The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie2023, Vol. 68(4) 269‐282© The Author(s) 2022
Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/07067437221140387TheCJP.ca | LaRCP.ca
Abstract
Objective:This study examined the prevalence of elevated maternal anxiety and/or depression symptoms up to eight years after childbirth and the association between role and relationship strains during parenting and mental health challenges from three to eight years after childbirth.
Methods: This study used data from the All Our Families longitudinal pregnancy cohort. Role and relationship strain factors and anxiety and depression symptoms were measured at repeated time points from four months to eight years after childbirth. The proportion of women with elevated anxiety and/or depression was calculated at each available time point. Generalized estimating equation models were used to examine the association between role and relationship strain factors and anxiety and/or depression from three to eight years after childbirth. Predicted probability of having anxiety and/or depression was estimated across those with and without challenges with roles and relationships. The models were adjusted for known risk factors such as maternal income and perinatal anxiety and/or depression.
Results: The prevalence of elevated anxiety and/or depression ranged from 18.8% (at four months) to 26.2% (at eight years). The adjusted odds ratio of anxiety and/or depression was 3.5 (95% CI = 2.9, 4.3) for those juggling family responsibilities and 2.4 (95% CI = 2.0, 3.0) for those with stressful partner relationship compared to their counterparts. Similarly, experiencing financial crunch and poor partner relationship were associated with increased mental health difficulties. Women without challenges in roles or relationships had a 23% lower predicted probability of anxiety and/or depression than those with the challenges.
Conclusions: Monitoring mothers for anxiety and depression beyond the postpartum period and strategies that address role and relationship challenges may be valuable to women at risk of anxiety and depression.
La présente étude a examiné la prévalence de l’anxiété maternelle élevée et/ou des symptômes de dépression jusqu’à 8 ans après un accouchement, et l’association entre le rôle et les tensions de la relation durant la parentalité et les problèmes de santé mentale entre 3 et 8 ans après un accouchement.
Méthodes: La présente étude a utilisé des données de la cohorte de grossesse longitudinale Toutes nos familles. Les facteurs des tensions des rôles et relationnelles et les symptômes anxieux et dépressifs ont été mesurés à des points dans le temps répétés entre 4 mois et 8 ans après l’accouchement. La proportion des femmes ayant une anxiété élevée et/ou une dépression était calculée à chaque point dans le temps disponible. Des modèles d’équation d’estimation généralisée ont servi à examiner l’association entre les facteurs de stress des rôles et relationnels et l’anxiété et/ou la dépression de 3 à 8 ans après l’accouchement. La probabilité prédite d’avoir de l’anxiété et/ou de la dépression était estimée chez celles ayant ou non des problèmes avec les rôles et relationnels. Les modèles ont été ajustés pour les facteurs de risque connus comme le revenu maternel et l’anxiété et/ou la dépression périnatale.
Résultats: La prévalence de l’anxiété élevée et/ou de la dépression oscillait entre 18,8 % (à 4 mois) et 26,2 % (à 8 ans). Le rapport de cotes ajusté de l’anxiété et/ou de la dépression était de 3,5 (IC à 95 % 2,9 à 4,3) pour celles qui conciliaient les responsabilités familiales et de 2,4 (IC à 95 % 2,0 à 3,0) pour celles ayant une relation stressante avec un partenaire comparativement à leurs homologues. De même, les difficultés financières et une mauvaise relation avec un partenaire étaient associées à des difficultés accrues de santé mentale. Les femmes sans difficultés dans leurs rôles ou relations avaient une probabilité prédite 23 % plus faible d’anxiété et/ou de dépression que celles éprouvant ces difficultés.
Conclusions: Surveiller l’anxiété et la dépression chez les mères après la période du postpartum et les stratégies qui abordent les difficultés de rôles et relationnelles peuvent être valables pour les femmes à risque d’anxiété et de dépression.
