Postpartum depression among Pakistani women in Norway ...

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Abstract. Objective. To assess the prevalence of and risk factors for postpartum depression among Pakistani women in Norway. Methods. A total of 207 pregnant ...
The Journal of Maternal-Fetal and Neonatal Medicine, December 2008; 21(12): 889–894

Postpartum depression among Pakistani women in Norway: Prevalence and risk factors


Medical Faculty, Department of Obstetrics and Gynecology, University of Oslo, Rikshospitalet University Clinic, Oslo, Norway, 2National Resource Centre for Womens’s Health, Rikshospitalet, Oslo, Norway, 3Norwegian Institute of Public Health, Oslo, Norway, and 4Physicians/Medical doctors Ytterdahl, Lillesand, Norway (Received 13 May 2008; revised 7 June 2008; accepted 3 July 2008)

Abstract Objective. To assess the prevalence of and risk factors for postpartum depression among Pakistani women in Norway. Methods. A total of 207 pregnant Pakistani women living in Norway participated in a questionnaire study. The author interviewed the women face to face during pregnancy and 6 to 12 weeks after delivery. The Edinburgh postnatal depression scale was used to identify the risk cases. Results. Only 7.6% of the immigrant Pakistani women were depressed postpartum. High scores on the life event scale, a history of prior depression, single marital status, a poor relationship to one’s partner and an age of 30 years or more were found to be significant risk factors for postpartum depression. Conclusions. The prevalence of postpartum depression among immigrant Pakistani women seems to be low compared with the prevalence reported in immigrant populations elsewhere, it was however only slightly lower than the study of ethnic Norwegians (8.9%). The risk factors were similar to results from international reports; moreover, there were few cultural differences in risk factors between ethnic Norwegian and Pakistani immigrants.

Keywords: Pakistani immigrant women, Norway, Edinburgh postnatal depression scale

Introduction Mental diseases are frequent and among the most common complications associated with women’s pregnancies and childbirth [1]. Unipolar depression is the most common type, but bipolar affected illness, obsessional disorders and anxiety may also occur and represent a considerable health problem that affects not only the women but also their children and family [1,2]. Postpartum depression is a significant public health problem with a prevalence varying from 4.5 to 28% [3–7], with cultural differences in frequencies and risk factors [8,9]. An international study that explored levels of postpartum depression in nine countries representing five continents showed that European and Australian women had the lowest levels, US women had intermediate, whereas women from Asia and South America had the highest levels of depressive symptoms [10].

Young age [11,12], being single [13], high parity [8], low education and illiteracy [11,12], unemployment [11,12], financial difficulties and low social class have been reported as risk factors [11,12]. Being an immigrant was also an important factor [8,9]. Before 1970, Norway’s population was primarily homogeneous. Thereafter, there has been a considerable influx of immigrants, particularly from Asia and Africa. Today people who originate from Pakistan constitute the largest immigrant group in Norway and representing about 8% of the non-western immigrant population. The majority live in Oslo. The first Pakistani men came as economic immigrants 30 years ago. Most women came for marriage, and most were cousins or relatives of their husbands. Even after many years in Norway, many of them still do not speak Norwegian. The Pakistani immigrants represent a minority group with a very different culture compared with

Correspondence: Soen Eng Yap Bjerke, MD, Trivind Health Center, 3540 Nesbyen, Norway. Fax: þ47 32070253. E-mail: [email protected] ISSN 1476-7058 print/ISSN 1476-4954 online Ó 2008 Informa Healthcare USA, Inc. DOI: 10.1080/14767050802320340


