Postpartum Depression and Birth Experience in Russia

Background In European countries, postpartum depression (PPD) occurs in 13–19% of women. The statistics indicate that postpartum depressive disorders affect up to 300,000 women in Russia annually. There is still an extremely acute lack of psychological comfort provided to women during labor in Russia. Objective To our knowledge, ours is the first study that examines the association between childbirth experience and the risk of PPD in Russia. Design We collected data from 190 Russian-speaking mothers, ages 19 to 46, (M = 32 ± 4.3) two months after their delivery. Results Birth satisfaction and physical well-being two months after delivery were significantly inversely associated with PPD. Birth satisfaction negatively correlated with the perceived severity and unpredictability of labor, and positively correlated with physical well-being two months after delivery. The presence of a partner and a personal midwife or doula at birth was associated with higher birth satisfaction. Conclusions Our results emphasize the significance of childbirth satisfaction in the context of PPD and suggest the importance of individual professional support during labor.

Introduction support during labor (Bohren et al., 2017;Saisto, Salmela, Nurmi, & Halmesmaki, 2001). However, in Russia, women frequently lack support during labor, since small regional maternity hospitals can still prevent partners from attending the birth, and a doula or private midwife is available only by paid contract, not through the public healthcare sector (Novkunskaya, 2017).
Taken all together, these factors indicate that women may be at higher risk for developing PPD in Russia. However, to our knowledge, no study has investigated this risk or protective factors against it in relation to PPD. us, the aim of our study was to examine the association between obstetric factors, childbirth satisfaction, and continuous support during labor with PPD symptoms two months a er delivery.
We hypothesized that 1) a higher level of PPD symptoms was associated with a lower level of childbirth satisfaction, poorer physical well-being a er delivery, and delivery mode (emergency cesarean vs. elective cesarean vs. vaginal birth); and 2) a higher level childbirth satisfaction was associated with delivery mode (vaginal vs. elective cesarean vs. emergency cesarean birth), better physical well-being a er delivery, and mode of birth support (support by a partner, doula or private midwife vs. no support).

Study design
Data collection took place from June 2018 to February 2019. e women received an invitation to take part in the study through thematic communities and training classes for moms-to-be and new parents. Questionnaires were sent to respondents via e-mail a er their written consent to participate was received. e participants were interviewed two months a er delivery (the average age of the children was 1.9+0.22 months). e inclusion criteria were 1) being at least 18 years old, and 2) giving birth no more than two months ago.

Participants
One hundred ninety (190) women participated in the study. All participants spoke Russian and lived in big cities (population over 500,000). e characteristics of the sample are presented in the Table 1. More than 96 percent (96.3%) of the participants gave birth in maternity hospitals and 3.7% gave birth at home. More than one third (34.3% = 65) of the participants showed clinically signi cant depressive symptoms ( Table 1). 48.7% of the participants gave birth in Moscow and the Moscow Region; 14.4% in other regions of the Russian Federation; 18.2% in European cities; 9.6% in Israel; and 9.1% in former USSR countries.

Procedures
e Russian version (Yakupova, 2018; Cronbach's α = 0.84) of the Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden, & Sagovsky, 1987) was used to esti- mate PPD symptoms. It is a 10-item questionnaire scale rated on a 4-point Likert scale, ranging from 0 to 3, which indicates how the mother has felt during the previous week. A score of 10 and higher is considered to indicate symptoms of depression. e participants were asked to measure the discrepancy between their expectations about labor and real experience ("How closely did your expectations of childbirth match reality?") on a 5-point Likert scale (1 = "did not at all" to 5 = "matched completely"). We also asked the participants to assess the perceived severity of their birth experience ("How hard was the birth experience for you?") on a 5-point Likert scale (1 = "easy" to 5 = "extremely hard").
We used the Russian version (Yakupova, 2019; Cronbach's α = 0.70) of the Birth Satisfaction Scale Revised Indicator (BSS-RI), a short 6-item self-report questionnaire, to assess birth satisfaction (the subscales include the level of stress and anxiety, feeling of control, and medical sta support) (Martin, Martin, & Redshaw, 2017). A 3-point Likert scale was used for each question (range 0-2), with the higher scores representing greater birth satisfaction.
We also asked the participants to assess their health condition at the moment of the screening (two months a er delivery) on a 5-point Likert scale (1 = "very poor" to 5 = "very good"). Finally, we collected data on the participants' socio-demographic characteristics, such as the number of children, the mode of delivery, gestational age, place and time of delivery, and type of delivery support.

