R E P R O D U C T I V E
H E A L T H
Psychological distress of new Spanish mothers
VICENTA ESCRIBA, ROSA MAS, PATR1ZIA ROM1TO, MARJE JOSEPH SAUREL-CUBIZOLLES *
Background: The birth of a child usually brings about important changes in the life of women and many mothers
experience psychological distress at this time. The objective of this study was to assess the impact of social factors
and living conditions on new mothers' psychological distress one year after childbirth. In particular, sododemographic characteristics of the mother, job characteristics, quality of marital life, perinatal factors and the baby's
hearth were considered. Methods: The study population were primiparous or secundiparous women who had a child
in the main regional public hospital of Valencia (Spain) and who had performed paid work during pregnancy.
Information was collected by means of a questionnaire sent by post one year after childbirth. For hundred and
ninety-eight women were included in the data analysis after excluding 30 women who revealed previous psychiatric
history. The outcome variable (psychological distress of mothers one year after childbirth) was assessed using the
12 item version of the General Health Questionnaire (GHQ-12). The explanatory variables were variables related to
characteristics of marital life, the baby's health, job conditions, perinatal conditions and sododemographic
characteristics of the mother. Univarlate and multivariate analyses were conducted. Results: The percentage of cases
with a GHQ-12 score higher than 3 was 29.7. The probability of psychological distress of mothers one year after
childbirth was higher among those women who reported that the relationship with their partner was fair/poor/very
poor (adjusted OR 5.2 and 95% Cl: 2.5-10.7), among those who argued with their partner over the shareout of
domestic chores and childcare (adjusted OR 2.6 and 95% Cl: 1.6-4.2), among those whose child had been sick over
the past year (adjusted OR 1.9 and 95% Cl: 1.1-3.5) and among those who had important financial problems
(adjusted OR 2.2 and 95% Cl: 1.3-3.7). No statistically significant association was found with factors related to
perinatal conditions and job conditions. Conclusions: The psychological distress of mothers during the first year of
life of their child is related to quality of marital life, the child's health and the existence of important financial
problems.
Keywords: baby's health, job conditions, marital factors, new mothers, perinatal factors, psychological distress
T
he birth of a child, particularly when it is the first, usually
brings about important changes in the life of women and
many mothers experience mental suffering at this time.
The prevalence of mental suffering during this period
varies from one study to another depending on the type
of mental health disorders studied, on the indicators used
to measure them and on the period of time in which the
measurement is carried out. O'Hara and Swain's1 review
of non-psychotic postpartum depression indicated that
approximately 13% of new mothers experience depression.
According to an older review the probable prevalence of
psychiatric disorder in women one year after childbirth is
2O%.2
A wide range of factors have been mentioned in the
literature as related to the psychological distress of
* V. Escrlba', R. Mis', P. Romrto2, MJ. Sauret-Cubizolles1
1 The Valendan Institute of Studies In Public Health (IVtSP),
Regional Ministry of Health, Generalctat Valenaana, Valencia, Spain
2 Department of Psychology, University of Tneste, and
IRCCS Burto Garofolo, Trieste. Italy
3 INSERM Unit 149, Paris, France
CofTwpondence: Vkenta Escrlbi, MD PhD, IVESP, OJuan deGaray, 21,
46017 Valencia. Spain, tel./Tax +34 6 386936*3869370,
e-mail: vescribaOsan.gva.es
mothers with babies and small children.1'3 These factors
may be grouped as follows: sociodemographic factors,
perinatal factors and factors related to marital life and the
health and characteristics of the child. As far as sociodemographic factors are concerned, being a young
mother, belonging to a low socioeconomic class or having
a low income have been reported to be associated widi
psychological distress.1'1*' Marital status does not seem to
be associated with mental distress.1 Factors related to the
couple's relationship, such as marital conflicts, lack of
partner support and lack of father's participation in domestic chores and in the care of the baby, are associated
with mothers' mental distress.1'6'7 Modiers of children
who are ill or temperamentally difficult report higher
levels of psychological distress. Moreover, Brown et al.'s
results showed an increase in postnatal depression rates in
women who had an assisted delivery (caesarean, forceps
or vacuum extraction) and among those who bottle fed.
Having a previous psychiatric history (such as anxiety and
depression) is also likely to be associated with modiers'
mental distress.6'10
The objective of this study was to assess die impact of
social factors and living conditions on psychological distress of modiers one year after childbirth. In particularly,
Psychological distress of new Spanish mothers
sociodemographic characteristics of the mother, job
characteristics, quality of marital life, perinatal factors
and the baby's health were considered.
