INTRODUCTION

Pregnancy and the postpartum period are associated with women’s physical and emotional disturbance, and in one in five cases, leads to the development of postpartum depression (PPD)¹. The global prevalence of PPD is about 17.7%, but this can vary by nation². Cultural and economic differences play a significant role in PPD³, with a prevalence of 10% to 15% in Western countries and 18.6% in low- and middle-income countries⁴. Ethnic inequalities also matter⁵. In addition, non-indigenous, indigenous, and immigrant women within high-income countries have significantly different PPD scores⁶. Despite the high prevalence of PPD worldwide, many cases are not diagnosed and remain untreated, resulting in negative consequences for mother and child⁷. Maternal mental health is critical for developing a child’s healthy brain and physical, social, and emotional well-being in the first 1001 days, from conception to two years.

There are several predictors of postpartum depression described in the literature. The most significant contributors to PPD are antenatal depression and anxiety, previous psychiatric illness, poor marital relationship, being young, being unmarried, negative attitude towards pregnancy, lack of social support, and stressful life events^8,9. These events can include natural disasters, growing up with divorced parents, losing a loved one unexpectedly, and experiencing emotional or physical abuse¹⁰. Studies also suggest that women with a prior pregnancy loss were 35% more likely to require post-partum psychiatric treatment¹¹. Furthermore, bereaved women had nearly 4-fold higher odds of having a positive screen for depression¹². The prevalence of PPD in women was relatively high during COVID-19¹³, and the pandemic highlighted existing barriers to the treatment of peripartum mood disorders¹⁴. Additionally, the prevalence of perinatal depressive disorders was 24.2% among all women who are migrants and 32.5% among displaced people¹⁵.

In Ukraine, one in three people experienced at least one mental health problem in their lifetime; depression was prevalent in 6% of the general population; apparent gender differences are also seen – anxiety disorders and depression are more prevalent among women compared to men¹⁶. Ukraine has a highly centralized single-payer healthcare system, where healthcare is free for everyone¹⁷. In this system, mental health treatment was available in big psychiatric institutions with limited access to services at the primary level in the community. In 2017, Ukraine started reforming the health system by changing the government’s financial guarantees of public medical services¹⁸. The changes made in the mental health system led to significant budget cuts for most state psychiatric hospitals. This resulted in mental health services being provided through primary healthcare and community services. However, this created challenges for the primary healthcare system as there was limited training and managing responsibilities between professionals¹⁹. Although evidence-based interventions for mental health treatment are slowly being integrated into service provision, mental healthcare for women during their perinatal journey is still a concern. Several professionals such as family doctors, outpatient and inpatient gynecologists, and breastfeeding consultants provide services during this period. However, only a few of them have received training in perinatal mental health and can respond to women’s mental health needs. Therefore, many women seek help from non-governmental organizations in their local communities or online, relying on peer-to-peer support.

There is limited epidemiological data on maternal mental health in Ukraine. However, some information is available about displaced mothers. A significant fraction of the Ukrainian population has been displaced by force²⁰, with relocation of civilian women and children^21-23. The consequences of migration can be particularly damaging for mothers and babies. Studies have shown that the trauma of forced displacement can have long-term adverse effects on mental health, leading to an increased risk of depression and post-traumatic stress disorder²⁴. Displaced pregnant women in Ukraine had a 34.8% frequency of post-traumatic stress disorder²⁵, 3.3 times higher reactive anxiety, and 2.6 times higher personal anxiety²⁶. There is also evidence indicating that forcefully displaced populations have an increased risk of reactive and personal anxiety, depressive manifestations, autonomic dysfunction, insomnia, and premature termination of pregnancy²⁷. The ongoing research aims to investigate the impact of forced displacement on perinatal mental health, including anxiety, post-traumatic stress, depression, and birth trauma symptoms²⁴. However, the other factors associated with PPD among Ukrainian mothers are not well understood in the literature. The purpose of this study is to understand the association between PPD and various potentially stressful life events, such as breastfeeding difficulties, child death, unresolved pregnancy, forced displacement, COVID-19 pandemic lockdown, and marital and financial status, among Ukrainian women.

METHODS

RESULTS

Table 1 presents the characteristics of study participants. This analysis used the final sample of 1634 women who participated in the online survey during their perinatal period.

