Postpartum depression in cambodia women trầm cảm sau sinh ở phụ nữ campuchia

ABSTRACT Cambodia is one of the developing countries where postpartum depression has a high predictive rate.. Besides having a high rate, most postpartum depression, like other maternal

VIETNAM NATIONAL UNIVERSITY HA NOI

UNIVERSITY OF EDUCATION

TEP PHARIN

POSTPARTUM DEPRESSION IN CAMBODIA WOMEN

MASTER’S THESIS IN PSYCOLOGY

HANOI, VIETNAM: April, 2016

VIETNAM NATIONAL UNIVERSITY HA NOI

UNIVERSITY OF EDUCATION

TEP PHARIN

POSTPARTUM DEPRESSION IN CAMBODIA WOMEN

MASTER’S THESIS IN PSYCOLOGY Major: Clinical psychology of children and adolescents

Code: Pilot

Supervisor: Prof Dr Bahr Weiss

Dr Tran Thanh Nam

HANOI, VIETNAM: April, 2016

SUPERVISOR’S RESEARCH SUPERVISION

STATEMENT

TO WHOM IT MAY CONCERN

Name of program: Master‟s degree of Art in Clinical Psychology, specialize in Child and

Adolescent Clinical Psychology

Name of candidate: Tep Pharin

Title of research: Post-partum depression in Cambodia women

This is to certify that the research carried out for the above titled master„s thesis was completed by the above named candidate under my direct supervision This thesis material has not been used for any other degree I played the following part in the preparation of this thesis:

Supervisor (s)………

Date………

ABSTRACT

Cambodia is one of the developing countries where postpartum depression has a high predictive rate Unfortunately, there is no data on postpartum depression This study was the first study which explored the rate of postpartum depression and anxiety in women in Cambodia According to GAD -7 measures, 26% of our participants had moderate and severe anxiety According to EPDS, 30% of our participants had moderate and severe depression The rate of anxiety and depression among our participants are very high Therefore, policy makers, researchers, health practitioners should pay more attention to the issues in order to improve the life of women and their infants There should be more research into these issues in order to have a better understand of these issues Particularly, the next research should include more women, expand the age‟s ranges of participants as well as the geographic of the participant in order to achieve a more representative sample

TABLE OF CONTENTS

ABSTRACT iv

Table of Contents v

ACKNOWLEDGEMENT vi

1.1 Background and Rationale of the Research 1

1.2 Research Problem 2

1.3 Research Objectives 3

1.4 Scope of the Research 3

1.5 Significance of the Research 4

PART II - LITERATURE REVIEW 5

2.1 What is postpartum depression? 5

2.2 Measures of Postpartum Depression 5

2.3 Prevalence of postpartum depression around the world 6

2.4 Effect of post-partum depression on the child 8

2.4 Risk factors in postpartum depression: 9

PART III - RESEARCH METHODOLOGY 13

3.1 Sample and data collection 13

3.2 Instrument and Scales 13

3.3Ethics 15

3.4 Data Analysis 16

PART IV - RESULTS 17

4.1 Demographic characteristics 17

4.2 Preliminary analyses: Mean levels of variables 19

4.3 Primary analyses: Prediction of postpartum depression, and anxiety 24

PART V - DISCUSSION 27

PART VI - CONCLUSION AND RECOMMENDATION 32

6.1 Conclusion: 32

6.2 Recommendations 33

REFERENCES 35

ACKNOWLEDGEMENT

I would first like to thank my thesis advisors Dr Bahr Weiss and Dr Nam Tran who always provided patient and insightful responses whenever I ran into a trouble spot or had a question about my research or writing His guidance helped

me in all the time of research and writing of this thesis I could not have imagined having a better advisor and mentor for my Ph.D study

I would also like to acknowledge The University of Education, Vietnam National University and well as National Institutes of Health give me a chance to participate in their wonderful Master program Without they precious training it would not be possible to conduct this research

Finally, I must express my very profound gratitude to my parents and to my husband for providing me with unfailing support and continuous encouragement throughout my years of study and through the process of researching and writing this thesis This accomplishment would not have been possible without them Thank you

PART I - INTRODUCTION

1.1 Background and Rationale of the Research

In modern society, the role of women is increasing, leading to more of a focus

on issues surrounding them Among the issues, health, especially mental health is getting more attention from policy makers, researchers, and practitioners Mental health becomes an important issue for woman because improving mental health improves the quality of life for the woman as well as their functioning in society According to The National Institute of Mental Health (2015), woman are faced with many mental health problems, common ones being anxiety, bipolar disorder, attention deficit hyperactivity disorder, borderline personality disorder, eating disorders, postpartum depression, depression, and schizophrenia Among these problems, postpartum depression is known as one of the most common mental health issues in mothers and prenatal woman (Hanlon 2013)