METHODS
This study is part of an international research project on
mothers' health in the first year after childbirth involving
Spain, Italy and France. The international study was
longitudinal collecting data at three time points. The first
survey was in the two days after the delivery during the
stay in the maternity unit and conducted by an interviewer. The second was five mondis later by a phone
interview. The third one was 12 months after childbirth,
by postal questionnaire. The design of the surveys was
similar in the diree countries but the collection was taken
at different calendar times. The women included in the
Spanish study were mothersfromdie end of May 1992 to
the beginning of September 1992. In this paper we present
the resultsfromdie third cross-sectional analysis referring
to die psychological distress of modiers one year after
childbirth.
The study population were primiparous or secundiparous
women who had a child in die main regional public
hospital of Valencia (Spain) and who had performed paid
work during pregnancy. Exclusion criteria were residence
outside the province of Valencia, stillbirth or deadi
shortly after birth and multiple births. Sample size was
calculated for die most unfavourable prevision (p=0.5),
widi a confidence level of 95% and precision of 4%. Of
die 8,000 annual births which take place in die above
hospital a sample size of 558 was calculated, which was
increased by 60 women with a view to possible losses,
non-response and unexploitable questionnaires, consecutive sampling being subsequently performed.
Information was collected by means of a questionnaire
sent by post one year after childbirth. Two days after
delivery the response rate was 95.9% (593 women). Of
die women who responded at this first cut-off point, 560
(94.4%) responded at die five mondi point and 545
(91.9%) at die 12 mondi point. In die data analysis
presented below only 528 women who completed to die
diree steps of die survey were included. Non-respondents
did not differ significantly from participants in sociodemographic and professional characteristics. Moreover,
given diat die psychological distress of a modier is highly
related to previous psychiatric history,6''°die women who
reported having suffered depression, anxiety and epilepsy
before becoming pregnant (30 women) at die first interview were excluded from die analysis. Therefore die
sample considered in diis analysis was made up of 498
women.
The outcome variable (psychological distress of die
modier one year after childbirth) was assessed using die
12 item version of die General Healdi Questionnaire
(GHQ-12), used as a two-point score rating problems as
present or absent and ignoring frequency.11 The version
translated into Spanish by Mufioz et al.12 was used. The
cut-off point chosen was die 3 I 4 score given diat it is a
prevalence study;'' dierefore a score of 4 or more indicates
a probable case of non-psychotic psychiatric disturbances/
disorders.
Explanatory variables were
• variables related to characteristics of marital life (share
out of domestic chores and child care, arguments over
die share out of domestic chores and quality of die
couple's relationship) and to die baby's healdi (baby ill
during die first year of life and baby wakes up at night),
• perinatal variables, such as type of delivery (vaginal or
caesarean), sex of baby, pre-term birth (<37 weeks of
gestation) and type of feeding one year after childbirth
(breast or bottle) and
• variables related to sociodemographic characteristics of
die mother such as age, parity, living with a partner,
level of education, social class, important financial
problems and return to work one year after childbirth.
Furthermore, for diose women who had returned to work
one year after childbirth die effect of job conditions
(profession, employment status, number of hours worked
per week and effect of childbirth on work) on psychological distress was studied.
Occupation was coded by means of die International
Uniform Classification of Occupations and four basic
groups were established: professionals/technicians, administrative staff, services/commerce/catering staff and
manual workers. The group of services, commerce and
catering staff is mainly made up of sales assistants, nursing
auxiliaries, nursery staff, hairdressers, waitresses and
cooks. Manual workers are mainly unqualified workers
(seamstresses, butchers, packers and cleaners).
For social class coding die occupation of die modier and
father were taken into account. In die event of non-agreement between die two die highest level of occupation was
chosen.
For the share out of domestic chores between the couple
an indicator was made which is an eight-variable mean:
shopping, cooking, washing dishes and clearing up the
kitchen, tidying the house and light cleaning, general
house cleaning, washing clothes/filling or emptying the
washing machine, ironing and performing administrative
tasks (paying bills, going to the bank, etc.). In die same
way, another indicator was made using four variables for
the shareout of child care: preparing the baby's food,
feeding die baby, getting up at night if necessary and
badiing die baby.
In order to study the association between independent
and dependent variables, a simple analysis was first carried
out. Contingency tables are shown, contrasting the existence of a relation by means of a f} test and measuring die
strengdi of the association through the odds ratio (OR)
with a 95% confidence interval, using the Cornfield
method. In order to study die effect of explanatory variables on psychological distress, a logistic regression model
was used, obtaining an adjusted OR (Odds Ratio) and a
95% confidence interval.