Statistical analysis
e main variables of the study were: PPD (based on EPDS scores); physical wellbeing a er delivery; birth satisfaction (based on BSSR-RI scores); and the subjective severity and unpredictability of labor.
Spearman's correlation coe cient was used to estimate the relationship between PPD, birth satisfaction, physical well-being, and the predictability and subjective severity of labor.
Multiple linear regression analysis examined the factors predicting PPD, where PPD was a dependent variable, and birth satisfaction, physical well-being a er delivery, perceived severity of birth experience, and predictability of birth were entered in the model as the independent variables. e data met the assumptions for multiple regression analyses; the residuals were normally distributed a er the square root transformation of the dependent variable. Model 1 explored unadjusted associations; Model 2 was adjusted for maternal age, gestational age at birth, and the number of children.
We used the Kruskal-Wallis test to assess the di erences in the levels of PPD, physical well-being, and childbirth satisfaction between the groups with di erent kind of labor support (alone; with partner; with doula or midwife and partner; or with doula or midwife without partner) and mode of delivery. We analyzed the differences in individual support depending on the country of birth by the chi-square test.
All analyses were performed using IBM SPSS Statistics 22.

Results
e level of childbirth satisfaction correlated negatively with PPD (rho = -.28; p < .01) ( Table 2). Women with higher PPD scores more o en perceived their labor as severe (rho = .21; p < .01). A serious discrepancy between the reality and expectations of childbirth was negatively associated with satisfaction with childbirth (rho = -.40; p < .01). No statistically signi cant relationship was found between the mode of delivery [vaginal (VB), emergency caesarean (ECS), or elective caesarean section (ELCS)], and the level of PPD. Neither did these groups di er in the quality of physical wellbeing a er childbirth.
Satisfaction with childbirth was signi cantly lower in women who had emergency caesarean sections than in those who gave birth vaginally (H = 8.17; p = .017). VB and ELCS women did not signi cantly di er in their levels of childbirth satisfaction. ECS mothers perceived their delivery as being more di cult than VB and ELCS mothers did (H = 19.22; p < .001, and H = 17.26; p < .001, respectively). Similarly, the ECS mothers' expectations about the childbirth tended to di er more o en from the reality than those of VB mothers (H = 8.42; p = .015) and ELCS mothers (H = 8.21, p = .003).
In our study, 36.1% (n = 69) of the participants gave birth unaccompanied, while 69.3% (n = 121) had individual support ( Table 1). Women who were accompanied by a midwife and a partner during childbirth showed the highest average level of childbirth satisfaction ( Table 1). Signi cantly higher birth satisfaction scores occurred in the group with doula/midwife and partner support, compared to unaccompanied birth (H = -3.32; p = .001).
Childbirth satisfaction and well-being a er childbirth did not signi cantly differ based on the country in which the delivery took place. However, there were signi cant country di erences in the support given at the time of delivery, so that in Russia, women gave birth to a child without the support of her partner, a personal midwife or a doula more o en than in Europe and Israel (Χ 2 = 34.844; p < 0.001).
Multiple linear regression analysis showed that levels of birth satisfaction, physical well-being a er delivery, perceived severity of the birth experience, and the predictability of labor process contributed signi cantly to the regression model F (7, 183) = 8.80; p < .001, and accounted for 26% of the variance in PPD. Signi cant predictors of PPD were physical well-being a er delivery (B = -2.504; p < .001) and birth satisfaction (B = -.481; p = .007). Controlled for maternal age, gestational age at birth, and the number of children, the model explained 25% of variance in PPD ( Table 3). Note. B = Unstandardized B. SE = Standard Error. 95% CI = 95% Con dence Interval. p = p-value.