Keywordsanxiety and depression, role strain, partner relationship and support, time crunch, financial crunch, women after childbirth
One in five Canadians experiences mental health difficulties each year.1 By 40 years of age, up to half of the Canadian population will have experienced and recovered from a mental health difficulty, and almost all will have been impacted by the mental health difficulties of relatives, friends or caregivers.1 Beyond individual impacts, mental health difficulties place significant strain on communities, the economy and the health care system.1 As such, primary and secondary prevention of mental illness is a significant public health priority.
A large body of evidence suggests that untreated maternal mental health challenges, including anxiety and depression, are salient risk factors for child and family functioning.2–8 Approximately 12–17% of mothers experience depression during the prenatal or postpartum period and their children are at increased risk of experiencing mental health difficulties themselves.9–13 Evidence including large systematic reviews and meta-analyses shows that maternal depression and anxiety in the postpartum period have long-term consequences for mothers and their families, including declines in marital relationship satisfaction and maternal–child attachment, elevated risks for recurrence of maternal depression and poor child developmental outcomes.14–18
Research to date has focused exclusively on the first year postpartum, with some limited research (mostly on depressive symptoms) beyond one year.4,19–24 A longitudinal study reported that 21% of mothers have elevated depressive symptoms at some point in the three years after childbirth.19 Other studies have noted that 12–16% of mothers have persistently high depressive symptoms20,24 and 11% of mothers have persistently elevated anxiety symptoms from early pregnancy up to seven years.24 These studies examined the sociodemographic, perinatal and health behaviour factors of the depressive symptoms19–21,24; however, little is known about what psychosocial factors or stressors contribute to mothers’ mental health beyond the first year postpartum.
Bio-ecological theory posits that different factors at various levels of the social ecology interact with each other over time to contribute to a health outcome.25 Distal factors are those that indirectly impact outcomes (e.g., social support), while proximal factors are those that directly influence the outcome (e.g., available time, financial strain and marital stress). It is well known that several distal factors increase the risk for poor maternal mental health after birth and during early childhood: poor social support, previous mental health difficulties, a history of adverse childhood experiences and lower socioeconomic status.20,26–29 Given that mental distress occurs in the context of interpersonal relationships and family dynamics and is transactional in nature, proximal factors or current life stressors, including relational strain with a partner or within the family and family responsibilities during parenting may also play an important role in explaining shifts or changes in maternal mental health.25,30,31 Understanding the role of diverse proximal factors in influencing maternal mental health difficulties is critical for informing how to best improve maternal mental health and well-being. This study aimed to improve our understanding of the extent to which the roles and relationship challenges mothers experience contribute to patterns of mental health over time.
Specifically, this study had two objectives: (a) to examine the prevalence of elevated maternal anxiety and/or depression symptoms up to eight years after childbirth; and (b) to examine the association (relative and absolute) between role and relationship strains during parenting and mental health challenges from three to eight years after childbirth, adjusting for known risk factors for mental health (sociodemographic and economic factors and previous mental health experience).
The All Our Families study (AOF) is an ongoing pregnancy cohort in Calgary, Alberta, Canada. AOF began in 2008 and recruited 3,387 women in pregnancy.12,32 In brief, a population-based strategy was used to recruit women from city-wide medical laboratory offices, maternity clinics and community outlets, allowing for a representative sample of pregnant women in an urban centre. Waves of data collection included: twice in pregnancy and at four months, and one, two, three, five and eight years after the index delivery. The longitudinal response rate over time has been over 70%.12,32 A range of outcomes related to child development and maternal well-being have also been assessed over time in a consistent manner to allow for the examination of patterns of functioning across the lifespan. Details on cohort characteristics and variables measured for each wave are described elsewhere.12,32 We extracted data from women who participated in data waves at four months and one, two, three, five and eight years (all were COVID-19 pre-pandemic data) after the index delivery and linked the data across the waves for the purposes of this study. The All Our Families cohort study was approved by the Conjoint Health Research Ethics Board at the University of Calgary.
