Based on the results of our study, 17.81% of women could be classified as suffering from PPD (with accordance to the cutoff point of 12/13 EPDS). This is in line with the results obtained in the largest systematic literature review to date, where the global prevalence of PPD was estimated to be around 17.22%4. However, in the Polish context, our results showed a higher prevalence of PPD when compared with the results of the ongoing project “Next Stop: Mum” (7% when assessed by midwives and 12% during a telephone survey). Interestingly, that project also included an online platform and the results showed that PPD was indicated in 70% of the women who completed it. Nonetheless, when comparing data on the prevalence of PPD, we should consider the time and the method of data collection, as well as the studied population. When it comes to the time of data collection, in our study, the EPDS-based test was completed after an average of 30 days (SD 18.08) postpartum, while in “Next Stop: Mum” data was collected up to a year after delivery. Moreover, we used an online survey as a data collection method that limits direct contact (compared to data collection by midwives or a telephone survey), and thus may be a more reliable source of information, since, given the sensitivity of the issue, women may be less prone to directly share their feelings, concerns, and struggles for fear of being judged. Also, the online survey can give them a greater sense of anonymity. Given that the “Next Stop: Mum” project also collected data via an online survey, it should be noted that the authors themselves recommend caution in interpreting the indicated high prevalence of PPD. This is because the public online platform is mainly the source of help and information for individuals who may already be experiencing depressive symptoms, and therefore the data should not be considered as representative and generalized on the population of postpartum women5,35.
In general, our results underline the significant role of social support during pregnancy in reducing the risk of developing PPD independently of the numerous control variables, such as pregnancy complications, education, place of residence, breastfeeding, or type of delivery. We tested nine social support subscales from the BSSS, and for seven of them (with the exception of support-seeking), we confirmed our hypothesis that the higher levels of social support during pregnancy were significantly associated with a lower risk of PPD. In turn, the higher score of the need for support dimension was significantly associated with a higher risk of PPD. This applies to both perceived (subjective perceptions of the support available from others) and received (actually received, i.e., specific supportive activities) support, which are considered separate constructs that can demonstrate different relationships with variables of interest36. The strongest association was found for currently received instrumental and informational support. Unsurprisingly, higher socioeconomic status37 and Apgar scores were associated with a lower risk of PPD38,39. This study also confirmed the significant role of multiparity for PPD—those women for whom this was not their first birth had a lower risk of PPD than women who had never given birth before40.
To the best of our knowledge, this is the second overall and the first prospective study assessing the relationship between social support and the risk of PPD conducted among women living in Poland. The first study, using similar measurement methods (i.e., the EPDS scale with a cut-off point taken at 13 points, the BSSS, and regression analysis) was conducted in 2012 on a much smaller sample of 101 women who had given birth at the Department of Obstetrics of the Medical University of Gdansk19. Nevertheless, the profile of the study participants was similar—they were mostly women from large cities and with tertiary education, whose mean EPDS score was 7.92. In that study, the authors showed that dimensions of social support, such as perceived available instrumental support and need for support, had a significant impact on the risk of PPD. These results are only partially consistent with ours, as the directions of the relationship are the same, but the magnitude of the effect is smaller. It is also important to emphasize that in that study, social support was assessed after pregnancy, unlike in our study, where it was measured during pregnancy19. The observed differences in results compared to our study may be related to methodological differences, including study design, accounting for different confounding factors, and a smaller sample size19.
Considering PPD from an evolutionary perspective, it is necessary to refer to the fact that humans evolved as cooperative (communal) breeders—they rely on allomaternal help to care for their children and tend to exhibit cooperative childrearing behaviors in order to increase the offspring’s survival probability18,23. This emphasizes the need to involve members of the mother’s social network in raising and investing in the offspring. The evolutionary perspective, in a way, relieves the woman of complete responsibility for the childcare burden and shows the need for relatives and society to provide assistance to ensure the child’s proper development and the woman’s health23. As cooperative breeders, humans need extensive support, both during pregnancy and after childbirth (during the process of raising children) due to the significant energy costs of parental care. The lack of support leads to numerous mental health adversities for mothers, such as PPD, anxiety, and stress, which might result in decreased investment in the child41,42. In our study, we explored the effect of general social support, but a recent study suggests that it is important from whom this support is received, for example, whether from the husband or from other family members18. Therefore, to achieve a more comprehensive understanding of the impact of social support, future research should also consider such connections.
Lack of family or social support is a major problem associated with relatively recent socioeconomic changes, in particular, the transition from multigenerational to nuclear families. Nowadays, often it is the father who remains the only relative providing key support to the mother in raising the children18. However, it is common that a woman who cannot count on sufficient support from kins, seeks and finds support from other sources. As we demonstrated previously, during the COVID-19 pandemic, women who attended inpatient antenatal classes had significantly lower levels of anxiety (as measured by the STAI-State tool) compared to women who did not participate in such classes25. In addition, the same trend was observed for the occurrence of depression during pregnancy—women who attended the antenatal classes had a significantly lower score on the EPDS compared to women who did not participate25. Therefore, it could be expected that, in addition to educational function, antenatal classes also play a role in the psychosocial well-being of the pregnant woman. They provide an opportunity to obtain support at all its dimensions, mainly emotional and informational, through the exchange of information and experiences between parents-to-be so they can better prepare themselves for the upcoming changes. Moreover, a woman attending the birthing classes can expand her social network increasing received social support.
Although the strengths of our study are its sample size (932 women) and its prospective design, our results should be interpreted in light of certain limitations. First, no data were collected on pre-existing psychiatric conditions, such as depression or bipolar disorder, which are strongly associated with the risk of PPD31. Second, we have assessed PPD after an average of four weeks postpartum, however it is established that PPD can occur within 6 weeks after childbirth to even the second half of a child’s first year and given that our results may be underestimated. Third, the study sample was relatively homogenous—most women were from large cities, highly educated, and possessing high socioeconomic status. Fourth, our study relied on self-reported data collected through an online platform. It is possible then that participants’ ratings related to PPD symptoms could be underestimated or overestimated depending on individual characteristics43. Fifth, we collected data during the COVID-19 pandemic, and for this reason, our results should be considered with caution, as generalizing to another period may be difficult.
In summary, the results from this study demonstrate the crucial role of various kinds of support during pregnancy for maternal well-being, with a particular focus on their mental health. Pregnant women who receive greater support and are more satisfied with the level of support are less likely to develop PPD. These findings also highlight the need to identify women with low levels of support, as well as those with other risk factors, such as low socioeconomic status, younger age, or high-risk pregnancy status, due to the fact that they are more likely to experience depressive symptoms after delivery6,31.
Finally, our results can support the development of effective interventions focused on women’s emotional support in order to decrease risk of PPD. One such intervention could be education of pregnant women and their partners during antenatal classes focused on the importance of the role of loved ones’ support in minimizing postpartum complications and the occurrence of PPD.
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