Domestic Violence Experience, Past Depressive Disorder, Unplanned Pregnancy, and Suicide Risk in the First Year Postpartum: Mediating Effect of Postpartum Depression
Article information
Abstract
Objective
This study aimed to examine the relationship between domestic violence, past depressive disorder, unplanned pregnancy, suicide risk, and postpartum depression among Korean women using a mediation model approach.
Methods
A web-based, cross-sectional survey was performed from September 21 to September 30, 2022. Participants included 1,486 women in their first year postpartum from Chungnam Province, South Korea. The generalized linear model mediation was analyzed using the R-based Jamovi 2.3.21 version program.
Results
Of all participants, 8.7% had domestic violence experience, 7.5% had been diagnosed with depressive disorder by the doctor in the past, 33.0% had reported that the last pregnancy was unplanned, 39.9% had postpartum depression, and 11.2% of the participants had a suicide risk. Among the participants with a high risk of suicide, 34.4%, 37.5%, 53.1%, and 96.9% reported experiencing domestic violence, past depressive disorder, an unplanned pregnancy, and postpartum depression, respectively. Postpartum depression partially mediated the relationship between domestic violence, past depressive disorder, and suicide risk and completely mediated the relationship between unplanned pregnancy and suicide risk.
Conclusion
Our findings highlight the necessity for screening and early intervention for suicide risk and postpartum depression from pregnancy to the first year postpartum.
INTRODUCTION
Many women experience mental health issues during pregnancy and after childbirth, such as depression, elevated anxiety, high levels of stress, and suicide risk [1]. Suicide during pregnancy and after childbirth is one of the main causes of maternal and perinatal mortality [2]. Women during the postpartum period were reported to attempt suicide more often than in the general female population [3]. Maternal suicide was reported to be the leading cause of death from 6 weeks to a year after childbirth in the United Kingdom [4]. According to the results of the Korea Population Health and Welfare Association in 2017, 3 out of 10 women experienced postpartum depression and had suicidal ideation after childbirth [5].
Importantly, domestic violence experience and past depressive disorder are risk factors for postpartum depression and suicidal behaviors among women after childbirth [6,7]. Previous studies have also found an association between domestic violence and suicide risk [8,9]. In addition, unplanned pregnancy has been reported as a predictor of postpartum mental health [10,11].
Postpartum depression is a prevalent mental health issue and a leading risk factor for suicide. Previous researchers have found that women with depression after childbirth may have suicidal ideation, which could lead to suicidal plans or attempts [4,12,13]. Recent studies provide increasing evidence that the risk factors for suicidality and postpartum depression might be interrelated [3,14-16]. A previous study also reported that postpartum depression completely mediated the relationship between neuroticism and suicide risk among postpartum women [17].
Though several studies provided the initial evidence supporting the relationships between past mental illness, past traumatic events, postpartum depression, and suicide risk among women [1,2,17,18], the findings were limited by the small sample sizes, lack of various variables, and lack of pathway analysis. Furthermore, previous findings have focused on antepartum depression and suicide risk in women during pregnancy rather than after childbirth [19,20]. Little research has been conducted on the relationship between domestic violence experiences, past depressive disorder, unplanned pregnancy, suicide risk, and postpartum depression symptoms among women after childbirth. Maternal mental health and suicide risk factors are likely to worsen during pregnancy and for at least 1 year after childbirth [21].
Therefore, the goals of this study were: 1) to examine the prevalence of postpartum depression according to the suicide risk group, and 2) to investigate the mediating role of postpartum depression in domestic violence experience, past depressive disorder, unplanned pregnancy, and suicide risk in the first year postpartum.
METHODS
Data and study population
We conducted a web-based, cross-sectional survey from September 21 to September 30, 2022. The participants were 5,234 mothers registered at the Public Health Welfare Center in Chungnam Province, South Korea. Women in South Korea could register for the Maternal and Child Health Service from 40 days before the scheduled delivery to 30 days following the date of childbirth, in order to get reproductive health, delivery, and childcare services. Of these, 1,490 mothers in the first year postpartum agreed to the web-based survey and completed the questionnaire (response rate: 28.5%). We evaluated the sociodemographic characteristics, domestic violence, past depressive disorder, unplanned pregnancy, suicide risk, and postpartum depression of the mothers in the first year postpartum. After excluding respondents with missing data, 1,486 women were included in the final study population.
