Implications for practice and research

• The importance of physical and mental health in the postnatal period has been recognised in this study and in other research.1 ,2

• Postnatal visiting has declined in the UK and satisfaction with postnatal care is low compared to other aspects of maternity care. Further research should focus on cost-effective strategies to improve this.

Context

Many women experience a range of physical and mental health problems of varying severity and duration following childbirth. The interaction between physical symptoms and mental health has not been extensively researched, although some studies have reported associations.1 ,2 Some interventions have been found to be more effective than others in improving outcomes.3 ,4

Findings

A total of 1507 women returned completed questionnaires, an estimated response rate of 28-31%, with under-representation from women aged 25 years or less and those born overseas from non-English speaking backgrounds. Follow-up percentages at 3, 6 and 12 months were 95%, 93% and 90%, respectively. Analyses reported in the paper relate to the 1305 women who completed all questionnaires.

The period prevalence of depression in the first year was 16.1%. Exhaustion, severe headaches and pelvic pain were associated with more than threefold odds of concurrent depression at 3 months. Other physical symptoms were also associated with depressive symptoms.

Commentary

This study confirms the findings of other research in this area, suggesting that postnatal depression is relatively common, that it does not necessarily decline over the first postnatal year and that it is associated with physical symptoms, especially exhaustion.1 ,2 ,5 The authors note that the association between physical and mental health is likely to be bidirectional: women with physical problems are more likely to be depressed, but being depressed may also make them more aware of their physical discomfort, delay helpseeking and disengage them from treatment.

A major strength of this paper is the prospective design; women were recruited in pregnancy and more than 90% (1305 women) were followed up for 12 months. The study is also strengthened by the use of standardised instruments to assess morbidity. However, the method of mailed invitation via participating hospitals meant that there was no exact information about the denominator—it is not known exactly who was invited to participate. The estimated response rate of 28-31% is low, with under-representation of young and foreign born women particularly apparent. Furthermore, women with depressive symptoms were less likely to complete all follow-up questionnaires and therefore more likely to be excluded from these analyses. The reported prevalence of depression may therefore be an underestimate. Exclusion of multiparous women and those without sufficient English, although performed for pragmatic reasons, limits the generalisability of the results. Ethnic minority women in particular may be more at risk of postnatal depression.6

Nevertheless, this study reports a strong association between physical and mental health which represent important findings. Health professionals need to be aware of this research and of the need to provide the necessary ongoing support to women.