Almost all survey participants (93.7%) were married, only 4.4% were divorced/separated/widowed, and 1.9% were single. Assessing their financial difficulties, only 11.7% respondents were able to make significant savings; 35.8% to buy some expensive things or save money; 32.9% had enough money for food, clothes and could save a little; 18% of women have enough money just for food, and 1.7% did not have enough money even for food. About 4.6% of women recognized themselves as internally forcefully displaced. About 13% of women reported severe troubles with breastfeeding; 28.4% had a little trouble and resolved it with help. More than one-third of respondents (37.8%) had a little trouble and resolved it without any help. About 20.8% did not have trouble with breastfeeding at all. Only 2.3% of respondents experience the death of a child. A little bit less than half of respondents (45.2%) had a pregnancy that did not end in a live birth because of a miscarriage, an abortion, or the child was stillborn. While 54.8% did not have such experience with unresolved pregnancy. Only 3.1% of respondents recognize themselves and their family members as those who were affected by COVID-19. The pandemic lockdown made 4.4% of study participants constantly feel anxious/afraid about the COVID-19 pandemic, and 12.1% felt anxious/afraid most days but could find ways to distract themselves. More than half (54.4%) felt anxious/afraid sometimes. About 13.9% of the sample described themselves as hardly ever anxious/afraid, and 15.2% indicated they were not anxious/afraid.

We found that 39.0% of respondents scored ≥13 on the EPDS, which indicates postpartum depression symptoms. Valid EPDS scores ranged from 0 to 30 with a mean of 11.41 (SD=6.09). The data for PPD scores is approximately normally distributed with skewness of 0.407 and kurtosis of -0.319.

In the independent sample t-test, we found that mean EPDS scores for 1528 women who did not experience forced displacement (mean=11.44, SD=5.99) were significantly higher than mean EPDS scores for the 74 women who experienced forced displacement (mean=9.31, SD=5.69). The results indicate that women who experienced forced displacement have a PPD score of 2.20 less than women who have not experienced forced displacement [t(1606)=3.05, p<0.01] with a moderately small size effect (Cohen’s d=0.363).

In the chi-squared test, we found that there was a significant relationship between financial difficulties and pandemic lockdown (χ²=66.34, p<0.001), with a weak effect (Cramer’s V=0.101). Those who can afford to buy some expensive things or save money hardly ever feel anxious/afraid about pandemic lockdown (41.7%, n=93). Women who had enough money for food and clothes but could not buy expensive things also felt anxious/afraid about pandemic lockdown most days (39.5%, n=77). The number of those who could make savings and did not feel anxious/afraid about the pandemic lockdown at all was small (n=32). Also, a small number of women did not have enough money even for food and felt constantly anxious/afraid about the pandemic lockdown (n=8). Even though this is the smallest group of people (those who selected ‘we do not have enough money for food even’), almost one-third were always afraid, while for all the richer groups, less than 7% reported being always afraid.

Based on one-way between-subjects ANOVA, Welch’s test indicated a significant difference in women’s PPD scores based on their marital status [F (2;5836)=3.23, p<0.05], with a small size effect (η²=0.005). Divorced/separated/widowed women had the highest level of postpartum depression (mean=13.25, SD=7.29). A Games-Howell post hoc test did not indicate significant differences in depression scores between these groups.

In non-parametric correlation, we found a small positive correlation between women’s PPD scores and household income per month (Spearman’s rho=0.112, p<0.001). The relationship was positive, indicating the household income per month increased, and so did PPD scores. Women who had higher household income were more likely to experience postpartum depressive symptoms (Table 2).

The multivariate logistic regression model was statistically significant [χ²(15)=59.67, p<0.01]. The model explained 12.5% (Nagelkerke R²) of the variance in postpartum depression and correctly classified 61.0% of cases. The predictors are presented in Table 3. Significant breastfeeding characteristics included having so much trouble that women were not able to breastfeed, having a little trouble that was resolved with help, and having a little trouble that was resolved without any help. Women having so much trouble that they were not able to breastfeed were 3.5 times more likely to have postpartum depression than women who had no trouble at all. Women having a little trouble that was resolved with help were 2.0 times more likely to have postpartum depression. Women having a little trouble that was resolved without any help were 2.1 times more likely to have postpartum depression.

Significant pandemic characteristics are feeling anxious/afraid not at all, hardly ever feeling anxious/afraid, feeling anxious/afraid sometimes, and feeling anxious/afraid most of the days. Women who were afraid all the time were five times more likely to experience PPD compared to women who did not feel afraid at all, and 2.5 times more compared to women who felt anxious/afraid most of the day. Significant financial difficulties were described as being unable to buy expensive things or save money. Women who did not have enough money for food were five times more likely to experience PPD compared to women who could afford to buy some expensive things or save money. The unresolved pregnancy, death of a child, COVID-19 affection, and forced displacement were not associated with postpartum depression.

DISCUSSION

In this study of pregnant Ukrainian women and mothers who gave birth during 2016–2020, we found: 1) that the prevalence of PPD in this sample was higher compared to the average PPD scores in LMICs; 2) a positive association between PPD scores and such potential stressful life events as breastfeeding difficulties, pandemic lockdown, and financial difficulties; and 3) no association between PPD scores and unresolved pregnancy, death of a child, being affected by COVID-19, and forced displacement.

