For most women having a baby, especially their first child, is a significant transitional life event.¹ The first weeks and months postpartum may be associated with emotional upheaval.² The nursing mother tries to meet the needs of her baby, to adapt to the changes in her sleep pattern and to recover from the process of delivery physically.³ Also, the depth of their feelings may be related to hormonal changes, fatigue and the pain of incisions, swollen breasts or sore nipples.⁴ Post-partum period involves changes in marital and family relationships and is commonly a cause of additional financial burden, even among households with relatively high income⁵ but worse among the low socioeconomic class.^6,7

Post-partum depression (PPD) and anxiety affect approximately 10% – 20% of all mothers in Western societies.⁸ A prevalence of 23% – 31% was reported for PPD in Southeastern Nigeria,^9,10 while Fatoye et al.¹¹ reported that between 5% and 38% of women suffer from PPD in Southwestern Nigeria. The differences in the prevalence might be because of the effect of social, cultural, lifestyle and racial factors on depression.¹² These statistics indicate that PPD might be a very common experience in Nigeria. Post-partum depression is related to the level of social support,² previous depressive illness, stress, psychological factors and obstetric factors.^6,7

Some psychosocial stressors in pregnancy may be because of cultural influence issues relevant to Igbo culture where marriage is patrilineal, with emphasis on begetting a child, especially a male child, to sustain a family lineage and to guarantee the position of the woman in the family.¹³ In Igbo culture and practices, not begetting a child, especially a male child, is one of the most relevant factors that could influence marital discord, and this could lead to marital dissatisfactions. Also, in Igbo culture and tradition, it is believed that a woman is not just married to a man but to the extended family, and for this, to a great extent, the in-laws have an influence on the marriage. Pressures from the extended family sometimes compound psychosocial stress postpartum. Psychosocial stressors in pregnancy or early postpartum is a strong predictor of post-partum depressive symptoms,^14,15,16,17 and marital problems during pregnancy increase the risk of PPD and anxiety.^18,19,20 However, the causal pathways between psychosocial stressors and depression may go in both directions.¹⁷

Post-partum depression can develop at any point during the first year of postpartum, with a peak of incidence in the first 4 months of postpartum.^21,22 The mother may suffer an inability to take care of her new baby either emotionally or physically, which can impair early bonding and attachment process between mother and baby and could also hinder effective infant care skills¹ and, if untreated, can affect the quality of mother-child relationship with deleterious effects on the child’s cognitive, psychosocial and physical development.^1,23 PPD may also adversely affect the marital relationship.²³

Depression often co-occurs with other disorders, especially anxiety symptoms.^24,25 Some authors^26,27 have also found associations between experiencing stressful life events and maternal depression and anxiety. Previous studies have shown high correlations between measures of depressive and anxiety symptoms and relationship adjustment.^25,28 Braverman and Britton²⁹ reported a significant positive association between post-partum anxiety, as well as depression and infant mobility, temperament, adaptability and sensibility. Generally, PPD and anxiety may have implications for marital satisfaction.

Marital satisfaction can be defined as a subjective experience of one’s personal happiness and contentment in a marital relationship.³⁰ Greeff³¹ describes marital satisfaction as marital relationship in which couples have many agreements with each other on many variables such as family happiness, spouse’s satisfaction with the sexual relationship, satisfaction with general quality of life, family strengths, flexibility in the way free time is spent in the marital relationship, sound relationships with family and friends, conflict management and resolution, and communication within the marriage. The couple is satisfied with the type and level of their relations and the type and quality of leisure times, and has proper management of their finances and time.³¹

There is a significant relationship among PPD, quality of marital relationship and mental health.^32,33 Previous community surveys have shown that marital adjustment is concurrently,³⁴ and prospectively,³⁵ associated with anxiety disorders, and those anxiety symptoms could predict a decline in marital adjustment over time.³⁶ Lower marital adjustment is prospectively associated with an onset of anxiety disorders in non-pregnant mothers.³⁵

Given the high prevalence of PPD and anxiety, their multifactorial nature and their association with poor marital satisfaction, and the importance of mental health promotion in women, any attempt to reduce any risk factors affecting their incidence can lead to a decreased rate of depression and anxiety. The development of the relevant framework is important to develop the type of strategies that could be put in place for the prevention, early detection of women at risk, and for the appropriate intervention programme to be instituted for such mothers by addressing possible risk factors such as poor marital satisfaction through active case findings, counselling and social support during antenatal visits, as well as increasing the resources available for mental health services.

The study on PPD and anxiety becomes more imperative in this part of the world, and more so given the dearth of information on their correlates in the sub-Saharan African settings, when compared to the Western world, and the importance of mental health promotion in women. It is pertinent to conduct empirical investigations of factors associated with these disorders, as any reasonable attempt to reduce any of the confirmed risk factors affecting the incidence of PPD and anxiety can go a long way in reducing the high prevalence. This study was aimed to assess the prevalence of PPD and anxiety and to investigate their relationship with marital satisfaction in low-risk women in Enugu, Southeastern Nigeria. These should be an urgent challenge for Nigerian public health officials.

