Poor social support as a risk factor for antenatal depressive symptoms among women attending public antennal clinics in Penang, Malaysia

Pregnant women with poor social support are at higher risk for depression but despite the association with many health related events to both mother and child, antenatal depression is less studied compared to post-natal depression. An extensive literature search failed to show any published study conducted in Malaysia on antenatal depression and the risk of poor social support on it probably because like in other Asian cultures, social support is typically high in Malaysia. Pregnancy is generally considered an opportunity to expand the family lineage, so expecting mothers generally receive good physical, emotional and social support from family and friends.

Malaysia is undergoing extensive rural to urban migration with most young people moving to cities for better employment opportunities. As a result of this migration, there is a transformation from extended to nuclear family household system resulting in most expecting mothers to lose the traditional social support system and inadvertently losing the proven mechanism in easing, obtaining and maintaining psychological changes and preventing depressive symptoms during pregnancy.

This study was conducted among 3000 pregnant women who attended antenatal clinics in Penang, Malaysia to determine the risk of antenatal depressive symptoms due to poor social support. One in five participants had depressive symptoms and poor social support was significantly associated with depressive symptoms.

Depression, a type of mental disorder which is portrayed by marked alterations in mood, is associated with distress and/or impaired functioning [1]. Depression is projected to be the second leading cause of disability worldwide by 2020 and the fourth leading contributor to the global burden of disease [2]. Depression can range from mild, moderate to severe depression [3]. People with depression utilize more health care services, become a burden to caregivers, have decreased quality of life and are at risk for suicide [4].

Depression is more prevalent in women [5] and it has been reported that depression is the leading cause of disability adjusted life years for women globally [2]. Due to hormonal changes, women of child bearing age, particularly pregnant women, are at higher risk for depression [6‐8]. Prevalence of antenatal depression has been reported as high as 20% [9, 10]. The prevalence rates reported for antenatal depression could be an underestimate considering that depressed women are less likely to participate in research due to fear, denial and stigma related to mental illness and probably because symptoms of depression could be mistaken for changes which normally occur during pregnancy, resulting in many women not seeking mental health services [11, 12]. Despite the high prevalence and high relapse rates reported for antenatal depression, less is known concerning factors affecting antenatal depression compared to post-natal depression [10, 13, 14].

Antenatal depression has been shown to have long lasting detrimental effect, not only on expecting mothers but also on their children and family [10, 15‐17]. Although increased risks to adverse obstetrics outcome is controversial [18] some studies have shown an association of depression during pregnancy with poor attendance to antenatal clinics, intra uterine growth retardation, low birth weight, preterm delivery and failure to thrive in infants [9, 19‐22] Women with antenatal depression are also at higher risk of preeclampsia and birth difficulties [9]. Depression during pregnancy has been linked to risk taking behaviours and unhealthy lifestyle habits including poor dietary habits leading to poor nutrition, smoking and illicit substance abuse [11, 23, 24]. Depression during pregnancy has been shown to be a predicator for postpartum depression [9, 13, 25] and can be a risk factor for depression during subsequent pregnancy’s [22, 26].

The risk factors for antenatal depression include genetic, environmental, psychological, biological and lack of social support [10, 27, 28]. Social support is important during the emotional and physical changes that occur in pregnancy [25, 29, 30] and it has been shown to be an important protective factor against depression. Lack of social support is an important risk factor for depression in pregnancy [13, 23]. Social support may be emotional or practical support which may be objective i.e. what is actually received or subjective i.e. what is perceived to have been received from partners, spouses, family members, friends, co-workers and neighbours etc. [31‐33]. In this study social support is defined as the perceived support received from family members, husband/partner and friends. It is postulated that there is a correlation between perceived social support and monoamine activity in the brain [34‐36].

