Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada

Abstract

French

Objective

This study examined the prevalence of elevated maternal anxiety and/or depression symptoms up to eight years after childbirth and the association between role and relationship strains during parenting and mental health challenges from three to eight years after childbirth.

Methods

This study used data from the All Our Families longitudinal pregnancy cohort. Role and relationship strain factors and anxiety and depression symptoms were measured at repeated time points from four months to eight years after childbirth. The proportion of women with elevated anxiety and/or depression was calculated at each available time point. Generalized estimating equation models were used to examine the association between role and relationship strain factors and anxiety and/or depression from three to eight years after childbirth. Predicted probability of having anxiety and/or depression was estimated across those with and without challenges with roles and relationships. The models were adjusted for known risk factors such as maternal income and perinatal anxiety and/or depression.

Results

The prevalence of elevated anxiety and/or depression ranged from 18.8% (at four months) to 26.2% (at eight years). The adjusted odds ratio of anxiety and/or depression was 3.5 (95% CI = 2.9, 4.3) for those juggling family responsibilities and 2.4 (95% CI = 2.0, 3.0) for those with stressful partner relationship compared to their counterparts. Similarly, experiencing financial crunch and poor partner relationship were associated with increased mental health difficulties. Women without challenges in roles or relationships had a 23% lower predicted probability of anxiety and/or depression than those with the challenges.

Conclusions

Monitoring mothers for anxiety and depression beyond the postpartum period and strategies that address role and relationship challenges may be valuable to women at risk of anxiety and depression.

Keywords

anxiety and depression role strain partner relationship and support time crunch financial crunch women after childbirth

Background

One in five Canadians experiences mental health difficulties each year.¹ By 40 years of age, up to half of the Canadian population will have experienced and recovered from a mental health difficulty, and almost all will have been impacted by the mental health difficulties of relatives, friends or caregivers.¹ Beyond individual impacts, mental health difficulties place significant strain on communities, the economy and the health care system.¹ As such, primary and secondary prevention of mental illness is a significant public health priority.

A large body of evidence suggests that untreated maternal mental health challenges, including anxiety and depression, are salient risk factors for child and family functioning.^2–8 Approximately 12–17% of mothers experience depression during the prenatal or postpartum period and their children are at increased risk of experiencing mental health difficulties themselves.^9–13 Evidence including large systematic reviews and meta-analyses shows that maternal depression and anxiety in the postpartum period have long-term consequences for mothers and their families, including declines in marital relationship satisfaction and maternal–child attachment, elevated risks for recurrence of maternal depression and poor child developmental outcomes.^14–18

Research to date has focused exclusively on the first year postpartum, with some limited research (mostly on depressive symptoms) beyond one year.^4,19–24 A longitudinal study reported that 21% of mothers have elevated depressive symptoms at some point in the three years after childbirth.¹⁹ Other studies have noted that 12–16% of mothers have persistently high depressive symptoms^20,24 and 11% of mothers have persistently elevated anxiety symptoms from early pregnancy up to seven years.²⁴ These studies examined the socio-demographic, perinatal and health behaviour factors of the depressive symptoms^19–21,24; however, little is known about what psychosocial factors or stressors contribute to mothers’ mental health beyond the first year postpartum.

Bio-ecological theory posits that different factors at various levels of the social ecology interact with each other over time to contribute to a health outcome.²⁵ Distal factors are those that indirectly impact outcomes (e.g., social support), while proximal factors are those that directly influence the outcome (e.g., available time, financial strain and marital stress). It is well known that several distal factors increase the risk for poor maternal mental health after birth and during early childhood: poor social support, previous mental health difficulties, a history of adverse childhood experiences and lower socioeconomic status.^20,26–29 Given that mental distress occurs in the context of interpersonal relationships and family dynamics and is transactional in nature, proximal factors or current life stressors, including relational strain with a partner or within the family and family responsibilities during parenting may also play an important role in explaining shifts or changes in maternal mental health.^25,30,31 Understanding the role of diverse proximal factors in influencing maternal mental health difficulties is critical for informing how to best improve maternal mental health and well-being. This study aimed to improve our understanding of the extent to which the roles and relationship challenges mothers experience contribute to patterns of mental health over time.

Specifically, this study had two objectives: (a) to examine the prevalence of elevated maternal anxiety and/or depression symptoms up to eight years after childbirth; and (b) to examine the association (relative and absolute) between role and relationship strains during parenting and mental health challenges from three to eight years after childbirth, adjusting for known risk factors for mental health (socio-demographic and economic factors and previous mental health experience).

Methods

Study Design and Participants

The All Our Families study (AOF) is an ongoing pregnancy cohort in Calgary, Alberta, Canada. AOF began in 2008 and recruited 3,387 women in pregnancy.^12,32 In brief, a population-based strategy was used to recruit women from city-wide medical laboratory offices, maternity clinics and community outlets, allowing for a representative sample of pregnant women in an urban centre. Waves of data collection included: twice in pregnancy and at four months, and one, two, three, five and eight years after the index delivery. The longitudinal response rate over time has been over 70%.^12,32 A range of outcomes related to child development and maternal well-being have also been assessed over time in a consistent manner to allow for the examination of patterns of functioning across the lifespan. Details on cohort characteristics and variables measured for each wave are described elsewhere.^12,32 We extracted data from women who participated in data waves at four months and one, two, three, five and eight years (all were COVID-19 pre-pandemic data) after the index delivery and linked the data across the waves for the purposes of this study. The All Our Families cohort study was approved by the Conjoint Health Research Ethics Board at the University of Calgary.