S. E. Y. Bjerke et al.

Norwegians, and they may feel very alienated from their Norwegian counterparts. In addition, rates of prenatal and postnatal depression in Pakistan was reported as high (28%) [6].Thus, we might expect an even higher prevalence of depression in this group than in the ethnic Norwegian group. There are very few studies of health problems among the immigrant populations in Norway, and as far as we know, none on postpartum depression. The objective of the current study was to identify the prevalence and elucidate the risk factors for postpartum depression among Pakistani immigrant women in Norway. Material and methods The study is linked to The Norwegian Mother and Child Cohort Study (MoBa study) [14]. This is an ongoing prospective longitudinal study, which aims to include 100,000 pregnant women and their partners, and is Norway’s largest investment in researching causes of diseases and health problems of mothers and children. Knowledge about environmental toxins, infections, dietary factors, labor-strain, hereditary factors and other factors responsible for impaired health is required. The MoBa study is primarily a questionnaire study in Norwegian and has not been translated to other languages. The immigrants are not participants in the MoBa study. The objective of our study was to look at the immigrants and we selected the largest immigrant group in Norway, the Pakistani. We contacted the two maternity hospitals in Oslo: Rikshospitalet and Ulleva˚l University Hospitals, where the pregnant women underwent their ultrasound screening at 17–18 weeks of gestation. In addition, the public health centers in two regions in Oslo (Grunerløkka and Grønland), where most of Pakistani women had their prenatal and postnatal check-ups, were contacted. A total of 208 Pakistani women were invited to participate in the study. 207 women were included after they had given their personal consent and signatures. All women were living in Oslo or one of the suburbs. The first author (Bjerke YSE) interviewed the women in person during a period of 2 years, once during pregnancy and a second time postpartum. The questionnaire used within 3 months after birth, was a structured questionnaire [15] which included the Edinburgh postnatal depression scale (EPDS) [16]. Ten women were not interviewed postpartum, including one woman who suffered from a late miscarriage, two women with stillbirths, and one whose baby died a few days after delivery. Three

women had moved to Pakistan, one woman refused to be interviewed after birth, another had moved to an unknown address and one woman had been killed. This left a total of 197 women interviewed at the two points in time. Almost half of the participants (91 women) did speak Norwegian. For the remaining, professional interpreter and/or family members were used as interpreters. Variables A structured questionnaire was used and the following information was collected [15]. Demographic and socio-economic factors. Age, marital/ cohabitation status, family structure, employment status, educational level, social class. Reproductive factors and history. Mean age of menstrual debut and premenstrual complaints, the number of children, previous miscarriages, previous induced abortions, stillbirths and pregnancy complications such as hyperemesis gravidarum, pelvic pain, pregnancy experience, length of time to become pregnant without contraception, mode and length of delivery, person(s) present at delivery, anxiety and mood during labour, contentment with hospital stay, breastfeeding, the sex and health of the baby. Somatic diseases. Incidence during the previous year, information obtained by answering the following checklist: asthma, hay fever/allergy, high-blood pressure, cardiovascular disease, diabetes, thyroid disease, gynecological disease, muscular/skeletal/ articular disease, migraine/headache, cancer or other somatic diseases not listed above. Psychiatric history. History of hereditary depression, previous depression. Interpersonal relationship. The participant has persons outside the family that she can confide in that, helps her with housework, or care for the family. The coding is ‘yes’ or ‘no’. Attachment to partner was asked for and coded as ‘closely attached to partner’, ‘partly’ or ‘not attached at all’. Life events. Major life events during the last 12 months. The life events included 10 different items: (1) separation or divorce; (2) serious problems in marriage or cohabitation; (3) problems or conflict with family, friends or neighbors; (4) problems at work or in place of education; (5) economic problems; (6) serious illness or injury; (7) serious illness or injury within the nuclear family/among close

Postpartum depression in an immigrant minority


were dichotomised in the statistical analyses as high score (10) or low score (510) [15].

family members; (8) traffic accident, fire or theft; (9) loss of a closely related person; and (10) other difficulties. The answers were graded according to the woman’s reaction to the event: not so difficult/ difficult/very difficult, and the sum of scores from each item (graded according to severity on a scale of 1–3) was used as a negative life event indicator (coded: ‘0 points’, ‘1–5 points’, or ‘45 points’). The women with 0 points reported no major events.

Statistical analyses All data were registered in SPSS. Descriptive statistics (including means, standard deviations, frequencies and percentage) were calculated for the demographic variables. Crude odds ratios for being depressed (EPDS 10) with 95% confidence intervals were estimated by logistic regression analyses.

