In China, Women Who Give Birth to Girls Face An Increased Risk of Postpartum Depression
Chinese women enrolled in a cohort study to identify factors associated with postpartum depression were more likely to suffer from the condition if they had given birth to a girl instead of a boy.1 The risk of depression was also elevated among women older than 25, those who considered their living conditions dissatisfactory and those who had had at least four previous pregnancies.
The findings of the few studies that have examined the issue of fetal gender and postpartum depression have varied across cultures, with those in Asian societies finding an association and those in Western societies finding no evidence of a link. Because the Chinese literature lacks studies that go beyond descriptive data, the researchers conducted a cohort study among women who had recently given birth in Changsha, the capital of Hunan Province.
Women aged 18–40 were recruited when they visited the obstetric unit of any of four participating hospitals for a postpartum exam between September 2004 and January 2005. Women who had a psychological illness or a history of psychological illness, or who had had major pregnancy and obstetric complications were excluded from the sample, as these factors could be associated with postpartum depression. After collecting clinical and demographic information from the women, research nurses assessed them for postpartum depression using the Chinese version of the Edinburgh Postnatal Depression Scale.
The 300 women in the sample were, on average, 28 years old, and almost all (99%) were married. About two-thirds (61%) had given birth via cesarean section, and nearly one-fifth (17%) had postpartum depression. None knew the sex of their infant before birth. Women who had given birth to a boy and those who had delivered a girl were similar in age, marital status and education. Higher education, classified as 15 years or more, was slightly more common among women who had had a boy (24%) than among those who had had a girl (19%). Nine percent of women who had given birth to a girl reported having had three or fewer prenatal care visits, compared with only 1% of those whose baby was a boy. However, four in 10 women in each group reported nine or more prenatal care visits. More than 40% in each group reported very satisfactory living conditions, but only 6% of women who gave birth to a girl reported dissatisfactory living conditions, compared with 17% of women who gave birth to a boy.
This was the first pregnancy for about half of the women in both groups. The proportion of women who had a spontaneous vaginal delivery for this birth was twice as high among women who gave birth to a boy as among those who gave birth to a girl (40% vs. 23%). Sixteen percent of women who gave birth to a boy had had four or more pregnancies previously compared with 9% of those who gave birth to a girl. The majority of women had a cesarean section, but this mode of delivery was more common among women who gave birth to a girl than among those who gave birth to a boy (70% vs. 55%).
Women who gave birth to a girl tended to live in higher income households than those who gave birth to a boy. Some 55% of each group lived in middle-income households (with earnings of 1,000–2,000 yuan per month). However, 29% of women who delivered a girl and 11% of those who delivered a boy lived in households with higher income, while 16% of women who gave birth to a girl and 36% of those who gave birth to a boy lived in households with lower income.
Twenty-five percent of women who gave birth to a girl had postpartum depression, compared with 12% of women who gave birth to a boy. Among women who had had fewer than nine prenatal care visits, 21% were depressed, compared with 13% of those who had had nine or more visits. Nearly one-fifth (19%) of women older than 25 were depressed, while only 8% of women aged 25 or younger fell into this category. Depression was more common among women who had had at least four previous pregnancies than among those who had had three or fewer (24% vs. 15–18%). The proportion of women with postpartum depression did not differ between women who delivered via cesarean section and those who delivered vaginally (17–18%). About 38% of women who reported dissatisfactory living conditions had postpartum depression, compared with 14–15% of those who reported satisfactory or very satisfactory living conditions. Interestingly, the proportion of women with postpartum depression rose with the level of household income; 13–15% of women in households earning 2,000 yuan or less monthly were depressed, while 30% of women in the highest household income bracket had depression.
In a multivariate regression analysis, women who delivered a girl had significantly higher odds of postpartum depression than those who gave birth to a boy (odds ratio, 2.8). Compared with women for whom this was the first pregnancy, those who had had four or more previous pregnancies had a risk of postpartum depression almost three times as high (2.9). For women who reported dissatisfactory living conditions, the odds of postnatal depression were seven times as high as for those who reported very satisfactory living conditions (7.4).
The investigators acknowledge that their sample was too small for a stratified analysis and that a selection bias may have occurred if women who were very depressed or who had no feelings of postpartum depression decided not to participate. Another factor that could create bias, they note, is that the sample included only women who returned for a postpartum checkup rather than all women who gave birth in the four participating hospitals. Because prenatal factors do not appear to have been associated with the occurrence of postpartum depression, the investigators suggest that if a woman gives birth to a girl, a lack of familial support—stemming from a desire for sons to carry on the family name and provide economic support to their parents—may make her more vulnerable to postpartum depression. —S. Ramashwar
1. Xie R et al., Fetal gender and postpartum depression in a cohort of Chinese women, Social Science & Medicine, 2007, 65(4):680–684.