Determining the Predictors of Postpartum Depression in Vietnamese Women: Mediating Effect of Maternal Role Strain

다국어 초록 (Multilingual Abstract)

Postpartum depression is a significant public health issue which has not only negative effects on maternal postpartum health but also on family relationship and infant growth and development. In Vietnam, postpartum depression is not usually cared in the community as well as in the health care system because it is insufficiently screened or diagnosed and followed up during the postpartum period. Moreover, there is very little research analyzing, predicting factors of postpartum depression. Especially there is less study of the mediating effects of maternal role strain among self-efficacy, social support, infant temperament, and postpartum depression in Vietnam. Moreover, the support of the theoretical model in which self-efficacy, social support, and infant temperament were linked to postpartum depression symptoms through their effects on maternal role strain is important both contribute to conceptual understanding of these processes and to seek effective interventions for postpartum depression in Vietnamese women. Thus, the purposes of this study are to identify the predictors for postpartum depression and determine the mediating effects of the maternal role strain on the relationship among the degree of self-efficacy, infant temperament, social support, and postpartum depression.
Methods: The focus of correlational descriptive research design was performed on 190 mothers who were the first birth from four weeks to six months and be enrolled to give vaccination in 12 community health centers of Hue city in Vietnam. Data gathering tools included the “Perceived Self-Efficacy Scale”, “Maternal Social Support Scale”, “Difficult Infant Temperament Scale”, “Maternal Role Strain Scale”, and “Edinburgh Postnatal Depression Scale (EPDS)”. Data analysis was done by using the SPSS software, which was based on descriptive statistics and statistical independent t-test or one-way ANOVA test, mediation. These were tested by a series of multiple regressions by using Baron and Kenny methods. The Sobel test was used to test the significance of the mediating effects.
Results: The prevalence of probable postpartum depression which had the EPDS score at or greater cut-off of 13 points was 18.9%. There were a significant differences between postpartum depression and mother’s occupation (t=-2.86, p=.005), relationship with her husband (F=5.91, p=.003), stressful life events (t=2.94, p=.004), paid maternity leave (F=6.83, p=.001), and gestational age (t=3.32, p=.001), history of mental health (t=3.86, p<.001), self-efficacy (r=-.15, p=.030), and social support (r=-.38, p<.001), infant temperament (r=.40, p<.001), and maternal role strain (r=.59, p<.001). Furthermore, there was identified paid maternity leave (β=-.16, p=.004), gestational age (β=.15, p=.005), history of mental health (β=-.19, p=.002), self-efficacy (β=.12, p=.031), and the maternal role strain (β=.47, p<.001) as the prediction of postpartum depression. The regression model with significant predictors explains 46% of the variance. As the mediating effects, maternal role strain had a full mediating effect on the relationship between self-efficacy and postpartum depression. Besides, maternal role strain was also a partial mediating effect on the relationship between maternal social support, infant temperament and postpartum depression among postpartum women.
Conclusion: The findings of this study contribute to nursing science by identifying the mediating effects of maternal role strain on postpartum depression in Vietnam. Future research suggests solutions for professional experts of community mental health to develop effective intervention strategies which aims at the reduction of maternal role strain to decrease the impact of self-efficacy, social support, infant temperament on postpartum depression.

목차 (Table of Contents)

• Determining the Predictors of
• Postpartum Depression in
• Vietnamese Women: Mediating Effect of Maternal Role Strain
• Nguyen Thi Phuong Thao
• Department of Nursing
• Graduate School, Inje University, Republic of Korea
• A thesis submitted to the Graduate School of
• Inje University in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing
• Advisor: Prof. Jang, Haena
• December.2020
• Approved by Committee of the Graduate School of Inje University in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing
• Nguyen Thi Phuong Thao
• Chairman of Committee Prof. Bae, Jeong Yee
• Committee Prof. Oh, Jina
• Committee Prof. Lee, Yun Mi
• Committee Prof. Shin, So Young
• Committee Prof. Jang, Haena
• Graduate School Inje University, Republic of Korea
• December.2020
• CONTENTS
• ABSTRACT………………………………………………...………………...…..i
• I. INTRODUCTION……………………………………..………...……………..1
• A. Background………………………………………………...……………....1
• B. Purpose of research …..……………………………..............……………..5
• C. Definitions of terms ………….……………………………...…………….6
• II. LITERATURE REVIEW……………………………………….……….…….9
• A. Postpartum depression………………………………...……………….…..9
• 1. Overview of postpartum depression…………………...…..………….…..9
• 2. The consequences of postpartum depression………………….…………13
• B. Influencing factors for postpartum depression………………….….….…18
• 1. Maternal factors……………………..………………...…….….…....18
• 2. Infant factors…………………………………………………..……..27
• 3. Environmental factors……………..……………………….……...…29
• C. Research framework………………………………………….……....……33
• 1. Transactional model of stress and coping ……………………….…..33
• 2. Conceptual framework ………………………………..……………..37
• III. RESEARCH METHODS………………………………………………..….40
• A. Study design…………………………………………………….………...40
• B. Sample and setting……………………………………………………….40
• 1. Sampling strategies…………………….………….…………………...40
• 2. Sample size…………………..………………………………………...41