Variable Measurement and Definitions

Outcomes: Outcome included maternal anxiety and depression symptoms at four months, and one, two, three, five and eight years after childbirth (six data points). The Edinburgh Postnatal Depression Scale (EPDS) (at four months and one year) and the Center for Epidemiological Studies Depression scales (CES-D) (at two, three, five and eight years) were used to measure self-report symptoms of depression.^33,34 Validated cut-offs of ≥10 on the EPDS and ≥16 on the CES-D were used to categorize women ‘at risk’ of clinically significant levels of depression in postpartum period.^34,35 The Speilberger State Anxiety Inventory (SSAI), 20-item scale (SSAI-20) at four months and one, two and three years after childbirth and the six-item scale (SSAI-6) at five and eight years after childbirth were used to measure self-report transitory symptoms of anxiety.^36–38 A validated cut-off of ≥40 on the SSAI-20 and a cut-off of 1 standard deviation above the mean on the SSAI-6 were used to categorize transitory high levels of anxiety.³⁹ No validated cut-off is available for the SSAI-6, but a 1 standard deviation cut-off performs similarly to the 40 point cut-off on the longer version and has been previously used in the literature.^40–42 SSAI measures transitory levels of anxiety, that is, how the mother felt at the time of measurement.³⁷

Exposures: Seven variables under five domains capturing role and relationship strains during parenting were assessed. Specifically, time crunch, financial crunch, juggling family, work or other responsibilities, intimate relationship experience and partner relationship (includes partner emotional and practical support, happiness and tension) experienced by mothers. We have used the overall term “role strain” for three constructs: time crunch, financial crunch and juggling responsibilities. Time crunch and experience with the close relationship were measured using validated scales.^43–45 Questions for the remaining variables were developed by AOF research team that involves leading content experts in maternal–child health and mental health. These variables were measured in data waves at three, five and eight years after childbirth. All of these variables, except time crunch and the intimate relationship variables, were measured in two data waves. We collapsed similar variable categories with the small cell counts to facilitate statistical analysis and increase study power. Questionnaire items, variable categories, and data points of AOF study are presented in Supplementary Table 1.

Known risk factors: This included maternal age, marital status, education, income, self-identified ethnicity, immigration status, parity and perceived social support, which was measured during pregnancy. Additional risk factors included perinatal anxiety and/or depression (measured by EPDS and SSAI-20), maternal history of adverse childhood experiences (measured at three years after the index childbirth) and subsequent childbirth (measured at three years after the index childbirth). These risk factors have been consistently associated with maternal mental health challenges during the postpartum period and early childhood.^20,26–29 Variables were analysed as continuous variables if they were measured in continuous scales: maternal age, social support score and adverse childhood experience were analysed as continuous variables, and the remaining were analysed as categorical variables.

Analysis

The proportion of women with high levels of anxiety, depression and either anxiety and/or depression at each time point after childbirth was calculated. Participants who responded to any of the role and relationship strain variables that were measured in any data wave at three, five and eight years after childbirth were included in subsequent analyses (n = 2,398). Repeated measures logistic regression analysis, using generalized estimating equation (GEE) models were built to examine associations between each role and relationship strain variable and anxiety and/or depression at any time from three to eight years after childbirth. GEE models incorporated the repeated measurements (three measurements) from a single respondent and produced the population-averaged effect (pooled estimate) on anxiety and/or depression within that period accounting for within-subject correlations between measurements.⁴⁶ Exchangeable working correlation and robust standard errors were used in the GEE analyses.⁴⁶ A GEE with an exchangeable working correlation allows us to maximally utilize every follow-up outcome data available in each measurement timepoint.⁴⁶ The GEE does not provide insight into the timing of emergence of mental health symptoms, but rather allows us to understand the association between risk factors and mental health in the general parenting population, which can guide the allocation of resources for intervention. In the GEE models, time crunch, intimate relationship experience and financial strain variables were analysed as continuous variables and jugging responsibilities and partner relationship were analysed as categorical variables. We combined the role and relationship strain variable if it was measured at repeated data timepoints after childbirth and used it as any timepoint. All final models were adjusted for known risk factors for mental health: maternal age, marital status, education, income, ethnicity, immigration status, parity, subsequent childbirth, social support, perinatal anxiety and/or depression and adverse childhood experiences. The model results are reported as pooled adjusted odds ratio (aOR), with 95% confidence intervals (CIs).

The performance of the final GEE models was evaluated by measures of model calibration (brier score – the average squared error difference between the observed outcome and a prediction, the correspondence between predicted and observed outcome rates, and Hosmer–Lemeshow goodness of fit) and discrimination accuracy (area under the receiver operating characteristic curve, AUC). To obtain the model calibration measure, the predicted probability of anxiety and/or depression for each woman was estimated and was categorized into five risk groups (<15%, ≥15–30%, ≥30–45%, ≥45–60% and ≥60). Finally, the adjusted predicted probability of having anxiety and/or depression was estimated (at the average value of covariates or known risk factors for mental health) using the final GEE model for each role and relationship strain variable and assessed the absolute difference at the population level. For time crunch, intimate relationship experience and financial strain continuous variables predicted probabilities or absolute differences were compared across the specific values.

Results

The sociodemographic characteristics of the AOF cohort at recruitment and the cohort participation in each data waive after childbirth are shown in Supplementary Table 2. As shown in Table 1, the prevalence of elevated anxiety and/or depression ranged from 18.8% to 26.2% at all timepoints up to eight years after childbirth. The prevalence was 18.8%, 19.9%, 19.6%, 19.4%, 22.8% and 26.2% in four months, one, two, three, five and eight years, respectively. A total of 42.2% of women had elevated anxiety and/or depression at least once between four months and eight years of childbirth, 33.3% had it at one or two timepoints and 8.9% had it in >2 time points.

Table 1.

Prevalence of Elevated Maternal Anxiety and Depression Symptoms Across Different Data Points up to Eight Years after Childbirth.

Data points after childbirth and cohort sample size	Missingn (%)	Anxiety^a		Missingn (%)	Depression^b		Anxiety and/or depression
Data points after childbirth and cohort sample size	Missingn (%)	Mean score(95% CI)	Prevalence^c% (95% CI)	Missingn (%)	Mean score(95% CI)	Prevalence^d% (95% CI)	Prevalence% (95% CI)
4 months, n = 3,057	116 (3.8)	30.3 (20.0, 30.7)	15.0 (13.7, 16.3)	17 (0.05)	4.3 (4.1, 4.5)	12.1 (11.0, 13.3)	18.8 (17.4, 20.2)
1 year, n = 1,574	63 (4.0)	32.1(30.6, 31.5)	17.0 (15.1, 18.9)	11 (0.01)	4.4 (4.2, 4.5)	12.4 (10.8, 14.1)	19.9 (18.0, 22.0)
2 years, n = 1,596	20 (1.3)	30.7 (30.3, 31.1)	15.4 (13.6, 17.2)	0 (0)	4.4 (4.2, 4.6)	12.5 (11.0, 14.3)	19.6 (17.7, 21.6)
3 years, n = 1,993	21 (1.0)	30.7 (30.3, 31.1)	15.2 (13.7, 16.9)	2 (0)	7.7 (7.4, 8.0)	12.4 (11.0, 13.9)	19.4 (17.7, 21.2)
5 years, n = 1,991	65 (3.3)	9.3 (9.2, 9.5)	16.4 (14.8, 18.1)	59 (0.3)	8.5 (8.1, 8.9)	16.1 (14.5, 17.8)	22.8 (21.0, 24.7)
8 years, n = 2,074	145 (7.0)	10.1 (10.0, 10.3)	17.4 (15.7, 19.1)	127 (6.0)	9.2 (8.8, 9.6)	18.6 (17.0, 20.4)	26.2 (24.3, 28.2)
Anytime between 4 months and 8 years, n = 3,146:
At least 1 time (overall)			34.3 (32.6, 36.0)			30.7 (29.1, 32.3)	42.2) (40.5, 43.9)
>2 times			6.6 (5.8, 7.5)			6.1 (5.3, 7.0)	8.9 (8.0, 10.0)
≤2 times			27.7 (26.2, 29.3)			24.6 (23.1, 26.1)	33.3 (31.7, 35.0)