Measures
Independent variables
The independent variables, including domestic violence experience, past depressive disorder, and unplanned pregnancy [4], were assessed by responding (yes or no) to the questions “Have you experienced domestic violence in your lifetime prior to this pregnancy?,” [9] “Have you ever been diagnosed with a depressive disorder by a doctor prior to this pregnancy?,” and “Was this pregnancy planned with your spouse?.” [10,11]
Dependent variables
The P4 screener is a brief evaluation tool used to assess potential suicide risk [22]. The P4 screener consists of four P’s (pre-Q: thought of actually hurting yourself, Q1: past suicide attempts, Q2: suicide plan, Q3: probability of completing suicide, and Q4: preventive factor).
Q1 responded (yes or no) to the question: “Have you ever attempted to harm yourself in the past?” Q2 responded (yes or no) to the question: “Have you thought about how you might actually hurt yourself?” Q3 responded (not at all, somewhat likely, or very likely) to the question, “How likely do you think it is that you will act on these thoughts about hurting yourself or ending your life sometime over the next month?” Q4 responded (yes or no) to the question: “Is there anything that would prevent or keep you from harming yourself?” Depending on the responses, the participants were classified into the normal (pre-Q=no), low-risk (Q1 or Q2=yes, Q3 and Q4=no), or high-risk (Q3=somewhat likely or very likely, or Q4=no) groups.
Mediation variables
Postpartum depression was evaluated using the Korean version of the Edinburgh Postnatal Depression Scale [23]. It consists of 10 items (4-point scale) and ranges in total scores from 0 to 30. Higher scores indicate higher levels of postpartum depression [24]. A cutoff value of 10 or higher was used to distinguish postpartum depressive symptoms [25].
Sociodemographic variables
Sociodemographic factors included age (i.e., 20–29, 30–39, and 40–49 years), parity based on this pregnancy (i.e., one, two, three, or more), education level (i.e., high school graduation and college or higher), employment status (employed full-or part-time, employed/maternity leave, and unemployed), and monthly household income level (i.e., lower than 2, 2–2.99, 3–4.99, and 5 million won or more).
Statistical analysis
Descriptive statistics were analyzed using SPSS (version 25.0; IBM Corp., Armonk, NY, USA). The study populations were divided into groups depending on whether they had a suicide risk (normal, low-risk, and high-risk groups). Differences in demographic characteristics between the groups were analyzed by performing the chi-square test or Fisher’s exact test, when applicable. Suicide risk variables were defined as those that included the low-and high-risk groups, which were analyzed in nominal form.
To examine the mediating effect of postpartum depression on the association between unplanned pregnancy, domestic violence, and suicide risk, the generalized linear model (GLM) mediation was analyzed using the medmod module of the Jamovi 2.3.21 version program (The jamovi project, Sydney, Australia) [26]. The GLM mediation model in the Medmode module of the R-based Jamovi software takes a path estimate approach rather than stepwise regression analysis, and it is possible to estimate the standard error and resolve problems that violate the normal distribution [27]. All statistical significance levels were set at p<0.05.
Ethical considerations
Informed consent was obtained from all eligible participants before enrollment. All procedures were conducted in accordance with the relevant regulations and guidelines. The study was approved by the Institutional Review Board (approval number: MC22ZISI0095).
RESULTS
Table 1 presents the sociodemographic characteristics of the participants. In total, 11.2% reported a suicide risk. Of them, 2.2% reported a high risk of suicide. In addition, 8.7% had domestic violence experiences, 7.5% had been diagnosed with depressive disorder by a doctor in the past, 33.0% reported that the last pregnancy was unplanned, and 39.9% of women had postpartum depression.