• 3. Setting of the study ………………………………………..……….…42
• C. Instruments……………………………………………………………….43
• 1. General,maternal, depression related characteristis…………….…….43
• 2. Self-efficacy……………………………………………………….….44
• 3. Social support………………………………………………………....45
• 4. Maternal role strain……………………………………………….…...46
• 5. Infant temperament…………………………………………………....47
• 6. Postpartum depression………………………………………………...48
• 7. Vietnamese translation………...….………..……………………….…50
• D. Data collection……………………………………...………………….…52
• 1. Research asssistant training…………………………………….….…..52
• 2. Pilot study……………………………………………………….….….52
• 3. Survey procedure……………………………………………….….…..53
• E. Ethical consideration……………………………………………....………56
• F. Data analysis…………………………………………………….………....57
• IV. RESULTS…………………………………………………………….….….59
• 1. Participants’characteristics……………………….……………………..59
• 2. Level of self-efficacy, social support, infant temperament, maternal role strain and postpartum depression………………………………….…….65
• 3. Differences in postpartum depression according to the general characteristics…………………………………………………….……....67
• 4. Differences in postpartum depression according to maternal characteristics and depression related characteristics……..……………………...……...69
• 5. Correlations between self-efficacy, social support, infant temperament, maternal role strain and postpartum depression…………………...….….72
• 6. Predictors of postpartum depression……………………………...………74
• 7. The mediating effect on postpartum depression……………………...…..76
• V. DISCUSSION…………………………..……………………………………82
• 1. Prevalence of postpartum depression and the level of self-efficacy, social support, infant temperament, maternal role strain……….…...…………..82
• 2. Factors associated with postpartum depression……………….…..………86
• 3. Correlations between self-efficacy, social support, infant temperament, maternal role strain and postpartum depression……………….…………91
• 4. Influencing factors of postpartum depression……………………………..93
• 5. The mediating effect on postpartum depression………………...…….…..98
• 6. Limitations…...……………………………………………………..……106
• 7. Implications…………………...…………………………………………107
• A. Conclusion………………………………………………………...….…110
• B. Recommendations…………………………………………………….…112
• References ………………………………………………………….………….113
• APPENDICES………………………………………………………………....143
• Appendix 1. Approval letter from IRB at Inje University, Korea………….…143
• Appendix 2. Approval letter from IRB at Hue University of Medicine and Pharmacy, Vietnam (English version)………………….….…….146
• Appendix 3. Approval letter from IRB at Hue University of Medicine and Pharmacy, Vietnam (Vietnamese version)………………..……..147
• Appendix 4. Approval letter for using survey………………………………...148
• Appendix 5. Informed consent………………………………………….…......151
• Appendix 6. Surveys instruments for the study……..………………………...155
• Appendix 7. Community health centers in Hue…………………………….…184
• LIST OF TABLES
• Table 1. General Characteristics of Participants………………………….…….61
• Table 2. Maternal Characteristics of Participants ……………………………...63
• Table 3. Depression related Characteristics of Participants……………….……64
• Table 4. Level of Self-efficacy, Social Support, Infant Temperament Maternal Role Strain and Postpartum Depression of Participants .……..…..66
• Table 5. Postpartum Depression according to General Characteristics…………..….68
• Table 6. Postpartum Depression according to Maternal Characteristics………..70
• Table 7. Postpartum Depression according to Depression related Characteristics.…...71
• Table8. Correlations between Self-efficacy, Social Support, Infant Temperament, Maternal Role Strain and Postpartum Depression…………………..73
• Table 9. Predictors of Postpartum Depression…………………….…………….75
• Table 10. Mediating Effect of Maternal Role Strain on the Relationship between Self-efficacy, Social Support, Infant Temperament and Postpartum Depression…………………………………….………………………80
•  
• LIST OF FIGURES
• Figure 1. Transactional model of stress and coping………………..……….…..37
• Figure 2. Conceptual framework of this study..………….………….………….39
• Figure 3. Flow chart of data collection……………………………….…………55
• Figure 4. Mediating effect of maternal role strain on the relationship between self-efficacy, social support, infant temperament and postpartum depression………………………………………………….………81
• ABSTRACT
• Determining the Predictors of
• Postpartum Depression in Vietnamese Women:
• Mediating Effect of Maternal Role Strain
• Nguyen Thi Phuong Thao
• (Advisor: Prof. Jang, Haena, R.N, PhD)
• Department of Nursing
• Graduate of School, Inje University
• Background: Postpartum depression is a significant public health issue which has not only negative effects on maternal postpartum health but also on family relationship and infant growth and development. In Vietnam, postpartum depression is not usually cared in the community as well as in the health care system because it is insufficiently screened or diagnosed and followed up during the postpartum period. Moreover, there is very little research analyzing, predicting factors of postpartum depression. Especially there is less study of the mediating effects of maternal role strain among self-efficacy, social support, infant temperament, and postpartum depression in Vietnam. Moreover, the support of the theoretical model in which self-efficacy, social support, and infant temperament were linked to postpartum depression symptoms through their effects on maternal role strain is important both contribute to conceptual understanding of these processes and to seek effective interventions for postpartum depression in Vietnamese women. Thus, the purposes of this study are to identify the predictors for postpartum depression and determine the mediating effects of the maternal role strain on the relationship among the degree of self-efficacy, infant temperament, social support, and postpartum depression.
