Social capital in pregnancy and postpartum depressive symptoms: A prospective mother–child cohort study (the Rhea study)

Abstract

Background

Depression, and to a lesser extent postpartum depressive symptoms, have been associated with characteristics of the social environment and social capital. Up to the present, mostly cross-sectional studies have explored such an association without providing a clear temporal relationship between social capital and depression.

Objectives

To estimate prospectively the effect of individual-level self-reported maternal social capital during pregnancy on postpartum depressive symptoms.

Design

Prospective mother–child cohort (Rhea study).

Settings

4 prenatal clinics in Heraklion, Crete, Greece.

Participants

All women for one year beginning in February 2007. From the 1388 participants, complete data were available for 356 women.

Methods

Women self-completed two questionnaires: The Social Capital Questionnaire at about the 24th week of gestation and the Edinburgh Postnatal Depression Scale (range 0–30) at about the 8–10th week postpartum. Maternal social capital scores were categorized into three groups: the upper 10% was the high social capital group, the middle 80% was the medium and the lowest 10% was the low social capital group that served as the reference category. Multivariable log-binomial and linear regression models were performed for: the whole available sample; for participants with a history of depression and/or prenatal EPDS ≥ 13; for participants without any previous or current depression and prenatal EPDS score < 13. Potential confounders included demographic, socio-economic, lifestyle and pregnancy characteristics that have an established or potential association with maternal social capital in pregnancy or postpartum depressive symptoms or both.

Results

Higher maternal social capital was associated with lower EPDS scores (highest vs lowest group: β-coefficient = −3.95, 95% CI −7.75, −0.14). Similar effects were noted for the subscale value of life/social agency (highest vs lowest group: β-coefficient = −5.96, 95% CI −9.52, −2.37). This association remained significant for women with and without past and/or present depression only for the subscale value of life/social agency although with a more imprecise estimate. No effect was found for participation, a structural dimension of social capital.

Conclusions

Women with higher individual-level social capital in mid-pregnancy reported less depressive symptoms 6–8 weeks postpartum. Given the proposed association of perceptions of the social environment with postpartum depressive symptoms, health professionals should consider evidence-based interventions to address depression in a social framework.

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.