<0.001). According to the promax rotated matrix, the components are summarized in Table 2. Moreover, high Cronbach's alpha values were found for the EPDS (0.826) and PASS (0.920) scales respectively.

Bivariate analysis associated with postpartum depression
A higher mean depression score was found in mothers who had an illiterate/primary level of education (13.55) compared to all other categories, in those who were delivering the third child or more (12.84), in those who did not know if they were satisfied with the sex of the baby (18.00), in those whose babies wake up more than 5 times at night (14.04) and in those whose babies did not eat regularly compared to those who did (13.47 vs 10.22). Moreover, higher means depression scores were significantly found in mothers whose babies had health problems ( Table 3).

Bivariate analysis associated with postpartum anxiety
A higher mean anxiety score was found in mothers who had an illiterate/primary level of education (34.65) compared to all other categories, in those who delivered via the caesarian method (29.81), in those whose babies were males (29.64 vs 26.01), who were admitted to the NICU (32.63 vs 26.77), who wake up more than 5 times during the night and who did not eat regularly compared to those who did (32.76 vs 26.33). Moreover, higher means anxiety scores were significantly found in mothers whose babies had health problems (35.14 vs 27.05), in those who had complications during pregnancy (31. 36 Table 3).
Higher anxiety (r=0.628) and insomnia (r=0.359) were found to be significantly correlated with higher postpartum depression, whereas higher depression, higher insomnia (r=0.323) and higher number of waterpipes per week (r=0.59) were found to be significantly correlated with higher postpartum anxiety (Table 4).

Multivariable analysis
The results of a first stepwise linear regression, taking the postpartum depression score as the dependent variable and without taking the postpartum anxiety score as an independent variable, showed that higher insomnia (Beta=0.192), the baby having health problems (Beta=3.052) and having a National Social Security Funds (NSSF) insurance type compared to not (Beta=1.563) were significantly associated with higher postpartum depression, whereas having a delivery period less than 14 hours compared to 14 hours (Beta=-2.762), having a mother's secondary level of education compared to an illiterate/primary level (Beta=-3.405) and having a happy married life (Beta=-3.356) were significantly associated with lower postpartum depression ( Table 5, Model 1).
The results of a second stepwise linear regression, taking the postpartum anxiety score as the dependent variable and without taking the postpartum depression score as an independent variable, showed that higher insomnia (Beta=0.278) and the fact that the baby waked up more than 5 times per night compared to 1-2 times (Beta=4.324) were significantly associated with higher postpartum anxiety, whereas having a planned pregnancy compared to not (Beta=-5.081) and the fact that the baby eats regularly compared to not (Beta=-4.738) were significantly associated with lower postpartum anxiety (Table 5, Model 2).
The results of a third stepwise linear regression, taking the postpartum depression score as the dependent variable and taking the postpartum anxiety score as an independent variable, showed that higher postpartum anxiety (Beta=0.25), higher insomnia (Beta=0.11) and having complications during delivery (Beta=1.81) were significantly associated with higher postpartum depression, whereas having a mother's secondary level of education compared to an illiterate/primary level (Beta=-2.69) and having a delivery period less than 14 hours compared to a delivery period of 14 hours (Beta=-1.88) were significantly associated with lower postpartum depression ( The results of a fourth stepwise linear regression, taking the postpartum anxiety score as the dependent variable and taking the postpartum depression score as an independent variable, showed that higher postpartum depression score (Beta=1.38), a premature baby birth compared to those born at term with normal weight (Beta=4.25) and the use of technology help for delivery compared to not (Beta=2.10) were significantly associated with higher postpartum anxiety, whereas having a baby through a planned pregnancy (Beta=-4.66) was significantly associated with lower postpartum anxiety ( Table 5, Model 4).

Discussion
The current study identified the clinical factors associated with postpartum depression and anxiety among a sample of Lebanese women. Postpartum depression is a debilitating health disorder that mandates greater efforts to raise the awareness among pregnant females about its natural occurrence and the counseling strategies that can be employed to cope with this situation. In this study, several factors both related to the mother and the child contributed to postpartum depression. Specifically, if the mother was illiterate, had delivered more than 3 babies, had complications both during pregnancy and post-partum, encountered hypotension, anemia, or abortion had higher depression scores. Even factors related to the child as wakening more than 5 times per night, did not consume food regularly compared to normal neonate feeding habits, or had health problems all had a risk to have higher depression score. As for anxiety, there were some factors which were related in depression as well increase the score of anxiety as being illiterate, had complications both during pregnancy, encountered hypotension, and had unhappy marriage. Even factors related to the child as wakening more than 5 times per night, did not consume food regularly compared to normal neonate feeding habits, or had health problems all had a risk to have higher anxiety score in the post-partum period.