• Methods: The focus of correlational descriptive research design was performed on 190 mothers who were the first birth from four weeks to six months and be enrolled to give vaccination in 12 community health centers of Hue city in Vietnam. Data gathering tools included the “Perceived Self-Efficacy Scale”, “Maternal Social Support Scale”, “Difficult Infant Temperament Scale”, “Maternal Role Strain Scale”, and “Edinburgh Postnatal Depression Scale (EPDS)”. Data analysis was done by using the SPSS software, which was based on descriptive statistics and statistical independent t-test or one-way ANOVA test, mediation. These were tested by a series of multiple regressions by using Baron and Kenny methods. The Sobel test was used to test the significance of the mediating effects.
• Results: The prevalence of probable postpartum depression which had the EPDS score at or greater cut-off of 13 points was 18.9%. There were a significant differences between postpartum depression and mother’s occupation (t=-2.86, p=.005), relationship with her husband (F=5.91, p=.003), stressful life events (t=2.94, p=.004), paid maternity leave (F=6.83, p=.001), and gestational age (t=3.32, p=.001), history of mental health (t=3.86, p<.001), self-efficacy (r=-.15, p=.030), and social support (r=-.38, p<.001), infant temperament (r=.40, p<.001), and maternal role strain (r=.59, p<.001). Furthermore, there was identified paid maternity leave (β=-.16, p=.004), gestational age (β=.15, p=.005), history of mental health (β=-.19, p=.002), self-efficacy (β=.12, p=.031), and the maternal role strain (β=.47, p<.001) as the prediction of postpartum depression. The regression model with significant predictors explains 46% of the variance. As the mediating effects, maternal role strain had a full mediating effect on the relationship between self-efficacy and postpartum depression. Besides, maternal role strain was also a partial mediating effect on the relationship between maternal social support, infant temperament and postpartum depression among postpartum women.
• Conclusion: The findings of this study contribute to nursing science by identifying the mediating effects of maternal role strain on postpartum depression in Vietnam. Future research suggests solutions for professional experts of community mental health to develop effective intervention strategies which aims at the reduction of maternal role strain to decrease the impact of self-efficacy, social support, infant temperament on postpartum depression.
• Keywords: Postpartum; Depression; Self efficacy; Social support; Infant temperament; Maternal role strain.
• I. INTRODUCTION
• A. Background
• Having a newborn is the major transition that changes a bio-psychological and starting a new life for most women. This transition can create excitement, joys, and happiness. However, it can also send wretched feelings on mothers’ psychological health [1]. In about one-third to one-fifth of developing countries, women have significant postpartum psychological disorders ranging from mild to severe postpartum psychosis [2]. The most popular postpartum disorder is postpartum depression [3]. Postpartum depression is the most prevalent mental health problem with the onset of mood disorder symptoms within four weeks after giving birth [4].
• According to the World Health Organization, about 10% of pregnant women worldwide have a high risk of depression, and 13% of women who have just given-birth experience depression at some time [5]. A meta-analysis study reported that the global incidence of postpartum depression among mothers was estimated to be at 17.0% with the prevalence in Middle-East was the highest at 26.0% and Europe was the lowest at 8.0% [6]. The incidence of postpartum depression varies from country to country, society to society and continent to continent. The prevalence of postpartum depression in different Asian countries ranged respectively from 13.3% to 46.9% [7,8]. In Africa, the overall pooled incidence of postpartum depression was 16.8% [9]. The incidence of postpartum mental disorders is more prevalent in low and lower-middle-income countries, about 19.2% of women have postpartum depression [10]. The incidence of developing countries is higher than that in developed countries. While there is about 10.0% in developed countries and from 6.9% to 12.9% in high-income countries [10], in Vietnam, the prevalence of postpartum depression is different in different parts of the country from 15.8% to 27.6% [11-13].
• Postpartum depression is a significant public health issue which has not only negative effects on maternal postpartum health but also on family relationship and infant growth and development [14]. Mothers with postpartum depression often have fatigue, sleep disturbances. In terms of postpartum depression mothers tend to lack confidence and decrease their mother's excitement in their abilities to look after their child [15]. It also affects her ability to participate in normal activities. Postpartum depression increases the maternal possibility of diseases, physical damages. The worst consequences of postpartum depression are known as suicide [16]. Postpartum depression has been related to poor growth and development of infants [17]. Many studies reported that infants of mothers with postpartum depression were malnutrition and reduced physical growth compared to the infant of mothers without depression due to poor infant feeding practices of depressed mothers such as reduced frequency and quantity breastfeeding, feed solid food earlier [18]. Postpartum depression affects not only the infant's physical health but also long-term psychological impacts and cognitive development of the infant by evidence infants of depressed mothers who had poor cognitive outcome [19], higher fear score, and higher anxiety than infants of a non-depressed mother [20]. Depression in the early postpartum period was not only the vulnerable period in the marital relationship but also affected the mother-infant relationship. Depressed mothers felt less confident with their partners and made the relationship with them become more distant, difficult, and cold [21]. Besides, the partners of women with postpartum depression have high risk of mental health disorder [22]. Moreover, mothers with depression reduce the ability in interactions with their infants causing unsufficient infant's emotional and cognitive development.