Outcomes: Outcome included maternal anxiety and depression symptoms at four months, and one, two, three, five and eight years after childbirth (six data points). The Edinburgh Postnatal Depression Scale (EPDS) (at four months and one year) and the Center for Epidemiological Studies Depression scales (CES-D) (at two, three, five and eight years) were used to measure self-report symptoms of depression.33,34 Validated cut-offs of ≥10 on the EPDS and ≥16 on the CES-D were used to categorize women ‘at risk’ of clinically significant levels of depression in postpartum period.34,35 The Speilberger State Anxiety Inventory (SSAI), 20-item scale (SSAI-20) at four months and one, two and three years after childbirth and the six-item scale (SSAI-6) at five and eight years after childbirth were used to measure self-report transitory symptoms of anxiety.36–38 A validated cut-off of ≥40 on the SSAI-20 and a cut-off of 1 standard deviation above the mean on the SSAI-6 were used to categorize transitory high levels of anxiety.39 No validated cut-off is available for the SSAI-6, but a 1 standard deviation cut-off performs similarly to the 40 point cut-off on the longer version and has been previously used in the literature.40–42 SSAI measures transitory levels of anxiety, that is, how the mother felt at the time of measurement.37
Exposures: Seven variables under five domains capturing role and relationship strains during parenting were assessed. Specifically, time crunch, financial crunch, juggling family, work or other responsibilities, intimate relationship experience and partner relationship (includes partner emotional and practical support, happiness and tension) experienced by mothers. We have used the overall term “role strain” for three constructs: time crunch, financial crunch and juggling responsibilities. Time crunch and experience with the close relationship were measured using validated scales.43–45 Questions for the remaining variables were developed by AOF research team that involves leading content experts in maternal–child health and mental health. These variables were measured in data waves at three, five and eight years after childbirth. All of these variables, except time crunch and the intimate relationship variables, were measured in two data waves. We collapsed similar variable categories with the small cell counts to facilitate statistical analysis and increase study power. Questionnaire items, variable categories, and data points of AOF study are presented in Supplementary Table 1.
Known risk factors: This included maternal age, marital status, education, income, self-identified ethnicity, immigration status, parity and perceived social support, which was measured during pregnancy. Additional risk factors included perinatal anxiety and/or depression (measured by EPDS and SSAI-20), maternal history of adverse childhood experiences (measured at three years after the index childbirth) and subsequent childbirth (measured at three years after the index childbirth). These risk factors have been consistently associated with maternal mental health challenges during the postpartum period and early childhood.20,26–29 Variables were analysed as continuous variables if they were measured in continuous scales: maternal age, social support score and adverse childhood experience were analysed as continuous variables, and the remaining were analysed as categorical variables.
The proportion of women with high levels of anxiety, depression and either anxiety and/or depression at each time point after childbirth was calculated. Participants who responded to any of the role and relationship strain variables that were measured in any data wave at three, five and eight years after childbirth were included in subsequent analyses (n = 2,398). Repeated measures logistic regression analysis, using generalized estimating equation (GEE) models were built to examine associations between each role and relationship strain variable and anxiety and/or depression at any time from three to eight years after childbirth. GEE models incorporated the repeated measurements (three measurements) from a single respondent and produced the population-averaged effect (pooled estimate) on anxiety and/or depression within that period accounting for within-subject correlations between measurements.46 Exchangeable working correlation and robust standard errors were used in the GEE analyses.46 A GEE with an exchangeable working correlation allows us to maximally utilize every follow-up outcome data available in each measurement timepoint.46 The GEE does not provide insight into the timing of emergence of mental health symptoms, but rather allows us to understand the association between risk factors and mental health in the general parenting population, which can guide the allocation of resources for intervention. In the GEE models, time crunch, intimate relationship experience and financial strain variables were analysed as continuous variables and jugging responsibilities and partner relationship were analysed as categorical variables. We combined the role and relationship strain variable if it was measured at repeated data timepoints after childbirth and used it as any timepoint. All final models were adjusted for known risk factors for mental health: maternal age, marital status, education, income, ethnicity, immigration status, parity, subsequent childbirth, social support, perinatal anxiety and/or depression and adverse childhood experiences. The model results are reported as pooled adjusted odds ratio (aOR), with 95% confidence intervals (CIs).
