265

ORIGINAL
Relationship between maternal mental status and social
supports during pregnancy and until one month afterchildbirth in a local city
Aya Kondou1, Toshiyuki Yasui2, and Mari Haku1
Department of Midwifery, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan, 2Department of Reproductive and Menopausal Medicine, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
1

Abstract : The aim of this study was to clarify the relationship between maternal mental status and social supports during pregnancy and until one month after childbirth in order to evaluate the actual situation in a local
city. A survey was conducted on 78 pregnant women who completed the CES-D (depression score), STAI (anxiety
score) and Social Support Scale. Data were collected four times : during the second trimester, the third trimester,
postpartum hospitalization, and 1 month after childbirth. The CES-D and STAI scores were initially high during
pregnancy and decreased during the postpartum period. The Social Support Scale score, however, was initially
low during pregnancy and increased during the postpartum period. The CES-D and STAI scores was significantly
and negatively correlated with The Social Support Scale score during all four time periods. Participants ≧ 35
years of age scored lower on The Social Support Scale than did participants < 35 years of age in the second trimester, third trimester, and 1 month after childbirth. These findings should assist with the implementation of a comprehensive support center and may be useful for a local city in Japan. J. Med. Invest. 68 : 265-270, August, 2021
Keywords : maternal mental status, social supports, in a local city, a prospective cohort study

INTRODUCTION
In Japan which is a declining birthrate and an aging population, a problem of the perinatal mental health such as postpartum depression occurs. According to the investigation of theperinatal mental health, the prevalence of postpartum depression is 10%–15% (1), and the prevalence is higher than otherperinatal disorders. Using the Edinburgh Postnatal Depression
Scale (EPDS) as a measure, a systematic review of the literaturefound that the prevalence of postpartum depression is averaged
around 17.7%, with a low of 3% in Singapore and a high of 38%
in Chile (2).
On the other hand, antenatal depression is notable healthproblem as well as postpartum depression. Psychological stressand anxiety in pregnancy are associated with delayed motor
development, mental development (3), and emotional problems
in children (4). In prior studies on the working pregnant women,
primiparous working women have high levels of mental health(5), about 70 % of the working pregnant women have an impatience (6). Thus, the mental health during pregnancy has an
influence not only on mother but also on children.
A recent study reported the risk factors of postpartum depression are prenatal depression, prenatal stress, marital relationship and life stress (7). In Japan, there are reports that the
postpartum women aged < 20 years and aged ≧ 35 years havehigh EPDS score (8). According to the study of older primiparas,
they have high prevalence of shoulder stiffness, back pain andwrist pain (9) and the high level of fatigue (10) at one month afterchildbirth.
Moreover, one of the important risk factors for postpartum
Received for publication November 18, 2020 ; accepted April 25, 2021.
Address correspondence and reprint requests to Aya Kondou, Department of Midwifery, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan, 3-18-15, Kuramoto-cho,
Tokushima, 770-8503, Japan and Fax : +81-88-633-9081.

depression is the lack of social support (11, 12). Young parents
found it easy to receive postpartum support because they often
lived near their parents in the local city, a 2011 survey reported(13). And therefore, the local city was the good environment
to receive support easily in childcare. In this present decreasein the number of births, pregnant women who do not have anexperience to play with children in a home and an area is increasing. Moreover, there are few friend and place in a trouble
for pregnant women.
In reference to the Finnish neuvola model, we will install “Thecomprehensive support centers for Maternal with Child Health”
where a pregnant woman can feel free to consult in the wholecountry across interfamily support. This study examines therelationship between mental health status and social support
during pregnancy and through the first month postpartum
in order to evaluate the actual situation in the local city. This
study’s findings should assist with the plans in providing acomprehensive support center for maternal and child health ina local city.

METHODS
SurveyThis was a prospective cohort study conducted between July
2018 and March 2020 in an emergency hospital staffed withmidwives and postpartum mental health supports in. Participants were women > 20 years of age, without severe pregnancy
complications and no mental disorders. Their children were
determined to be physically normal, and there had been no severe postpartum health problems or unusual problems with thedelivery.
Data were collected four times : during the second trimester,
the third trimester, postpartum hospitalization, and 1 monthafter childbirth. During the second trimester, we asked thewomen to participate in the study and obtained a signed consent. During each of the four periods, we have distributed a

The Journal of Medical Investigation Vol. 68 2021

266

A. Kondou, et al. maternal mental status, social supports

self-administered questionnaire which the women completed
and mailed back.

Instruments
In addition to the three scales discussed below, we asked themothers about their age, number of previous births, type ofdelivery, occupation, whether they work at night, and whether
they visited their parents’ home. We asked about their primary
support person, and we inquired about their satisfaction for thisperson using a 5-point Likert scale, from 1 (very satisfied) to 5
(very dissatisfied).