• A number of research reported that there are different risk factors causing postpartum depression including history of physical abuse [23], mothers’s income level [9,24], unsupportive spouse [25], maternal education status [26], younger mothers [24,27], being more likely to be unemployed ones [27], and the violence from intimate partners [9] were more likely to predict postpartum depression. Besides, obstetric-related factors consist of cesarean section [25], a poor obstetric condition [9], and labor complications [26], having more than two children [26], history of abortion [16,28], low birth weight [28], and postpartum physical complications [23] were factors significantly associated with postpartum depression. Moreover, social and behavioral factors including recent stressful life events [25], poor social support [9,29], the history of depression [9,23,24,29], and the sleeping difficulty of the mothers [26] were the significant predictors for postpartum depression.
• In Vietnam, postpartum depression has been usually ignored in the community and in the health care system due to insufficient screening or no diagnosing and following up during the postpartum period. The lack of programs of mental health screening and knowledge supporting about postpartum depression for women during postpartum may lead to less attention to this problem. If they are interested and diagnosed with mental disease, they also fear to be isolated from society and stigmatization. In recent years, the issue of postpartum depression has been studied in Vietnam. Some maternity hospitals in the country have initially been surveyed on this topic, most of these studies, however, were done from the perspective of determining the prevalence of postpartum depression [12,13]. In fact, there is very little research analyzing predictors of postpartum depression. Not only can the early identification of postpartum depression help the physicians identify and have proper treatment of common mental disorders it also promotes with development of mental health caring services as well.
• The results of previous studies reported that there was much evidence on the influence of self-efficacy [30], maternal role strain [31], social support [32], and infant temperament [33] on postpartum depression. However, the role of maternal role strain has been considered to be a variable major which affects postpartum depression. Moreover, the theoretical model in which self-efficacy, social support, and infant temperament were linked to postpartum depression symptoms through their effects on maternal role strain, were not investigated adequately in Vietnam. Thus, the support of this theoretical model identifies the mediating effects of maternal role strain, which is important both to contribute to conceptual understanding of these processes and to seek effective interventions for postpartum depression in Vietnamese women.
• B. Purposes of research
• The purposes of this study are to identify predictors of postpartum depression and investigate the maternal role strain as a mediator of the relationship between self-efficacy, social support, infant temperament, and postpartum depression in postpartum women. The specific purposes are:
• 1) Examine the status of general, maternal depression related to characteristics of the participants.
• 2) Examine the level of self-efficacy, social support, infant temperament, maternal role strain, and postpartum depression of the participants.
• 3) Identify the differences in postpartum depression according to the general, maternal, and depression related characteristics.
• 4) Examine the relationship between postpartum depression and self-efficacy, infant temperament and social support, maternal role strain.
• 5) Identify the factors affecting postpartum depression.
• 6) Verify the mediating effects of the maternal role strain on the relationship between postpartum depression and self-efficacy, infant temperament, social support.
• C. Definitions of terms
• 1. Postpartum depression
• 1.1. Theoretical definition
• Postpartum depression is defined as any mild to severe depressive symptoms which occur between two weeks and one year after childbirth [34].
• 1.2. Operational definition
• In this study, the definition of postpartum depression means the score measured by using the Edinburgh Postpartum Depression Scale (EPDS) with the higher the scored, the greater the degree of postpartum depression.
• 2. Self-efficacy
• 2.1. Theoretical definition
• Self-efficacy is defined as the confident ability of an individual who can organize or perform required behaviors and achieve the desired outcomes or accomplish the goals [35].
• 2.2. Operational definition
• In this study, the definition of self-efficacy means the score was measured by the perceived self-efficacy scale of Reece [36] to assess the level of self-efficacy in early parenting of mothers. The higher the score is, the greater the level of self-efficacy.
• 3. Social support
• 3.1. Theoretical definition
• Albrecht and Adelman [37] defined social support as "a verbal and nonverbal communication between recipients and providers that reduces uncertainty about the situation, the self, the other or the relationship and functions to enhance a perception of personal control in one’s life experience".
• 3.2. Operational definition
• In this study, the definition of social support means the score was measured using the maternity social support scale of Webster et al.[38] to assess the levels of social support that the mother received during the postpartum period, and the higher the score is, the more social support is.
• 4. Maternal role strain
• 4.1. Theoretical definition
• Maternal role strain is defined as the tension and difficult feelings of the mother in fulfilling the maternal role obligation.
• 4.2. Operational definition
• In this study, the definition of maternal role strain means the score was measured by using the maternal role strain scale of Steffensmeier [39] and was revised by Bae [40] with the higher total scored, the greater the risk of postpartum depression.
• 5. Infant temperament
• 5.1. Theoretical definition
• Infant temperament is defined as the special feelings and behavior of an infant that is of biological origin and occurs early in development [41].
• 5.2. Operational definition
• In this study, the definition of infant temperament means the score was measured by using the difficult infant temperament scale of Macedo et al. [42] to access the relationship between the infant temperament and perceptions of the mother.