Women with postpartum depression experience depression symptoms: sadness, worries, withdraws, and thoughts harming themselves and their children Postpartum depression is different from other kinds of depression because its symptoms start to develop within one year after the mother gives birth Because postpartum happens during a critical time, its effects go beyond the common effects of general depression, creating significant consequences for the suffering mothers and their children While having a baby should be a happy time, postpartum depression makes the mothers suffer sadness After giving birth, the mothers need to cover from the labor, experiencing postpartum depression symptoms prevents them from recovering normally and adds another burden for them to cope with The symptoms of postpartum depression also prevent the suffering mothers from completing their duties with their children, thus affecting their childrens‟ development Additionally, its symptoms are opposite from the typical feelings of new mothers Instead of being happy to have a baby and feeling

skilled enough to take care of their children, Bilszta, Ericksen et al (2010) showed evidence that woman suffering from postpartum depression have some belief and fear that prevent them from seeking help, making the effects of the issues even heavier

Postpartum depression is well known in developed countries O'hara and Swain (1996) did a meta-analysis of 59 studies The total participants were 12,810, and their analysis showed that the prevalence of postpartum depression was 13% Gavin, Gaynes

et al (2005) did a more recent systematic review that showed that the frequency of postpartum depression was 19.2% with 7.1% for major depression and 12.2% for minor depression Two large studies done in Europe recently both predicted that the occurrence of postpartum depression is about 9.2% to 9.6% (Navarro, García-Esteve et

al 2008, Banti, Mauri et al 2011) Although the rates vary between these studies, they show that the prevalence of postpartum depression is quite significant among woman

Like many other mental health issues, postpartum depression is not getting as much attention in developing countries as it is in developed countries In their recent review the data of postpartum depression in low and middle income country, Parsons, Young et al (2012) conclude that much less is known about this issue in developing countries compared to what has been determined in the high income countries Among available data, the rate of postpartum depression in developing countries varies from 4.9% (Nepal) to 33% (Vietnam) Southeast Asia has a significant rate of postpartum depression: 11.5% (Malaysia), 13.3% (Thailand), 16.3%, and 33% (Vietnam) Besides having a high rate, most postpartum depression, like other maternal depression, remains undiagnosed and untreated in middle and low income countries Therefore, greater attention needs to be paid to postpartum depression in developing countries

1.2 Research Problem

Cambodia is one of the developing countries where postpartum depression has a high predictive rate Unfortunately, there is no data on postpartum depression As a Cambodian woman, I believe that Cambodian woman carry a lot of burdens during the

time surrounding the birth of a baby Culture beliefs and practices could put more stress during the postpartum time for mothers First, the society is hierarchical, woman have “double duty” both working and taking care of the family (Ebihara, Mortland et

al 1994) thus, woman undergo a lot of stress and pressure The Khmer has a proverb

"num min thom cheang nil" meaning that parents know to choose who to married better than a child (Ebihara, Mortland et al 1994) Many married couples in Cambodia are still arranged, which leads to potential problems including an unhappy married life, thus reducing the support the women have during their postpartum time White (2004) also pointed out some potential harmful traditional practices including a high salt diet during the postpartum period, drinking Khmer medicines infused in rice wine while roasting, labor work at home (delivery the child at home) In order to have better understanding about postpartum depression, our study aims to be the first study to investigate the rate of and the risk factors surrounding postpartum depression among Cambodian women The results of the study will provide information to policy makers and practitioners to improve the lives of mothers in Cambodia

1.3 Research Objectives

The aims of this research study are (1) To assess the incidence of postpartum depression in Cambodian women; (2) To identify risk factors for postpartum depression in Cambodian women; (3) To assess at the relationships among factors related to postpartum depression in Cambodian women

1.4 Scope of the Research

Very little research has been conducted on postpartum depression in Cambodia This research study will be focused on a sample of 50 women in a single district on the province of Kandal (Mukh Kampul district) in Cambodia Research was collected during a 1-month time frame in May 2015.This research study will focus on the potential risk factors of postpartum depression in Cambodian women The main target group consists of 50 mothers who delivered their babies in the period of 3 to 6 months