CES-D
The CES-D (the Center for Epidemiologic Studies Depression)scale was developed by Radloff (14), and it was then translated
into Japanese by Shima et al. (15). It consists of 20 items anduses a 4-point Likert scale. We asked respondents to choose oneof the following responses for each question as it applied to their
physical or mental conditions : 0 (rarely or none of the time, < 1
day / week) ; 1 (some or a little of the time, 1–2 days / week) ; 2 (occasionally or a moderate amount of time, 3–4 days / week) ; and3 (most or all of the time, 5–7 days / week). Scores ranged from 0
to 60, with higher scores indicating greater levels of depression.
The cut-off point was 16 points. The reliability of this scale has
been examined.

STAI
The STAI has been defined as a scale that divides anxiety into
state and trait anxiety based on the state-trait anxiety theory of
Spielberger et al. (16). The STAI is comprised of 20 state anxiety
items, which evaluate present feelings, and 20 trait anxiety items
examining everyday feelings. We only used the state anxiety
questions to inquire about present feelings in this study. The stateanxiety uses a 4-point Likert scale ranging from 1 (does not apply
at all) to 4 (applies very well). Scores range from 20 to 80, withhigher scores indicating higher levels of state anxiety. The cut-off
point is 42 points. The reliability of this scale has been examined.

Social Support Scale
The Social Support Scale was developed by Zimet et al. (17-19),
and it was translated to Japanese by Iwasa et al. (20). The scaleconsists of 12 items ; each of which is comprised of three factors
as follows : “support by the important person,” “support by thefamily,” and “support by a friend.” It is scored using a 7-point
Likert scale ranging from 1 (we do not think so at all) to 7 (wethink so very much) points. Scores range from 12 to 84, withhigher scores indicating higher levels of social support. The
Cronbach alpha for this study was 0.921 in the second trimester,
0.945 in the third trimester, 0.951 during the postpartum hospitalization, and 0.950 1 month after childbirth.

untary. We stated that there was no penalty or disadvantage
for refusing to participate, that confidentiality would be maintained, that withdrawal from the study was possible even after
giving their consent, and that the data obtained would not be
used for any other purpose apart from the study. We then used aquestionnaire with an ID number for data collection for each fourtimes the questionnaire was filled out. However, no individual
was specifically identified, and the privacy of the participants
was protected. This study was approved by the Ethics Committee of Tokushima University Hospital (approval no. 3165).

RESULTS
In total, 139 participants have agreed to participate in the
study ; however, 61 were excluded either due to peripartum maternal or infant abnormalities or failure to answer all questions
on the four separate questionnaires, which narrowed down theparticipants into 78 (56.1%). The average age of the participants
was 34.9 ± 4.7 years, and 48.7% were determined to be primiparous. The proportion of participants who were ≧ 35 years of age
was 56.4%. Among primiparous women, the proportion of participants who were ≧ 35 years of age was 52.6% (20 / 38). Of all theparticipants, 82.1% held jobs and the most common support person was their husband on all four of the questionnaires (Table 1).
Table 1. Demographic data of the participants

N = 78
number(proportion)age (years)

age (Mean ± SD)

34.9 ± 4.7

number of previous births

primiparous women

38 (48.7)

multiparous women

40 (51.3)

aged < 35

34 (43.6)

aged≧35

44 (56.4)

age (in primiparous women'sgroup) (n = 38)

aged < 35

18 / 38 (47.4)

aged≧35

20 / 38 (52.6)

type of delivery

Vaginal

64 (82.1)

Cesarean section

14 (17.9)

don't work

14 (17.9)

a working women

64 (82.1)

Yes

6 (7.7)No

58 (74.4)

don't work

14 (17.9)

Yes

29 (37.2)

No

49 (62.8)

age

work
whether they work at night

whether they visited theirparents' home

Data analysis

Changes over time of the CES-D, STAI, and Social Support Scale

The demographic data of the participants was evaluated using
descriptive statistics. Changes in the three scales’ scores overtime were determined using the Friedman test. Meanwhile, theBonferroni method was used for subsequent multiple comparisons. We analyzed the correlation among the three scales’ scores
using Spearman’s rank correlation coefficient test. We analyzed
the association between demographic information and the threescales’ scores using the t-test and the Mann-Whitney U test. Statistical analyses were conducted using SPSS Statistics version
25 (IBM Corp.).

