Relationship of Postpartum Depression with Spiritual Well-Being and Some Demographic Variables among Women Referring

Introduction ostpartum depression is a disorder affecting individuals’ social ability accompanied with extreme complications in the mother, neonate, and family of the patient (1). The results of a systematic review indicated that the mean of the prevalence of postpartum depression in Iran is 28.7% (2). On the other hand, the prevalence of postpartum depression in different countries is reported to be within the range of 5-40% (3). The symptoms of postpartum depression include depressed mood, irritability, insomnia, and frequent dizziness (4). Despite the controversies surrounding the definition of postpartum depression, the diagnostic and statistical manual of mental disorders describes this disorder as a major event occurring in the first four postpartum weeks (5). According to the available evidence in Iran, the risk factors for postpartum depression are the history of depression, genetic predisposition, low maternal level of education, lack of social support, and occupational status of women (6). Spiritual well-being is considered one of the important dimensions of well-being, which P Abstract


Introduction
ostpartum depression is a disorder affecting individuals' social ability accompanied with extreme complications in the mother, neonate, and family of the patient (1).The results of a systematic review indicated that the mean of the prevalence of postpartum depression in Iran is 28.7% (2).On the other hand, the prevalence of postpartum depression in different countries is reported to be within the range of 5-40% (3).The symptoms of postpartum depression include depressed mood, irritability, insomnia, and frequent dizziness (4).Despite the controversies surrounding the definition of postpartum depression, the diagnostic and statistical manual of mental disorders describes this disorder as a major event occurring in the first four postpartum weeks (5).According to the available evidence in Iran, the risk factors for postpartum depression are the history of depression, genetic predisposition, low maternal level of education, lack of social support, and occupational status of women (6).Spiritual well-being is considered one of the important dimensions of well-being, which provides a coherent and integrated relationship between internal forces (7).Evidence shows that spiritual well-being can improve or undermine mental health and lead to contradictory results in this regard (8,9).Therefore, researchers have conducted extensive studies to examine the relationship between spiritual health and various aspects of life (10).The results of a study conducted by Smith and Murray indicated a reverse relationship between spiritual well-being and symptoms of postpartum depression (11,12).However, some studies indicate a direct relationship between the two-mentioned variables (13,14).Moreover, the study of spiritual well-being and depression is culturally sensitive, meaning that the investigation of these variables requires localized studies.The present study aimed to evaluate the relationship between spiritual well-being and postpartum depression of women referring to health centers.Moreover, it is important to consider psychological factor as one of the significant risk factors for the incidence of postpartum depression, as well as the variability of postpartum depression factors and spiritual well-being variables with respect to the investigated culture.Therefore, with regard to the lack of relevant studies in this research area and importance of postpartum depression, this study aimed to determine the relationship of postpartum depression with spiritual wellbeing and some demographic variables in women referring the health centers affiliated to Qom University of Medical Sciences, Qom, Iran, in 2017.

Methods
This descriptive-correlational study was performed on all the women referring to health centers affiliated to Qom University of Medical Sciences.In total, 196 eligible women were selected through a multistage sampling method.In doing so, all healthcare centers affiliated to Qom University of Medical Sciences were selected at first, followed by a random selection of subjects from these centers.The sample size was calculated with 95% confidence interval and 10% margin of error.The study population composed of 200 individuals based on the obtained score of the correlation coefficient between spiritual wellbeing and depression among patients suffering from cancer (r=0.23) in a study conducted by Khazri et al. (15).
The inclusion criteria were 1) willingness to participate in the study, 2) Islamic religion, 3) age range of 18-45 years, 4) a maximum of one month postpartum, 5) no complication in delivery process, 6) parity, 7) no need for special care, 8) no use of psychiatric medication (e.g., antidepressants and antiepileptics), 9) no history of depression and chronic diseases (e.g., cardiovascular disease, diabetes, and cancer), 10) no chronic disease in immediate relatives (e.g., malignant cancer), 11) and no history of mental distress (e.g., death of family members, severe traffic accidents, addiction in the family) in the last six months.
After the approval of the Ethics Committee of Qom University of Medical Sciences (IR.MUQ.REC.1397.004)and submission of a reference letter to the healthcare centers, sampling was carried out through observing the ethical considerations of the Declaration of Helsinki (16).First, the participants completed a demographic questionnaire, including age, body mass index [BMI], gravidity, type of delivery, history of abortion and stillbirth, gender of the infant, occupational status, level of education and physical activity.Afterwards, they completed the Edinburgh Postnatal Depression Scale (EPDS) and Spiritual Health Questionnaire (SHQ) from the perspective of Islam.
The EPDS was designed by Cox et al. in 1978.This scale has 10 multiple-choice questions, and each question is allocated a score within the range of 0-3.In this regard, the lowest and highest scores of the scale are 0 and 30, respectively.According to the results, scores≥13 confirm the diagnosis of depression, whereas scores within the range of 0-9 demonstrate the lack of depression.It is worth noting that scores within the range of 10-12 indicate a borderline score between the presence and absence of postpartum depression (17).Montazeri  To score the behavioral dimension, score 1 is allocated to the alternative of never, whereas the scores 2,3,4, and 5 are given to the alternatives of rarely, sometimes, frequently, and always.In addition, the lowest and highest scores are 48-240, respectively.Moreover, the higher the obtained scores in the questionnaire, the higher the level of spiritual well-being.
In addition, the scores in the range of show low levels of spiritual well-being, while the scores of 116-240 demonstrate a high level of spiritual well-being.In a study conducted by Amiri et al., the validity of this questionnaire was approved using content validity method.Moreover, the reliability of the present tool was evaluated by Amiri et al. at the Cronbach's alpha of >0.7 and was confirmed at the same level using the test-retest (19).
Data analysis was performed in SPSS (version 22) using descriptive (mean, standard deviation, and frequency) and analytical (independent t-test, one-way ANOVA, and Pearson's correlation coefficient) statistics.In addition, P-value less than 0.05 was considered statistically significant.
Data collected from four subjects were incomplete.Therefore, the statistical analysis was performed on 196 women referring to health centers affiliated to Qom University of Medical Sciences.