Notes: Missing data were managed using individual variable-wise approach (i.e., missing data were deleted while calculating each estimate in each data point). Missing data on anxiety and/or depression was minimal, <1% in each datapoint. CI = confidence interval.

The Edinburgh Postnatal Depression Scale (EPDS) (at four months and one year) and the Center for Epidemiological Studies Depression scales (CES-D) (at two, three, five and eight years) were used to measure self-report symptoms of depression.

The Speilberger State Anxiety Inventory (SSAI), 20-item scale (SSAI-20) at four months and one, two and three years after childbirth and the six-item scale (SSAI-6) at five and eight years after childbirth were used to measure self-report symptoms of anxiety.

Prevalence of elevated depression: EPDS cut-off ≥10 or CES-D cut-off ≥16

Prevalence of elevated anxiety: SSAI-20 cut-off ≥40 or SSAI-6 cut-off ≥13 and SAI cut-off ≥14 at five years and eight years, respectively.

Of 2,398 study participants, the mean age was 31 years, and the majority of women were married/common law, white and born in Canada/lived in Canada five or more years, and had some or completed post-secondary education. The proportion of women exposed to challenges with roles and relationships at any time from three to eight years after childbirth is presented in Table 2. A higher proportion of women with elevated anxiety and/or depression had role and relationship challenges than those without (Table 3).

Table 2.

Characteristics of Study Participants who Responded to Role and Relationship Strain Study Variables Between Three and Eight Years After Childbirth (n = 2,398)^a.

Characteristics	n (%)	(95% CI)
Maternal age (mean and standard deviation)	2275	30.8 (4.4)
Parity:
No previous birth	1193 (50.3)	48.3, 52.3
Previous birth to at least one birth	1179 (49.7)	47.7, 51.7
Addition of family member in the 8 years after the index birth (i.e., subsequent childbirth):
No	1241 (62.3)	60.1, 64.4
Yes	751 (37.7)	35.6, 39.9
Marital status:
Married/common law	2275 (95.4)	94.5, 96.2
Other	109 (4.6)	3.8, 5.5
Ethnicity:
Other	445 (18.6)	17.2, 20.3
White/Caucasian	1939 (80.9)	79.7, 82.9
Time in Canada (immigration status):
Born in Canada/lived here 5 + years	2180 (91.6)	90.4, 92.7
Lived in Canada less than 5 years	200 (8.4)	7.4, 9.6
Education:
High school or less	206 (8.6)	7.6, 9.8
Some or completed post-secondary	2179 (91.4)	90.2, 92.4
Income:
Less than $60,000	333 (14.4)	13.1, 15.9
$60,000 or more	1975 (85.6)	84.1, 87.0
Social support score (measured by Medical Outcomes Survey Support Scale) (median and interquartile range)	2373	92.1 (80.3, 98.7)
Elevated anxiety and/or depression symptoms during pregnancy^b:
No	1891 (79.4)	77.7, 81.0
Yes	491 (20.6)	19.0, 22.3
Maternal history of adverse childhood experience (median and interquartile range)^c	1984	1 (0, 3)
Time crunch (mean and standard deviation):		3.9 (2.4)
Lower level (score <7)	1600 (83.1)	81.3, 84.7
Higher level of time crunch (score ≥7)	326 (16.9)	15.3, 18.7
Financial crunch - worries about having enough money to do important things for family:
1 rarely/never	414 (18.9)	17.8, 20.6
2	331 (15.1)	13.6, 16.6
3	154 (7.0)	6.0, 8.2
4	208 (9.5)	8.3, 10.8
5	368 (16.8)	15.3, 18.4
6	436 (19.9)	18.3, 21.6
7 always	284 (12.9)	11.6, 14.4
Juggling family, work or other responsibilities:
Never difficult or sometimes difficult	1897 (81.7)	80.1, 83.3
Difficult most of the time or always difficult	424 (18.3)	16.8, 19.9
Experience with intimate relationship in general (mean and standard deviation):		28.4 (10.2)
Lower level of insecure adult attachment (score <39)	1585 (82.6)	80.8, 84.2
Higher level of insecure adult attachment (score 39 or more)	335 (17.5)	15.8, 19.2
Social and/or emotional support received from partner:
Very satisfied or satisfied	1729 (77.1)	75.3, 78.8
Unsatisfied or very unsatisfied	513 (22.9)	21.2, 24.7
Practical support provided by partner:
Most or all of the time	1375 (61.3)	59.3, 63.3
None or a little or some of the time	867 (38.7)	36.7, 40.7
Degree of happiness in partner relationship:
Happy/very happy/extremely happy/perfectly happy	1691 (75.5)	73.7, 77.2
Extremely unhappy/quite unhappy/a little unhappy	549 (24.5)	22.8, 26.3
Relationship tension with partner:
No tension	1028 (46.9)	44.9, 49.0
A lot of tension or some tension	1162 (53.1)	51.0, 55.1
Elevated anxiety and/or depression after childbirth^d, at:
3-years after childbirth	389 (19.4)	17.7, 21.2
5-years after childbirth	440 (22.8)	20.9, 24.7
8-years after childbirth	512 (26.2)	24.3, 28.2
Number of study participants who responded to the any of the study variables at:		-
3-years after childbirth	1992
5-years after childbirth	1934
8-years after childbirth	1956

Notes: Role and relationship strain study variables include: Time crunch, financial crunch, juggling with family, work or other responsibilities, experience with intimate relationship in general and partner support and relationship. Missing data varied by variables. Missing data were deleted using individual variable-wise deletion approach.