The CES-D score was 8.0, 9.0, 7.0, and 4.0 in the second trimester, third trimester, during postpartum hospitalization, and1 month after childbirth, respectively. A significant difference
was observed between the second trimester and 1 month afterchildbirth, between the third trimester and 1 month after childbirth, and between the postpartum hospitalization and 1 monthafter childbirth (P < 0.001).
The state anxiety score (STAI) was 38.5, 37.5, 35.0, and 31.0 in
the second trimester, third trimester, during postpartum hospitalization, and 1 month after childbirth, respectively. The averagescore in the second trimester was deemed to be the highest, and allscores gradually decreased throughout the remainder of the study
period. Each of the initial three study periods was significantly
different from the period 1 month after childbirth (P < 0.001).

Ethical consideration
We informed the participants both verbally and in writing
about the purpose of the study and that participation was vol-267

The Journal of Medical Investigation Vol. 68 August 2021
The Social Support Scale score was 72.5, 72.5, 76.0, and 76.5
in the second trimester, third trimester, during postpartum
hospitalization, and 1 month after childbirth, respectively. A significant difference was determined between the second trimester
and the postpartum hospitalization, between the third trimester
and the postpartum hospitalization, between the second trimester and 1 month after childbirth, and between the third trimester and 1 month after childbirth (P < 0.001).
The score for support by the important person on the Social
Support Scale was 25.5, 24.0, 27.0, and 27.0 in the second trimester, third trimester, during postpartum hospitalization, and1 month after childbirth, respectively. There was a significant
difference between the second trimester and the postpartum
hospitalization, between the third trimester and the postpartum
hospitalization, and between the third trimester and 1 monthafter childbirth (P < 0.001). The score for support by the family
was 25.0, 25.0, 26.0, and 27.0 in the second trimester, third
trimester, during postpartum hospitalization, and 1 month afterchildbirth, respectively. Significant difference was also observed
between the second trimester and the postpartum hospitalization
and between the third trimester and the postpartum hospitalization (P < 0.001). The sore for support by a friend was 23.0, 23.0,
24.0, and 24.0 in the second trimester, third trimester, during
postpartum hospitalization, and 1 month after childbirth, respectively. There was a significant difference between the second
trimester and the postpartum hospitalization, between thethird trimester and the postpartum hospitalization, between thesecond trimester and 1 month after childbirth, and between thethird trimester and 1 month after childbirth (P < 0.001) (Table 2).

Correlation among the three scales
The CES-D score was significantly and negatively correlatedwith the Social Support Scale score in the second trimester,
third trimester, during postpartum hospitalization, and 1 monthafter childbirth (r = -.30 to -.48, P < 0.01). Also, the STAI score
was significantly and negatively correlated with the Social
Support Scale score in all four times (r = -.28 to -.46, P < 0.01).
However, the STAI score was not significantly correlated withthe score of support by the family in the postpartum hospitalization period (Table 3).

Association between demographic data and the scales’ scores
Age
Participants aged < 35 years have been determined to havesignificantly higher Social Support Scale scores than those aged
≧ 35 years in the second trimester (P = 0.017). Those < 35 years
had a significantly higher Social Support Scale score in the third
trimester (P = 0.041). Finally, participants aged < 35 years hada significantly higher Social Support Scale score 1 month afterchildbirth (P = 0.044).
We divided 38 primiparous women into two groups. One wasaged < 35 , the other was aged ≧ 35. We investigated the association with the scale score. There was no significant difference
between two groups in all for four times.

Night work
We divided a working woman into two groups. One was the participants who worked in the night, the other was the participants
who did not work in the night in the second trimester. One group
had a significantly lower CES-D and STAI score than the other(P = 0.034 and 0.040, respectively). One group had a significantly
higher Social Support Scale score than the other (P = 0.024)(Table 4).

Table 2. Changes over time of the CES-D, STAI, and Social Support Scale
the state anxiety(STAI)

the CES-D

N = 78for support by theimportant person on
the Social Support
Scale

the Social
Support Scalefor support by
the family on theSocial Support
Scale

for support bya friend on the Social
SupportScale

second trimester

8.0 (4.0, 13.0)

a38.5 (32.0, 46.0)

a72.5 (66.0, 80.0)

a25.5 (23.0, 27.0) bc

25.0 (23.0, 28.0)b

23.0 (20.0, 25.0)

third trimester

9.0 (5.0, 12.0)

a37.5 (34.0, 45.0)

a72.5 (65.0, 79.0)

a24.0 (23.0, 28.0)c

25.0 (22.0, 28.0)b

23.0 (20.0, 25.0)aapostpartum hospitalization

7.0 (4.0, 10.0)a35.0 (30.0, 41.0)

a76.0 (69.0, 82.0)b27.0 (24.0, 28.0)

a26.0 (24.0, 28.0)

a24.0 (21.0, 27.0)b

1 month after childbirh

4.0 (1.0, 8.0)b31.0 (24.0, 39.0)b76.5 (67.0, 82.0)b27.0 (24.0, 28.0) ab

27.0 (23.0, 28.0) ab

24.0 (21.0, 28.0)bChanges in the three scales’ score over time were determined using the Friedman test.
Meanwhile, the Bonferroni method was used for subsequent multiple comparisons.
Values were presented as Median (25th, 75th perzentile).
Different letters indicated significant differences at P < 0.05 between sites.