1.5 Significance of the Research

Even though the sample of this study is small, it is the first data collected on postpartum depression in rural areas in Cambodia This data allows an estimate on the prevalence and the seriousness of postpartum depression in Cambodia The result, therefore, could make policy makers pay more attention to the issue This data also tries to provide an understanding of some risk factors for postpartum depression Understanding these risk factors would help practitioners in implementing prevention and intervention strategies to help the postpartum women

PART II - LITERATURE REVIEW

2.1 What is postpartum depression?

Postpartum depression (PPD) is a type of clinical depression that occurs after a woman gives birth It also called postnatal depression Its symptoms include the same symptoms as other forms of depression, such as sadness, anhedonia, low self-esteem, changes in eating and sleeping habits, lack of energy, reduced interest in sex, and irritability Although the majority of women who experience PPD have mild symptoms postpartum that disappear over the course of several weeks after birth, postpartum depression can be severe and last a number of months PDD often begins within the first few weeks after giving birth, but research studies have found that about half of cases of PDD actually begin prior to giving birth (Chen et al., 2008; Yonkers et al., 2001) According to the American Psychiatric Association Diagnostic Statistical Manual of Mental, Fifth Edition (DSM-5), post-partum depression is defined as a major or minor depressive episode affecting women within four weeks after childbirth but it is commonly believed by clinicians and researchers to occur anytime within the first year postpartum (APA, 2013)

2.2 Measures of Postpartum Depression

The mostly widely used measure to assess postpartum depression is the Edinburgh Postpartum Depression Scale It has been used in many research studies and many countries around the world It was first developed by Scottish health centers in Edinburgh and Livingston It has 10 items that are rated with a 0, 1, 2, 3 Likert scale on the severity of the PPD symptoms The total score is calculated by adding up the points together from the total of 10 questions In addition, the Postpartum Depression Screening Scale (PPDS) (Beck & Gable, 2000) is sometimes used to screen for PPD The PPDS is a longer questionnaire than the EPDS It contains containing 35items and produces 7 subscales These subscales include disturbance in (1) Sleeping and Eating;

(2) Anxiety / Insecurity, (3) Emotional Lability, (4) Mental Confusion, (5) Loss of Self, (6) Guilt and shame, (7) Suicidal Thoughts The PPDS is generally considered a valid questionnaire, but the EPDS is more often used because the EPDS is shorter

2.3 Prevalence of postpartum depression around the world

The nature, prevalence and determinants of mental health problems in women during pregnancy and in the year after giving birth have been thoroughly investigated

in high-income countries O'hara and Swain (1996) did a meta-analysis of 59 studies The total participants were 12,810 Their analysis showed that the prevalence of postpartum depression was 13% Among the59 studies, 31 studies used interview-based methods, and 29 studies used self-report measures The overall prevalence of postpartum depression via the self-report measure was 14% Gavin, Gaynes et al (2005) conducted a more recent systematic review, covering literature up to 2003, and they only looked at studies that used interview-based assessment This review showed that the rate for postpartum depression were 19.2% with 7.1% for major depression and 12.2% for minor depression There are no further systematic reviewsto date, however, there is some new data Two large studies done in Europe recently both predicted that the prevalence of postpartum depression is about 9.2% to 9.6% (Gaynes, Gavin et al

2005, Banti, Mauri et al 2011) It is noticeable that the rate of postpartum depression varies from 9.2% to 19.2% The most important factors that contribute to this variety is the difference in diagnostic criteria, especially the time period O'hara and Swain (1996) consider the postpartum period to be up to the first eight weeks after the delivery while the review of Gaynes includes the first 12 weeks Despite all the differences in rates, this data confirms that the rate of postpartum depression in high income countries is quite significant

A systematic review have shown that in these settings, about 10% of pregnant women and 13% of those who have given birth 2 experience some type of mental

disorder, most commonly depression or anxiety.3 Social, psychological and biological etiological factors interact, but their relative importance is debated

Mental health issues in general get much less attention in developing countries than in developed ones The mental health of women who have just given birth living

in low- and lower-middle-income countries has received less research attention, in part because greater concern has been focused on preventing deaths related to pregnancy Parsons, Young et al (2012) reviewed data on postpartum depression in middle and low income countries and concluded that much less is known about this issue compared to what has been found in the high income countries However, this issue might have a strong impact on the lives of women in middle and low income countries

as it has been suggested that in low resource countries women are less likely to experience post-partum mental problems due to the support from social and traditional cultural practices used during and after pregnancy As the result, postpartum depression

is now attracted great attention (Hanlon 2013)