In many Asian cultures including Malaysia, the perinatal period is valued because it is an opportunity to expand the family lineage and in general expecting mothers receive good physical, emotional and social support from family and friends [37]. However, Malaysia is undergoing extensive rural to urban migration with most young people moving to cities for better employment opportunities. As a result of this migration, there is a transformation from extended to nuclear family household system [38] resulting in most expecting mothers to lose the traditional social support system which usually comes from family members and inadvertently lose the proven mechanism in easing, obtaining and maintaining psychological changes during pregnancy and preventing depression in pregnant women [39].

Despite the association with many health related events to both the mother and child, antenatal depression is less studied compared to post-natal depression [12]. Early identification of antenatal depression provides the opportunity for the provision of best health care possible for both the mother and fetus in the primary health care setting [12, 14, 40]. Social support can be used to help identify women at higher risk of depression [30]. An extensive literature search failed to show any published study conducted in Malaysia on antenatal depressive symptoms and the risk of poor social support on it. Although research on antenatal depressive symptoms has been studied in other countries especially in the west, cultural differences may affect prevalence and associated risk factors [11, 22]. Complementing this literature with research from other contexts, such as Malaysia, is critical to ensuring the results are generalizable and reflect contextual differences. Although in general, social support is high in Malaysia especially during pregnancy but changing social structures in the country may cause a change in the social support level and may inadvertently affect depression in pregnancy. Because of these reasons the objective of this study was to determine the prevalence of antenatal depressive symptoms and the association of social support on antenatal depressive symptoms.

Out of the 3270 patients approached in the health clinics, 3000 agreed to participate and were screened using EPDS. A total of 600 (20%) pregnant women had depressive symptoms.

Table 1 shows the demographic profile of the participants. The age of the participants ranged from 16 to 50 years old with a mean age of 29. Most (85.7%) of the participants were in the less than 35 years old age group. Majority were Malays (76.5%) followed by Chinese (12.1%), Indians (9.7%) and of the other races (1.7%). Most were employed full time (62.9%) followed by those unemployed (35.5%) and living with partners (68.8%).

Concerning the social support variables, most of the husbands/partners in this study were very supportive (66.6%) or supportive (31.5%) of the pregnancy and only 2% of them were not, less or fairly supportive. Overwhelmingly the families of the participants were supportive of the pregnancy (97.4%). Using the OSS-3 scale to gauge social support most of the participants had moderate support (61.3%) followed by poor support (22%) and strong support (16.7%).

Table 2 shows the risk of depressive symptoms associated with the variables which were studied. Participants whose husbands/partners are ‘not, less and fairly supportive’ (OR 1.9 95% CI 1.1;3.5) and husbands/partners who are ‘supportive’ (OR 1.4 95% CI 1.2;1.7) are at higher odds of having depressive symptoms compared to participants whose husbands/partners are ‘very supportive’. Differences in age, race, religion, occupation and living arrangement were not statistically significant. Participants with poor social support, gauged using OSS-3, had about twofold higher odds of having depressive symptoms compared to participants with moderate and strong support (OR 2.1 95% CI 1.8;2.7).

As shown in Table 3, a binary logistic regression was conducted using social support variables, the model had an overall correct predicted percentage of 80.0% and Nagelkerke R square 0.031. There is a twofold higher odds of having depressive symptoms among those with poor social support..

Considering that an expecting mother’s psychological factors are important in the wellbeing of the mother and child [11, 15‐17, 19‐24, 27, 62], it is imperative that antenatal depressive symptoms are quickly identified. Poor social support can be a trigger to screen for depressive symptoms in pregnancy [12]. Screening pregnant women for social support can help identify women with higher risk of depressive symptoms [30, 63]. Because of the high cost associated with clinician interviews, some researchers have suggested using screening tools to identify depressive symptoms [13, 64]). All pregnant women attending the maternal and child health clinics should be screened for antenatal depressive symptoms by the nursing staff using the validated translated version of the EPDS. This screening can be followed with a more structured depression scale for women screened positive for the first screen [26].