Participants who responded to any of the role and relationship strain study variables in any data wave at three, five and eight years after childbirth. Number of participants who responded to any of the study variables at the data wave was similar to the foundational sample size of the respective data wave.

Edinburgh Postnatal Depression Score (EPDS) cut-off ≥10 and/or Speilberger State Anxiety Inventory (SSAI) cut-off ≥40.

Maternal history of adverse childhood experiences was measured at three years after childbirth. Maternal age, parity, marital status, ethnicity, immigration status, education, income, perceived social support and anxiety and/or depression were measured during pregnancy at recruitment. Subsequent childbirth was measured at five years after the index childbirth.

Elevated depression: Center for Epidemiological Studies Depression Scales (CES-D) cut-off ≥16. Elevated anxiety: Speilberger State Anxiety Inventory (SSAI) cut-off ≥40 was used at three years, and SAI cut-off ≥13 and SAI cut-off ≥14 were used at five years and eight years, respectively.

Table 3.

Distribution of Role and Relationship Strains During Parenting of Study Participants by Patterns of Anxiety and/or Depression Symptoms Between Three Years and Eight Years After Childbirth.

Role and relationship strain variables	Elevated anxiety and/or depression after childbirth^a
	At 3 years		At 5 years		At 8 years
	Yes, n = 386% (95% CI)	No, n = 1,605% (95% CI)	Yes, n = 440% (95% CI)	No, n = 1,492% (95% CI)	Yes, n = 512% (95% CI)	No, n = 1,444% (95% CI)
Time crunch:	N/A^b	N/A^b			N/A^b	N/A^b
Lower level (score <7)			60.6 (56.0, 65.1)	89.7 (88.1, 91.2)
Higher level of time crunch (score ≥7)			39.4 (34.9, 44.0)	10.3 (8.8, 11.9)
Financial crunch - worries about having enough money to do important things for family:	N/A^b	N/A^b
1 rarely/never			10.9 (8.3, 14.2)	32.4 (30.1, 34.8)	14.8 (12.1, 18.2)	31.1 (28.6, 33.4)
2			10.7 (8.1, 13.9)	18.8 (16.9, 20.8)	12.1 (9.6, 15.2)	20.1 (18.1, 22.2)
3			9.1 (6.7, 12.2)	8.1 (6.8, 9.6)	8.6 (6.5, 11.4)	8.3 (6.9, 9.8)
4			8.2 (6.0, 11.1)	8.7 (7.3, 10.2)	12.5 (9.9,15.7)	9.3 (7.8, 10.8)
5			18.9 (15.5, 22.8)	12.2 (10.6, 14.1)	16.4 (13.4, 19.9)	14.7(13.0, 16.6)
6			22.5 (18.8, 26.6)	13.3 (11.7, 15.2)	18.4 (15.2, 21.9)	11.5 (10.0, 13.3)
7			19.8 (16.3, 23.8)	6.5 (5.4, 7.9)	17.2 (14.1, 20.7)	5.2 (4.2, 6.5)
Juggling family, work or other responsibilities:			N/A^b	N/A^b
Never difficulty or sometimes difficulty	67.4 (62.5, 71.9)	91.6 (90.1, 92.9)			72.2 (68.2,75.9)	93.6 (92.2, 94.7)
Difficult most of the time or always difficult	32.6 (28.1, 37.5)	8.4 (7.1, 9.9)			27.8 (24.1, 31.8)	6.4 (5.3, 7.8)
Experience with intimate relationship in general:	N/A^b	N/A^b			N/A^b	N/A^b
Lower level (score <39)			55.1 (50.4, 59.8)	90.6 (89.0, 92.0)
Higher level of insecure adult attachment			44.9 (40.2, 49.6)	9.4 (8.0, 11.0)
Social and/or emotional support received from partner:			N/A^b	N/A^b
Very satisfied or satisfied	78.7 (74.1, 82.7)	91.8 (90.4, 93.1)			67.3 (62.9, 71.4)	84.4 (82.3, 86.2)
Unsatisfied or very unsatisfied	21.3 (17.3, 25.9)	8.2(6.9, 9.6)			32.7 (28.6, 37.1)	15.6 (13.8, 17.7)
Practical support provided by partner:			N/A^b	N/A^b
Most or all of the time	62.5 (57.3, 67.3)	76.4 (74.2, 78.4)			54.8 (50.2, 59.3)	70.0 (67.5, 72.4)
None or a little or some of the time	37.5 (32.7, 42.7)	23.6 (21.6, 25.8)			45.2 (40.7, 49.8)	30.1 (27.6,32.5)
The degrees of happiness in relationship:			N/A^b	N/A^b
Happy/very happy/extremely happy/perfectly happy	74.7 (69.9, 79.1)	93.1 (91.8, 94.3)			65.1 (60.6, 69.3)	81.9 (79.7, 83.8)
Extremely unhappy/quite unhappy/a little unhappy	25.3 (21.0, 30.1)	6.8 (5.7, 8.2)			34.9 (30.7, 39.4)	18.1 (16.2, 20.3)
Relationship with the partner:					N/A^b	N/A^b
No tension	29.4 (24.9, 34.4)	62.7 (60.2, 65.1)	29.3 (25.1, 33.9)	62.9 (60.4, 65.3)
A lot of tension or some tension	70.6 (65.6, 75.1)	37.7 (60.2, 65.1)	70.7 (66.1, 74.9)	37.1 (34.7, 39.6)

Note: Role and relationship strain variables were measured at three to five or eight years after childbirth. Participants responded to any of the variables that were measured at three, five and eight years after childbirth were included. Except time crunch and intimate relationship variables, all variables were measured two times. Variables were analysed based on their measurement time points. Missing data varied by variables. Missing data were deleted using pair-wise deletion approach. Chi-squared test P values indicated a significant difference in challenges with roles and relationships across those with and without anxiety and/or depression (P-value was <0.0001 for each variable).

N/A: not applicable; the analysis was not applicable as the role and relationship strain variable was not measured at that time point.