Table 3. Correlation among the three scales

N = 78the Social
Support Scale scoresecond trimester
third trimester
postpartum
hospitalization
1 month afterchildbirh

the scores forsupport by theimportant personon the Social
Support Scalethe scores forsupport by thefamilythe scores forsupport bya friend

the CES-D score-0.31**-0.31**-0.27*-0.30**

the score of the state anxiety score (STAI)-0.36**-0.36**-0.26*-0.40**

the CES-D score-0.31**-0.35**-0.31**-0.25*

the score of the state anxiety score (STAI)-0.45**-0.47**-0.39**-0.39**

the CES-D score-0.30**-0.36**-0.24*-0.26*

the score of the state anxiety score (STAI)-0.28*-0.26*-0.21-0.28*

the CES-D score-0.48**-0.51**-0.41**-0.44**

the score of the state anxiety score (STAI)-0.46**-0.47**-0.45**-0.41**We analyzed the correlation among the three scales' using Spearman's rank correlation coefficient test. ** P < 0.01 , * P < 0.05.

7.5 (4.0, 13.0)
8.0 (4.5, 13.0)

don't worka working womenwork

8.6 (6.2)

8.0 (5.0, 9.0)

5.0 (1.0, 9.0)
3.0 (1.0, 7.0)

Yes

No

whether they visited their parents' home

3.0 (0.0, 7.0)
5.0 (2.0, 10.5)

aged < 35aged≧35

4.5 (1.0, 9.5)

aged≧35age (in primiparous women's group)

3.5 (0.0, 5.0)

aged < 35

3.5 (1.0, 9.0)
4.0 (1.0, 7.0)

primiparous women

multiparous women(n = 38)

age

number of previous births

7.0 (4.0, 10.5)
8.0 (7.0, 10.0)

Vaginal

Cesarean section

type of delivery

6.0 (3.0, 10.0)
8.0 (5.0, 15.5)

aged < 35aged≧35age (in primiparous women's group)

6.0 (3.0, 9.0)
8.0 (5.0, 11.5)

aged < 35aged≧35(n = 38)age

7.0 (4.0, 12.0)

primiparous women

multiparous women

number of previous births

6.0 (4.0, 13.0)
8.5 (5.5, 12.5)

aged < 35aged≧35age (in primiparous women's group)

6.0 (4.0, 13.0)
9.0 (6.0, 12.0)

aged < 35aged≧35(n = 38)age

7.5 (4.0, 13.0)
9.0 (5.0, 12.0)

primiparous women

multiparous women

number of previous births

3.5 (3.0, 6.0)
8.0 (5.0, 14.0)

Yes

No

whether they work at night(n = 64)

9.8 (6.4)

aged < 35aged≧35age (in primiparous women's group)(n = 38)

6.0 (4.0, 14.0)
8.0 (5.0, 13.0)

aged < 35aged≧35

8.0 (4.0, 14.0)
8.0 (4.5, 13.0)

primiparous women

multiparous women

0.466

0.210

0.241

0.884

0.248

0.067

0.034

0.877

0.455

0.214

0.652

0.034

0.739

0.565

0.385

0.912

31.0 (24.0, 41.0)

28.0 (24.0, 38.0)

32.5 (24.0, 38.5)

28.0 (23.0, 41.0)

30.5 (24.0, 37.5)

31.0 (24.0, 41.0)

31.0 (25.5, 38.0)

30.5 (23.0, 40.0)

37.0 (10.8)

35.5 (8.3)

40.0 (10.1)

35.8 (8.7)

37.1 (9.0)

34.1 (8.3)

33.7 (7.4)

38.0 (9.5)

39.5 (9.2)

36.7 (7.7)

40.2 (9.4)

36.8 (8.6)

39.2 (9.8)

38.2  (8.5)

39.0 (34.0, 45.0)

31.0 (24.0, 36.0)

38.4 (9.4)

41.1 (11.0)

40.2 (9.8)

37.5 (7.5)

40.3 (10.1)

37.9 (8.9)

39.6 (10.5)

38.9 (8.8)

the score of thestate anxiety
score(STAI)

