Introduction  

Pregnancy and labor are special events of the lives of women and their families. Pregnancy cause physiological and psychological changes and affects the functioning of different body organs. These changes cause symptoms and complaints in pregnant women and may occur naturally per pregnancy, but complications arise for mother and embryo if symptoms intensify ^[1]. If pregnant women do not adapt themselves with these changes, they are exposed to a high level of stress.

Bairami reported that the prevalence of psychiatric disorders in the first, second, and third trimester of pregnancy is 0.029, 0.028, and 0.039 respectively. ^[2] Today, the health of mother and child is the main goal for the social and economic development of every society ^[3]. According to the results of the studies conducted on preterm labor, various factors such as physical and psychological stress ^[4], depression ^[5], anxiety ^[3] social relationships and support and self-care ^[6] are related to the preterm labor. Preterm labor is referred to as delivery before thirty-seven weeks of pregnancy (259 days from the first day of the last menstruation) ^[6], which is the cause of about two-thirds of the neonate deaths ^[3]. The prevalence of preterm labor is reported by 5% in developed and 25% in developing countries. The costs of taking care of premature infants are estimated to be over $ 5 billion in the United States ^[7]. Preterm labor has been rising in Iran ^[8].

Short-term complications in premature infants include respiratory problems, persistent arterial duct, necrotizing enterocolitis, or intestinal gangrene, and intracranial hemorrhage and its long-term complications include congenital malformations, neurodevelopment disorders such as cerebral palsy, hydrocephalus, seizures, vision hearing, behavioral problems, and airway disorders ^[7]. Other maternal complications of preterm labor include concern and anxiety, complications of prolonged rest, complications of tocolytic, and sedative drug use. The embryonic complications include respiratory distress syndrome due to lack of lung evolution, premature body organs, the possibility of hypothermia due to low-fat tissue and damage to the skull and intracranial hemorrhage during labor and the probability of infection and anemia ^[9]. Premature infant birth is one of the major problems in society. In addition to causing economic and psychological problems in the family, it also causes the loss of financial and human resources. In research conducted in Boston, America (1997), it was reported that premature neonates had a more negative behavioral pattern than mature ones. Also in a study conducted in Dublin Hospital (1995) in a 3-years period, prematurity has been one of the major contributors to neonates' mortality ^[10].

The prevalence of postpartum depression has been reported 10-20% in recent studies conducted all around the world ^[11]. Also, postpartum depression has a high prevalence in Iran. It is reported 29% in the study of Salehi-Kasaei (1994) ^[12] and 27% in the study of Behboudi (2002) ^[13].

Methods:

This research was a descriptive cross-sectional study. The study population included pregnant women who had preterm labor at least 6 weeks to one year ago and did not have a history of depression, a history of referral to a psychiatrist, and taking psychiatric drugs and also were under surveillance of one of the health centers in Jahrom city. A stratified random sampling method was used to enter 115 eligible women to the study. The study data were collected using a two-part questionnaire. The first part included maternal demographic information such as age, level of education, spouse's level of education, job, number of pregnancies, number of children, the abortion history, the type of delivery, the child's gender, the unintended pregnancy, child's unwanted gender from the father's and the mother's point of view, type of child feeding, and baby's medical problems in the first week after birth. The second part consisted of questions about depression based on Beck's questionnaire. Beck's Depression test was introduced in 1961 by Beck and his colleagues for the first time. It was revised in 1971 and re-introduced in 1978. Since then, over 30 years after its introduction, more than 1,000 studies have been carried out about it or it was used in those researches. In Iran, this questionnaire has been standardized by Okhovvat and is widely used to measure depression in the normal and with mentally disordered people.

The Beck Depression questionnaire is known as a cross-cultural test that is applicable to all social classes. The respondents are required to rank the intensity of their symptoms on a scale from zero to three (0-3). Its questions are related to areas such as the feeling of failure and guilt, irritability, sleep disturbances, and lack of appetite. The validity and reliability of this questionnaire have been evaluated extensively since it was introduced about 30 years ago. Analysis to determine the internal consistency of the usual 21-items version of this test has shown that the coefficients range from 0.73 to 0.93 with an average of 0.76. In the present study, the 21-items version of this questionnaire was used. The total score of 0-14 is considered normal or individuals with depression at the normal level, 15-31 is representative of the mild depression level, 32-47 represents the moderate level, and 48-63 is considered as severe depression.

After obtaining permission from the vice-chancellor of research at Jahrom University of Medical Sciences, the researcher was referred to the health-care centers (a referral center for mothers in the postpartum period). All participants received information about the study objectives and provided written informed consent and then the questionnaires were delivered to them. Data were analyzed and summarized using descriptive statistics and tables consisting of frequencies and percentages and estimating the distribution of the frequencies of the variables in terms of depression.

Results:

A total number of 115 women with preterm labor participated in the study. Most of the participants (95.7%) were under 30 years old and their mean age was 29.2 ± 3.75. Almost half of the mothers (53.9%) and 63.5% of fathers had a diploma or lower than diploma degree. The majority of the mothers (73.9%) were housewives. Nearly half of the mothers (45.2%) had only one child, 29.6% had 2 children and the rest 25.2% had three children. 59.1% of the participants had a vaginal delivery and the rest 40.9% had cesarean deliveries. More than half of the newborn babies (65.2%) were girls. 10.4% of the mothers had an unintended pregnancy. The gender of 7.8% of the infants was unwanted from the point of view of the child's father, and also 7.8% from the mother's point of view. Half of the mothers (52.2%) fed their children with breast milk. 27.8% had a history of abortion. 71.3% of the infants had experienced a medical problem in the first week after birth (Table 1).

The mean depression score was 13.085 ± 14.33. A higher score indicates a more severe level of depression. 58.3% of the women did not have depression (0-14), 33% of them had mild depression (31- 15%) and only 8.7% had moderate depression (32-47%). A severe level of depression was not observed in participating women. The results of the study showed that there is a significant relationship between the number of children and depression (p-value = 0.001) so that single-child mothers suffered from depression more than the others. Also, there is a significant relationship between the number of pregnancies, the abortion history, the type of delivery, the child's gender, unintended pregnancy, child's unwanted gender from the father's and the mother's point of view, and type of child feeding and depression (p-value <0.05). Mothers with the first pregnancy had experienced depression more than the other ones. Women with a history of abortion had a lower incidence of depression than those without a history of abortion. Depression in women with a vaginal delivery was higher than women with cesarean delivery. Results also showed that mothers who had delivered a girl baby experienced a higher level of depression than mothers with a boy. Also, the results indicated that the incidence of depression was the highest in the mothers who used hybrid milk to feed their babies.

Depression was higher in mothers aged 20 to 25 years than in mothers aged 26 to 35 years. The average depression in mothers
with postgraduate education was higher than other groups. The rate of depression in mothers was not significantly different according to the education of the wife, the rate of depression was higher in working women than housewives. Depression was also higher in women who had no history of miscarriage and had a normal delivery.

Depression was lower in women who had a son than in women who had a daughter.

The incidence of depression in cases of unwanted pregnancies was higher for parents. The prevalence of depression was higher in single women and mothers who fed their infants hybrid. The results of this study also showed that it was higher in the first delivery and the average incidence of depression was higher in women whose child had a medical problem at birth. (Table2).