Result
In this study, the mean age of the participants was 28.58±5.97years.The majority of the subjects were overweight in terms of BMI.In addition, the method of delivery of 108 subjects (55.1%) was C-section.Regarding the level of education, 150 participants (76.5%) had diplomas or higher degrees.Furthermore, most subjects (85.2%) were housewives, and the mean score of sexual health of the participants was reported as 229.30±10.82.
Out of 196 women participating the research, 20 individuals (10.2%) received a postpartum depression score above 12, whereas the depression score of 15 participants (7.6%) was in the range of 10-12.Furthermore, the obtained results of one-way ANOVA showed that postpartum depression had a significant relationship with the mean score of spiritual well-being as well as cognitive/emotional and behavioral dimensions (P<0.001;Table 1).Table 3 tabulates the comparison of the postpartum depression score among the investigated subjects in terms of some demographic variables.The results showed a higher level of depression among women with some specific features, including overweight, C-section and a history of abortion, a male neonate, an educational level below a diploma, mean age of above 35 years, and no physical activity.The results of one-way ANOVA indicated a statistically significant difference between the mean score of postpartum depression and the number of pregnancies (P=0.011) in the participants.In addition, an independent t-test showed that postpartum depression was significantly related to the type of delivery (P=0.020),abortion history (P=0.031),occupational status (P=0.020), and level of education (P=0.009) in the participants (Table 3).

Discussion
According to the results of the present study, the subjects had a high level of spiritual wellbeing.The results revealed that high scores of spiritual well-being were observed in the women, who referred to healthcare centers with fewer symptoms of postpartum depression.In addition, it was shown that a significant number of patients (10.2%) had postpartum depression, which was consistent with the results obtained by Man et al., indicating depression rate of 11.7% in women referring to the clinic after delivery (20).
The mean score of overall spiritual health and its dimensions in different levels of postpartum depression was evaluated in the current study.The findings demonstrated that women with a post-delivery depression score above 12 had lower cognitive/emotional and behavioral dimensions of spiritual well-being and overall spiritual well-being scores.
Moreover, the postpartum depression score had a significantly negative correlation with the total score of spiritual well-being as well as cognitive/emotional and behavioral dimensions.In other words, the total score of spiritual well-being and dimensions of cognition/emotion and behavior decreased in subjects with the increase of postpartum depression.A study in 2007 showed that the spiritual well-being score of pregnant women had a significantly negative with their depression score, which was in line with our findings (17).The obtained results of other studies revealed that spiritual well-being can improve the psychological aspects of patients .
In the current research, there was a significant relationship between the level of education and postpartum depression, which is in congruence with the results obtained by Sehati et al. (24).Contrary to our findings, Esmaeili et al. (2013) showed the lack of significant relationship between the level of education and this type of depression (25).Evidence suggests that a high level of education increases the mothers' awareness of their social rights, and consequently improves collaboration and increases access to information resources (26).
Sehati et al. marked a significant relationship between the gravidity and maternal postpartum depression (24), which was consistent with our findings.However, the results of the mentioned study showed no significant relationship between the type of delivery and postpartum depression (24), which was in contrast with the findings of the current study.
Edward et al. mentioned that postpartum depression was more prevalent among women who received a C-section (27), which was in line with our results.Black demonstrated that the history of abortion and stillbirth had a significant correlation with postpartum depression (28), which was consistent with the results of the current study.Nonetheless, the results of a study conducted by Sehati et al. contradicted our results (24).In this research, there was a direct relationship between occupational status and postpartum depression, which was consistent with the results obtained by Sehati et al. (24).
The data in this study were collected through self-report.It is recommended to conduct future studies to evaluate the relationship between postpartum depression and spiritual well-being with regard to the social and economic support of mothers.

Conclusion
According to the results of the current research, women referring to the healthcare centers affiliated to Qom University of Medical Sciences had a favorable level of spiritual well-being.In other words, an increase in the spiritual well-being of women after pregnancy decreased their depression level.Moreover, considering the results of the present study, it could be claimed that demographic characteristics, such as gravidity, a method of delivery, occupational status, and level of education, were correlated with postpartum depression.Therefore, with regard to the importance of controlling the negative effects of postpartum depression on mothers, neonates, and family of the patient, it is recommended to improve the level of spiritual well-being in pregnant mothers.

Table 1 .
Comparison of spiritual well-being and different levels of postpartum depression from the perspective of Islam

Table 2 .
Correlation between the score of postpartum depression and the scores of spiritual well-being from the

Table 3 .
Comparison of the mean and standard deviation of postpartum depression in women referring to healthcare centers based on some demographic variables