Each role and relationship strain variable was significantly associated with elevated anxiety and/or depression symptoms after childbirth from three to eight years, adjusting for known risk factors (Table 4). The odds of anxiety and/or depression were 3.5 times higher for a group of women who had frequent difficulties with juggling responsibilities compared to those who reported less frequent difficulties with juggling responsibilities (pooled aOR = 3.5, 95% CI = 2.9, 4.3). The pooled aOR of anxiety and/or depression was 2.4 (95% CI = 2.0, 3.0) for a group of women who had a stressful relationship with their partner compared to those who reported no stressful relationship with their partner. Similar patterns were found among those with a time crunch, financial crunch, poor intimate relationship experience and poor partner support compared to their counterparts (Table 4). The calibration and discrimination accuracy (AUC) of the models were adequate (Supplementary Table 3), except some predicted probabilities were over 10 points higher than the observed values (models overestimating the risk).

Table 4.

Association Between Role and Relationship Strains During Parenting and Anxiety and/or Depression Between Three and Eight Years after Childbirth (Using Generalized Estimating Equation Models).

Role and relationship strain variables	Anxiety and/or depression
Role and relationship strain variables	cOR (95% CI)	aOR (95% CI)
Time crunch (scale score 0–10)	1.40 (1.35, 1.46)	1.32 (1.26, 1.38)
Financial crunch – worries about having enough money to do important
things for family (scale score 1–7)	1.33 (1.28, 1.38)	1.24 (1.19, 1.30)
Juggling family, work or other responsibilities:
Never difficulty or sometimes difficulty	Ref	Ref
Difficult most of the time or always difficult	4.03 (3.38, 4.81)	3.50 (2.87 4.28)
Experience with intimate relationship in general (scale score 1–84)	1.09 (1.08, 1.10)	1.07 (1.06, 1.08)
Social and/or emotional support received from partner:
Very satisfied or satisfied	Ref	Ref
Unsatisfied or very unsatisfied	2.05 (1.72, 2.44)	1.69 (1.37, 2.08)
Practical support provided by partner:
Most or all of the time	Ref	Ref
None or a little or some of the time	1.88 (1.61, 2.21)	1.55 (1.28, 1.87)
The degrees of happiness in relationship:
Happy/very happy/extremely happy/perfectly happy	Ref	Ref
Extremely unhappy/quite unhappy/a little unhappy	2.33 (1.96, 2.76)	1.92 (1.57, 2.34)
Relationship with the partner:
No tension	Ref	Ref
A lot of tension or some tension	2.86 (2.41, 3.38)	2.44 (2.00, 2.98)

Notes: Role and relationship strain variables were measured at three to five or eight years after childbirth. Except time crunch and intimate relationship variables, all variables were measured two timepoints after childbirth. The variable that was measured repeatedly was combined. All variables, except time crunch, financial crunch and intimate relationship, were measured at three years. Logistic regression analysis generalized estimating equation models considered the correlations of anxiety and depression status between multiple measurements (three, five and eight years after childbirth) and produced the population-averaged estimates. The models were adjusted for known risk factors: maternal age, social support and adverse childhood experiences as continuous variables; marital status, education, income, ethnicity, immigration in Canada, parity, subsequent childbirth after the index childbirth and perinatal anxiety and/or depression as categorical variables. The model was developed for each individual variable. cOR = crude odds ratio; aOR = adjusted odds ratio; CI = 95% confidence interval.

Table 5 shows pooled predicted probability (and absolute difference of probability) of anxiety and/or depression from three to eight years, between those with and without the challenges with roles and relationship dynamics, adjusting for known risk factors. The adjusted predicted probability of anxiety and/or depression was higher by 21% among those with higher levels of a time crunch, by 22% among those who always experience financial crunch, by 23% among those who experience difficulties with juggling responsibilities and by 23% among those with poor intimate relationship, compared to their counterparts. The predicted probability of anxiety and/or depression among those who had poor partner relationship experience was also high.

Table 5.

Adjusted Predicted Probability of Anxiety and/or Depression Between Three and Eight Years after Childbirth by Role and Relationship Strains During Parenting.

Role and relationship strain variables	Anxiety and/or depression
Role and relationship strain variables	Predicted probability(95% CI)	Absolute difference(95% CI)
Time crunch:		0.21 (0.16, 0.25)
Lower level (score <7)	0.15 (0.14, 0.17)
Higher level of time crunch (score 7 or more)	0.36 (0.31, 0.41)
Financial crunch – worries about having enough money to do important things for family:		0.22 (0.16, 0.27)
Rarely/never	0.13 (0.08, 0.13)
Always	0.32 (0.27, 0.37)
Juggling family, work or other responsibilities:		0.23 (0.19, 0.27)
Never difficulty or sometimes difficulty	0.15 (0.14, 0.17)
Difficult most of the time or always difficult	0.38 (0.33, 0.43)
Experience with intimate relationship in general:		0.23 (0.18, 0.28)
Lower level (score <39)	0.15 (0.14, 0.17)
Higher level of insecure adult attachment	0.38 (0.33, 0.43)
Social and/or emotional support received from partner:		0.09 (0.05, 0.12)
Very satisfied or satisfied	0.17 (0.15, 0.18)
Unsatisfied or very unsatisfied	0.25 (0.22, 0.29)
Practical support provided by partner:		0.07 (0.04, 0.10)
Most or all of the time	0.16 (0.14, 0.18)
None or a little or some of the time	0.23 (0.21, 0.25)
The degrees of happiness in relationship:		0.11 (0.8, 0.15)
Happy/very happy/extremely happy/perfectly happy	0.16 (0.15, 0.18)
Extremely unhappy/quite unhappy/a little unhappy	0.27 (0.24, 0.30)
Relationship with the partner:		0.13 (0.10, 0.16)
No tension	0.12 (0.10, 0.13)
A lot of tension or some tension	0.24 (0.22, 0.27)

Notes: Role and relationship strain variables were measured at three to five or eight years after childbirth. Except time crunch and intimate relationship variables, all variables were measured two timepoints after childbirth. The variable that was measured repeatedly was combined. All variables, except time crunch, financial crunch and intimate relationship, were measured at three years. Logistic regression analysis generalized estimating equation models considered the correlations of anxiety and depression status between multiple measurements (three, five and eight years after childbirth) and produced the population-averaged estimates. The models were adjusted for known risk factors: maternal age, social support and adverse childhood experiences as continuous variables; marital status, education, income, ethnicity, immigration in Canada, parity, subsequent childbirth after the index childbirth, and perinatal anxiety and/or depression as categorical variables. The model was developed for each individual variable. CI = 95% confidence interval.

