Pregnancy is a welcomed event, usually associated
with psychological and behavioral changes, especially
for women who have become pregnant by an assisted
reproductive technology (ART) (
The prevalence of PPD has been reported as 10-15%
in different countries; however, in a systematic review
carried out by Halbreich and Karkun, the prevalence of
PPD was 0-60% in 40 countries (
In recent years, the impact of infertility on the mental
health of couples has been more widely considered.
Of note, infertility is a very unpleasant experience for
many couples (
Studies have shown that mothers who conceive via ART
are more emotionally vulnerable and have higher levels of
distress compared to those who conceive naturally (
Based our searches, there has been no study in Iran that compared PPD in mothers who conceived via ART with those who conceived naturally. Therefore, we designed this study to use the EPDS to compare the frequency of PPD and its risk factors among these groups.
This historical cohort study investigated 406 mothers of 3-9-month-old infants. We used convenience sampling methods for patient selection. The control group consisted of 308 mothers who had natural pregnancies and referred to the health centers affiliated with three main medical universities in Tehran, Iran for child vaccinations. The ART group consisted of mothers with 3-9-month-old infants convinced by ART and selected from the registry data bank at Royan Institute, Tehran, Iran. From these, we selected 98 mothers as the ART group.
The study was approved by the Ethics Committee of Royan Institute. All mothers signed a consent form before completing the questionnaire. The questionnaire was completed by each of the control group mothers. The ART mothers were contacted by telephone to complete the questionnaire. Questions that pertained to the mothers’ and infants’ ages, education, occupation, number of children, delivery method, history of infant hospitalization, breastfeeding, causes of infertility in women with infertility issues, and history of depression, along with the EPDS, were answered by each mother.
The EPDS is one of the most important screening tools
used to identify PPD. It is a short, 10-item questionnaire
that has a score from 0 to 30. Questions 1, 2, and 4 are
scored from 0 to 3, whereas questions 3 and 5-10 are
scored from 3 to 0 are scored (
The sample size was calculated based on at least 4% of the clinical differences of 2.6% depressed for the ART group and 6.7% depressed for the control group in EPDS between the ART and control groups. In order to determine the sample size, the power to detect the difference and type one error were set to 0.8 and 0.05, respectively.
Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) software, version 20. Results were presented as proportions (percentages) and mean ± standard error (SE) or standard deviation (SD). One-way ANOVA, followed by Tukey and Dennett’s tests for multiple comparisons, were used to compare depression scores among education levels, causes of infertility, numbers of pregnancies and breastfeedings. The chi-square test was applied to compare the numbers of depressed individuals between the control and ART groups. The t test was used to compare continuous variables between normal and depressed samples. P<0.05 were considered statistically significant.
The mean age of the mothers was 28.87 ± 5.18 years (range: 17-51 years) and the infants had a mean age of 5.37 ± 1.30 months (range: 3-9 months). The percentage of mothers who reported PPD were 26.0% in the control group and 20.4% in the ART group, which was not statistically significant (P=0.26).
The mean ± SE score for EPDS in mothers who conceived naturally was 8.38 ± 0.35 and it was 7.59 ± 0.63 for mothers who conceived via ART. The difference was not statistically significant (P=0.27).
Our results showed that among mothers who conceived
naturally, education level, occupation, and history of
depression were significantly related to PPD. However,
among mothers in the ART group, the type of delivery,
history of infant’s hospitalization, and history of depression
had a statistical correlation with PPD (
Comparison between the studied variables and PPD scores in the control and ART groups
|Variables||Naturally conceived||ART conceived|
|Less than diploma (n=58)||9.98 (0.88)||6.92 (1.09)|
|Diploma (n=131)||8.79 (0.53)||9.12 (1.04)|
|Higher than diploma (n=119)a||7.15 (0.52)||6.30 (1.06)|
|Employed (n=71)||5.69 (0.64)||6.95 (1.45)|
|Housewife (n=236)||9.14 (0.39)||7.76 (0.69)|
|Type of delivery||P=0.21||P=0.016*|
|Vaginal (n=102)||7.73 (0.59)||12.33 (3.84)|
|Cesarean (n=205)||8.67 (0.43)||7.44 (0.52)|
|History of infant hospitalization||P=0.21||P=0.016*|
|No (n=96)||9.04 (0.60)||10.03 (1.32)|
|Yes (n=210)||8.09 (0.43)||6.35 (0.61)|
|History of depression||P=0.015*||P=0.03*|
|No (n=15)||12.20 (1.63)||12.12 (1.23)|
|Yes (n=287)||8.21 (0.36)||7.18 (0.65)|
|Number of last pregnancies||P=0.99||P=0.56|
|One (n=277)||8.33 (0.36)||8.02 (0.77)|
|Two (n=18)||8.27 (1.50)||6.45 (1.08)|
|Three or more (n=2)||8.50 (6.50)||6.85 (2.72)|
|Number of children||P=0.36||P=0.13|
|One (n=172)||8.57 (0.47)||8.19 (0.79)|
|Two or more (n=131)||7.92 (0.53)||6.13 (1.0)|
|Baby feeding status||P=0.17||P=0.49|
|Breastfeeding (n=181)||8.95 (0.44)||6.93 (0.87)|
|Breastfeeding plus milk powder (n=91)||7.78 (0.70)||8.76 (1.37)|
|Milk powder (n=34)||7.29 (1.0)||7.53 (1.16)|
*; Significant at P<0.05, a; Significant between groups with education levels of less than diploma and higher than diploma, SE; Standard error, ART; Assisted reproductive technology, and PPD; Postpartum depression. Data are presented as mean ± SE.
Our results also showed that causes of infertility were
Comparison of PPD scores and causes of infertility
|Causes of infertility||n (%)||Mean score(± SE)||P value|
|Male factor||57 (58.2)||8.31 (0.86)||0.26|
|Female factor||19 (19.4)||4.73 (1.26)|
|Both (male and female) factors||14 (14.3)||7.07 (1.24)|
|Unexplained||8 (8.1)||10.12 (2.36)|
SE; Standard error and PPD; Postpartum depression.
We evaluated the occurrence of PPD among mothers
who conceived via ART in comparison with those who
conceived naturally due to the impact of mothers’ PPD
in caring for their infants. In our study, the occurrence of
PPD was 20.4% in the ART group and 26% in the control
group. These results were consistent with other studies
in Iran (
About 13-19% of mothers who have recently given birth
experience depression during the postpartum period (
PPD is a multidimensional disorder. The determination
of factors (biological, psychological, and social) that
predispose a mother to PPD will help identify at-risk
Our study showed a significant relationship between
PPD and type of delivery in mothers who conceived by
ART, which did not agree with the results reported by
Sadr et al. (
Vigod et al. (
The results of our study showed no significant
relationship between occupational and educational status
in both groups. Two previous studies have shown that
working mothers probably have a protective factor for PPD
Limitations of this study included the relatively low sample size in the ART group and limited access to this patient population since some of these women lived in other cities and only referred to Royan Institute for infertility treatment before pregnancy. In addition, we did not have consents from all of the women who became pregnant after ART at Royan Institute and could not enroll them in this study. Further studies with larger sample sizes are recommended.
This study reveals that the occurrence of PPD in mothers who conceived naturally is similar to those who conceived via ART. Our study has also provided evidence that levels of education, occupation, type of delivery, history of infant hospitalization, and history of depression are risk factors for PPD in mothers. These factors, rather than conception via ART, should be given further prominence in interventions to prevent PPD in women.