• II. LITERATURE REVIEW
• A. Postpartum depression
• 1. Overview of postpartum depression
• During pregnancy and after giving birth, many mothers change the mood and emotions and can cause changes in the emotional and biochemical processes of childbirth and adjustment to parenthood. That change can increase the risk of mood disturbance and psychiatric morbidity. About 10.0% to 20.0% of mothers are affected by prenatal mental health problems during this time. Some common mental health problems consist of depression and anxiety disorders [5]. Postpartum depression is shown to have a negative impact on the relationship between the mother and her baby and can have long-term consequences if is untreated.
• Postpartum depression is defined as a non-psychotic depression which causes are unknown and the onset, the duration is different. Postpartum depression can occur any time during postpartum period such as within four weeks after giving birth, the first three months, the first six months, or even one week after childbirth. Two diagnostic systems give different definitions of postpartum depression. According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) of the American Psychiatric Association, postpartum depression is a major depressive disorder with the onset of depressive symptoms that appears within 4 weeks after giving birth [4]. In contract, the International Statistical Classification of Diseases and related Health Problems (ICD–10) reported that postpartum depression is a mild mental disorder occurring within 6 weeks after giving birth, can last for any time period from two weeks to one year postpartum [34].
• However, some authors remain controversial about the definition of postpartum depression. Early postpartum depression was defined as depressive symptoms onset occurring within two months after childbirth [43] and late postpartum depression as major depression onset with depressive symptoms which began from two months to one year following birth [44].
• Maternity blues is a group of psychological and psychiatric symptoms, which usually affect women within beginning the first day after giving birth and can prolong to ten days or even several weeks, and not considered as a pathological condition [45]. The prevalence of maternity blues in individual studies was estimated to be 10.0% to 80.0% [46]. According to a systematic review study about the incidence of maternity blues, the rate of maternity blues was 13.7% to 76.0% in the 26 studies. Among women in Africa, this rate was greatest at 49.6% [47]. Even though it is not classified as a pathological condition, maternity blues is an important and clear risk factor and maybe a strong predictor of developing postpartum depression [48,49]. The higher the blues scored, the greater the risk of postpartum depression [50,51]. In a study about maternity blues, the EPDS was used to assess postpartum depression and the risk factor for depression components showed that women with increasing maternity blues scores may lead to an increased risk of postpartum depression [52].
• Clinical expressions of postpartum depression and general depression are similar. Based on the diagnostic criteria for major depressive disorder in the DSM-V [4], women who are diagnosed with postpartum depression when she had from five to nine diagnostic criteria in at least two weeks period in which depressed mood or reducing substantially interest in all or most activities must be attended to diagnose postpartum depression. Besides that, the other clinical symptoms of postpartum depression including feelings of worthlessness or guilt, sleep disturbance, psychomotor agitation or retardation, difficulty in concentration, reduced energy, significant gain weight or loss of weight or appetite, excepting suicidal ideation must be appeared on most days [4].
• Postpartum depression is occurred by a combination of many causes including physical and mental factors. Quickly decreasing the degree of estrogen and progesterone hormone in the body of women after giving birth may lead to a change in her mood. However, there is no strong evidence that hormonal variation is the main cause for the development of postpartum depression. Besides that, some factors can cause postpartum depression consisting of sleep disorder, being insomniac may lead to physical exhaustion or getting the rest incompletely to recover fully from childbirth [53]. Moreover, breastfeeding for a short duration can also cause postpartum depression due to the decreasing level of the mother’s progesterone [54].
• Postpartum depression is a common complication of the mother during the postpartum period. The incidence of postpartum depression worldwide is high and occurs in developing more popular than the developed countries, nearly 20% in developing countries [55] and about 10% in developed countries [10]. The rate of postpartum depression in Asia and South Africa is higher than in Europe, Australia, and the USA. This rate is different from country to country, from race to race, or from region to region. Overall, postpartum depression affects from 10.0% to 15.0% of all new mothers [56]. A systematic review study reported that the prevalence of postpartum depression in high-income countries is 19.2% in the first 12 weeks postpartum [55], and in low and middle-income countries is 19.8% [57]. In Asian countries, the incidence of postpartum depression ranged from 3.5% to 63.3% where Pakistan and Malaysia had the highest and the lowest. In Africa, the overall pooled prevalence of postpartum depression was 16.8% [9]. A recent study about postpartum depression across cultures reported that the prevalence of postpartum depression ranged from 4.0% to 63.9% where Japan was the lowest rates and America was the highest rates [7]. Another study about postpartum depression among healthy mothers found that the rate of postpartum depression was 12.0% among healthy mothers without a prior history of depression while the incidence of general depression was 17.0% in which the Middle-East having the highest rate was 26.0% and Europe having the lowest was 8.0% [6].
• The incidence of postpartum depression varies depending on the definition used, an assessment tool used whether it is a screening tool or a diagnostic process that is used, time an interval of assessment which may vary from a few days up to several years, different study designs including prevalence or incidence, and geographical area [58].
• 2. The consequences of postpartum depression
• Like the consequences of general depression, the consequences of postpartum depression causes personal feeling wretched and decreasing the ability to function effectively of mother in any areas of her life. During postpartum, the main responsibility of the mother is taking care of the infant, and if depression occurs and untreated, it causes negative consequences for both infants and mothers such as obstruct the mother-child relationship, influence maternal role, and may lead to a variety of negative child outcomes in the short and long term.