Among available data, Fisher et al (2012) recently conducted a meta-analysis that examined the prevalence of PPD in LMIC They identified 47 studies in LMIC that had assessed post-partum depression They conducted a meta-analysis to review the studies, and found that the overall rate of postnatal depression was 20%, significantly higher than the 13% rate in high income countries (Fisher et al., 2012) It is noticeable that most of the studies that were included in Fisher‟s review recruited people through health care/ health facility centers This population is less likely to represent woman in the middle and low income countries where woman have limited access to health care

In another review, Villegas, McKay et al (2011) look at the data in rural area in both developed and developing countries Their data suggested that the overall rate of postpartum depression was 27.0% The rate of postpartum depression for rural woman

in developing countries is significantly higher than in developed countries (31.3% vs 21.5%) No Southeast Asian countries were included in this review The last review

was from Parsons and colleagues in 2012 These authors showed that the rate of postpartum depression in developing countries varied from 4.9% (Nepal) to the highest

at 33% (Vietnam) Southeast Asia has quite a significant rate of postpartum depression: 11.5% (Malaysia), 13.3% (Thailand), 16.3%, 33% (Vietnam)

2.4 Effect of post-partum depression on the child

Research has found that there are a number of negative outcomes associated with a mother‟s post-partum depression and child functioning These include low birth weight, child behavior problems, children‟s somatic complaints, learning difficulties in school, a poor growth trajectory, and emotional mental health problems (Zuckerman

&Beardslee, 1987) Research in England has shown that postpartum depression can increase the risk of infant death from Sudden Infant Death Syndrome As they become older, children of depressed mothers are more likely to be depressed themselves (James, & Blackmore,2002) However, as a mother‟s depression improves, the situation for the child also improves

Behavioral Development Mothers with PDD often pay less attention and are

less responsiveness to their children They also are role models for negative mood and emotions and problem solving Longitudinal studies that have compared behaviors of mothers with and without PPD, and their children‟s outcomes have found that children with mothers with PPD were less likely to set behavioral limits with their children and less likely to implement behavioral consequences if they did set limits to follow through if they did set limits (Kochanska et al., 1987) Children of mothers appeared more passively oppositional, and have less develop age-appropriate autonomy (Kuczynsk et al., 1990) Children of mother‟s with PPD are more likely to negatively respond to friendly approaches from other children, less likely to engage in physical play or creative play than children of mothers without PDD

Cognitive and Academic Development There is an association between

maternal PDD and attention deficit/hyperactivity disorder (ADHD) In a study

conducted by Lesesne et al (2003), 9,529 mother-child dyads were assessed, and a moderately large correlation was found between maternal depression in ADHD, even after adjusting for the child‟s age, sex, race, household income and type of family structure Other studies using large samples have found similar effects of PDD on child cognitive development Studies on large samples all agree on the negative impact of maternal postpartum depression on a child‟s cognitive development Early experience with a depressed mother predicts of reduced cognitive functioning In a study by Sharp

et al (1995), children of depressed mothers showed a decrease on standardized tests of intellectual ability, particularly in regard to abstract intelligence Other aspects of cognitive development, such as language functioning, also have been shown to be affected negatively by maternal post-partum depression

Thus, research shows that maternal post-partum depression can have serious effects on the child‟s development It also has shown that these effects may persist into adolescence

2.4 Risk factors in postpartum depression:

Risk factors of a disease are any biological, cultural, or social features of a person that would heighten the probability of experiencing the disease (WHO 2016)

On the other hand, a protective factor is one that decreases the risk of developing a disease In order to determine risk factors, epidemiologists use statistics to determine the correlation between the existence of the disease and factors contributing to it It is important to emphasize that risk factors are not the causes of the disease However, they could provide hypotheses for the etiology ofit In other words, some risk factors could be the cause of the disease, but the relationships have not been proven To some extent, risk factors are used in screening tests if they are strongly associated with the disease (Wald, Hackshaw et al 1999)

Etiology of Postpartum Depression Currently, there are two models that

explain the etiology of postpartum depression The first is the hormone withdraw

model, which focuses on the biological aspect The second is the cognitive model, which focuses on stressful factors in life The hormone withdraw model proposes that postpartum depression is mainly caused by the fact that steroid hormones, estradiol and progesterone, change dramatically during the postpartum period (O'hara and McCabe 2013) The cognitive behavior model proposes that stressful events during postpartum period cause depression (O'Hara, Rehm et al 1982) However, there is little evidence

to support both of the theories, and the mechanism behind how postpartum depression develops is still unknown (O'hara and McCabe 2013)

