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Research

Relation between place of residence and postpartum depression

Simone N. Vigod, Lesley A. Tarasoff, Barbara Bryja, Cindy-Lee Dennis, Mark H. Yudin and Lori E. Ross
CMAJ September 17, 2013 185 (13) 1129-1135; DOI: https://doi.org/10.1503/cmaj.122028
Simone N. Vigod
Women’s Mental Health Program (Vigod), Women’s College Hospital; Department of Psychiatry (Vigod, Dennis, Ross), University of Toronto; Women’s College Research Institute (Vigod, Dennis, Ross); Social and Epidemiological Research Department (Tarasoff, Ross), Centre for Addiction and Mental Health; Dalla Lana School of Public Health (Tarasoff, Ross), University of Toronto, Toronto, Ont.; Midwives Grey Bruce (Bryja), Owen Sound, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Dennis), University of Toronto, Toronto, Ont.; Department of Obstetrics and Gynecology (Yudin), St. Michael’s Hospital; Department of Obstetrics and Gynecology (Yudin), University of Toronto, Toronto, Ont.
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  • For correspondence: simone.vigod@wchospital.ca
Lesley A. Tarasoff
Women’s Mental Health Program (Vigod), Women’s College Hospital; Department of Psychiatry (Vigod, Dennis, Ross), University of Toronto; Women’s College Research Institute (Vigod, Dennis, Ross); Social and Epidemiological Research Department (Tarasoff, Ross), Centre for Addiction and Mental Health; Dalla Lana School of Public Health (Tarasoff, Ross), University of Toronto, Toronto, Ont.; Midwives Grey Bruce (Bryja), Owen Sound, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Dennis), University of Toronto, Toronto, Ont.; Department of Obstetrics and Gynecology (Yudin), St. Michael’s Hospital; Department of Obstetrics and Gynecology (Yudin), University of Toronto, Toronto, Ont.
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Barbara Bryja
Women’s Mental Health Program (Vigod), Women’s College Hospital; Department of Psychiatry (Vigod, Dennis, Ross), University of Toronto; Women’s College Research Institute (Vigod, Dennis, Ross); Social and Epidemiological Research Department (Tarasoff, Ross), Centre for Addiction and Mental Health; Dalla Lana School of Public Health (Tarasoff, Ross), University of Toronto, Toronto, Ont.; Midwives Grey Bruce (Bryja), Owen Sound, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Dennis), University of Toronto, Toronto, Ont.; Department of Obstetrics and Gynecology (Yudin), St. Michael’s Hospital; Department of Obstetrics and Gynecology (Yudin), University of Toronto, Toronto, Ont.
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Cindy-Lee Dennis
Women’s Mental Health Program (Vigod), Women’s College Hospital; Department of Psychiatry (Vigod, Dennis, Ross), University of Toronto; Women’s College Research Institute (Vigod, Dennis, Ross); Social and Epidemiological Research Department (Tarasoff, Ross), Centre for Addiction and Mental Health; Dalla Lana School of Public Health (Tarasoff, Ross), University of Toronto, Toronto, Ont.; Midwives Grey Bruce (Bryja), Owen Sound, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Dennis), University of Toronto, Toronto, Ont.; Department of Obstetrics and Gynecology (Yudin), St. Michael’s Hospital; Department of Obstetrics and Gynecology (Yudin), University of Toronto, Toronto, Ont.
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Mark H. Yudin
Women’s Mental Health Program (Vigod), Women’s College Hospital; Department of Psychiatry (Vigod, Dennis, Ross), University of Toronto; Women’s College Research Institute (Vigod, Dennis, Ross); Social and Epidemiological Research Department (Tarasoff, Ross), Centre for Addiction and Mental Health; Dalla Lana School of Public Health (Tarasoff, Ross), University of Toronto, Toronto, Ont.; Midwives Grey Bruce (Bryja), Owen Sound, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Dennis), University of Toronto, Toronto, Ont.; Department of Obstetrics and Gynecology (Yudin), St. Michael’s Hospital; Department of Obstetrics and Gynecology (Yudin), University of Toronto, Toronto, Ont.
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Lori E. Ross
Women’s Mental Health Program (Vigod), Women’s College Hospital; Department of Psychiatry (Vigod, Dennis, Ross), University of Toronto; Women’s College Research Institute (Vigod, Dennis, Ross); Social and Epidemiological Research Department (Tarasoff, Ross), Centre for Addiction and Mental Health; Dalla Lana School of Public Health (Tarasoff, Ross), University of Toronto, Toronto, Ont.; Midwives Grey Bruce (Bryja), Owen Sound, Ont.; Lawrence S. Bloomberg Faculty of Nursing (Dennis), University of Toronto, Toronto, Ont.; Department of Obstetrics and Gynecology (Yudin), St. Michael’s Hospital; Department of Obstetrics and Gynecology (Yudin), University of Toronto, Toronto, Ont.
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Article Figures & Tables