• 2.1. Consequences for mothers
• Postpartum depression is known related to more negative physical and psychological of the mother's health and decreasing the quality of the mother's life. According to a study about the consequences of maternal postpartum depression, physical health, psychological health, relationship, and risky behaviors were maternal consequences during postpartum [16]. There were very few researches related to maternal physical health. Most of the studies focused on the potential factors that lead to postpartum depression such as sociodemographic characteristics stressful life events, family history of mental health, personality factors, social support, ignoring almost maternal physical health. Physical health associated with significantly postpartum depression [59]. Regarding psychological health, several studies showed depressed mood was a significant predictor of psychological health status in the future. Some overall psychological health problems which mother faced including low self-esteem, being less happy, high levels of anger, more dysphoric, sadder, and less responsive to negative stimuli. Besides, anxiety were factors which increase the incidence of depressed mothers, postpartum depression at 3 months manifested anxiety disorder more than without depression mothers at 6 months postpartum [16].
• Social relationships and partner relationships were also factors that influence postpartum depression. Depressed mothers were lower social support scores than without postpartum depression mothers. Depressed mothers assess their relationship with their partner as more distant, cold, and difficult, and felt less confident. Addictive behavior and suicidal ideation were the risk behaviors of the consequence of maternal postpartum depression. Smoking is usually popular among mothers with severe postpartum depression [60], however, there was no significant relation to drinking and postpartum depression [61]. Many studies reported that mothers who had a high degree of postpartum depression were related to an increased incidence of suicidal ideation and imagine the action of infanticide [62,63].
• 2.2. Consequences for infant
• A large amount of literature determined the consequences of postpartum depression on child development consisting of the consequences that were associated with anthropometry, physical infant health, behavioral and cognitive development of the infant.
• Some studies found that a significant effect of postpartum depression on the infant’s weight and infant's length [64,65]. The infants of mothers who were experienced postpartum depression gained less weight than infants without postpartum depression mothers and this situation was similar to the stunting of infants. Regarding physical infant health, some studies indicated that postpartum depression had a significant association with the physical health of infants. The infants of depressed mothers had diarrhea more days and more diarrheal episodes per year [66]. Besides, overall pain, pain response during routine vaccinations, a febrile disease in infants reported more than in the infants of depressed mothers [67,68]. Moreover, postpartum depression was associated with an increased risk of infant morbidity, an increased three-fold risk of mortality in 6 months infants, increased risk of mortality approximately two-fold at 12 months of age [69].
• Some studies indicated a negative association between cognitive development in infants and postpartum depressive symptoms. Kaplan, Danko, and Cejka [70] specifically emphasized that the delay in an infant’s cognitive development due to the insensitivity of mother and maternal postpartum depressive symptoms affect indirectly the quality of the family environment and from that point impacted direct early cognitive development of the child. Furthermore, postpartum depression was predicted as an effective factor in poorer language and intelligence quatient development in children [71].
• Some researches demonstrated postpartum depression affected significantly negative behavior in infants. Behavioral traits in a child with depressed mothers consists an increasing behavioral problems at 2 years of age, mood disorders and more difficult temperament, internalizing and externalizing psychopathology, negative and positive emotionality of the child [72,73]. Besides, that mother who experienced during the first six months postpartum depression is related to the behavioral problems from early childhood to adolescence [72].
• 2.3. Consequences for mother-child interactions
• Postpartum depression affects negative mother-child bonding from as early as the first year of an infant's life, particularly during the first three months it influences important for the development of a healthy mother-child relationship. Another study reported women who were postpartum depression at week 4, were five times more likely to decreasing mother-child bonding at the same time as women without postpartum depression [74]. Maternal depression showed fewer close of maternal-child bonding and less positive engagement as compared to non-depressed mothers, separating in activities between mother and child such as reading books, playing games, and talking with their babies [75]. Besides women with postpartum depression experienced more difficulties, more negative perceptions with children in their relationships, lower emotional involvement with the newborn. The babies of depressed mothers have expressed fewer positive effects, less vocalization, decreasing activity levels, fewer expressions of interest, and more intense response [74]. A number of studies found that postpartum depression of mothers affects the psychological development of children as evidenced by the child is greater vulnerability to anxiety, less positive affect, less positive interaction with their mothers and with strangers [74]. The consequences on the child of depressive depression are not only limited to infancy but also can extend into the first year of the infant's life or even school age [74,75].
• B. Influencing factors for postpartum depression
• Predictors of postpartum depression may be special problems for the researcher. There are no predictive instruments available to screen postpartum depression which allows early interventions. Some predictors of postpartum depression maybe find out in the Asian countries but maybe not appropriate in Western countries and vice versa. According to the seminal meta-analysis of postpartum depression predictors study [76], the strongest significant predictors of postpartum depression that related to a history of mental health psychological distress during pregnancy, low social support, poor social and marital interactions, and stressful life events. Besides, an update about predictors of postpartum depression study [77] reported that the other predictors of postpartum depression were prenatal anxiety, self-esteem, infant temperament, socioeconomic status. Therefore predictors of postpartum depression were found in the literature review including maternal factors, infant factors, and social factors.