Outcome variables. Measures of mental health. EPDS was included in the questionnaire. The EPDS is a 10-item self-rating scale designed to identify postnatal depression that is translated to many languages, and is recommended and widespread in primary care [16]. EPDS items concern matters such as having been able to laugh, having looked forward with enjoyment to things, having blamed oneself unnecessarily, having been anxious or worried for no good reason, having felt scared or panicky for no good reason, experiencing overload, having been so unhappy that it has caused sleeping problems, having felt miserable or sad, having been so unhappy as to have cried, thoughts of harming oneself. Each EPDS item is scored 0–3 and the maximum total score is 30. The EPDS has been translated into Norwegian and validated [3,17]. The EPDS scores

Results A total of 197 Pakistani women completed the study; 15 suffered were depressed postpartum according to Table I (EPDS score 10). The prevalence of depression among Pakistani women was 7.6%. The average age was 28.0 years (range 19–43 years; SD 5.0 years). The majority (97%) were married and more than one-third lived in extended families, 70% (138) had more than one child. None of the Pakistani women had an education at the university level, 54 (27%) had 9 years of schooling, whereas 67 (34%) had a high school level, and one was illiterate. Most of the women (69%) were unemployed (Table I).

Table I. Relative risk of postpartum depression expressed as odds ratios with a 95% confidence interval according to demographic and socioeconomic factors among 197 Pakistani women. EPDS  10 Risk factor

Yes, N (%)

No, N (%)

Total N

Crude odds-ratio (95% CI)

15 (7.6)

182 (92.4)


Age of the woman 530 years 430 years

4 (3) 11 (14)

114 (97) 68 (86)

118 79

1 4.6 (1.4–15.0)*

Marital status Married Single

12 (6) 3 (60)

180 (94) 2 (40)

192 5

1 22.5 (3.4–147.8)*

Family structure Nuclear Extended

9 (7) 6 (9)

121 (93) 61 (91)

130 67

1 1.3 (0.5–3.9)

Unemployment No Yes

2 (3) 13 (10)

59 (97) 123 (90)

61 136

1 3.1 (0.7–14.3)

(94) (90) (0) (93)

54 67 0 76

0.8 (0.2–3.7) 1.7 (0.5–5.5) 0 1

125 (91) 57 (97)

138 59

1 3.0 (0.6–13.6)

Educational level 9 years of school High school level University level Others Number of children 41 child 1 child *Statistical significance.

3 7 0 5

(6) (10) (0) (7)

13 (9) 2 (3)

51 60 0 71


S. E. Y. Bjerke et al.

Risk factors for postpartum depression The different risk factors and their significance are given in Tables I and II. Advanced age was one risk factor: 14% of the 79 women over 30 years old suffered from postpartum depression. This was significantly different from the 3% depression rate observed in 118 women under 30 years (OR 4.6, 95% CI 1.4–15.0). Among the five (3%) mothers who for different reasons were single, three women were depressed after delivery (OR 22.5, 95% CI 3.4–147.8). Considering the women with prior depression, six out of 10 (60%) suffered from a new incidence of depression in the postpartum period (OR 29.7, 95% CI 7.1–124.1).

Of the 12 women who did not show a close attachment to their partners, four (33%) suffered from postpartum depression (OR 8.6, 95% CI 2.2– 33.5). Out of the total 197 women, 26 (15%) women scored high on the life-event scale. Of these, 13 (50%) suffered from postpartum depression with high OR (84.5, 95% CI 17.2–415.2). In fact 13 of the 15 (87%) of those experiencing postpartum depression had previously had a distressing life event. Discussion The prevalence of postpartum depression (EPDS score 10) among Pakistani women in Norway was lower (7.6%) than that reported elsewhere in the

Table II. Relative risk of postpartum depression expressed as odds ratio with a 95% confidence interval according to sociological and biological factors among 197 Pakistani women. EPDS  10 Risk factor

Yes, N (%)

No, N (%)


Crude odds-ratio (95%CI)

15 (7.6)

