Social capital in pregnancy and postpartum depressive symptoms: A prospective mother–child cohort study (the Rhea study)
Introduction
The months following delivery are a period where women are vulnerable to depression. In contrast with publicly accepted notions of motherhood, women often face conflicting expectations and may report a sense of loss of control over their lives (Beck, 2002). Up to 25% of new mothers may have depressive symptomatology in the first 6 months after birth, although the prevalence varies across studies and depends on cultural factors, the measurement of the symptoms and the socioeconomic position of the participants (Giakoumaki et al., 2009, Leahy-Warren et al., 2011). Mothers’ depressive symptoms are a key public health concern because they are an independent factor for future depressive episodes, major depression and physical distress. They may also have adverse effects on the depressive symptoms of newborns’ father and/or her partner (Posmontier and Waite, 2011) and foster a pattern of parenting that is linked to children's low emotional and cognitive outcomes (Letourneau et al., 2010, Tronick and Reck, 2009).
Previous studies have shown that low social support, high life and childcare stress, poor marital relationships, low socioeconomic, immigrant, poverty and single marital status and decreases in income, are predictors of postpartum depressive symptomatology even after adjustment for low self-esteem, poor pregnancy outcomes, prenatal depression and other possible confounders (Beck, 2008, Dearing et al., 2004, Pearlstein et al., 2009, Rich-Edwards et al., 2006). The idea that characteristics of the social environment in which people live are associated with depressive symptoms is not new. Mair et al. (2008) reviewed the relevant evidence and reported associations of neighborhood social processes and interactions with depression, although the causal pathway could not always be determined. Community disorder has been reported to intensify the detrimental effects of personal risk factors on psychological well-being (Cutrona et al., 2000). When gender is introduced to the equation, most studies show that social support, social networks and social environment ‘have larger effects on the health of women than of men’ (Smith and Lincoln, 2011, p. 991). In this context, there is not sufficient knowledge about how social capital is associated with postpartum depressive symptoms.
Social capital's main definitions are related to the resources that are embedded in social networks, in the reciprocal social exchanges and in mutual aid that are usually fostered in trusting relationships (Kawachi et al., 2008, Kritsotakis and Gamarnikow, 2004). The two main and distinct theoretical and measurement approaches to social capital relate to the communitarian and the individualistic paradigms. The first is proposed by Putnam (2000), who argues that communities rich in local networks, social interactions and participation in communal processes present better economic, human, health and social indices. One of the proposed mechanisms for this effect is that such communities facilitate cooperation that results in common benefit. In this paradigm, social capital is a community-level attribute measured mainly at the ecological level. Bourdieu (1997), on the other hand, argues that the individual's revenues from participating in social networks are much more important than the formation of a cohesive community. The participating individual secures benefits by participating in these networks (Portes, 1998) and gains access to material assets and to informational, emotional and appraisal support. These benefits are the key elements for the creation of human capital and personal development. In this approach, social capital measured at the individual level quantifies the respondent's assessment of their social environment, and their level of participation in the community social networks (De Silva et al., 2005).
An additional distinction is made between cognitive and structural attributes of social capital. The former corresponds to perceptions, beliefs and feelings (e.g. trust, sense of belonging) while the latter aim to assess what people actually do and how they behave in their social environment (e.g. participation, networks). This theoretical diversity is reflected in the contradictory results of the influence social capital may have on depression and generally in mental and physical health (Kritsotakis et al., 2009).
It is now recognized that different dimensions of social capital affect health outcomes in a different way (Kawachi et al., 2008, Kritsotakis et al., 2011). In their review, De Silva et al. (2005) found that social capital at the individual level was inversely associated with common mental disorders, but there was no clear result when investigating the association between ecological-level social capital and common mental disorders. Although Wu et al. (2010) argued that interactions in safe and friendly social environments provide the necessary support that contributes to reduced depressive symptoms, more recent findings support the idea that individual level perceptions of social capital are a compelling protective factor for mental health and depressive symptomatology. Åslund et al. (2010) examined whether depressive symptoms are affected by two measures of individual-level social capital in a sample of 7757 adolescents in Sweden. They concluded that both low neighborhood social capital and low general social trust increase the odds of having depression. Similarly, low self-reported workplace social capital was a predictor of depression indicators, an association that was not significant for the aggregate-level social capital (Kouvonen et al., 2008, Oksanen et al., 2010).
The aim of this paper is to estimate prospectively the effect of individual-level self-reported maternal social capital during pregnancy on postpartum depressive symptoms, measured by the Edinburgh Postpartum Depression Scale (EPDS), in singleton pregnancies in a cohort of pregnant women in Crete-Greece (Rhea study). Our hypothesis was that higher maternal social capital would be associated with lower EPDS scores.
Section snippets
The mother–child cohort in Crete (Rhea study)
The ‘Rhea’ study is a mother–child cohort which examines prospectively a population-based sample of pregnant women and their children, at the prefecture of Heraklion, Crete, Greece. Women were recruited from 2 public and 2 private prenatal clinics for one year beginning in February 2007. The prenatal clinics were located in the capital city of the prefecture but provided service to families in both rural and urban areas. The one public hospital is a tertiary referral center. The study protocol
Results
Complete information was available for main model variables for 356 women. Table 1 summarizes the demographic, environmental and behavioral characteristics of pregnant women and their relation to EPDS scores. The women included in the analyses were similar to non-participants and those excluded from the analyses in age, parity and birth outcomes, but the former were more likely to be of Greek origin and have higher education. They were also more likely to smoke less and be more physically
Discussion
This study examined prospectively the association of individual self-reported social capital during pregnancy with postpartum depressive symptoms. We evaluated cognitive and structural social capital dimensions, i.e. total social capital, participation in the community and value of life/social agency. Confirming our research hypothesis, we concluded that women with higher social capital reported lower postpartum depressive symptoms as assessed by the EPDS. High social capital may have a
Conclusion
In conclusion, the present study supports previous findings and contributes additional suggestive insight that higher individual-level social capital is associated with lower self-reported depressive symptoms. Being in the highest social capital group in mid-pregnancy was associated with less depressive symptoms 6 to 8 weeks postpartum. This effect was also noted for women with and without past and/or present depressive symptomatology that placed a higher value on the cognitive social capital
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