• 1. Maternal factors
• 1.1. Demographic factors
• Research about demographic information is considered as one of the widest risk factors for postpartum depression. Some demographic factors such as low socioeconomic status, unplanned or unwanted pregnancy, and single marital status were the demographic factors predictors of postpartum depression. However, some studies reported that demographic information such as mother's age, marital status, education, number of children, parity were not the risk factor for postpartum depression [76].
• There was a contradiction in the relationship between socioeconomic status and postpartum depression. Some studies reported that low socioeconomic status had a part in the increase of postpartum depression, whereas others showed that this status was not the risk factors of postpartum depression [78,79]. A study conducted on 198 first-time mothers in Northern California [78] to identify the relationship between socioeconomic status and postpartum depressive symptoms found that low socioeconomic status was related to increasing postpartum depression in the last month of pregnancy and similar to from two to three months after giving birth. Mothers who had four risk factors of socioeconomic status including low monthly income, low education, unmarried, unstable occupation were eleven times higher postpartum depression than mothers who had no risk factors of socioeconomic status. Similarly, a study in Southeast Nigeria [79] revealed that lower socioeconomic status was significantly associated with postpartum depression. Furthermore, a poor socioeconomic status because of earthquake disaster was also a predictor of postpartum depression depression [80].
• Unplanned pregnancy is common worldwide, from 2015 to 2019, each year there were approximately 121 million unwanted pregnancies, defined as a pregnancy a woman did not mean to have [81]. Despite the drop incidence of unwanted pregnancy globally, until now the prevalence remains high, especially in developing countries. Unwanted pregnancy not only affects the mother's health but also the health of children. Some studies reported that unintended pregnancies were associated with maternal mental health consisting of prenatal and postpartum depression [82,83]. A meta-analysis of cohort about the relationship between unwanted pregnancy and postpartum depression found that mothers who got unwanted pregnant were at a higher significant risk of developing postpartum depression than those who had planned to be pregnant [83]. Similarly, in a study about unintended births and the risk of postpartum depression reported that the incidence of postpartum depression in mothers who had an unwanted birth in Ethiopia, India, Peru, and Vietnam was respectively 44.0%, 38.0%, 35.0%, 24.0%. This rate was higher than mothers who had planned a birth were respectively 26.0%, 29.0%, 26.0%, and 21.0% [84].
• The single marital status of the mother often faces some disadvantages problems such as low-income and less time to play with her child. The single marital can cause maternal vulnerability which affects the happiness and mental health of the mother and the child's development. Some evidence showed that marital status was an important predictor of postpartum depression. Studies on Nigerian women indicate that single marital status was a negative and significant predictor of postpartum depression that means neonate women who are not married experienced postpartum depression more than women who are married [85]. Similarly, the other study reported that if the mother did not live with the father of their child or mothers living without partners at 6 weeks postpartum were one of the strongest predictors of postpartum depression [82,86].
• 1.2. Prenatal mental health
• Prenatal depression is one of the factors that are associated with a higher risk of postpartum depression. There is much evidence in explaining these relationships. Researches were done in many countries, such as Pakistan [87], Saudi Arabia [88], France [23], South Africa [89], Bangladesh [90], South-East Nigeria [24], Korea [91], showed that during the pregnancy period, most of the mothers who were experienced depression also will have depressive symptoms after giving birth. The appearance of depression during pregnancy is a powerful factor in predicting postpartum depression. Besides that, prenatal depression is also predictors of postpartum depression when compounded with other factors such as immigration and substance abuse [92,93].
• A prospective longitudinal study about maternal health factors as risks for postpartum depression [94] reported that for women experiencing postpartum depression, prenatal depression was the strongest positive association. These findings emphasize the diagnosis prenatal depression played an important role in the onset of postpartum depression and the necessity to promote timely and adequate prevention intervention methods.
• One of the strongest predictors of postpartum depression is anxiety. Prenatal anxiety affects not only the mother during pregnancy but also postpartum [95,97,98]. However, very few studies have investigated the appearance of anxiety disorders in the prenatal and postnatal periods. This may be related to anxiety being assumed to be part of prenatal and postpartum depression. Nowadays increasing evidence reported that co-morbid anxiety may be a significant feature in the occurrence of both prenatal and postpartum depression. Depression and anxiety are two factors that easily during the pregnancy period, and when having higher anxiety during this period is one of the highest risk factors for depression. Another study found that women who had experienced prenatal anxiety were about three times more likely to develop depression during the pregnancy period [95]. A study was conducted in the Arab region [96] reported there are six types of research reported that anxiety, depression, and stress during pregnancy was related to the occurrence of postpartum depression. Besides that, a study was conducted in Iran women the presence of characteristics anxiety from twenty-eight to thirty-eight weeks of pregnancy period raised the risk of postpartum depression during the postpartum period in the first three months [97]. Likewise, research was done among women in the third trimester of pregnancy, two days later and six weeks postpartum in Croatia [98] reported that the estimated rate of high anxiety during pregnancy was 35.0%, two days after giving birth was 17.0%, and at six weeks postpartum was 20.0% that means there is a reduction in anxiety degree after giving birth. Comorbidity of anxiety and postpartum depression was 75.0%. Characteristics of anxiety and state of anxiety in early postpartum are significant predictors of postpartum anxiety. Anxiety is a common mental disorder in the postpartum period. As there is no overlap completely between anxiety symptoms and postpartum depression the screening program for postpartum mental health should include both depression and anxiety.