182 (92.4)


Premenstrual tension No Slight Noticeable – annoying

2 (3) 11 (10) 2 (11)

66 (97) 99 (90) 17 (89)

68 110 19

1 3.7 (0.8–17.1) 3.9 (0.5–29.6)

History of spontaneous abortion No Yes

11 (7) 4 (12)

153 (93) 29 (88)

164 33

1 1.9 (0.6–6.4)

History of stillbirth No Yes

13 (7) 2 (25)

176 (93) 6 (75)

189 8

1 4.5 (0.8–24.6)

9 (6) 2 (12) 4 (16)

146 (94) 15 (88) 21 (84)

155 17 25

1 2.2 (0.4–11) 3.1 (0.9–11)

Breastfeeding No Yes

2 (25) 13 (7)

6 (75) 176 (93)

8 189

1 0.2 (0.4–12)

Somatic diseases No Yes

14 (9) 1 (3)

145 (91) 37 (97)

159 38

1 0.3 (0.0–2.2)

178 (95) 4 (40)

187 10

1 29.7 (7.1–124.1)*

174 8 172 8 3

(93) (80) (94) (67)

187 10 182 12

1 0.3 (0.6–1.6) 1 8.6 (2.2–33.5)*

169 (99) 13 (50)

171 26

1 84.5 (17.2–415.2)*

Mode of last delivery Vaginal delivery without complications Vaginal delivery with strain Operative delivery

Prior depression No Yes Interpersonal relationship Yes No Closely attached to partner Partly or not attached to partner No partner Life events 0 point More than one point *Statistical significance.

9 (5) 6 (60) 13 2 10 4

(7) (20) (6) (33)

2 (1) 13 (50)

Postpartum depression in an immigrant minority world (9–15%) [3–6]. However, in a recent study of ethnic Norwegians, the prevalence of postpartum depression was only slightly higher (8.9%) than in our study [15]. The interview was performed in Norwegian, not in ‘Urdu’, the original Pakistani language. 91 women did speak Norwegian. For the remaining, professional interpreter and family members were used as interpreters. The presence of family members during the interview might have led to underreporting of depressive symptoms [16]. In 71% of the cases, the husbands were present at the interview. However, we analyzed the results of those ‘to be alone’ and those ‘who had their husbands with them’ and found no significant difference in prevalence of depressive symptoms. Kirmayer showed that disturbances in mood, affect and anxiety are not viewed as mental health problems in many cultures, but rather of a social or moral nature [18]. It is possible that immigrant Pakistani women did not perceive depression as a mental problem. However, in different studies from Pakistan the depression in connection with pregnancy and delivery reached 28% [6]. We found four different significant risk factors for postpartum depression in the Pakistani immigrants (Tables I and II). The most important was a high score on the life event (OR 84.5), the second was a history of prior depression (OR 29.7), thereafter being single (OR 22.5), followed by an age over 30 years (OR 4.6). Many previous studies have shown risk factors for postpartum depression similar to those we have revealed in this study. In the ethnic Norwegian study, the risk factors demonstrated were primiparous, not having breastfed, prior depression, poor attachment to partner and high stress of life-event [15]. Pakistani women in Norway had some of the risk factors to ethnic Norwegian: prior depression, poor attachment to partner and high stress of life-event. Rachman found that poor women in Pakistan had more psychological symptoms during pregnancies and they remained depressed 1 year after giving birth [19]. Current somatic illness [3,4,9], and life stress have been reported to be important risk factors for postpartum depression [6,15,20,21].This is in accordance with our results, which showed that a high score on life events was strongly associated with postpartum depression. Almost everyone, 13 out of 15 with postpartum depression had previously suffered from a traumatic life event. Previous psychiatric illness [3,12,20,21], depression during pregnancy were reported as risk factors for postpartum depression [21,22]. Six (60%) of 10 women in our study had prior depression, and they suffered of postpartum depression.


