Longitudinal patterns of the relation between anxiety, depression and posttraumatic stress disorder among postpartum women with and without maternal morbidities in Northwest Ethiopia: a cross-lagged autoregressive structural equation modelling

Abstract

Background: The postpartum period is a time where mothers can undergo significant changes that increase vulnerability for depression, anxiety and posttraumatic stress disorder symptoms. However, the direct and indirect factors of depression, anxiety and posttraumatic stress disorder symptoms and their direction of relationships following childbirth is not well investigated in Ethiopia. The aim of this study was to determine the direct and indirect factors of depression, anxiety and posttraumatic stress disorder symptoms and their direction of relationships following childbirth.

Methods: A total of 775 women consented to participate at the first, second and third follow-up of the study (6^th, 12^th and 18^th week of postpartum period) during October, 2020 - March, 2021. Women were recruited after childbirth and before discharge using the World Health Organization maternal morbidity working group criteria to identify exposed and non-exposed groups. A cross-lagged autoregressive path analysis and linear structural equation modelling were carried out using Stata version 16 software.

Results: Prevalence rates of anxiety were 18.5%, 15.5% and 8.5% at the 6^th, 12^th and 18^th week of postpartum respectively. The prevalence rates for depression were also found to be 15.5%, 12.9% and 8.6% respectively during the same follow up period and for posttraumatic stress disorder it was found to be 9.7%, 6.8% and 3.5% at the 6^th, 12^th and 18^th week of postpartum respectively. Moreover, anxiety and depression were found to be a causal risk factors for posttraumatic stress disorder in the postpartum period. Direct maternal morbidity, fear of childbirth, higher gravidity, perceived traumatic childbirth and indirect maternal morbidity were found to have a direct and indirect positive association with depression, anxiety and posttraumatic stress disorder. In contrast, higher parity, higher family size and higher social support have a direct and indirect negative association.

Conclusion: Postnatal mental health screening, early diagnosis and treatment of maternal morbidities, developing encouraging strategies for social support and providing adequate information about birth procedures and response to mothers' needs during childbirth are essential to improve maternal mental health in the postpartum period.

Keywords: Anxiety; Autoregressive; Cross-lagged; Depression; Maternal morbidities; Postpartum women; Posttraumatic stress disorder; Structural equation modelling.

Fig. 1

A flow diagram chart of study participants sampling procedure

Fig. 2

Cross-lagged autoregressive model assessing longitudinal stability and cross-lagged effects between anxiety and PTSD without controlling the direct and indirect effects of confounding variables. Note: All β’s are standardized estimates with their 95% CI

Fig. 3

Cross-lagged autoregressive model assessing longitudinal stability and cross-lagged effects between depression and PTSD without controlling the direct and indirect effects of confounding variables. Note: All β’s are standardized estimates with their 95% CI

Fig. 4

Cross-lagged autoregressive model assessing longitudinal stability and cross-lagged effects between depression and anxiety without controlling the direct and indirect effects of confounding variables. Note: All β’s are standardized estimates with their 95% CI

Fig. 5

A modified cross-lagged autoregressive structural equation model assessing autoregressive and cross-lagged effects of depression, anxiety and PTSD symptoms while controlling the direct and indirect effects of confounding variables. Note: All β’s are standardized estimates with their 95% CI; only significant and marginally significant path coefficients are included in the path diagram

Fig. 6

A modified structural equation model of the factors associated with PTSD symptoms without controlling the autoregressive and cross-lagged effects in postpartum women, Northwest Ethiopia. Note: β’s are standardized estimates with 95% CI

Fig. 7

A modified structural equation model of the factors associated with anxiety symptoms without controlling the autoregressive and cross-lagged effects in postpartum women, Northwest Ethiopia. Note: β’s are standardized estimates with 95% CI

Fig. 8

A modified structural equation model of the factors associated with anxiety symptoms without controlling the autoregressive and cross-lagged effects in postpartum women, Northwest Ethiopia. Note: β’s are standardized estimates with 95% CI