Risk factors O'hara and Swain (1996) did the first meta-analysis on

epidemiology research in postpartum depression, containing 59 studies with 12,810 subjects Their meta-analysis found the following risk factors for the development of postpartum depression: social class, life stressors during pregnancy, marital problems, lack of support from their partner during pregnancy, and previous mental health problems, particularly depression and anxiety A more recent review, from Stewart, Robertson et al (2003) which is covered 14,000 subjects, identified a broader picture

of risk factors The same risk factors that were identified in the first review remained the strongest risk factors: depression and anxiety during pregnancy, previous history of depression, stressful life events during of the early puerperium, and low levels of social support The moderate risk factors were high levels of childcare stress, low self-esteem, neuroticism, and infant temperament (Stewart, Robertson et al 2003) The moderate risk factors seem to focus on the stressors that occur after the pregnancy apart from low self-esteem Small predictors were pregnancy problems, relationship problems, negative thoughts, and social class (Stewart, Robertson et al 2003) This recent review also pointed out that the following factors were not the risk factors for postpartum depression: age, ethnicity, education level of the mother, and the gender of the child (Stewart, Robertson et al 2003) There are significant differences between the two meta-analyses For example, social class was a strong risk factor in the first review, but

it was only small risk factors in the more recent review It should be noticed that the two meta-analyses were done in different times, the second review was done in 2004 while the first review was done in 1996 With an 18 year difference, some factors could change the way they affect the mothers For example: low social class in the first review could mean bad situations like hunger, but low social class in the second review could mean that the mother used aid money from the government Despite these differences, the meta-analyses converge on some core themes, moderate to strong risk factors of postpartum depression are: depression (history or during the pregnancy), postpartum blues (short depression after delivery), anxiety during pregnancy, low self-esteem, neuroticism, stressful live events including childcare problems, marital problems, and a lack of social support Modest risk factors are: unwanted pregnancy, medical problems during pregnancy, social class (SES), married status (single), and a challenging infant O'hara and McCabe (2013)

Risk factors in low and middle income countries Most of the meta-analysis

were based on data from high income countries, therefore, their findings may not reflect the situation in middle and low income countries (O'hara and McCabe (2013) Fisher et al (2012) conducted a meta-analysis that only focused on data from middle and low income countries to identify the risk factors for common mental disorders during the perinatal period Common mental disorders were: depressive, anxiety, adjustment, and somatic disorders They found the risk factors: social and economic status, problems in couple relationships, lack of social support from family and communities, problems with health including reproductive health, history of mental health problems, and infant characteristics Coast, Leone et al (2012) pointed out that most of the research focused on individual levels of the risk factors while the role of neighborhoods, communities, and locations were ignored The points of Coast, Leone

et al (2012) are very important for research in Southeast Asian since neighborhoods, communities, and locations have important roles in the culture, although it is difficult

to assess these factors Besides risk factors, Fisher, Mello et al (2012) also identified protective factors: more years of education, having a stable job, having an employed partner, belonging to the ethnic majority group, and traditional postpartum care from a trusted person

PART III - RESEARCH METHODOLOGY

3.1 Sample and data collection

The sample in this study consisted of 50 women who had given birth in the last

3 – 6 months Sampling involved the convenience sampling technique In order to obtain the sample, women‟s names were obtained by contacting village chiefs in the Mukh Kampus district of Cambodia‟s Kandal province The researchers also received names of women in this district who had given birth recently at the local hospital in the district Individual interviews were completed by trained student research assistants who were current students at the Department of Psychology at the Royal University of Phnom Penh All women participants in the study were interviewed in their home Each interview took approximately one hour to complete and followed the interview protocol described next

3.2 Instrument and Scales

The research interview questionnaire was designed to measure post-partum depression (PPD) as well as some potential factors that may relate to PPD in women today Demographic items were included such as age, years of education, number of children, employment status, health ratings and experiences of domestic violence

Post-Partum Depression In order to measure Post-Partum Depression (PPD)

the Edinburgh Postnatal Depression Scale 1 (EPDS; Cox, Holden & Sagoysky, 1987) was used This test was developed in 1987 and has been used extensively as a measure

of PPD in many different countries and cultures and translated into numerous languages For example, the EPDS has been translated into languages such as Chinese (Wang, Guo, Lau, Chan, Kin, Yin, & Chen, 2009), Chichewa (Stewart, Umar, Tomenson & Creed, 2013), Portuguese (Matijasevich, et al., 2014), and Iranian (Montazeri, Torkan, & Omidvari (2007) The EPDS includes 10 questions that are each rated on a four-point scale When scored, there is a maximum score of 30 for this test