0.524

0.629

0.988

0.671

0.573

0.182

0.124

0.027

0.332

0.108

0.618

0.040

0.425

0.359

0.287

0.740

P value
73.0 (68.0, 80.0)

the Social
Support Scalescore

76.0 (67.0.81.0)

79.0 (70.0, 82.0)

77.5 (65.0, 81.5)

80.0 (70.0, 84.0)

75.0 (65.0, 80.5)

80.0 (70.0, 84.0)

75.5 (67.5, 80.5)

78.0 (67.0, 84.0)

76.0 (72.0, 84.0)

76.0 (69.0, 82.0)

73.5 (69.5, 81.5)

79.5 (72.0, 83.0)

74.5 (66.5, 80.5)

79.0 (73.0, 83.0)

76.0 (68.0, 81.0)

76.5 (71.0, 83.0)

72.0 (66.5, 77.5)

78.0 (70.0, 81.0)

71.0 (63.5, 76.0)

75.5 (70.0, 81.0)

71.0 (63.0, 78.0)

73.5 (68.0, 79.0)

72.0 (66.0, 79.0)

81.0 (80.0, 83.0)

73.0 (66.5, 80.0)

68.5 (61.0, 78.0)

71.7 (7.4)

75.7 (7.4)

69.0 (65.5, 79.0)

75.5 (71.0, 81.0)

72.0 (65.5, 79.5)

We analyzed the association between demographic information and the three scales’ scores using the t-test and Mann-Whitney U test.
Values were presented as Mean(SD) or Median(25th, 75th perzentile).

1 month afterchildbirh

postpartum
hospitalization

third trimester

second trimesteragenumber of previous births

the CES-D score P value

Table 4. Association between demographic data and the scales’ scores

0.256

0.213

0.044

0.184

0.690

0.253

0.064

0.703

0.236

0.041

0.284

0.024

0.155

0.109

0.017

0.224

P value

27.0 (23.0, 28.0)

27.0 (24.0, 28.0)

27.0 (24.0, 28.0)

27.5 (24.0, 28.0)

26.0 (23.0, 28.0)

27.0 (24.0, 28.0)

26.0 (23.5, 28.0)

27.0 (24.0, 28.0)

27.0 (24.0, 28.0)

26.5 (24.0, 28.0)

25.0 (24.0, 28.0)

27.0 (24.0, 28.0)

25.5 (23.5, 28.0)

27.0 (25.0, 28.0)

27.0 (24.0, 28.0)

26.5 (24.0, 28.0)

24.5 (23.0, 26.5)

26.0 (24.0, 28.0)

24.0 (22.5, 26.0)

25.0 (24.0, 28.0)

24.0 (23.0, 27.0)

25.0 (23.0, 28.0)

25.5 (23.0, 27.0)

28.0 (27.0, 28.0)

26.0 (23.5, 27.5)

23.0 (21.0, 27.0)

25.0 (23.0, 27.0)

27.0 (24.0, 28.0)

24.0 (23.0, 27.0)

27.0 (24.0, 28.0)

24.0 (22.5, 27.0)

26.0 (23.0, 28.0)

0.367

0.502

0.195

0.457

0.679

0.486

0.153

0.634

0.211

0.030

0.221

0.043

0.084

0.246

0.066

0.248

the scores for support
by the important
P value
person on the Social
Support Scale

26.0 (23.0, 28.0)

28.0 (24.0, 28.0)

27.0 (23.5, 28.0)

28.0 (24.0, 28.0)

25.5 (22.0, 28.0)

27.0 (24.0, 28.0)

26.0 (22.5, 28.0)

27.0 (24.0, 28.0)

27.0 (26.0, 28.0)

26.0 (24.0, 28.0)

26.0 (24.0, 27.0)

26.5 (26.0, 28.0)

26.0 (23.5, 28.0)

27.0 (25.0, 28.0)

26.0 (23.5, 28.0)

26.0 (25.0, 28.0)

24.5 (23.0, 26.5)

26.5 (24.0, 28.0)

24.0 (22.0, 27.0)

26.0 (24.0, 28.0)

24.5 (22.0, 28.0)

26.0 (24.0, 28.0)

25.0 (23.0, 28.0)

28.0 (28.0, 28.0)

25.5 (23.0, 28.0)

24.0 (21.0, 26.0)

24.5 (23.0, 28.0)

27.0 (25.0, 28.0)

24.0 (22.0, 27.5)

26.5 (24.0, 28.0)

24.5 (22.0, 27.5)