Validation of both scales
In our study, the EPDS scale items converged over a three-factors solution outlining a total of 64.73% As for the PASS scale items, in our study it joined over a total of 7 factors, explaining a total of 65.12% of the variance, and leading to an internal consistency of alpha Cronbach alpha = 0.920.
These findings are different from those with the original developers (four factors) but similar in terms of internal consistency (Cronbach alpha = 0.96) 35 . The validation of this scale in Turkey 30 revealed that the Cronbach's Alpha value for the scale is = 0.95, and the sub-dimensions obtained by explanatory factor analysis are: (1) general anxiety and specific fear, (2) perfectionism and control, (3) social anxiety and adjustment disorder, (4) acute anxiety and trauma. This test was also validated in Bangladesh 29 and the exploratory factor analysis showed 4 factor solution of the Bangla PASS (1. Acute anxiety 2. General worry and specific fears 3. Perfectionism control and trauma 4. Social anxiety); whereas the temporal stability and internal consistency was also satisfactory (Cronbach's Alpha .970). The Australian validation in its turn, suggested a four-factor structure addressing symptoms of (1) acute anxiety and adjustment, (2) general worry and specific fears, (3) perfectionism, control and trauma and (4) social anxiety, with an excellent reliability (Cronbach's α = 0.96) 35 . As seen above, alpha Cronbach values show a very small variation between different countries, which means that these populations share very close anxiety and depression postpartum symptoms.

Factors associated with depression
This study revealed that the rate of depression and anxiety in the post-partum Lebanese population was 61.8% and 67.7% respectively where this finding is higher than a study done by Pan-Yen Lin, et al and meta-analysis which stated that the occurrence of depression was 5.1% at the fourth week of postpartum and 5.7% at 2 months postpartum 36,37 . In addition, it has been reported that the prevalence of post-partum depression affects about 10-15% of adult mothers annually with depressive symptoms lasting more than 6 months 38 . The rate of depression in this study is similar to another study conducted by Halbreich et al. that reported around 60% prevalence rate of depression 39 .
In this study, the factors that were associated with post-partum depression are higher post-partum anxiety, insomnia, and complications development during pregnancy. In this study insomnia was highly associated with the development of post-partum depression since sleep deprivation might be a trigger factor for the onset of certain psychological problems encountered post-delivery as the onset of mania and unbalanced sleep pattern is more prevalent in new mothers 40 . Maintenance of balanced sleeping hours aids in the relaxation and minimizes the risk of depression. In this study, secondary level of education compared to illiterate was associated with lower PPD that could be potentially explained by the increased levels of maturity, greater exposure to certain life experiences, and to more education that enables mothers to deal with the emotions allied with motherhood more than less educated females 41 .
Additional research is required to elucidate the relation between the level of education and postpartum depression as the results from studies are contradictory since some studies reported no association between the level of education and PPD and others noted that education is a predictor of PPD 42,43 .
Our study found that complications during delivery is strongly associated with PPD which can be explained by the emergence of physical and mental troubles encountered by the mother due to the fear from the consequences of complications development, where this outcome is consistent with the outcomes of other studies 17,44 . Our study found that delivery periods of less than 14 hours had a more protective effect compared to duration more than 14 hours which can be demonstrated by the pain associated with giving birth that increases the risk of PPD development as the duration of labor is prolonged.