Discussion

Interpretation

Our findings suggest that a high proportion of women continue to experience anxiety (transitory high levels of anxiety) and/or depression symptoms beyond the postpartum period. The observed prevalence of elevated anxiety and/or depression was higher than in the first-year postpartum. Our study showed that 42% of mothers experienced elevated anxiety and/or depression at some point within an eight-year period after childbirth, with 9% having had experienced it in at least three timepoint measurements (indicating persistent symptoms) and 33% had experienced it in one or two timepoint measurements (indicating intermittent symptoms). A prospective cohort study found that 21% of mothers experience elevated depression symptoms at some point in the three years postpartum.¹⁹ The higher prevalence in our study (42% vs 21%) is most likely related to the assessment of both anxiety and depression and the longer follow-up period; that is, with a longer study period or more data points, there will be a higher number of people with elevated symptoms at some point in the total period. The prevalence in our study (measured using a symptom or screening scale) may be higher than the prevalence derived using diagnostic instruments.¹¹ However, this would not impact the trends of prevalence over time. The women with elevated depressive and/or anxiety symptoms do not necessarily meet criteria for a depressive and/or anxiety disorder requiring treatment. Rather, these symptoms indicate potentially clinically elevated levels of symptomatology. The early detection of these symptoms provides a basis for the early management of these symptoms and selection of women who require further assessment for diagnosis of disorders and early treatment.

Our findings showed that the challenges with roles and relationships were strongly associated with elevated anxiety and/or depression after childbirth from three to eight years after childbirth, above and beyond the known risk factors such as socioeconomic factors and a history of anxiety and/or depression.^20,26–29 This implies that high levels of time and financial crunch, challenges with family or work responsibilities and poor intimate and partner relationship/support can be targets for prevention or management, beyond the social determinants of health. Literature on the association between roles and relationship dynamics and maternal mental health challenges over years when they are parenting small children (or early childhood) is scarce. According to existing but limited studies, employment-related problems (organizational culture, workload and earning instability), household and childcare-related workload, changes in financial circumstances at the individual or family level and marriage/family instability might impact the maternal roles and relationships.^31,47,48

The stressors of mothers with young children, including feeling rushed and short on quality time with their children, friends, partners or hobbies, financial strains, difficulties in balancing personal and family life and challenges in partner relationship, may influence their mental health through behavioural, physiological and psychosocial pathways.^49,50 For example, the stress of relationship strain can result in adopting mental health-compromising behaviours as a coping mechanism to deal with stress.^31,49 Prolonged exposure to stress may result in withdrawal from social networks and support systems that might otherwise buffer these effects.^51,52 Mothers’ stress coping skills and socioeconomic factors can also buffer the effects of these stressors.^31,49

Elevated maternal anxiety and/or depressive symptoms when parenting young children have the potential for deleterious impacts on maternal and childhood health such as maternal chronic diseases, impaired parenting and mother–child bonding, childhood emotional problems and suboptimal social and communication skill.^9,14–18 Postpartum maternal mental illness has been regarded as a major public health problem,⁵³ with a recommendation of monitoring and support; however, little focus is given to mental health difficulties beyond the early postpartum period. The majority of previous studies focus on the assessment of mental health status during pregnancy and one-year postpartum and its impacts on childhood development. Our study highlights that mental health beyond the early postpartum period may be just as crucial as perinatal mental health and provides a clarion call for ongoing support for long-term maternal mental health.

Implications and Future Directions

Our findings underscore the importance of assessing maternal mental health after childbirth, continuously beyond the early postpartum period to intervene early to support healthy child development and maternal well-being. Providers, including nurses, primary care practitioners and obstetricians, should be aware of the potential for ongoing mental health difficulties among mothers. In addition to the well-baby visits, an integrated maternal mental health monitoring in routine primary care could be particularly beneficial for families. For example, primary care practitioners identify/manage those with a high probability of mental health challenges (focusing on relatively modifiable and proximal factors such as time and financial crunch, difficulties with juggling family responsibilities and poor partner relationships), and if necessary, referrals to mental health services should be made. Furthermore, health promotion policies, social programs and workplace structure may need to be adjusted, paying attention to mothers’ family or other responsibilities, relationship quality and economic stability. Avenues for future research include examining maternal mental challenges as children enter adolescence (and trajectories over time after childbirth); exploring whether the challenges with role and relationship dynamic influence childhood and early adolescent developmental outcomes; whether these risk factors change over time in a woman's life-course; and whether these novel risk factors and the previously known risk factors have time-dependent effects on maternal and child developmental outcomes over time.

Strengths and Limitations

Strengths of the current study include the analysis of maternal mental health data at repeated time points after childbirth measured by validated anxiety and depression instruments in a prospective study design. This study makes a novel contribution by assessing maternal mental health up to eight years after childbirth as well as the association of roles and relationships with maternal mental health over time. However, the results should be interpreted within the context of limitations. The exposures and outcome variables were measured using maternal self-report: mothers experiencing challenges with role and relationships may view their mental health status more negatively. The cohort sample size was low specifically in the years 1 and 2 due to the funding delay for follow-up, and subsequently the follow-up eligibility of the cohort was passed. Although the longitudinal survey response rate over time of >70% and the minimal missing data on anxiety and/or depression (<1%) in each survey waive is considered high for longitudinal studies, selection bias is possible if the non-response does not hold the missing completely at random (MCAR) assumption. It is likely that the sample with the elevated anxiety and/or depression dropped more than those without the elevated anxiety and/or depression, which can underestimate the prevalence outcome over time. GEE analysis assumes MCAR: if non-response was also differential by exposure (strain) status, we would expect our associations to be conservative. Furthermore, the MCAR assumption is less of a problem for the purpose of our study – assess whether the certain characteristics are associated with an increased odds of anxiety and/or depression at any time between three and eight years – as GEE utilized every outcome data available in each measurement and the timing of outcome is not important. The observed associations do no necessary indicate causation: we analysed prevalent outcomes using GEE; the temporal relationship between exposure and outcome is less clear unlike in time to event data or analysis. Some of our models’ predicted probabilities were over 10 points higher than the observed values: the models might have overestimated the absolute difference in probability of anxiety and/or depression, between those with and without the challenges with roles and relationship dynamics. The sample reflected a relatively socio-economically advantaged population, and more disadvantaged women were more likely to drop out over time. This may result in an underestimate of anxiety and depression, as these tend to be higher among women with fewer economic resources and those of minority background.⁵⁴ Examining these associations in marginalized women is an important future direction.