Being single was also reported as risk factor [13]. From a traditional and cultural standpoint, simultaneously being single and a mother has been considered a shame in Asia. We confirmed the association between being a single mother and postpartum depression, even if there were only a few women (three of five) in our study in this category. This is in contrast to Norwegian women where being a single mother no longer seems to be a burden [15]. In a British study, Pakistani mothers living in extended families were more depressed and anxious than those in nuclear families [23]. Social isolation and poor relationships with their spouses and the spouse’s parents have been shown to be risk factors for postpartum depression [4,8,24,25]. Perhaps Pakistani women in Norway did not feel socially isolated, because one-third lived in extended families and none of these reported depression. However, poor attachment to the partner was the risk factor in our study and ethnic Norwegian study [15]. However, because the majority of husbands were present at the interview, the reliability of our data in this respect is questionable. In previous studies, the risk of postpartum depression was mainly related to socio-economic and family variables [4]: High parity [8,21], the gender of the child (female) [4], low education [11,12], being a housewife [11,12], being an immigrant [8,9]. These factors did not show an association to postpartum depression among Pakistani women in our study. Integration is a question of equal rights in society, which is a central part of Norwegian immigration policy. In 1997, the Norwegian government declared that immigrants should have the same rights to health care as the rest of the population (ministry of Local Government and Labour 1997) [26]. Integration is also a question of equity in health outcomes. This may explain that in Norway being an immigrant or belonging to different socio-economic groups do not give different health outcomes compared with ethnic Norwegians and Pakistani women in the rural districts of Pakistan [15,19]. Previous reproductive failure or problems such as stillbirth have been related to depression and anxiety in the next pregnancy and puerperium [27]. Among our Pakistani women, two suffered from stillbirth in the current pregnancy, but they were excluded from the postpartum questionnaire. When considering a history of previous stillbirths, eight women (4%) had experienced these events, 25% of these women were depressed. However, the results were not significant, because our study was not large enough to study such rare events. Women who experience stress during childbirth [20], or emergency delivery have been shown to have


S. E. Y. Bjerke et al.

an incidence of twice the risk of developing postpartum depression [28]. We had 42 women (21%) in this category, but only six (14%) suffered from postpartum depression and we thus did not confirm this risk factor. Breastfeeding did not influence postpartum depression in our study. This is in contrast to the study by Alder where mothers who exclusively breastfed their babies for at least 12 weeks, or who were taking contraceptives, had a higher incidence of postpartum depression than those who were not ‘on the pill’ or who partially breastfed [29]. Postpartum depression has been shown to have a significant negative impact on breastfeeding duration in other studies [30]. In conclusion, being a Pakistani immigrant in Norway does not seem to result in a higher risk of postpartum depression. On the contrary, the prevalence is lower than in most studies. Acknowledgements The authors thank the women who participated in the study, the midwives and assistants in the prenatal clinic who facilitated the data collection. The study was supported by Norwegian Women’s Public Health Association. References 1. Brockington IF. Postpartum psychiatric disorders. Lancet 2004;363:303–310. 2. Sinclair D, Murray L. Effects of postnatal depression on children’s adjustment to school. Teacher’s reports. Br J Psychiatry 1998;172:58–63. 3. Berle JO, Aarre TF, Mykletun A, Dahl AA, Holsten F. Screening for postnatal depression. Validation of the Norwegian version of the Edinburgh Postnatal Depression Scale, and assessment of risk factors for postnatal depression. J Affect Disord 2003;76:151–156. 4. Chandran M, Tharyan P, Muliyil J, Abraham S. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India. Incidence and risk factors. Br J Psychiatry 2002;181:499–504. 5. Josefsson A, Berg G, Nordin C, Sydsjo G. Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 2001;80:251–255. 6. Rahman A, Iqbal Z, Harrington R. Life events, social support and depression in childbirth: perspectives from a rural community in the developing world. Psychol Med 2003;33: 1161–1167. 7. Dørheim Ho-Yen S, Tschudi Bondevik G, Eberhard-Gran M, Bjorvatn B. The prevalence of depressive symptoms in the postnatal period in Lalitpur district, Nepal. Acta Obstetrica et Gynecologica Scandinavica 2006;85:1186–1192. 8. Danaci AE, Dine G, Deveci A, Sen FS, Icelli I. Postnatal depression in Turkey: epidemiological and cultural aspects. Soc Psychiatry Psychiatr Epidemiol 2002;37:125–129. 9. Small R, Lumley J, Yelland J. Cross-cultural experiences of maternal depression: Associations and contributing factors for Vietnamese, Turkish and Filipino immigrant women in Victoria, Australia. Ethn Health 2003;8:189–206.