Demographic characteristics of study participants (N=1,486)
Table 2 lists a comparison of demographic and clinical variables by suicide risk groups based on P4 screener. Among the participants who did not have a suicide risk, 34.6% showed postpartum depression. Of mothers in the low-risk group for suicide, 78.4% were found to have postpartum depression. In addition, among the participants in the high-risk group for suicide, 56.3% had one childbirth, 59.4% graduated college or higher, 78.1% were unemployed, 34.4% had a domestic violence experience, 37.5% had past depressive disorder, 53.1% had an unplanned pregnancy, and 96.9% had postpartum depression. There were statistically significant differences between suicide risk groups in all variables except age (p<0.05).
Comparison of demographic and clinical variables by suicide risk groups based on P4 screener
Table 3 presents the direct, indirect, component, and total effects of GLM mediation. The mediation model pathways were statistically significant. This shows that postpartum depression partially mediated the relationship between domestic violence experience and suicide risk (β=0.04, standard error [SE]=0.01, bootstrap 95% confidence interval [CI] 0.03–0.07, p<0.001). Additionally, postpartum depression plays a role in partially mediating the relationship between past depressive disorder and suicide risk (β=0.06, SE=0.01, bootstrap 95% CI 0.05–0.10, p<0.001). Postpartum depression completely mediated the relationship between unplanned pregnancy and suicide risk (β=0.04, SE= 0.01, bootstrap 95% CI 0.01–0.04, p<0.001).
Direct, indirect, component, and total effects of the GLM mediation model
Figure 1 shows the path diagram of the GLM mediation model. The mediation model represented domestic violence experience, past depressive disorder, and unplanned pregnancy as predictors of suicide risk through the mediation of postpartum depression.
Path diagram of the GLM mediation model. Mediation model for domestic violence experience, past depressive disorder, and unplanned pregnancy as predictors of suicide risk through the mediation of postpartum depression. Significant paths are presented by asterisks (*p<0.05; **p<0.01; ***p<0.001). GLM, generalized linear model.
DISCUSSION
This study analyzed the impact of domestic violence, past depressive disorder, and unplanned pregnancy on suicide risk by exploring the mediating pathways of postpartum depression.
This study found that 11.2% of women had a suicide risk during the first year postpartum. A previous study reported that the prevalence of suicide risk between pregnancy and the postpartum period was 5%–14% [2]. When comparing the current findings to those of previous studies, we need to be careful because of the different periods of postpartum or the operational definitions of postpartum depression and suicide risk. Suicidal behaviors are considered a significant issue in postnatal women because of their profound impact on the risk to the baby’s neuropsychological development, the woman’s life, and the family’s functioning [28]. Therefore, it is necessary to examine trends in suicide risk among mothers. It is necessary to establish a policy for continuous mental health monitoring of mothers at risk of suicide.
The current study found that domestic violence experience was a significant risk factor for suicide. According to prior studies, domestic violence experience was strongly associated with high-risk suicidal behaviors [6,29,30], which is consistent with the current findings. Another study reported the mediating effect of domestic violence on depression and suicide risk [31], Similarly, in Japan, women who experienced physical abuse had seven times the odds ratio of postpartum depression compared to those who did not experience abuse [32]. In addition, several studies have shown that mothers who have experienced past domestic violence might be significantly more likely to have a suicide risk [9,16,33,34].
The present study indicated that unplanned pregnancy had no direct effect on suicide risk; however, it did have a significant effect on postpartum depression. Our findings show that postpartum depression completely mediated the relationship between unplanned pregnancy and suicide risk. The present results are similar to the prior findings that women who get unplanned pregnancies compared to those who get planned pregnancies have a significantly higher risk of developing postpartum depression [11]. Furthermore, an unplanned pregnancy may have a negative impact on the mental health of mothers and children in the long term [10].
Our study indicates a link between past depressive disorder and suicide risk. Past depressive disorder is highly associated with suicide risk [10,11,28]. These findings are supported by prior results demonstrating that past psychiatric history is a consistent risk factor for suicidal behaviors and postpartum depression among women [35,36].