The performance of the final GEE models was evaluated by measures of model calibration (brier score – the average squared error difference between the observed outcome and a prediction, the correspondence between predicted and observed outcome rates, and Hosmer–Lemeshow goodness of fit) and discrimination accuracy (area under the receiver operating characteristic curve, AUC). To obtain the model calibration measure, the predicted probability of anxiety and/or depression for each woman was estimated and was categorized into five risk groups (<15%, ≥15–30%, ≥30–45%, ≥45–60% and ≥60). Finally, the adjusted predicted probability of having anxiety and/or depression was estimated (at the average value of covariates or known risk factors for mental health) using the final GEE model for each role and relationship strain variable and assessed the absolute difference at the population level. For time crunch, intimate relationship experience and financial strain continuous variables predicted probabilities or absolute differences were compared across the specific values.
The sociodemographic characteristics of the AOF cohort at recruitment and the cohort participation in each data waive after childbirth are shown in Supplementary Table 2. As shown in Table 1, the prevalence of elevated anxiety and/or depression ranged from 18.8% to 26.2% at all timepoints up to eight years after childbirth. The prevalence was 18.8%, 19.9%, 19.6%, 19.4%, 22.8% and 26.2% in four months, one, two, three, five and eight years, respectively. A total of 42.2% of women had elevated anxiety and/or depression at least once between four months and eight years of childbirth, 33.3% had it at one or two timepoints and 8.9% had it in >2 time points.
Of 2,398 study participants, the mean age was 31 years, and the majority of women were married/common law, white and born in Canada/lived in Canada five or more years, and had some or completed post-secondary education. The proportion of women exposed to challenges with roles and relationships at any time from three to eight years after childbirth is presented in Table 2. A higher proportion of women with elevated anxiety and/or depression had role and relationship challenges than those without (Table 3).
Each role and relationship strain variable was significantly associated with elevated anxiety and/or depression symptoms after childbirth from three to eight years, adjusting for known risk factors (Table 4). The odds of anxiety and/or depression were 3.5 times higher for a group of women who had frequent difficulties with juggling responsibilities compared to those who reported less frequent difficulties with juggling responsibilities (pooled aOR = 3.5, 95% CI = 2.9, 4.3). The pooled aOR of anxiety and/or depression was 2.4 (95% CI = 2.0, 3.0) for a group of women who had a stressful relationship with their partner compared to those who reported no stressful relationship with their partner. Similar patterns were found among those with a time crunch, financial crunch, poor intimate relationship experience and poor partner support compared to their counterparts (Table 4). The calibration and discrimination accuracy (AUC) of the models were adequate (Supplementary Table 3), except some predicted probabilities were over 10 points higher than the observed values (models overestimating the risk).
Table 5 shows pooled predicted probability (and absolute difference of probability) of anxiety and/or depression from three to eight years, between those with and without the challenges with roles and relationship dynamics, adjusting for known risk factors. The adjusted predicted probability of anxiety and/or depression was higher by 21% among those with higher levels of a time crunch, by 22% among those who always experience financial crunch, by 23% among those who experience difficulties with juggling responsibilities and by 23% among those with poor intimate relationship, compared to their counterparts. The predicted probability of anxiety and/or depression among those who had poor partner relationship experience was also high.