10. Affonso DD, De AK, Horowitwz JA, Mayberry LJ. An international study exploring levels of postpartum depressive symptomatology. J Psychosom Res 2000;49:207–216. 11. Inandi T, Elci OC, Ozturk A, Egri M, Polat A, Sahin TK. Risk factors for depression in postnatal first year, in eastern Turkey. Int J Epidemiol 2002;31:1201–1207. 12. Irfan N, Badar A. Determinants and pattern of postpartum psychological disorders in Hazara division of Pakistan. J Ayub Med Coll Abbottabad 2003;15:19–23. 13. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry 1987;150:662–673. 14. Magnus P, Irgens LM, Haug K, Nystad W, Skjaerven R, Stoltenberg C, MoB study group. The Norwegian mother and child cohort study (MoBa). Int J Epidemiol 2006;35: 1146–1150. 15. Eberhard-Gran M, Eskild A, Tambs K, Samuelsen SO, Opjordsmoen S. Depression in postpartum and nonpostpartum women: Prevalence and risk factors. Acta Psychiatr Scand 2002;106:426–433. 16. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry 1987;150:782–786. 17. Eberhard-Gran M, Eskild A, Tambs K, Schei B, Opjordsmoen S. The Edinburgh postnatal depression scale: Validation in a Norwegian community sample. Nord J Psychiatry 2001;55:113–117. 18. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. J Clin Psychiatry 2001;62:22–28. 19. Rachman A, Creed F. Outcome of prenatal depression and risk factors as persistence in the first postnatal year: Prospective Rawalpindi, Pakistan. J Affect Disorders 2007; 100:115–121. 20. Watson JP, Elliot SA, Rugg AJ, Brough DI. Psychiatric disorder in pregnancy and the first postnatal year. Br J psychiatry 1984;144:453–462. 21. Dørheim Ho-Yen S, Tschudi Bondevik G, Eberhard-Gran M, Bjorvatn B. Factors associated with depressive symptoms among postnatal women in Nepal. Acta Obstetricia et Gynecologica 2007;86:291–297. 22. Chaudron LH, Klein MH, Remington P, Palta M, Allen C, Essex MJ. Predictors, prodromes and incidence of postpartum depression. J Psychosom Obstet Gynaecol 2001; 22:103–112. 23. Shah Q, Sonuga-Barke E. Family structure and the mental health of Pakistani Muslim mothers and their children living in Britain. Br J Clin Psychol 1995;34:79–81. 24. O’Hara MW. Social support, life events, and depression during pregnancy and the puerperium. Arch Gen Psychiatry 1986;43:569–573. 25. Lee DT, Yip AS, Leung TY, Chung TK. Ethnoepidemiology of postnatal depression. Prospective multivariate study of sociocultural risk factors in a Chinese population in Hong Kong. Br J Psychiatry 2004;184:34–40. 26. Ministry of Local Government and Labour. Immigration and the multicultural Norway (in Norwegian)., 1997. 27. Hughes PM, Turton P, Evans CD. Stillbirth as risk factor for depression and anxiety in the subsequent pregnancy: Cohort study. BMJ 1999;318:1721–1724. 28. Koo V, Lynch J, Cooper S. Risk of postnatal depression after emergency delivery. J Obstet Gynaecol Res 2003;29:246–250. 29. Alder EM, Cox JL. Breast feeding and post-natal depression. J Psychosom Res 1983;27:139–144. 30. Misri S, Sinclair DA, Kuan AJ. Breast-feeding and postpartum depression: Is there a relationship? Can J Psychiatry 1997;42:1061–1065.

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