Conclusions

Elevated anxiety (transitory high levels of anxiety) and depression continue to be a concern among women up to 8-years after childbirth. Challenges with roles and relationships during parenting including financial, time, family responsibility and relationship strain highly contributed to mental health concerns. These findings extend the current understanding that anxiety and depressive symptoms are mostly burdensome in the first year postpartum and suggest that monitoring/support should be extended beyond that period. Clinicians may identify those with a very high probability of elevated anxiety and/or depressive symptoms using relatively modifiable factors such as challenges with roles and relationships in addition to previously known distal risk factors.

Supplemental Material

sj-docx-1-cpa-10.1177_07067437221140387 - Supplemental material for Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada

Supplemental material, sj-docx-1-cpa-10.1177_07067437221140387 for Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada by Kamala Adhikari, Nicole Racine, Erin Hetherington, Sheila McDonald and Suzanne Tough in The Canadian Journal of Psychiatry

Supplemental Material

sj-docx-2-cpa-10.1177_07067437221140387 - Supplemental material for Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada

Supplemental material, sj-docx-2-cpa-10.1177_07067437221140387 for Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada by Kamala Adhikari, Nicole Racine, Erin Hetherington, Sheila McDonald and Suzanne Tough in The Canadian Journal of Psychiatry

Supplemental Material

sj-docx-3-cpa-10.1177_07067437221140387 - Supplemental material for Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada

Supplemental material, sj-docx-3-cpa-10.1177_07067437221140387 for Women's Mental Health up to Eight Years after Childbirth and Associated Risk Factors: Longitudinal Findings from the All Our Families Cohort in Canada by Kamala Adhikari, Nicole Racine, Erin Hetherington, Sheila McDonald and Suzanne Tough in The Canadian Journal of Psychiatry

Footnotes

Acknowledgements

All our families cohort study was funded through Alberta Innovates Interdisciplinary Team Grant # 200700595; Alberta Children's Hospital Foundation; and Max Bell Foundation.

Author Contributions

Kamala Adhikari, Sheila McDonald and Suzanne Tough were involved in the conception and design of the study. Kamala was responsible for conducting the analysis, interpreting the data and drafting the manuscript. Nicole Racine and Erin Hetherington contributed to conception and study design. All authors provided interpretation and intellectual content to the manuscript draft. All authors read and approved the final draft.

Authors’ Note

Supplementary file has been submitted to provide additional information about this research. Data types such as statistical data file, statistical codes, text files, tables, additional charts and graphs necessary to understand the research will be provided upon the request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Kamala Adhikari

Supplemental Material

Supplemental material for this article is available online.

References

Mental Health Commission of Canada. Making the case for invesitng in mental health in Canada; 2010.

Goodman

Rouse

Connell

, et al. Maternal depression and child psychopathology: a meta-analytic review. Clin Child Fam Psychol Rev. 2011;14(1):1–27.

Priel

Zeev-Wolf

Djalovski

, et al. Maternal depression impairs child emotion understanding and executive functions: the role of dysregulated maternal care across the first decade of life. Emotion. 2020;20(6):1042–1058.

Mughal

Giallo

Arnold

, et al. Trajectories of maternal stress and anxiety from pregnancy to three years and child development at 3 years of age: findings from the All Our Families (AOF) pregnancy cohort. J Affect Disord. 2018;234:318–326.

Phua

Kee

MZL

Meaney

. Positive maternal mental health, parenting, and child development. Biol Psychiatry. 2020;87(4):328–337.

Ahun

Consoli

Pingault

, et al. Maternal depression symptoms and internalising problems in the offspring: the role of maternal and family factors. Eur Child Adolesc Psychiatry. 2018;27(7):921–932.

Koutra

Roumeliotaki

Kyriklaki

, et al. Maternal depression and personality traits in association with child neuropsychological and behavioral development in preschool years: mother-child cohort (Rhea Study) in Crete, Greece. J Affect Disord. 2017;217:89–98.

Adhikari

Patten

Lee

, et al. Risk of adverse perinatal outcomes among women with pharmacologically treated and untreated depression during pregnancy: a retrospective cohort study. Paediatr Perinat Epidemiol. 2019;33(5):323–331.

Goodman

. Intergenerational transmission of depression. Annu Rev Clin Psychol. 2020;16:213–238.

10.

Gotlib

Goodman

Humphreys

. Studying the intergenerational transmission of risk for depression: current Status and future directions. Curr Dir Psychol Sci. 2020;29(2):174–179.

11.

Woody

Ferrari

Siskind

, et al. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord. 2017;219:86–92.

12.

McDonald

Lyon

Benzies

, et al. The All Our Babies pregnancy cohort: design, methods, and participant characteristics. BMC Pregnancy Childbirth. 2013;13(Suppl 1):S2.

13.

Adhikari

Patten

Williamson

, et al. Neighbourhood socioeconomic status modifies the association between anxiety and depression during pregnancy and preterm birth: a community-based Canadian cohort study. BMJ Open. 2020;10(2):e031035.

14.

Rogers

Obst

Teague

, et al. Association between maternal perinatal depression and anxiety and child and adolescent development: a meta-analysis. JAMA Pediatr. 2020;174(11):1082–1092.

15.

Kingston

Tough

. Prenatal and postnatal maternal mental health and school-age child development: a systematic review. Matern Child Health J. 2014;18(7):1728–1741.

16.

Hentges

Graham

Plamondon

, et al. Bidirectional associations between maternal depression, hostile parenting, and early child emotional problems: findings from the all our families cohort. J Affect Disord. 2021;287:397–404.

17.

Hentges

Graham

Fearon

, et al. The chronicity and timing of prenatal and antenatal maternal depression and anxiety on child outcomes at age 5. Depress Anxiety. 2020;37(6):576–586.

18.

Slomian

Honvo

Emonts

, et al. Consequences of maternal postpartum depression: a systematic review of maternal and infant outcomes. Womens Health (Lond). 2019;15:174550651984404.

19.