We found that the prevalence of postpartum depression among women participating in the survey was higher compared to the prevalence of postpartum depression among women in LMICs, where it is considered to be 18.6%⁴. The variability in PPD prevalence might be caused by cross-cultural variables, differences in perception of mental health, and its stigma³⁰. According to Quirke et al.³¹, there is a high lack of knowledge and understanding about most types of mental illnesses among adults in Ukraine and a high degree of social distance. There are beliefs that seeking help may be a sign of weakness. It can be explained that the image of mental health has been associated with political abuses in psychiatry and stigmatizing attitudes, and discriminating practices against people with any form of disability³². However, women in our study were invited to participate in it by non-governmental organizations providing support for new mothers. They might have been more aware of maternal mental health compared to the general population.

The prevalence of PPD symptoms (39%) among females within our sample is in the range of prevalence of PPD (from 0% to 60%) reported in the literature on PPD scores in non-Western countries³⁰. While the studies might use different reporting styles³³, the Edinburgh Postnatal Depression Scale (EPDS) has been widely used for detecting perinatal depression and research for over 30 years and has been translated into 60 languages, including Ukrainian. While it is the most popular screening tool, there is a discussion that it is misused, and its authors recommend future studies to evaluate its use and validity in naturalistic community populations and to determine the psychometric properties and practical usefulness of the EPDS when completed online²⁹. Despite using EPDS in our online study, women who participated in it were at different stages of their perinatal journey – from being pregnant to being a mother of children aged 0–5 years – and talked about their symptoms during the study. We collected data at the pandemic’s beginning, which may have affected the study results. Chen et al.³⁴ highlighted that the pooled prevalence of PPD during the COVID-19 pandemic was 34%, which is much higher than those from previous research during the non-pandemic period.

Our second finding contributes to the literature on predictors of PPD symptoms. Breastfeeding difficulties, pandemic lockdown, financial difficulties, divorce, separation, or death of a spouse were all found to be risk factors for PPD, and this is consistent with literature review and meta-analysis of the prevalence and risk factors associated with PPD during the COVID-19 pandemic³⁴.

The association between breastfeeding difficulties and PPD symptoms is in line with previous studies before and during the pandemic³⁴. However, while the association between breastfeeding difficulties and PPD has been found previously, numerous studies on the topic of breastfeeding and postpartum depression have come to contrasting conclusions as to why this association exists³⁵. Some studies indicate the importance of educating nurses, family doctors, and family members to reduce the risk of postpartum depression in line with the UNICEF standards³⁶. Other studies explain that the stress associated with medical and societal pressures to breastfeed could impact mothers’ mental health.

We found an association between PPD scores and the pandemic lockdown that was in line with the Chen et al.²⁶ literature review and meta-analysis. Women reported that they were anxious/afraid during the pandemic lockdown, which can explain their financial situation. In this study, we found a very strong association between poverty and the mental health impacts of lockdowns. Every fifth respondent needed to meet the subsistence level for a mother and one child. To compare, the subsistence level in 2020 was UAH 2481 (US$91) for one adult and UAH 2100 (US$78) for a child under six years old. However, more research is needed as the number of household members and income per person may vary.

An unresolved pregnancy, death of a child, being affected by COVID-19, and forced displacement were not associated with postpartum depression in our study. Also, there was nothing about this in the Chen et al.³⁴ review. We hypothesize that internally forcefully displaced women might be more resilient and resistant to stress, and more research is needed to explore this possibility. Additional study is needed to examine the association between PPD and COVID-19 affections. Because the data were collected at the beginning of the pandemic and was affected by COVID-19, it might be understood differently since the cases increased across Ukraine during the pandemic and inadequately sampled during the internal forced displacement.

CONCLUSIONS

This study is the first of its kind to examine the factors that contribute to postpartum depression (PPD) among Ukrainian women. Our findings suggest that Ukrainian mothers experience symptoms of PPD that are associated with potentially stressful life events such as difficulties with breastfeeding, pandemic lockdown, financial struggles, and divorce/separation/death of a spouse. However, we did not find associations between PPD scores and unresolved pregnancy, death of a child, being affected by COVID-19, or forced displacement. It is important to note that multiple stressors may interact and negatively impact maternal mental health. Therefore, further research is needed to understand the effects of various stressors, particularly during forced displacement. This study highlights the importance of understanding the predictors of postpartum depression among Ukrainian mothers, which should be included in the training and continuing professional development of various professionals in Ukraine. This includes family doctors, outpatient and inpatient gynecologists, and breastfeeding consultants who aim to address the mental health needs of women.