26.0 (24.0, 28.0)

the scores forsupport by thefamily

0.105

0.216

0.056

0.287

0.300

0.195

0.058

0.511

0.201

0.029

0.492

0.046

0.200

0.155

0.039

0.076

P value

24.0 (21.0, 27.0)

24.0 (21.0, 28.0)

24.0 (20.0, 27.0)

24.5 (22.0, 28.0)

24.0 (20.0, 27.0)

24.0 (22.0, 28.0)

24.0 (20.0, 26.5)

24.0 (21.0, 28.0)

24.0 (20.0, 28.0)

24.0 (21.0, 27.0)

23.5 (21.0, 26.5)

25.5 (22.0, 27.0)

23.0 (20.0, 27.5)

25.0 (23.0, 27.0)

24.0 (20.5, 28.0)

24.5 (22.0, 27.0)

23.0 (21.5, 25.5)

24.0 (20.0, 26.0)

23.0 (20.0, 24.5)

24.0 (21.0, 25.0)

23.0 (20.0, 24.0)

24.0 (21.0, 26.0)

23.0 (20.0, 25.0)

25.5 (24.0, 27.0)

23.0 (20.0, 25.0)

22.0 (19.0, 24.0)

21.8 (3.7)

23.7 (3.3)

22.0 (19.0, 24.5)

24.0 (22.0, 25.0)

22.5 (20.0, 25.0)

23.0 (20.0, 25.0)

the scores forsupport by afriend

0.454

0.269

0.168

0.373

0.953

0.345

0.167

0.936

0.444

0.220

0.269

0.021

0.281

0.100

0.068

0.695

P value

268
A. Kondou, et al. maternal mental status, social supports

The Journal of Medical Investigation Vol. 68 August 2021
DISCUSSION
We investigated the changes in mental status and social
support among women from the second trimester of pregnancy
through 1 month after childbirth. During this period, the CES-D
and STAI scores were initially high during pregnancy anddecreased during the postpartum period. The Social Support
Scale score, however, was initially low during pregnancy andincreased during the postpartum period.
The CES-D and STAI scores was significantly and negatively
correlated with The Social Support Scale score in the second trimester, third trimester, during postpartum hospitalization, and1 month after childbirth. Lastly, participants ≧ 35 years of age
scored lower on The Social Support Scale than did participants< 35 years of age in the second trimester, third trimester, and1month after childbirth.

Changes in CES-D, STAI, and Social Support Scale scores over time
and their correlation
The CES-D score was highest in the third trimester, andthen, it gradually decreased and was significantly lower 1 monthafter childbirth than at any other time. In their longitudinal
study, Takehara et al., using the EPDS, found the proportion ofprimiparous women who were depressed peaked 2 weeks afterchildbirth and decreased 3 months after childbirth (21). In thiscurrent study, because the CES-D measures depression in bothmind and body, we found a depressive state to be low from theearly postpartum period to 1 month after childbirth. During theearly postpartum period, women experienced fatigue and stressdue to lack of sleep and rest due to pacifying a baby during thephysical recovery process. We found a depressed state to be higher during the postpartum hospitalization period than 1 monthafter childbirth, highlighting the need for rest in the postpartum
period.
The STAI score was highest in the second trimester and thengradually decreased and was significantly lower 1 month afterchildbirth than at any other time. Prior reports had noted that
the STAI score was higher during pregnancy than during the
postpartum period (22) and pregnant women had multiple anxieties about their delivery and the health of their fetuses (23). We
speculate that the pre-pregnancy anxieties decreased following
birth as women began to feel joy in childcare resulting in a lower
STAI score.
The Social Support Scale scores were low during pregnancy and increased during the postpartum period. The Social
Support Scale used in this study measures emotional support.
Because this study’s participants rarely felt the need of support,
and could provide self-care during pregnancy, they did not feelthat they received support from an important person, family, or
friend during pregnancy. However, after birth, the participants
began to feel the need for and received the support of family andfriends around childcare issues, leading to the increased Social
Support Scale scores in the postpartum period.
Prior studies of both domestic and foreign populations havefound the Social Support Scale score to be negatively correlatedwith a postpartum depression symptom score during the postpartum period (24-26). Also, in this current study, the CES-D
score was significantly and negatively correlated with the Social
Support Scale score in all four time periods as was the STAI
score. The result showed that understanding social support isimportant for prediction of postpartum depression.