A score of 13 or more is considered to be a significant 'case' of postnatal depression, while scores of 10 to12 represent 'borderline' and 0 to 9 'not depressed.' Like other portions of the research interview, this scale was translated in the Khmer language before data collection

Marital Satisfaction: The abbreviated Dyadic Adjustment Scale (Sabourin,

Valois & Lussier, 2005) was included to measure the quality of the relationship the women have with their spouse This scale has a total of six questions about how often the women in agreement with her partner One example item states “We (myself and

my partner) have enjoyable conversations” Each question is rated on a 6-point scale ranging from “we always agree” to “we always disagree” Higher scores (we always agree) are scored with 5 points and “we always disagree” responses are scored as 0 points A higher average score on these six-questions suggests better adjustment and quality in the primary relationship

General Life Satisfaction: Participants were also asked to rate their current

happiness level (on a 7-point scale) and completed the 5-item Satisfaction with Life Scale (Deiner, Emmons, Larson, & Griffin, 1985) This scale measures how satisfied a person is with their life with questions such as “In most ways my life is close to ideal” and “The condition of my life is excellent” Respondents are asked to rate each item for agreement a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree)

so that a higher average score represents higher satisfaction with life This scale has been translated into many languages and used in many different cultures This scale was previously translated into Khmer and can be accessed at www.internal.psychology.illinois.edu/~ediener/Documents/SWLS_Khmer.pdf

Anxiety Anxiety was assessed by the Generalized Anxiety Disorder – (GAD-7)

scale The GAD-7 is a widely used questionnaire that assesses anxiety The test was designed with seven items that assess symptoms that are aversive Each question has four choices on the Likert scale, from 0 to 3, and total points range from 0-21

points Subjects with 0-4 are considered to not have anxiety, from 5-9 are considered mild anxiety, from 10-14 anxiety medium, from 15 points or more is considered severe anxiety

Predictors of Postpartum Depression Inventory This scale assesses factors

that are hypothesize or that have been found to be related to postpartum depression These include economic status, self-esteem, anxiety and depression before birth, social support from the spouse, family, and friends, stressful life events, and stress in caring for children

Traditional Practices Questionnaire This questionnaire assesses culturally

specific traditions that follow childbirth in Cambodia As these cultural traditions may

be related to the development of postpartum depression, the many traditions were explored by the interviewer in both closed and open-ended questions For example, a list of traditional practices included taking traditional herbal medicines, maintaining a special diet, or engaging in daily practices such as avoiding drinking cold water, placing rice bags on the abdomen, or lying near a fire Further questions were asked about the purpose of these practices

All of the scales were collected into a single interview questionnaire and translated into Khmer Both the English and Khmer versions of the interview questionnaire are presented in Appendix 1

3.3 Ethics

All of the participants in this study were asked to volunteer their time to answer the questions of the interviewers No one was coerced to answer the questions, and if they became tired or no longer wished to answer the questions, they were told that they may stop the interview at any time The data collected was stored in a safe location and no names are attached to the responses so that all data are analyzed by group, and

no data is associated with the names of the individuals The study was approved by the Human Research Board at the Vietnam National University

3.4 Data Analysis

Data were entered in the SPSS version 21 for Window SPSS and SAS were used to analyze the data

PART IV - RESULTS

4.1 Demographic characteristics

Because this study focused on women, the gender of all participants was female Table 1 presents the demographics for the sample The women ranged in age from 19 years old to 34 years old, with a mean of about 26 years of age There was also a wide range of education, ranging from completing the 2nd grade to completing two years of college, with the mean years of education being about 7 (i.e., the average participant in this study did not enter junior high school) Almost all of the women were married (96%) The average monthly income of the women was $129 and the average monthly income of their partner (all women were living with a partner) was $176 Two thirds

of the women reported that their overall health was “good” with 20% reporting less than “good” health Most women were either employed (48%) or housewives (36%) with only 12% unemployed and looking for a job

The average number of children in the household was about 2.8, and the target child was on average about 5 months old when the interview was conducted Almost 2/3 of the women (64%) reported that their partner had a significant problem with alcohol, drugs, or gambling, and 14% reported that they had been physically abused and 2% reported that they had been sexually abused by their partner in the last year

Table 1 – Demographic Characteristics

Characteristic Mean (SD) [Min - Max] / %

Unemployed, don‟t want job % 2%

Number of children – Mean (SD) [Min- Max] 2.82 (1.00) [1 – 5]

Target child age: Months – Mean (SD) [Min- Max] 4.88 (1.20) [3– 6]