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    Table 1:

    Baseline characteristics of 6126 new mothers who completed the Maternity Experiences Survey, by location

    CharacteristicLocation; weighted % (95% CI)*
    Rural
    n = 1362
    Semirural
    n = 1225
    Semiurban
    n = 2187
    Urban
    n = 1352
    Maternal age, yr, mean (95% CI)29.7 (29.5–30.0)29.5 (29.2–29.8)29.5 (29.3–29.7)31.1 (31.0–31.3)
    Parity, primiparous39.6 (37.0–42.2)40.8 (37.9–43.6)49.4 (46.9–51.9)47.0 (45.5–48.6)
    Marital status, married or common-law92.7 (91.2–94.2)91.0 (89.4–92.6)88.6 (87.0–90.3)93.2 (92.2–94.2)
    Born in Canada89.0 (87.0–91.0)88.1 (86.0–90.2)87.2 (85.3–89.2)61.9 (59.9–63.9)
    Household income†
     Lowest10.5 (8.85–12.2)9.9 (8.12–11.6)12.0 (10.1–13.8)11.2 (9.82–12.5)
     Lower-middle23.9 (21.4–26.3)18.8 (16.4–21.3)21.5 (19.2–23.8)20.5 (18.7–22.3)
     Upper-middle37.6 (34.7–40.5)36.9 (33.9–40.0)36.6 (33.9–39.3)30.9 (28.9–32.9)
     Highest28.0 (25.2–30.8)34.4 (31.4–37.4)29.9 (27.3–32.5)37.4 (35.5–39.4)
    Education level
     Less than high school8.82 (7.3–10.4)9.87 (8.10–11.6)7.79 (6.42–9.16)5.94 (4.98–6.90)
     High school15.5 (13.4–17.6)16.2 (13.9–18.4)15.1 (13.0–17.1)10.8 (9.53–12.0)
     Some postsecondary19.0 (16.7–21.2)16.2 (14.0–18.3)16.9 (14.9–19.0)13.9 (12.5–15.4)
     Postsecondary56.8 (53.8–59.7)57.8 (54.8–60.8)60.2 (57.5–62.9)69.4 (67.5–71.2)
    History of depression16.4 (14.1–18.6)16.4 (14.2–18.6)18.7 (16.6–20.9)13.5 (12.0–14.9)
    Maternal health, excellent or very good73.3 (70.7–75.8)73.1 (70.4–74.8)75.1 (72.7–77.5)70.7 (68.8–72.6)
    Stress
     No. of life stressors in last 2 yr, mean (95% CI)1.25 (1.17–1.34)1.37 (1.27–1.46)1.38 (1.30–1.47)1.19 (1.13–1.25)
     Abuse in last 2 yr9.82 (8.21–11.4)12.6 (10.6–14.5)13.1 (11.3–14.9)9.94 (8.79–11.1)
    Labour and delivery complications14.3 (12.2–16.4)14.4 (12.3–16.5)14.6 (12.7–16.6)14.9 (13.4–16.3)
     Preterm birth6.06 (4.62–7.50)6.49 (4.90–8.08)6.67 (2.30–8.04)6.15 (5.13–7.18)
     Infant in NICU10.8 (8.98–12.5)11.0 (9.06–12.8)14.8 (12.8–16.8)13.0 (11.6–14.4)
    Social support
     Pregnancy
      None or a little of the time4.52 (3.28–5.76)4.05 (2.82–5.28)3.52 (2.54–4.51)6.21 (5.18–7.24)
      Some of the time6.65 (5.21–8.10)6.87 (5.29–8.46)6.25 (4.91–7.59)9.21 (8.00–10.4)
      Most of the time27.9 (25.2–30.6)30.0 (27.1–32.9)27.4 (24.9–29.9)31.4 (29.5–33.4)
      All of the time60.9 (58.0–63.8)59.1 (56.0–62.1)62.8 (60.1–65.5)53.1 (51.1–55.2)
     Postpartum
      None or a little of the time4.51 (3.32–5.70)5.34 (3.89–6.79)4.82 (3.67–5.96)6.53 (5.50–7.55)
      Some of the time9.48 (7.74–11.2)8.51 (6.84–10.2)8.42 (6.82–10.0)12.2 (10.8–13.6)
      Most of the time31.8 (29.0–34.5)33.4 (30.5–36.3)31.2 (28.6–33.9)34.1 (32.1–36.1)
      All of the time54.3 (51.4–57.1)52.8 (49.7–55.9)55.5 (52.8–58.3)47.2 (45.1–49.3)
    • Note: CI = confidence interval, NICU = neonatal intensive care unit.