Association between demographics and scale scores
Participants ≧ 35 years of age had lower Social Support
Scale scores than those < 35 years of age. Recently in Japan,
the proportion of older primiparas, ≧ 35 years of age, has been269

increasing (27), and there are reports that they are able to use
their life experiences in childcare (28, 29). However, Maehara
et al. reported that older primiparas are much less satisfied with
their social support than younger primiparas (30). Hence, older
primiparas demonstrate higher stress scores (31). In this current
study, there was no significant difference between older andyounger primiparas on the Social Support Scale score which we
believe to be due to the low number of participants.
There was no significant difference between women who
worked and those who did not on any of the scale scores. However, women who worked at night had significantly lower CES-D
and STAI scores than women who did not work at night in thesecond trimester. Women who worked at night had a significantly higher Social Support Scale score than women who did notwork at night. In a previous study, the mental stress level washigh in women who did shift work including night work (32), andin a survey which included biochemical data, pregnant women
working at night had evidence of increased psychologic stress(33). In this current study, women doing night work had low
CES-D and STAI scores, as well as little evidence of depression
and anxiety. In the local city, many women were employed in the
medical and welfare services sector. They were able to use theinformal social services of the family to supplement a shortage ofnight care centers, and family help was necessary to allow themto keep working.

Mental health support
In the local city, there are few formal social services to a pregnant woman and a problem about the mental health support ofthe pregnant woman. The support of the family is still essential
to a pregnant woman in a local city. Therefore, we think that it isimportant to examine a support method so that “The comprehensive support centers for Maternal with Child Health” becomesthe useful support resources of the pregnant woman living in
the local city.

STUDY LIMITATIONSThis survey was a prospective cohort study during the periodof the second trimester of pregnancy until 1 month after childbirth. There is the potential for significant bias of the results as
we only examined women who were relatively stable in mind andbody during their postpartum hospitalization and 1 month afterchildbirth. In the future, we plan to evaluate postpartum womenwith significant physical and emotional limitations postpartum.

CONCLUSIONS
We found that depressive symptoms and anxiety were elevated during pregnancy and decreased following birth, while thefeeling of having social supports was low during pregnancy andincreased during the postpartum period. These findings should
assist with the implementation of a comprehensive support center and may be useful for in a local city in Japan.

CONFLICT OF INTERESTS
No conflict of interests

ACKNOWLEDGEMENTS
We wish to thank all of the participants.

270

A. Kondou, et al. maternal mental status, social supports

REFERENCES
1.

Japan Association of Obstetricians and Gynecologists : Maternal Mental Health Manual (in Japanese). 2017
2. Hahn-Holbrook J, Cornwell-Hinrichs T, Anaya I : Economic
and health predictors of national postpartum depression
prevalence : a systematic review, meta-analysis, and meta-regression of 291 studies from 56 countries. Front Psychiatry 248 : 1-23, 2018
3. Huizink AC, Robles de Medina PG, Mulder EJ, Visser GH,
Buitelaar JK : Stress during pregnancy is associated with
development outcome in infancy. J CHILD PSYCHOLPSYC 44 : 810-818, 2003
4. O’Connor TG, Heron J, Golding J, Beveridge M, Glover
V : Maternal antenatal anxiety and children’s behavioural/
emotional problems at 4 years: report from the Avon Longitudinal Study of Parents and Children. Br J Psychiatry
180 : 502-508, 2002
5. Anan A, Li Y, Tsuji M, Nagamatsu Y, Chou S, Toyofuku K,
Nakatani J, Kawai K : Status of pregnant women’s mental
and physical stress and influences of work. JJOMT 65 : 201210, 2017
6. Shinkawa H, Shimada M, Hayase M, Inui T : A survey ofthe variety, incidence rate, and frequency of minor symptoms currently experienced by expectant mothers (in Japanese). JJpn Acad Midwif 23 : 48-58, 2009
7. Beck CT : Predictors of postpartum depression : an update.
Nurs Res 50 : 275-285, 2001
8. Harada N : Statistical analysis of risk factors for depressionof mothers with a high score on Edinburgh postnatal depression scale (in Japanese). J Health Sci 5 : 1-12, 2008
9. Iwata H, Mori E, Maehara K, Sakajo A, Aoki K, Tamakoshi
K : Shoulder stiffness, back pain, and wrist pain : Are older
primiparas more vulnerable?. Int J Nurs Pract 24 : 1-7, 2018
10. Iwata H, Mori E, Sakajo A, Aoki K, Maehara K : Course ofmaternal fatigue and its associated factors during the first 6
months postpartum : a prospective sohort study. Nurs Open
5 : 186-196, 2018
11. O’Hara MW, Swain AM : Rates and risk of postpartum
depression : A meta-analysis. Int Rev Psychiatry 8 : 37-54,
1996
12. Milgrom J, Gemmill AW, Bilszta JL, Hayes B, Barnett B,
Brooks J, Ericksen J, Ellwood D, Buist A : Antenetal risk
factors for postnatal depression : A large prospective study.
J Affect Disord 108 : 145-157, 2008
13. Research on childcare environment in urban and rural
areas (in Japanese). https://www8.cao.go.jp/shoushi/shoushi
ka/research/cyousa
23/kankyo/index_pdf.html
14. Radloff LS : The CES-D Scale : A self-report depression
scale for research in the general population. Appl Psychol
Meas 1 : 385-401, 1977
15. Shima S, Shikano T, Kitamura T, Asai M : New self-rating
scale for depression (in Japanese). Clin Psychiatry 27 : 717723, 1985
16. Hidano T, Fukuhara M, Iwawaki S, Soga S : State-trail
anxiety inventory-form JYZ manual (in Japanese). Zitumukyouikusyuppann, Tokyo, 2000
17. Dahlem NW, Zimet GD, Walker RR : The multidimensional
scale of perceived social support : a confirmation study. J
Clin Psychol 47 : 756-761, 1991
18. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff

KA : Psychometric characteristics of the Multidimensional
Scale of Perceived Social Support. J Pers Assess 55 : 610617, 1990
19. Zimet GD, Dahlem NW, Zimet SG, Farley GK : The multidimensional scale of perceived social support. J Pers Assess
52 : 30-41, 1998
20. Iwasa H, Gondo Y, Masui Y, Inagaki H, Kawai T, Otuka R,
Ogawa M, Takayama M, Imuda M, Suzuki T : Reliability
and validity of the Japanese version of Multidimensional
Scale of Perceived Social Support Scale among middle-aged
and elderly people living in a Japanese community (in Japanese). J Health welfare Stat 54 : 26-33, 2007
21. Takehara K, Tachibana Y, Yoshida K, Mori R, Kudo T :Prevalence trends of pre-and postnatal depresson in Japanese women : A population-based longitudinal study. J
Affect Disord 225 : 389-394, 201822. Sato K : Severity of anxiety and related factors among
women during gravid and puerperal period (in Japanese).
JJpn Acad Midwif 20 : 74-84, 2006
23. Kabeyama K, Sayama M : Clinical midwifery handbook-support based on life and culture- (in Japanese). Igaku-syoin, Tokyo, 2006
24. Leahy-Warren P, McCarthy G, Corcoran P : First-time
mothers: social support, maternal parental self-efficacy andpostnatal depression. J Clin Nurs 21 : 388-397, 2011
25. Xie R-H, Yang J, Liao S, Xie H, Wajker M, Wen SW : Prenatal family support, postnatal family support and postpartum depression. Aust N Z J Obstet Gynaecol 50 : 340-345,
2010
26. Kinjo H, Kawasaki K, Takeo K, Yuga M, Maruyama Y,
Imai KK : Depression symptoms and related factors on
pregnant and postpartum women in Japan (in Japanese).
Saku UNIV J Nurs 3 : 15-25, 2011
27. Kamiya K : Maternal and child health statistics of Japan (inJapanese). Mothers’ & Childrens’ Health & Welfare Association, Tokyo, 2012
28. Sakajo A, Mori E, Maehara K, Maekawa T, Ogawa H,
Morita A, Aoki K, Iwata H : Older Japanese primiparas’
experiences at the time of their post-delivery hospital stay.
Int J Nurs Pract 20 : 1-19, 2014
29. Mori E, Iwata H, Sakajo A, Maehara K, Ozawa H, Maekawa
T, Morita A, Saeki A : Postpartum experiences of older Japanese primiparas during the first mother after childbirth.
Int J Nurs Pract 20 : 20-31, 2014
30. Maehara K, Mori E, Tsuchiya M, Sakjo A, Iwata H, Ozawa
H, Aoki K, Morita A, Maekawa T, Mochizuki Y : Related
factors for improving maternal role confidence among primiparas with low confidence from discharge to 1 month afterchildbirth : a comparison between older and younger ages
(in Japanese). JJpn Maternal Health 56 : 264-272, 2015
31. Fujioka N, Kamezaki A, Kawamoto E, Shiomichi A, Tsuboi
Y, Fujii Y : The change with time of some stress in the 5 days
after delivery-Investigated and compared pregnancies over
the age 35 with those under 35-(in Japanese). JJpn Maternal Health 55 : 78-85, 2014
32. Anan A, Li Y, Tsuji M, Nagamatsu Y, Chou S, Toyofuku K,
Kawai K : Mental / Physical stress levels of female nurses’
working rotational shifts. JJOMT 67 : 167-174, 201933. Yamauchi H : Effects of shift work on psychophysical healthof pregnant women-Urinary Norepinephrine level and
STAI-A-State score-. Bull Kumamoto UNIV, Sch HealthSci 6 : 63-72, 2010