Discussion
To our knowledge, this is the rst study to examine the association between PPD and childbirth experience in Russian women. Our results show that lower birth satisfaction and physical well-being two months a er delivery were associated with higher levels of PPD. ese ndings corroborate previous studies indicating psychologically and physically traumatic childbirth experiences as a serious risk factor for depression a er childbirth (Yildiz, Ayers, & Phillips, 2017). It is further in line with the evidence that acute postpartum pain and persistent pain a er delivery are associated with increased risk of PPD (Eisenach et al., 2008). Our study showed that the mode of delivery (vaginal, emergency caesarean, or elective caesarean section) did not directly correlate with the risk of developing PPD. However, an emergency cesarean section seems to be harder for a woman, as this delivery mode was associated with lower childbirth satisfaction and the realities that fell short of the expectations. Subjectively, such childbirth is perceived as being more di cult.
ere are contradictory ndings in this regard, with some studies reporting elevated risk of PPD following emergency cesarean section (Yang, Shen, Ping, Wang, & Chien, 2011), while others nd no such association (Eckerdal et al., 2018), as is the case in our study. is may be because the important risk factor for postpartum depression is not a mode of delivery per se, but the emotions the woman is experiencing -a fear of an unexpected outcome, a fear for her baby's health, a feeling of guilt, etc. For example, mothers who had a strong antepartum preference for vaginal delivery, and then delivered by cesarean, may be at increased risk for depression in the early postpartum period (Houston et al., 2015). Importantly, this involves the quality of the support the woman gets from relatives and specialists (Noyman-Veksler, Herishanu-Gilutz, Kofman, Holchberg, & Shahar, 2015).
Our study's ndings indicate that the level of childbirth satisfaction in Russia does not signi cantly di er from that in European countries and Israel. Speci c to childbirth in Russia were lower rates of partner and doula support during the childbirth (especially in the provinces of Russia). is is the legacy of the Soviet system of obstetrics (Temkina, 2014). e presence of a partner or other family member during labor was only allowed in state hospitals beginning in 2012; nowadays there is a growing trend for an increased number of deliveries with the partner present (Novkunskaya, 2020).
Current Federal legislation in Russia does not establish woman's right to have more than one companion during labor. However, our study shows that childbirth with a doula or individual midwife and a partner's support is associated with higher levels of birth satisfaction and physical well-being a er delivery. ese results are consistent with the research data on the positive impact of doula assistance on the psychological well-being of women in childbirth (McLeish & Redshaw, 2019).
us, a doula may be a mediating specialist who helps the couple to go through the challenging birth experience (Lanning & Klaman, 2019). e results of our research emphasize the importance of the individual professional support during labor and its possible application for the prevention of PPD in Russia.

Conclusion
Our study showed that birth satisfaction and physical well-being two months a er delivery were inversely correlated with PPD. Perceived severity of labor and worse well-being a er delivery were associated with lower birth satisfaction. e presence of a partner and a personal midwife or doula at birth was associated with higher birth satisfaction, which indicates the importance of the individual professional support during labor as a possible avenue for PPD prevention.

Limitations
We used self-report methods to assess the levels of depression. Clinical interviews would supplement the results and make them more valid. A more detailed questionnaire about the woman's birth experience or a qualitative study would enrich the results about the association between birth satisfaction and perinatal a ective disorders. Further research with the larger group with doula or midwife support is needed.

Ethics Statement
is study was conducted according to the Declaration of Helsinki. e study was approved by the Ethical Committee of the Russian Psychological Society, approval ID #18-1102. We a rm that all the participants gave informed consent before taking part in the research.

Author Contributions
VY and AS conceived of the idea. VY developed the study design and performed the computations. AS veri ed the analytical methods and standards for results presentation. VY and AS discussed the results and contributed to the nal manuscript.

Con ict of Interest
e authors declare no con ict of interest.