The approval for the study was sought and obtained from the institutional review board (IRB) of the College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria. The study has, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Table 1 shows the distribution of the mothers according to age range, marital status, educational status, the area of residence, employment status, religion, and ethnicity. The age range was 20–46 years; mean and S.D. were 29.65 and ± 4.87, respectively. Most of the respondents were graduates of tertiary educational institutions (74.1%), and all the respondents went beyond the basic primary education with 1.6% of them dropping out of secondary school. About 97% of the mothers were married while 2.3% of them were single parents. The majority of the mothers (55.7%) were employed, while about 26% of them were unemployed.

The prevalence of post-partum anxiety was 31.1%, while that of PPD was 33.3%, and the prevalence of post-partum co-morbid anxiety and depression was 22% (See Table 2).

The scores on IMS scale were not normally distributed and had a median of 22.0. Note that the IMS scores above 39 indicate marital dissatisfaction, and 39.5% (122) of the mothers had marital dissatisfaction. The distribution of the scores of women on the IMS showed that 77 of 309 (24.9%) of the women scored 42 and fell within the 75th percentile. Four (1.0%) of them had anxiety, 15 (4.9%) had depression, and 33 (10.7%) had both anxiety and depression while 25 (8.1%) of them had neither anxiety nor depression. The numbers of women with both depression and anxiety had worse marital dissatisfaction, compared to those with either anxiety or depression alone.

Table 3 shows a Spearman’s rank-order correlation coefficient, which was run to assess the relationship among PPD, post-partum anxiety and marital satisfaction. Preliminary analysis showed the relationship to be monotonic, as assessed by the visual inspection of a scatter plot. There was a moderate positive correlation between total score on IMS and HADS total score on Depression Subscale, r^s = 0.419, p < 0.01. There was also a moderate positive correlation between total score on IMS and total score on HADS (Anxiety Subscale), r^s = 0.401, p < 0.01, where r is the degree of freedom, obtained from the ‘Sig. (two-tailed)’ row. (Note: The higher the score on IMS, the more dissatisfaction with the relationship is indicated).

A chi-square test for an association was conducted to examine the differences in socio-demographic data between mothers with and without PPD and PPA using the dichotomised measures of both the dependent and independent variables. The chi-square analysis found that there was a statistically significant association between educational attainment and PPD (χ²[1] = 7.797, p = 0.005) and PPA (χ²[1] = 8.537, p = 0.003).

A chi-square test for association was conducted examining the differences in socio-demographic data between mothers with and without marital satisfaction using the dichotomised measures of both the dependent and independent variables. The chi-square analysis found that there was a statistically significant association between age and marital satisfaction, (χ²[1] = 4.890, p = 0.027). There was also a statistically significant association between educational attainment and marital satisfaction (χ²[1] = 13.978, p = 0.005).

In Table 4, HADS anxiety subscale was positively related to most of the IMS items, except items 4 (I feel that I would not choose the same partner if I had to do it over), 10 (I feel that our life together is dull), 15 (I feel that we do not have enough interests in common) and 22 (I feel that we should do more things together). The strongest correlation with anxiety was found in item 12 (I feel that my partner doesn’t confide in me) (r = 0.37, p < 0.001).

The HADS Depression subscale was positively related to most of the IMS items, except items 3 (I feel that my partner really cares for me), 15 (I feel that we do not have enough interests in common) and 22 (I feel that we should do more things together). Items 4 and 22 which did not correlate significantly with anxiety were found to be significant correlates of depression. It was only item 22 that did not significantly correlate with any of the HAD subscales. The strongest correlation with depression was also found in item 12 (I feel that my partner does not confide in me) (r = 0.43, p < 0.001).

The study focused on women, who were in their 6th–14th weeks of postpartum, and was aimed to assess PPD and anxiety and to investigate their relationship with marital satisfaction in low-risk women. Over 74.0% of the respondents were graduates with a university degree, and all the respondents went beyond the basic primary education with only 1.6% of them dropping out of secondary school. This was a reflection of the realities of the Igbo society where high premium is, at present, placed on education, including, among the female gender, which is in line with the aphorism that said that when you educate a man, you educate a person, but when you educate a woman, you educate a complete nation; as the education of her children would be highly guaranteed; moreover, the education of every child starts from the family, and the mother is the first teacher.⁴⁹

The majority of the mothers (55.7%) were employed, while the unemployed or housewives and students constituted 26.0% and 17.2%, respectively. As such, beyond their indispensable roles as mothers and wives, women have remarkably contributed to the building of their nation’s economy as skilled and unskilled labourers, artisans, traders, farmers, civil servants, and professionals in different areas of human endeavour.⁵⁰ With these responsibilities, the nursing mother tries to meet the needs of her new born to adapt to the changes in her sleep pattern (most often the lack of sleep) and to recover physically from the delivery.⁴ All these factors could put the new mother at risk for psychological distress during the post-partum period.⁵