The data were introduced into Dbase III plus and for the
statistical treatment SPSS/PC+, EPIINFO and EGRET
packages were used.
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 9 1999 NO. 4
RESULTS
Sample characteristics
The average age was 28.2 years (sd = 4.2 years) 18% of
the mothers were under 25 years old, 47% were between
25 and 29 years old and 35% were women over 29 years
old. They were mainly married (97%) and 66% had their
first child. Concerning level of education, 68% had completed primary education, 16% secondary education and
16% were university graduates.
With regard to occupational characteristics, most of the
women (56%), worked in private companies, 18% were
employees of public companies, 17% worked in family
businesses and 9% worked as domestic staff. Concerning
occupations, 36% of them were manual workers, 29%
services, shop and catering workers, 2 1 % administrative
staff and 14% professionals or technicians. Regarding the
type of contract, 42% were permanent workers, 33% had
a fixed-term contract, 10% were self-employed or employers and 15% of the women did not have a job contract.
tropic drugs during the year following childbirth, reporting sleeping problems, lack of sexual desire and suffering
from fatigue one year after childbirth. The association
with visiting a general practitioner was of border line
significance.
Factors related to psychological distress of mothers one year
after childbirth
The rate of psychological distress was greater among
women who did not live with a partner and among those
who declared important financial problems (table 2). The
birth order (first or second), educational level, social class
of the household and returning to work during the first
year following childbirth were not significantly related to
the rate of psychological distress. No significant association was found with perinatal factors, i.e. type of delivery
(Caesarean section or vaginal), baby's sex, pre-term birth
(<37 weeks of gestation) and type of feeding (breast or
bottle) (results not presented).
Table 2 Psychological distress by sociodemographic factors
Indicator of psychological distress
Characteristics
Table 1 shows the association between the psychological
distress of mothers one year after childbirth, defined by a
GHQ-12 score higher than 3 and other indicators of
mental health such as self-reported symptoms or medical
consumption. The rate of GHQ-12 cases was 29.7%. This
percentage was positively related to intake of psychoTable 1 Association of the GHQ-12 by health indicators
Characteristics
Intake of psychotropic drugs
one year after childbirth
Yes:
No
p value
Visits general practitioner
one year after childbirth
Yes
No
p value
Sleep problems one year
after childbirth b
Yes
No
p value
Lack of sexual desire one year
after childbirth b
Yes
No
p value
N
31
466
114
382
234
263
149
348
% of cases"
61.3
27.7
0.000
36.8
27.5
0.055
44.4
16.7
0.000
45.6
23.0
0.000
Fatigue one year after childbirth
Yes
No
p value
301
196
Total
498
43.2
09.2
0.000
a: Percentage of cases with GHQ-12 score higher than 3.
b: These questions referred to the previous month.
29.7
Age (years)
<25
25-29
£30
p value
Parity
Secundiparous
Pnmiparous
p value
Lives with partner
Yes
No
p value
Education
University
Secondary
Primary
p value
Social class
Low
Medium
High
p value
Important financial
problems
No
Yes
p value
Return to work
No
Yes
p value
Total
N
% of cases"
OR
95% Cl
83
26.5
32.8
26.9
1.00
135
1.02
0.75-2.45
0.54-1.93
244
171
034
160
338
30.8
27.5
0.46
1.00
1.17
482
28.6
1.00
16
62.5
4.15
0.76-1.82
1.33-14.14
0.00
23.8
28.2
1.00
1.26
31.5
036
1.47
147
213
27.9
30.5
1.00
137
30.7
84
78
336
1.14
1.14
0.59-2.70
0.82-2.66
0.70-1.85
0.66-1.97
0.84
383
112
253
44.6
0.00
224
27.7
274
31.4
1.00
238
1.50-3.77
1.00
1.20
0.80-1.80
037
498
29.7
a: Percentage of cases with GHQ-12 score higher than 3.
Psychological distress of new Spanish mothers
Table 3 shows the association between psychological distress and job related factors in women who had returned
to work. The proportion of psychological distress was
higher among women who worked as service/commerce/
catering staff than among professionals or technicians.
The other factors were not clearly related to the outcome
variable.
The percentage of psychological distress was higher in
women who reported relationships with their partner as
fair, poor or very poor, in those who always carried out the
domestic chores and child care and in those who argued
(sometimes or often) over the share out of domestic
chores and child care (table 4) • Moreover, women whose
child had been ill over the previous year or those whose
child woke up at night were more often distressed.