Partner: Employment status of

Partner: Monthly income: US $ 175.58 (85.50) [40 – 550] Partner has alcohol, drug, or gambling problem % 64%

Past year, partner physically abused % 14%

Past year, partner sexually abused % 2%

4.2 Preliminary analyses: Mean levels of variables

Overall, participants reported on the Dyadic Adjustment Scale that they were

“happy” with their relationship, average=3.08 (with 2=A Little Unhappy, 3=Happy, 4=Very Happy) Participants reported that they almost always agreed with their partner about what they wanted from their life and family (Item #1, average=4.00), what was important to them individually and as a family (Item #2, average=4.08), and

on the amount of time they spent together (Item #3, average=4.02) They also reported that they had an enjoyable conversation between several times a week (Item #4, average=3.64), and calmly discussed something (Item #5, average=3.36) and worked together on a family matter (Item #6, average=3.02) once or twice a week

Table 2 – Dyadic Adjustment Scale

5=We always agree

1 What we want from life and our family A 4.00 (.99) [1 - 5]

2 What is important to each of us individually and

3 Amount of time spent togetherA 4.02 (.94) [1 - 5]

0=Never … 5=More than once a day

4 Have an enjoyable conversation B 3.64 (1.57) [0 – 5]

5 Calmly discuss something B 3.36 (1.57) [0 – 5]

6 Work together on something that needs to be

0=Extremely unhappy …

6=Perfect

7 Degree of happiness in relationship C 3.08 ((1.31) [1 – 6]

Notes: A 4=“We almost always agree” B 3= “Once or twice a week”, 4=“Once a day”

Table 3 – Psychopathology Levels

On the Predictors of PPD measure, 50% of participants stated that they had

been depressed during pregnancy, and 44% of these participants said that the depression had been severe; 32% of the participants had been depressed prior to this pregnancy and 12% had received professional treatment for depression Thirty-nine percent of the participants stated that the pregnancy was not planned, and 15% stated that the pregnancy was unwanted In regards to social support, 88% reported that overall they received adequate support from their partner, 92% reported that overall they received adequate support from their family, but only 68% reported receiving overall adequate support from friends Participants reported on average 1.74 (out of 6) stressful life events (e.g., death in family), and 2.51 (out of 7) challenges with their infant (e.g., infant having feeding problems)

Table 4 – Frequency for Predictors of Postpartum Depression

If yes, was this severe depression? 44%

Prior to this pregnancy, ever depressed? 32%

Adequate support from partner? (Mean support) 88% Adequate emotional support from partner? 92%

Receive adequate support from family? (Mean support) 92%

Receive adequate support from friends? (Mean support) 68%

Marriage going well? 82%

Stressful life events (Total number events) 1.74

Based on the Traditional Practices Measure, almost all of the women in the

sample used traditional practices to help them and their new child, with 88% using traditional medication, 76% using a special diet, and 94% using traditional rituals The most frequent rituals included sexual abstinence (84%), resting at home (68%), covering their abdomen with a thick cloth (59%), and using steam (58%) The least frequently used traditional practices were putting an ice bag on their abdomen (20%) and lying by a fire (10%)

Table 5 – Use of traditional practices

1 Have you used the traditional herb/medication during your postnatal period? 88%

2 During your postpartum period, have you been on a special diet because you

3 Have you used any traditional/ritual practices during your postpartum period to

4.3 Primary analyses: Prediction of postpartum depression, and anxiety

For the primary analyses, single variable regression with standardized data were used, thus, because the data were standardized, the β is on the same scale as a correlation The dependent variables were depression as measured by the EPDS and anxiety as measured by the GAD The predictors included the demographic variables,

the Dyadic Adjustment Scale Total Score, and the variables from the Predictors of

PPD measure

Overall, the most consistent predictor of postpartum depression and anxiety was

the relationship with the spouse Support from the Husband significantly predicted depression (β = -.45) and anxiety (β = -.49); Marital Satisfaction (as assessed by the

DAS) similarly significantly predicted depression (β = -.38) and anxiety (β = -.32) In

addition, Marital Status (not being married) significantly predicted anxiety (β = 37)

The only significant predictor of depression and anxiety that did not involve the

relationship with the husband was General Health, which significantly predicted

depression (β = -.37) and anxiety (β = -.36)

The variables that did not predict depression and anxiety also are interesting

Although Support from Husband was a significant predictor, Support from Family and

Support from Friends did not predict depression and anxiety Although they are

obviously important life variables, being abused by the husband, having an unwanted pregnancy, and income all did not significantly predict depression or anxiety

