Introduction

   Pregnancy, as a period of developmental crisis, is accompanied by physiological, psychological, and social changes that begins with fertilization and ends with childbirth (1). The biopsychosocial changes experienced by women during pregnancy increase the susceptibility to depression. Some psychological factors, such as anxiety during pregnancy, a previous history of depression, and other psychiatric illness and conflicting feelings towards pregnancy, can affect prenatal depression (2, 3). Lack of a partner, marital problems, living alone, divorce, poverty, absence or inadequacy of social support, social isolation, domestic violence, prior physical, emotional, and sexual violence, and use of cigarettes, alcohol, and substances are among the factors that prepare the ground for prenatal depression (3-8).

   According to the World Health Organization, one per five females in developing countries and one per ten females in developed countries experience severe depressive symptoms during pregnancy or postpartum period (9). In a systematic review, the prevalence of prenatal depression in high-income countries was reported to be 7-20%, whereas it was reported to be ≥ 20% in low- and middle-income countries (10). Based on the evidence, prenatal depression has the prevalence rates of 21.2%, 39.0%, 23.0%, and 24.5% in Brazil (4), South Africa (11), Ethiopia (12), and Nigeria (13), respectively. The prevalence of prenatal depression in Turkey has been reported to be between 27.3% and 75.0% (6, 14-16).

   Maternal mortality, morbidity, and suicide rates are increasing in women who are diagnosed with depression in the prenatal period and receive no treatment (17). In addition, many studies have indicated that prenatal depression is an important risk factor for postpartum depression. Furthermore, 50.0% of the women suffering from depression during pregnancy also suffer from depression in the postpartum period (3, 17, 18). It has been determined that pregnant women who are diagnosed with depression also have problems in their social relationships and have fears about being a parent (17). Regarding this, the lack of precautions during pregnancy and continuation of depression can increase the risk to the fetus. This negatively affects the mother-child relationship, thereby causing problems in the development of motor skills and language development in the neonate, as well as increasing gastrointestinal and respiratory tract infections. These children are also reported to experience affective and cognitive problems in the following years (17, 18).

   Early diagnosis and prevention of psychosocial reactions during pregnancy is very important for maternal and fetal health. Based on the literature review, no study has addressed the evaluation of the psychosocial health of pregnant women at the risk of depression in the prenatal period in each trimester. Regarding this, the present study was an attempt to provide data about psychosocial health and risk of depression in each trimester of pregnancy and contribute to the literature. With this background in mind, the current study was conducted to determine the relationship between psychosocial health status and risk of depression in pregnant women in Turkey.

Materials and Methods

   This descriptive-analytic study was carried out on 792 pregnant women referring to the Outpatient Clinic of the Meram Medical Faculty, Necmettin Erbakan University, Turkey, from 22 March to 30 June 2016. This hospital was chosen as it admits a high number of pregnant women with different sociodemographic characteristics. The data were collected by the researcher using the face-to-face interview method during March 22 to June 30 in 2016.   It took 15-20 min for each subject to collect the data.

   No study in Turkey has separately evaluated the frequency of the symptoms of depression and psychosocial health in each trimester during pregnancy. One study evaluated the prevalence of depression during pregnancy. The sample size was calculated based on a study reporting the rates of depression as 7.1%, 59.3%, and 33.6% in the first, second, and third trimesters, respectively (5). Sample size was determined using 95% confidence level and a relative precision of 5% using a table titled "Estimating the Proportion in a Society with Specific Accuracy" presented in a book (19). According to the mentioned study, depression had the risk rates of approximately 5%, 60%, 35% in the first, second, and third trimesters, and the sample sizes were 73, 369, and 350, respectively. The pregnant women who attended the outpatient clinic and met the inclusion criteria were selected using haphazard sampling, as a non-probability sampling method.

The inclusion criteria were: 1) willingness to participate in the study, 2) literacy, 3) age of ≥ 18 years, 4) posession of a healthy single fetus, 5) pregnancy without treatment, and 6) married status and living with the spouse. On the other hand, the exclusion criteria were: 1) current psychiatric illness and treatment history (based on subjects’ statements), 2) a chronic disease, 3) pregnancy-related systemic problems, 4) preterm labor and premature rupture of membranes (based on subjects’ statements and clinical diagnostic status).