Factors associated with anxiety
As for anxiety prevalence, the range was reported to be from 13 to 40% which is lower than the findings in this study 45 . This wide variation in the anxiety prevalence rates is highly reliant on the type of anxiety assessment, the scale depicted in the assessment, the cut-off score for anxiety, the severity of anxiety, the timing and the frequency of the assessment, and the country of origin 45,46 .
In this study, the high rates of anxiety in the post-partum period may relate to the fact that the anxiety scale scores were based on interviews where denying symptoms may be hindered through face-to-face contact.
The factors associated with postpartum anxiety in this study include higher postpartum depression, premature birth and the use of technology during delivery. The results of this study supporting the relation between preterm infants and post-partum anxiety is encountered in previous studies concluding that in preterm infant mothers, the risk of anxiety was 2.7 times higher than in full-term infant mothers 33,47 .
A multitude of studies have observed the combined relationship between symptoms of anxiety and PPD, which is consistent with the findings in this study 48 . Onset of anxiety can range from few days to few weeks after delivery and usually peaks in the first 2-3 months following childbirth. Postpartum anxiety appears mainly in mothers who have the fear from cot death. One plausible explanation that might elaborate on the reason why this accumulation of fear over time leads to postpartum anxiety is that: nocturnal vigilance deprives mothers from the normal sleeping pattern, since this causes them to remain awake listening to the breathing of the infant. Therefore, the irregular sleeping pattern and anxiety (through constant worrying) seem to be related. This recurrent checking for the safety and health of their children predisposes to anxiety and depression 49,50 .
In our study, anxiety was associated with planned pregnancy and an indifferent attitude to pregnancy. An unwanted pregnancy may significantly change life, be a stressful experience with different impacts on quality of life and may trigger certain psychological problems as anxiety 51 . In our study, the delivery of premature baby is associated with PPA which concluded the same in other studies 52,53 . The underlying reasons for this relation can be depicted by the isolation that the parents are exposed to after the delivery of premature babies that mandate hospitalization due to the difficulty in discharging premature infants without being admitted to neonatal intensive care units. During hospital admission to premature babies, mothers often experience negative thoughts and ideas and contradictory emotional reactions that is usually diagnosed as grief, sorrow, guilt, fear, anger, loss of self-esteem, and sense of failure 57 . This situation and feelings predispose mothers to anxiety.

Limitations
There are some limitations to this study. Prevalence rates of perinatal depression were assessed in this study using self-reported instruments such as EPDS, which is not considered solid evidence in the clinical depression diagnosis and typically overestimate incidence rates 58,59 . The EPDS is a screening test requiring further diagnostic confirmation through a structured or semi-structured interview.
Consequently, accurate conclusions cannot be drawn. The utilization of a comprehensive tool as Patient Health Questionnaire that aids in screening, diagnosing, monitoring, and measuring the intensity of depression is a more useful instrument. In addition, there might an information bias where participants might either over-or underestimate their symptoms. Also, a selection bias might be present since the sample was taken from doctor's clinics and is not representative of the whole population.

Clinical Implications
This highly prevalent problem of postpartum depression and anxiety among Lebanese women has several risk factors. An interplay of these factors is likely to play a role in causing postpartum depression and anxiety. Taking care of these highly modifiable risk factors can prevent PPD and PPA development. Thus, early recognition of risk factors for PPD/ PPA may aid clinicians in early intervention and management. A collaborative-care approach (for example, a mental-health professional and an obstetrician collaboration) would be appropriate to identify high-risk mothers for PPD and PPA development. Resolving marital and family conflicts before conception, helping the mothers to draw a support plan, having realistic expectations of birth and parenting, addressing issues of self-esteem and encouraging them to quit smoking and waterpipe might be some of the ways to prevent postpartum disorders. We also recommend that a psychiatrist and a psychologist attend a postnatal care unit to advise mothers at risk of developing PPD or PPA as well as other psychiatric disorders.

Conclusion
Depression and anxiety prevalence rates in the Lebanese population is higher compared to other countries which may in part be due to differences of regional, social, and environmental culture. It is worth concluding that great importance from healthcare professionals should be implemented to raise the awareness about PPD and create health promotion program to increase the well-being of delivery women. Different etiological factors could contribute to both depression and anxiety in the postpartum period, which could adversely affect both the mother and the infant. Preventive techniques should be employed early before delivery and even continued post-delivery to aid mothers on the most effective ways on how to cope with the situations and feelings experienced in this period.

Ethics Approval and Consent to Participate
The study protocol has been approved by the Holy Spirit University ethics committee. A written informed consent was acquired from each mother prior to entering the study.

Consent for publication
Not applicable.

Availability of data and materials
All data generated or analyzed during this study are not publicly available to maintain the privacy of the individuals' identities. The dataset supporting the conclusions is available upon request to the corresponding author.

Competing interests
The authors have nothing to disclose.

Funding
None.

Author contributions
EH, MO, ZS, HB, EH, DM and NK were responsible for the data collection and entry. SH designed the study; EH, MO and DM and drafted the manuscript; SH carried out the analysis and interpreted the results; SO and PS assisted in drafting and reviewing the manuscript; All authors reviewed the final manuscript and gave their consent; SH was the project supervisors.   Cronbach alpha for the EPDS scale= 0.826 and the PASS scale=0.920. Table 3. Bivariate analysis of categorical variables associated with postpartum depression and anxiety among the participan