Table 6 – Prediction of Postpartum Depression and Anxiety

PART V - DISCUSSION

The age range for this study sample is mainly on age range from 19 to 34 years old This range is somewhat limited because the reproductive age for Cambodia woman starts quite early at 15, according to the Population Census 2008 The education level of our sample seems to be low as most of our participants did not enter junior high school, however, this reflects the common situation for women rural area throughout the country Most of our participants are married and all of them are living with partners now While this situation is common, it is changing fast as male labor force is moving toward big cities In general, the next research could have done in a broader sample with more diversity, especially in term of ages and marriage status, to make a better generalization

The participants of this research live in extended families The average number

of children they have was about 3; and the number of people in home was 6.18 Therefore, at least one person who is not the member of nuclear family lives with them The extended family is quite common in Cambodia where home often includes three generations: grandparents, parents and children

Most of our participants were in middle class (92%) They had good health condition as only 6% reported having a poor health condition The majority of our participants worked out side home (48%) but a significant amount of them was house wives (36%) However, all of our participants hadtheir partners working which made financial burden low The main income of the family was from the male partners: a male partner earned 175.58 $ while a whole family earned 128.52$

In reporting about their husbands/partners, our participants provided an ambiguous picture On one hand, their partners encountered serious problems: 64% reported that their partners have alcohol, drug or gambling problems; 14% reported being physically abused by their partners When male partners encountered these problems, they were less likely to provide adequate supports for female partners These

problems would threaten the financial and emotional wellbeing of family, making family unsatisfied On the other hand, their partners still provided adequate support for them, including emotion support, day to day tasks and rely on partners when need help Also, generally our participants reported satisfied with their marriages It is possible that the drug, alcohol, gambling and physical abused problems were very common in rural areas, our participants normalized these problems and found way to satisfaction with their partners Nevertheless, when it came to reporting common life stress events, financial problems (68%) and marital problems (40%) were reported as the most frequent stressful life events As mentioned earlier, the main income for the family was from the husband, it could be concluded that the common stressful event came from the husbands

The data from Dyadic Adjustment Scale provides another aspect of our participant marriage or couple lives First, the participants of this research seems to have unified marriages or couple lives Most of participants stayed in marriage with the rate is 96% They highly agreed on the common goals and values for individual life and family life The mean of item 1 and 2 (indicating their level of agreement) in Dyadic Adjustment Scale are 4.00 and 4.08 respectively Finally, they spent good amount of time together as the mean of item 3 was 4.02 Secondly, our participants reported that the quality of their relationship are positive, even though the mean score

of these items was lower than the previous They had enjoyable conversations one or twice a week, calming discussing with each other once or twice a week According to the Western culture, this ratio of positive interaction between the couples is quite small However, in Cambodia culture, people do not express their feeling, rather they are quite introverted People often express their feeling through action, not by words Therefore, the ratio should be understood as a good indication of happy marriages The last item, working on something together, resulted in low score: 3.02 indicating that the couples do things together once or twice per weeks That ratio could be misleading as

the couples does not sharing their duties However, in Cambodia culture, husbands and wife could share responsibility but they do not do it together Third, our participants reported that in general, they were happy with their marriages (mean = 3.08) In general, most of our participants also reported that their marriages went well (82%)

The mental health of our participants were at high risk According to GAD -7 measure, 26% of our participants had moderate and severe anxiety According to EPDS, 30% of our participants had moderate and severe depression As Fisher, Mello

et al (2012) reported that the average prevalence of common perinatal mental health disorders in low and middle income countries is 15,9%, the rate of anxiety and depression in our participants are almost double than the normal rate of the common mental health disorders Comparing the rate of postpartum depression with the data from other low and middle income countries, the rate of our sample is in the highest group (the rate of this group is from 30% to 50%, Parsons, Young et al (2011)) Comparing with other countries in South East Asia, our rate ranks as the second, lower than Vietnam 33,% (Parsons, Young et al 2011) Comparing with the data from developed countries, our rate is almost double (these rate in developed countries are from 13% to 19% (O'hara and McCabe 2013) Literature in medical shows that poverty are associated with common mental health disorder (Lund, Breen et al 2010), the high rate of anxiety and depression in our sample are consistent with that conclusion

The factors that predicts postpartum depression and anxiety in our data was: General Health, Marital Status, Marital Satisfaction, and Support from Husband Among of them, the strongest predictions of postpartum was ranked in order from highest to lowest as follow: support from husband, marital satisfaction and general health These factors plays a protective factors as they have negative associate with postpartum depression For example: more score in support form husband will result in lower score of depression postpartum