   All procedures in the study were performed in accordance with the ethical standards of the institutional committee, the 1964 Helsinki Declaration and its later amendments, or comparable ethical standards. The project was approved by the Ethics Committee of Necmettin Erbakan University of Medical Sciences, Konya, Turkey (Code: 2016/466). Written informed consent was obtained from all the participants. In addition, the participants were informed about the possibility of leaving the project at any stage.

   The data were collected using a researcher-made questionnaire designed based on the literature (4, 8, 20-24), Pregnancy Psychosocial Health Assessment Scale (PPHAS) (25), and Edinburgh Postnatal Depression Scale (EPDS) (26). The sociodemographic characteristic questionnaire included questions about age, educational status, employment status, age at marriage, monthly income, family type, and spousal age, educational status, and employment status. In terms of obstetric characteristics, the questionnaire inquired about the current gestational week, abortion and curettage history, gender of the baby, desired gender of the baby, status of regular gestational control, and received prenatal care.

The PPHAS was developed by Yildiz (25) and validated to evaluate psychosocial health as a whole in pregnancy. This scale consists of 46 items and 6 sub-dimensions. The subgroups (factors) indicate the presence of problems in terms of situations affecting psychosocial health. The scale is a five-point Likert-type measurement tool (ranging from 1 to 5) with the minimum and maximum scores of 46 and 230, respectively. In this questionnaire, 29 items are scored inversely. The six sub-dimensions of this instrument cover pregnancy and partner-related characteristics (13 items), characteristics of anxiety and stress (8 items), characteristics of domestic violence (7 items), psychosocial support needs (4 items), family characteristics (4 items), and features belonging to physical and psychosocial changes related to pregnancy (6 items).

   In this instrument, the total score is divided by the number of items, the mean item score is determined, and the obtained result is between 1 and 5. The reduction of total score from 5 to 1 indicates the presence of a problem at that level in psychosocial health during pregnancy; accordingly, point 1 means that psychosocial wellbeing is very bad. The assessment is the same for all sub-dimensions. The Cronbach’s alpha coefficient of the scale has been reported as 0.93 (25). In the present study, the Cronbach's alpha coefficient of the scale was found to be 0.90.

   The EPDS was developed by Cox et al. (1987) to measure the risk of depression in pregnant and postpartum women and measure the level and change of depressive symptom intensity (27). This scale has been reported to have good validity and reliability in pregnancy and postpartum depression studies; accordingly, it has been used in many countries to date. The validity and reliability of the Turkish version of the EPDS was evaluated by Engindeniz et al. (2000). The internal consistency coefficient (Cronbach's alpha) of the EPDS was 0.79 with a cut-off score of 12/13.

   The EPDS is a scale that focuses on cognitive and emotional symptoms rather than the somatic symptoms of depression. It contains a total of 10 items and provides a four-point Likert-type measurement. Each item is scored across a range of 0-3. The total score of the scale is obtained by adding the item scores. In this instrument, a score of ≤ 12 is indicative of a risk-free group, whereas a score of ≥ 13 is representative of the risk group (26). The Cronbach's alpha coefficient of the EPDS in this study was found to be 0.81. 

   To analyze the data, descriptive statistics, Mann-Whitney U test, and Kruskal Wallis test were run using in SPSS software, version 22. In addition, descriptive statistics were evaluated using number, percentage, mean, and standard deviation. The Kolmogorov-Smirnov test was also used for the normality test. A p-value less than 0.05 was considered statistically significant.

Results

   The sociodemographic and fertility characteristics of the pregnant women are presented in Table 1. Table 2 presents the mean EPDS scores in the pregnant women according to trimesters, as well as the frequency of depression symptoms. The risk of depression in pregnant women (EPDS≥13) was found to be 28.2%, and the mean score was 9.41±4.81. In addition, the mean total score of the PPHAS was estimated at 4.05±0.45.

   When the mean EPDS scores of the pregnant women were analyzed according to their sociodemographic and fertility characteristics, it was found that the mean EPDS scores did not differ with respect to educational level, employment status, family type, spousal employment status, history of abortion, history of curettage, gestational week, neonatal gender, and status of regular gestational control (P˃0.05).