Table 5 shows the results of the multivariate analysis.
After adjustment for age, parity and social class, the rate
of psychological distress remained higher for women who
reported a poor relationship with their partner, who argued over the share out of domestic chores and child care
with their partner, women whose child had been ill over
the previous year and women who declared important
financial problems.
pregnancy, having or not having a job one year after birth
was not associated with psychological distress. Moreover,
among those who were employed, type of employer and
working hours were not associated with psychological
suffering. On the other hand, mothers belonging to the
occupation category of service/commerce/catering staff
were more likely to feel distressed. This occupation category is made up mainly of auxiliary nurses/nursery staff
(22%) and sales assistants (51%). Women in these jobs
are subjected to high psychological demands as a result of
having an unqualified job which requires intense social
contact (clients and patients): this could explain their
poor psychological health.
Other studies on therelationshipsbetween mothers' employment status and their mental health have yielded
conflicting results.14 Repetti et al.15 pointed out that, for
married women, labour force participation has a beneficial influence on self-reported general health, but only
among those with favourable attitudes towards employment. In our study, women who reported that childbirth
had a negative effect on their job performance had worse
psychological distress, but these results were not statistically significant. They also pointed out that studies examining the effect of occupational category on the health
of employed women have yielded inconsistent findings.
A possible explanation for this could be that occupational
categories may reflect the effects of differences in job
characteristics (physical, chemical and biological hazards,
job demands, job control, social support, etc.) or the
DISCUSSION
This article presents results on the relationships between
factors related to mothers' social environment and their
psychological well-being one year after child birth, in a
sample of primiparous and secundiparous Spanish women
who all had a job during
Table 3 Psychological distress by job related factors (in women who have returned to work)
pregnancy.
Results from the multivari- Characteristics
N
OR
% of cases*
95% CI
ate analysis show that factors Occupation
related to marital life (perProfessionals/technicians
60
1.00
21.7
ception of the relationship
Administrative staff
72
1.92
34.7
0.82-4.54
with the partner and arguService staff
73
2.82
43.8
1.23-6.56
ments with partner over the
Manual workers
59
23.7
1.12
0.44-2.89
share out of domestic chores
0.02
p value
and child care), having a Type of employer
baby who had health prob55
30.9
1.00
Public
lems and experiencing imPrivate permanent
98
1.08
32.7
0.50-2.35
portant financial difficulties
Private temporary
1.31
27
37.0
0.45-3.85
are all strongly associated
Self-employed
26
0.41
0.09-1.48
15.4
with mothers' psychological
1.12
No contract
12
33J
0.22-4.90
distress.
p value
0.46
Our results show that women Working hours per week
who present a high score on
<35
1.00
65
33.8
the GHQ-12 are also signi142
35-40
27.5
0J8-1.46
0.74
ficantly more likely to report
>40
1.20
63
38.1
0.55-2.64
sleep problems, lack of sexual
p value
0.28
desire and fatigue and to Effect of childbirth on job
have used some psychotropic
1.00
Works better/the same
29.5
241
drugs. These associations
2.00
0.90-4.43
Works worse
33
45.5
represent an indirect validap value
0.06
tion of the chosen indicator
of mental distress, the GHQ- Total
274
31.4
12.
In this sample of women who a: Percentage ofcasei with GHQ-12 score higher than 3.
had all worked for pay during
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 9 1999 NO. 4
effects of differences in the
personal characteristics and
home
backgrounds
of
women who work in different occupations. Results of
studies assessing the effect of
the number of hours worked
per week on die mental
health of mothers have also
revealed contradictory results. Gjerdingen et al.
showed that women's mental
health over the first post-partum year is worse in those
who work long hours. However, other authors pointed
out that part-time work was
no more beneficial for employed mothers than fulltime work. In our study, no
statistically significant differences were found between
psychological distress and
the number of hours worked.
This could be explained by
the same argument as before:
rather than the number of
hours worked, it is the occupational hazards, in particular psychosocial work hazards,
those which could explain
the mental health of women
in paid work.