These findings showed that the prevalence of postpartum depression was 39.9%. A previous study in South Korea reported that 6 out of 10 mothers experienced depressive symptoms within the first 5 years of childbirth [37]. Other studies have reported that the prevalence of postpartum depression ranges between 26% and 84% in mothers [38]. These findings suggest that postpartum depression is an important risk factor and a mediator of maternal suicide. Moreover, consistent with previous research [16,39,40], the current findings have been found that suicidal high-risk mothers tend to have a higher proportion of unemployment, have lower levels of education, and belong to a lower socioeconomic status. Postpartum depression and suicidal risk may adversely affect women, infants, and family members in the long term and pose severe public health problems [41]. Therefore, more attention should be paid to women with risk factors for postpartum depression and suicidal risk.
However, in South Korea, it should be considered that few mothers who actually experienced postpartum depression received healthcare interventions. According to the 2015 National Survey on Fertility and Family Health and Welfare, only 2.6% of married women who gave birth were diagnosed with or had received counseling for postpartum depression [42]. The Health Insurance Review and Assessment Service reported that at least 10% (approximately 43,600) of mothers suffered from postpartum depression based on the number of births in 2013, and only about 0.6% of them received treatment [35]. Therefore, to prevent postpartum depression, it is necessary to change the familial and social awareness system to actively link mothers to appropriate treatment. In particular, since unplanned maternal pregnancy affects postpartum depression, an evaluation and education on maternal depression are needed from the period when doctors examine and counsel prenatal mothers. In addition, psychoeducation should be included in prenatal education programs to increase awareness and literacy regarding mental health [43,44].
Our study has several limitations. First, because our study was cross-sectional, we could not analyze temporal relationships or causality. Second, the questionnaire responses were self-reported, potentially suggesting the social desirability bias or retrospective recall bias. Third, we did not consider all confounding variables associated with suicide risk. Fourth, cases of domestic violence were limited to those who had experienced domestic violence in the past. In a follow-up study, an in-depth analysis should be conducted by adding questions such as experiences of violence during this pregnancy, type of domestic violence, perpetrator, period, and frequency. Fifth, since the data in this paper is from the first year postpartum, we could not conduct a comparative analysis of other periods. In follow-up studies, long-term data collection is required to analyze whether there is statistical significance between the first year postpartum and subsequent follow-up data.
Despite the limitations, several implications could be drawn from the current study. First, this study has implications in that the pathway mediated by postpartum depression between an unplanned pregnancy and suicide risk is significant. That is, unplanned pregnancy is important because of its pervasive and significant influence on postpartum depression for mothers in the first year postpartum. Accordingly, women with unplanned pregnancies should be screened for postpartum depression, and the early detection of postpartum depression can help prevent suicide. Second, the present study highlights the prevalence of suicide risk among women in the first year postpartum and the need for systematic suicide risk screening. By extension, the results also indicate the need to evaluate postpartum depression and suicide risk in mothers who experienced domestic violence, were diagnosed with depressive disorder by a doctor in the past or had unplanned pregnancies. This suggests that primary and secondary preventive strategies for the occurrence of suicide risk during the postpartum period must be formulated.
In conclusions, this study verified that domestic violence experience, past depressive disorder, and unplanned pregnancy could predict suicide risk mediated by postpartum depression. Exploring the predictors and mediating pathways of suicide risk could be a major strategy for preventing suicide and promoting mental health in women after childbirth. Therefore, we should consider the risk factors for suicide when conducting psychological screening and intervention for pregnancy up to the first year postpartum.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are not publicly available to protect participants’ information but are available from the corresponding author upon reasonable request.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: all authors. Data curation: Mi-Sun Lee, Jung Jae Lee. Formal analysis: Mi-Sun Lee. Funding acquisition: Hooyeon Lee. Investigation: Jung Jae Lee, Hooyeon Lee. Methodology: all authors. Project administration: Hooyeon Lee. Software: Mi-Sun Lee. Supervision: Hooyeon Lee. Validation: Mi-Sun Lee, Hooyeon Lee. Visualization: Mi-Sun Lee. Writing—original draft: Mi-Sun Lee. Writing—review & editing: Mi-Sun Lee, Hooyeon Lee.
Funding Statement
This study was supported by the National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health & Welfare, Republic of Korea (Grant number: HA21C0225).
Acknowledgements
None