Our findings suggest that a high proportion of women continue to experience anxiety (transitory high levels of anxiety) and/or depression symptoms beyond the postpartum period. The observed prevalence of elevated anxiety and/or depression was higher than in the first-year postpartum. Our study showed that 42% of mothers experienced elevated anxiety and/or depression at some point within an eight-year period after childbirth, with 9% having had experienced it in at least three timepoint measurements (indicating persistent symptoms) and 33% had experienced it in one or two timepoint measurements (indicating intermittent symptoms). A prospective cohort study found that 21% of mothers experience elevated depression symptoms at some point in the three years postpartum.19 The higher prevalence in our study (42% vs 21%) is most likely related to the assessment of both anxiety and depression and the longer follow-up period; that is, with a longer study period or more data points, there will be a higher number of people with elevated symptoms at some point in the total period. The prevalence in our study (measured using a symptom or screening scale) may be higher than the prevalence derived using diagnostic instruments.11 However, this would not impact the trends of prevalence over time. The women with elevated depressive and/or anxiety symptoms do not necessarily meet criteria for a depressive and/or anxiety disorder requiring treatment. Rather, these symptoms indicate potentially clinically elevated levels of symptomatology. The early detection of these symptoms provides a basis for the early management of these symptoms and selection of women who require further assessment for diagnosis of disorders and early treatment.
Our findings showed that the challenges with roles and relationships were strongly associated with elevated anxiety and/or depression after childbirth from three to eight years after childbirth, above and beyond the known risk factors such as socioeconomic factors and a history of anxiety and/or depression.20,26–29 This implies that high levels of time and financial crunch, challenges with family or work responsibilities and poor intimate and partner relationship/support can be targets for prevention or management, beyond the social determinants of health. Literature on the association between roles and relationship dynamics and maternal mental health challenges over years when they are parenting small children (or early childhood) is scarce. According to existing but limited studies, employment-related problems (organizational culture, workload and earning instability), household and childcare-related workload, changes in financial circumstances at the individual or family level and marriage/family instability might impact the maternal roles and relationships.31,47,48
The stressors of mothers with young children, including feeling rushed and short on quality time with their children, friends, partners or hobbies, financial strains, difficulties in balancing personal and family life and challenges in partner relationship, may influence their mental health through behavioural, physiological and psychosocial pathways.49,50 For example, the stress of relationship strain can result in adopting mental health-compromising behaviours as a coping mechanism to deal with stress.31,49 Prolonged exposure to stress may result in withdrawal from social networks and support systems that might otherwise buffer these effects.51,52 Mothers’ stress coping skills and socioeconomic factors can also buffer the effects of these stressors.31,49
Elevated maternal anxiety and/or depressive symptoms when parenting young children have the potential for deleterious impacts on maternal and childhood health such as maternal chronic diseases, impaired parenting and mother–child bonding, childhood emotional problems and suboptimal social and communication skill.9,14–18 Postpartum maternal mental illness has been regarded as a major public health problem,53 with a recommendation of monitoring and support; however, little focus is given to mental health difficulties beyond the early postpartum period. The majority of previous studies focus on the assessment of mental health status during pregnancy and one-year postpartum and its impacts on childhood development. Our study highlights that mental health beyond the early postpartum period may be just as crucial as perinatal mental health and provides a clarion call for ongoing support for long-term maternal mental health.
Our findings underscore the importance of assessing maternal mental health after childbirth, continuously beyond the early postpartum period to intervene early to support healthy child development and maternal well-being. Providers, including nurses, primary care practitioners and obstetricians, should be aware of the potential for ongoing mental health difficulties among mothers. In addition to the well-baby visits, an integrated maternal mental health monitoring in routine primary care could be particularly beneficial for families. For example, primary care practitioners identify/manage those with a high probability of mental health challenges (focusing on relatively modifiable and proximal factors such as time and financial crunch, difficulties with juggling family responsibilities and poor partner relationships), and if necessary, referrals to mental health services should be made. Furthermore, health promotion policies, social programs and workplace structure may need to be adjusted, paying attention to mothers’ family or other responsibilities, relationship quality and economic stability. Avenues for future research include examining maternal mental challenges as children enter adolescence (and trajectories over time after childbirth); exploring whether the challenges with role and relationship dynamic influence childhood and early adolescent developmental outcomes; whether these risk factors change over time in a woman’s life-course; and whether these novel risk factors and the previously known risk factors have time-dependent effects on maternal and child developmental outcomes over time.