In our study, a strong association was found between different indicators of dissatisfaction or difficulties in
marital life and mothers' psychological distress one year
after birth. As also shown by
other authors, mothers who
do not live with a partner
have more psychological distress than those who do live
with a partner.16"18 Among
cohabiting women, those
who perceived their marital
life as fair, poor or very poor
(as opposed to good or very
good) had poorer psychological distress. Arguments
with the partner over the
share out of domestic chores
and child care also increased
the risk of psychological distress. In the bivariate analysis it was also found that
the risk of psychological distress was higher in women
Table 4 Psychological distress by mantal life and baby's healdi
Characteristics
Marital relationship after 12 months
Very good
Good
Faii/poor/very poor
N
181
242
58
p value
Domestic chores
Fatiier or mother equally/father frequently
Modier frequently
Modier always
p value
Childcareb
Father or mother equally/father frequently
Modier frequently
Modier always
p value
Arguments over share out of domestic chores
and childcare
No
Yes
p value
Baby healdi problems during the past year
No
Yes
p value
Baby wakes up at night
No
Yes
p value
Total
% of cases*
OR
19.9
1.00
25.6
69.0
1.39
8.95
95% CI
0.85-2.27
4.38-18.44
0.00
35
269
1.00
11.4
26.8
34.8
178
2.83
0.95-11.40
4.14
137-16.80
1.00
1.83
2.43
0.81-4.26
1.05-5.80
15.8
38.5
0.00
1.00
3J3
2.09-533
18.5
1.00
2.20
1.30-3.76
1.00
1.56
1.04-2.35
0.01
52
17.3
267
163
27.7
33.7
0.06
209
273
124
374
33.4
0.00
263
233
25.1
34.4
0.02
498
29.7
a: Percentage of cases with GHQ-12 score higher than 3.
b: Women excluded who did not live with partner.
Table 5 Logistic regression model of mother's psychological distress (presented as odds ratio) by
quality of marital life, baby's health, perinatal factors and sociodemographic factors
Marital relationship after 12 mondis
Very good
Good
Fair/poor/very poor
Arguments over share out of domestic chores
and childcare
No
Yes
Baby health problems during die past year
No
Yes
Important financial problems
No
Yes
N
Adjusted OR'
95% CI
179
240
58
1.00
0.92
0.55-1.55
5.21
2.54-10.67
206
271
1.00
2.56
1.56-4.20
118
359
1.00
1.96
1.11-3.46
372
1.00
2.18
1.29-3.68
105
N=477; women excluded who did not live with partner.
a: Odds Ratio adjusted for age, parity and social class that are no more significantly related to the outcome in this
model.
Psychological distress of new Spanish mothers
who always carry out the domestic chores. It was not
possible to introduce both variables into the multivanate
analysis at the same time due to them being highly correlated. In the event of introducing the domestic chores
variable into the logistic regression model it was found
that theriskof psychological distress was higher in women
who always carried out the domestic chores (adjusted OR
3.35 and 95% CI: 1.07-10.55). Several authors have
already shown an association between quality of marital
life (marital problems, marital dissolution, dissatisfaction
with the relationships as a couple and lack of partner
support), the lack of participation of the father in domestic chores and child care and mothers' psychological
These data may be better understood in the context of the
results of studies carried out in the field of family sociology. Family sociologists have pointed out that, the birth
of a baby, even when welcomed, may alter the life of
his/her parents, causing a state of crisis. In the majority of
couples there is a fall in satisfaction with marital life and,
in general, quality of life as a couple is reduced. This
worsening in quality of life is greater for the mother than
for the father.2
The Spanish mothers interviewed in this study were more
likely to report psychological distress when their baby had
some health problems. Similar results have also been
found by previous investigators. In other studies, being
of low socioeconomic status or having a low family income has been shown to be related to new mothers'
mental distress.7 In our study, no statistically significant
association was found between level of education, and
socioeconomic level of the couple and mothers' psychological distress; however, when mothers report the presence of serious financial problems they are more likely to
show greater psychological distress.
Although in cross-sectional studies nothing about causation can be stated, as mothers with previous psychiatric
history were excluded, this limitation was reduced. On
the other hand, relationships are not free of reporting bias.
Women who had psychological distress could remember
bad situations that are considered as risk factors better
(marital relations, arguments over share out domestic
chores and childcare, etc.).
These results concern a sample of Spanish women, interviewed one year after the birth of their first or second
child. They all had a job during pregnancy. As employed
women tend to be different in many health, social and
motivational characteristics from women who are not
employed, these data could not be generalized to the
general population of new mothers in Spain. Nevertheless, most of our results are consistent with those found in
the literature: mothers are more likely to report psychological distress if they are unhappy in their relationship,
if their baby has been ill and if they experience serious
economic problems. These results point to the important
role that the family and the social context may play in
influencing the psychological well-being of new mothers.
This study was supported by the 'Fondo de Investigaciones'
(94/0846) (Ministry of Health).
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Received 3 February 1998, accepted 24 September 1998