    • ↵* Unless otherwise stated.

    • ↵† Household income is reported by quartile.

    • View popup
    Table 2:

    Postpartum depression among 6126 new mothers who completed the Maternity Experiences Survey, by score on the Edinburgh Postnatal Depression Scale*

    CharacteristicEPDS ≥ 13,† weighted % (95% CI)EPDS score, weighted mean (95% CI)
    Location‡
     Rural, n = 13626.07 (4.66–7.48)4.94 (4.68–5.20)
     Semirural, n = 12256.96 (5.39–8.53)5.05 (4.78–5.33)
     Semiurban, n = 21875.31 (4.01–5.61)5.00 (4.77–5.24)
     Urban, n = 13529.16 (7.50–10.40)5.61 (5.41–5.81)
    Census metropolitan and census agglomeration areas
     Rural and small town, n = 12486.98 (5.48–8.48)5.03 (4.77–5.30)
     Large urban centre n = 48787.56 (6.75–8.37)5.33 (5.19–5.46)
    Rural and small-town areas, by metropolitan influence
     Strong, n = 3165.50 (2.94–8.06)5.18 (4.73–5.64)
     Moderate, n = 4447.05 (4.53–9.58)4.91 (4.47–5.35)
     Weak, n = 4408.31 (5.60–11.00)5.14 (4.68–5.60)
     None, n = 48NR4.06 (2.78–5.33)
    • Note: CI = confidence interval, EPDS = Edinburgh Postnatal Depression Scale, NR = not reportable.

    • ↵* Differences between groups were evaluated using χ2tests for categorical variables and independent t test or analysis of variance (ANOVA) for continuous variables.

    • ↵† EPDS ≥ 13 represents likelihood that a woman has postpartum depression.

    • ↵‡ p < 0.05 for differences between groups for both EPDS ≥ 13 and EPDS mean score.

    • View popup
    Table 3:

    Multivariable model for the relationship between population area size and postpartum depression (EPDS ≥ 13)

    Main exposure variableOdds ratio (95% CI)
    Unadjusted
    Population area size
     UrbanRef
     Semiurban0.56 (0.41–0.75)
     Semirural0.74 (0.56–0.99)
     Rural0.64 (0.48–0.85)
    Adjusted*
    Population area size
     UrbanRef
     Semiurban0.60 (0.42–0.84)
     Semirural0.90 (0.65–1.24)
     Rural0.80 (0.57–1.11)
    Parity, primiparous0.82 (0.64–1.05)
    Country of origin (Canadian-born v. non-Canadian-born)0.51 (0.39–0.67)
    Household income
     LowRef
     Low-middle0.88 (0.57–1.20)
     Middle-high0.82 (0.60–1.29)
     High0.80 (0.54–1.17)
    History of depression (v. no history)2.11 (1.60–2.79)
    Life stressors1.29 (1.20–1.38)
    Interpersonal abuse1.46 (1.06–2.00)
    Maternal health
     Good/fair/poorRef
     Excellent/very good0.40 (0.31–0.51)
    Postpartum social support
     LowRef
     Low-middle0.67 (0.45–1.00)
     Middle-high0.36 (0.25–0.52)
     High0.15 (0.10–0.23)
    • Note: CI = confidence interval, EPDS = Edinburgh Postnatal Depression Scale, ref = reference.

    • ↵* All variables were adjusted for all covariates in the model. We included variables that are known predictors of postpartum depression (history of depression, life stressors in past 2 yr, interpersonal abuse in last 2 yr, social support, maternal self-reported health) or those for which there were major differences between groups for possible prognostic variables (parity, country of origin, household income). Hosmer–Lemeshow for goodness of fit of the multivariable model X2 = 8.43, p = 0.4. All variance inflation factors < 1.30.

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Canadian Medical Association Journal: 185 (13)
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Relation between place of residence and postpartum depression
Simone N. Vigod, Lesley A. Tarasoff, Barbara Bryja, Cindy-Lee Dennis, Mark H. Yudin, Lori E. Ross
CMAJ Sep 2013, 185 (13) 1129-1135; DOI: 10.1503/cmaj.122028

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Relation between place of residence and postpartum depression
Simone N. Vigod, Lesley A. Tarasoff, Barbara Bryja, Cindy-Lee Dennis, Mark H. Yudin, Lori E. Ross
CMAJ Sep 2013, 185 (13) 1129-1135; DOI: 10.1503/cmaj.122028
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