Strengths of the current study include the analysis of maternal mental health data at repeated time points after childbirth measured by validated anxiety and depression instruments in a prospective study design. This study makes a novel contribution by assessing maternal mental health up to eight years after childbirth as well as the association of roles and relationships with maternal mental health over time. However, the results should be interpreted within the context of limitations. The exposures and outcome variables were measured using maternal self-report: mothers experiencing challenges with role and relationships may view their mental health status more negatively. The cohort sample size was low specifically in the years 1 and 2 due to the funding delay for follow-up, and subsequently the follow-up eligibility of the cohort was passed. Although the longitudinal survey response rate over time of >70% and the minimal missing data on anxiety and/or depression (<1%) in each survey waive is considered high for longitudinal studies, selection bias is possible if the non-response does not hold the missing completely at random (MCAR) assumption. It is likely that the sample with the elevated anxiety and/or depression dropped more than those without the elevated anxiety and/or depression, which can underestimate the prevalence outcome over time. GEE analysis assumes MCAR: if nonresponse was also differential by exposure (strain) status, we would expect our associations to be conservative. Furthermore, the MCAR assumption is less of a problem for the purpose of our study – assess whether the certain characteristics are associated with an increased odds of anxiety and/or depression at any time between three and eight years – as GEE utilized every outcome data available in each measurement and the timing of outcome is not important. The observed associations do no necessary indicate causation: we analysed prevalent outcomes using GEE; the temporal relationship between exposure and outcome is less clear unlike in time to event data or analysis. Some of our models’ predicted probabilities were over 10 points higher than the observed values: the models might have overestimated the absolute difference in probability of anxiety and/or depression, between those with and without the challenges with roles and relationship dynamics. The sample reflected a relatively socio-economically advantaged population, and more disadvantaged women were more likely to drop out over time. This may result in an underestimate of anxiety and depression, as these tend to be higher among women with fewer economic resources and those of minority background.54 Examining these associations in marginalized women is an important future direction.
Elevated anxiety (transitory high levels of anxiety) and depression continue to be a concern among women up to 8-years after childbirth. Challenges with roles and relationships during parenting including financial, time, family responsibility and relationship strain highly contributed to mental health concerns. These findings extend the current understanding that anxiety and depressive symptoms are mostly burdensome in the first year postpartum and suggest that monitoring/support should be extended beyond that period. Clinicians may identify those with a very high probability of elevated anxiety and/or depressive symptoms using relatively modifiable factors such as challenges with roles and relationships in addition to previously known distal risk factors.
All our families cohort study was funded through Alberta Innovates Interdisciplinary Team Grant # 200700595; Alberta Children’s Hospital Foundation; and Max Bell Foundation.
Kamala Adhikari, Sheila McDonald and Suzanne Tough were involved in the conception and design of the study. Kamala was responsible for conducting the analysis, interpreting the data and drafting the manuscript. Nicole Racine and Erin Hetherington contributed to conception and study design. All authors provided interpretation and intellectual content to the manuscript draft. All authors read and approved the final draft.
Supplementary file has been submitted to provide additional information about this research. Data types such as statistical data file, statistical codes, text files, tables, additional charts and graphs necessary to understand the research will be provided upon the request.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Kamala Adhikari https://orcid.org/0000-0003-2872-9496
Supplemental material for this article is available online.
1 Provincial Population and Public Health, Alberta Health Services, Edmonton, Alberta, Canada
2 Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
3 School of Psychology, University of Ottawa, Calgary, Alberta, Canada
4 Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Québec, Canada
5 Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
Corresponding Author:Kamala Adhikari, Department of Community Health Sciences, University of Calgary, 3280 University Drive NW, Calgary, Alberta, Canada T2N 1N4.Email: kamala.adhikaridahal@ucalgary.ca