Putnick

Sundaram

Bell

, et al. Trajectories of maternal postpartum depressive symptoms. Pediatrics. 2020;146(5):e20200857.

20.

Giallo

Cooklin

Nicholson

. Risk factors associated with trajectories of mothers’ depressive symptoms across the early parenting period: an Australian population-based longitudinal study. Arch Womens Ment Health. 2014;17(2):115–125.

21.

Matijasevich

Murray

Cooper

, et al. Trajectories of maternal depression and offspring psychopathology at 6 years: 2004 Pelotas cohort study. J Affect Disord. 2015;174:424–431.

22.

Campbell

Matestic

von Stauffenberg

, et al. Trajectories of maternal depressive symptoms, maternal sensitivity, and children's functioning at school entry. Dev Psychol. 2007;43(5):1202–1215.

23.

Bryson

Perlen

Price

, et al. Patterns of maternal depression, anxiety, and stress symptoms from pregnancy to 5 years postpartum in an Australian cohort experiencing adversity. Arch Womens Ment Health. 2021;24(6):987–997.

24.

Charrois

Mughal

Arshad

, et al. Patterns and predictors of depressive and anxiety symptoms in mothers affected by previous prenatal loss in the ALSPAC birth cohort. J Affect Disord. 2022;307:244–253.

25.

Urie

. Ecology of the family as a context for human development: research perspectives. Dev Psychol. 1986;22(6):723–742.

26.

Racine

Devereaux

Cooke

, et al. Adverse childhood experiences and maternal anxiety and depression: a meta-analysis. BMC psychiatry. 2021;21(1):28.

27.

Racine

Zumwalt

McDonald

, et al. Perinatal depression: the role of maternal adverse childhood experiences and social support. J Affect Disord. 2020;263:576–581.

28.

Wickham

Whitehead

Taylor-Robinson

, et al. The effect of a transition into poverty on child and maternal mental health: a longitudinal analysis of the UK millennium cohort study. Lancet Public Health. 2017;2(3):e141–e1e8.

29.

Hetherington

McDonald

Williamson

, et al. Social support and maternal mental health at 4 months and 1 year postpartum: analysis from the all our families cohort. J Epidemiol Community Health. 2018;72(10):933–939.

30.

Rudolph

Flynn

Abaied

, et al. Why is past depression the best predictor of future depression? Stress generation as a mechanism of depression continuity in girls. J Clin Child Adolesc Psychol. 2009;38(4):473–485.

31.

Thomas

Liu

Umberson

. Family relationships and well-being. Innov Aging. 2017;1(3):igx025.

32.

Tough

McDonald

Collisson

, et al. Cohort profile: the All Our Babies pregnancy cohort (AOB). Int J Epidemiol. 2017;46(5):1389–190k.

33.

Cox

Holden

Sagovsky

. Detection of postnatal depression. Development of the 10–item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–786.

34.

Vilagut

Forero

Barbaglia

, et al. Screening for depression in the general population with the Center for Epidemiologic Studies Depression (CES-D): a systematic review with meta-analysis. PLoS One. 2016;11(5):e0155431.

35.

Gibson

McKenzie-McHarg

Shakespeare

, et al. A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatr Scand. 2009;119(5):350–364.

36.

Marteau

Bekker

. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol. 1992;31(3):301–306.

37.

Spielberger

Lushene

. STAI manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press; 1970.

38.

Adhikari

Patten

Williamson

, et al.

Assessment of anxiety during pregnancy: are existing multiple anxiety scales suitable and comparable in measuring anxiety during pregnancy?

J Psychosom Obstet Gynaecol. 2021;42(2):140–146.

39.

Grant

McMahon

Austin

. Maternal anxiety during the transition to parenthood: a prospective study. J Affect Disord. 2008;108(1–2):101–111.

40.

Racine

Hetherington

McArthur

, et al. Maternal depressive and anxiety symptoms before and during the COVID-19 pandemic in Canada: a longitudinal analysis. Lancet Psychiatry. 2021;8(5):405–415.

41.

Hetherington

Racine

Madigan

, et al. Relative contribution of maternal adverse childhood experiences to understanding children's externalizing and internalizing behaviours at age 5: findings from the All Our Families cohort. CMAJ Open. 2020;8(2):E352–E3e9.

42.

Hetherington

McDonald

, et al. Risk and protective factors for mental health and community cohesion after the 2013 Calgary flood. Disaster Med Public Health Prep. 2018;12(4):470–477.

43.

Wei

Russell

Mallinckrodt

, et al. The experiences in close relationship scale (ECR)-short form: reliability, validity, and factor structure. J Pers Assess. 2007;88(2):187–204.

44.

Brennan

Clark

Shaver

. Self-report measures of adult romantic attachment. In: Simpson

Rholes

, editor. Attachment theory and close relationships. New York, NY: Guilford Press; 1998. p. 46–76.

45.

Zukewich

. Work, parenthood and the experience of time scarcity. Housing, Family and Social Statistics Division Statistics Canada; 1998.

46.

Wang

. Generalized estimating equations in longitudinal data analysis: a review and recent developments. Adv Stat. 2014;2014:303728.

47.

Hardy

Hill

Romich

. Strengthening social programs to promote economic stability during childhood. Soc Policy Rep. 2019;32(2):1–36.

48.

Duxbury

Higgins

Coghill

. Voices of Canadians: Seeking work-life balance Published by Human Resources Development Canada 2013. 2013.

49.

Dunkel Schetter

. Psychological science on pregnancy: stress processes, biopsychosocial models, and emerging research issues. Annu Rev Psychol. 2011;62:531–558.

50.

Racine

McDonald

Tough

, et al. Mediating mechanisms for maternal mental health from pre- to during the COVID-19 pandemic: mediators of maternal mental illness during COVID-19. J Affect Disord Rep. 2021;6:100287.

51.

Cohen

Wills

. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985;98(2):310–357.

52.

Barkman

Krishna

. Social epidemiology: Chapter 7- Social Network Epidemiology. In: Berkman

Kawachi

Glymour

, editors. Oxford: Oxford University Press; 2014. p. 234–289.

53.

Wisner

Chambers

Sit

. Postpartum depression: a major public health problem. JAMA. 2006;296(21):2616–2618.

54.

Myers

Lesser

Rodriguez

, et al. Ethnic differences in clinical presentation of depression in adult women. Cultur Divers Ethnic Minor Psychol. 2002;8(2):138–156.

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