Less than 3% of the mothers were single parents; this could be related to the cultural factors primarily, as Igbo culture believes so much in strong familial ties and does not encourage single parenthood in a mother’s parental home. This aspect of Igbo culture is taken seriously, given the shame it brings to a single mother and her family, fears of parental rejection or violent reaction.⁵¹ In addition, there is fear of stigmatisation and discrimination from her peers and family members and friends, partner’s negative reaction or refusal to admit being responsible for the pregnancy, poor financial support, religious ostracisation, social isolation, abuse, and expulsion from school or work.^52,53 Some factors could combine to make it very unlikely for many of such single teenage mothers to visit postnatal clinics in a tertiary hospital and could also force many of them into sheltered homes where they are taken care of, right from pregnancy to puerperium. However, Ossai and Uzochukwu,⁵⁴ in their study, reported a higher rate (urban area = 7.8% and rural area = 10.7%) in a survey of 540 clients of maternal health service in 18 of 440 primary health care centres in urban and rural primary health care centres in Enugu state, Southeast Nigeria, who attended antenatal and postnatal clinics.

Results showed that a considerable subgroup of nursing mothers (33.3%) reported moderate-to-severe symptoms of depression; while the mothers with some possibility of having PPD (mild depression) constituted 20.7% of the mothers. Those with severe depression were 5.8%. The mean score of women’s PPD was 8.44 ± 5. 3.87. Previous research in PPD has recorded a prevalence rate of between 5.0% and 38.0%.^8,9,10,11

Also, 35.9% of the mothers reported moderate-to-severe symptoms of anxiety; 22.0% of the mothers had mild PPA. Those with severe anxiety were 8.4%. The mean score of women’s post-partum anxiety was 8.39 ± 3.91. Previous research in PPA has recorded a prevalence rate of between 10.0% and 20.0%.^8,11 The differences in the prevalence might be because of the effect of social, cultural, lifestyle and racial factors on depression and anxiety.¹²

The prevalence of co-morbid post-partum anxiety and depression was found to be 22.0%; previous studies had reported prevalence ranging from 2.0% to 13.0% of co-morbidity for PPD and anxiety in the first year.^55,56

The study observed that the numbers of women with both depression and anxiety had worse marital dissatisfaction, compared to those with either anxiety or depression alone, and this is in line with report of previous studies suggesting that the mental health benefits of marriage are greater for those in ‘good-quality’ relationships in comparison to those in ‘poor-quality’ relationships.⁵⁷

The study found an association between educational attainment and PPD and PPA. Previous studies have pointed out the role of educational attainment in the aetiology of psychological distress, and low education has been pointed out as a risk factor in mental health disorders.⁵⁸

The study also found an association between marital satisfaction and age, and this was supported by previous studies.⁵⁹ Also, there was an association between marital satisfaction and education attainment, and this is supported by the previous study.⁶⁰

More importantly, this study showed that there is a significant and inverse relationship between marital satisfaction and post-partum anxiety, and this is supported by previous research involving community samples, which has shown that poor marital adjustment is associated with anxiety disorders.^34,35 Also, in this the study, a moderate and inverse relationship between marital satisfaction and PPD was observed, and this has been reported in related previous studies elsewhere.^32,61,62 However, O’Hara and Swain¹⁴ reported a small inverse relationship between poor marital relationship and PPD. Most women with PPD have lower levels of marital satisfaction and higher stress, and this may indicate the protective role of marital satisfaction in PPD³² and vice versa. The causal pathways between psychosocial stressors (as in degree of marital satisfaction) and depression may go in both directions.¹⁷Invariably, the study showed that there was a significant inverse correlation between depression, and anxiety with marital satisfaction in the post-partum period, and this has been reported in previous studies.^2,26,27,63 Atkinson and Rickel⁶⁴ found that, consistent with the behavioural perspective of PPD, perceived positive reinforcement was inversely related to PPD. The lack of intimacy and marital strife is linked to depression in women,⁶⁵ and anxiety symptoms predict a decline in marital adjustment over time.³⁶

The study found out in the analysis that item 12, which said: ‘I feel that my partner doesn’t confide in me’, had the strongest correlation with anxiety and depression. In a systematic review of 20 studies carried out in both rural and urban parts of Pakistan,⁶⁶ reported the absence of a confiding relationship, as among the other four factors perceived by women to affect their mental health.⁶⁶ This may not be out of place in Igbo culture, where the women have placed high premium on the trust of their husbands,⁶⁷ and the husbands not confiding in their wife would most likely be perceived by a woman as because of the lack of trust and confidence in her. The perceived lack of trust and confidence could be a source of significant psychosocial distress for the women, and this could serve as a guide to areas that can be targeted in preventative programs, that will also involve couple therapy. The quality of marital relationship significantly affects the quality of mental health,³³ and psychologically distressed individuals inadvertently contribute to the occurrence of stress in their lives, including stress in their intimate relationships, which increases the probability of the onset and maintenance of psychological distress.⁶⁸

There was a high prevalence of marital dissatisfaction, PPD and anxiety among nursing mothers in Enugu but with low detection rate. The effects of PPD and anxiety on the mother, her marital relationship and her infant make them essential conditions for early diagnosis, prevention and treatments.