• A history of previous mental health problems can be predicted postpartum depression. A systematic literature review research in the Arab region [96] about postpartum depression found that there are eleven studies in which previous personal history of mental health especially depression was the most consistent predictor of postpartum depression. In Australia [94], a previous mental health history of women plays an important role in the discovery of those who are the most vulnerable to postpartum depression. A study conducted in Saudi Arabia [88] report that the strongest predictors of postpartum depression were a family history of depression and lifetime history of mental illness. A study was conducted in France [99] women having previous mental illness problems history and during pregnancy, that increased the risk of this problem in the first trimester of pregnancy was detected to have postpartum depression after giving birth which prolonged until to the fifth birthday of the child.
• 1.3. Self-efficacy
• Self-efficacy is an individual's confidence that he or she has their ability to complete a successful task, achieve a goal, or control his/her own emotions, behavior, and motivations that were developed by Bandura [35]. According to Bandura, two important factors of self-efficacy affect the performance of a particular behavior including self-efficacy and outcome expectancy. Self-efficacy depends on whether we think in our ability we can do it and outcome expectancy is whether we think it will have good results. Self-efficacy influence importantly the level of exertion individuals perform to a given task and the degree of self-efficacy of each individual for one task cannot predict their self-efficacy for another task [35].
• For the new mother, perceptions of self-efficacy in parenting stem from her own past experience in caring for infants, her observations of other new mothers. With these sources of information, the mother develops her own perception of self-efficacy, which are her own judgments as to whether she is capable in carving out a certain level of performance in the care of her infant. According to Duprez [100], self-efficacy is the main factor associated with an individual's behavior and is significantly related to one's expectations, aspirations, resilience, and vulnerability, therefore, mothers with higher amounts of self-efficacy tend to adjust better to postpartum changes and have better functional status.
• 1.4. Maternal role strain
• As becoming a mother, the maternal roles are complex processes affected by personal and social factors such as supporting systems, economic conditions, and cultural situations [101,102]. Mother returns to work after having children are faced with new responsibilities and challenges, they are at risk for experiencing role strain because mothers spend more time and more attention to their children, they have to participate in caring their children such as feeding, soothing, helping or playing with their children. Likewise, women contribute more time than men to household tasks such as preparing meals and cleaning the house. Men are increasingly sharing the responsibilities of household chores; however, women are still spending almost double the amount of time dedicated to household tasks than men [101]. According to Stephanie [102] mothers had less strain when they perceived their work as beneficial to their children and, conversely, mothers reported more role strain since they perceived their employment as a disadvantage to their children's well-being. Besides that, mothers were able to learn on others, talk to friends, and receive actual assistance from other people reported lower levels of role strain. Furthermore, mothers who felt important and accepted demonstrated less role strain.
• Maternal role strain was also related to parental role quality [40]. A mother who described their parenting responsibilities as overwhelming increase levels of role strain than mothers who perceived their relationships with their children as rewarding. Previous research found that mothers who report positive home life experiences report enhanced psychological well-being and also, positive parenting experiences have been shown to reduce the effects of negative spillover [103].
• Levels of maternal role strain related to the number of depressive symptoms. Mothers had more depressive symptoms when they do not have enough time or energy to be the type of parent they would like to be displayed, the guilt that is associated with feelings of failure as a mother was associated with feelings of depression [104].
• 1.5. Stressful life events
• Life event stress is characterized by accumulating stress over time. Such stress proliferation can erode health over time [105]. Pregnancy can be a stressful time for many mothers. During pregnancy, acute stress may occur due to stressful life events such as loss of job or death of a loved one. Some women may live with chronic stress related to relationships of financial strain. Despite acute or chronic stress, all of which may contribute to the development of postpartum depression. A study conducted in Washington State women about stressful life events in pregnancy and postpartum depressive symptoms showed that among 6,415 women, 68.0% reported one or more stressful life events including financial (75.5%), partnerrelated (40.2%), emotional (39.1%) and traumatic (25.8%). 19.0% of mothers who had experienced postpartum depression out of whom 79.0% had more than one stressful life events one year before delivery. Women with no stressful life events reported postpartum depression more 1.7 times than women with any stressful life events [106]. Recent stressful life events were the strongest predictor of postpartum depression [25].
• A study with 298 women in Non-Hispanic American Indian/Alaska native mothers in Oregon from 13 to 24 months after giving birth [107] reported that 68.0% financial events, 60.8% emotional events, 45.8% partner-related events, 37.9% traumatic events, and 18.7% reported intimate partner violence in terms of stressful life experiences and there was a high risk of postpartum stressful life events and depression. Women who have experienced partner-related and traumatic postpartum stressful life events are at significantly increased risk for postpartum depressive symptoms [107].
• 2. Infant factors
• Infant temperament has been defined as the infant's behavioral style. It is how they behave in relation to the environment and care-giving which they receive [41]. How the child’s temperament is exhibited and perceived affects the developing relationship between the infant and mother. As the primary caregiver, maternal perceptions of infant temperament are important. Maternal perceptions and beliefs about the attributes of the infant affect how they care for their infant and the symbiotic relationship that will support the child’s cognitive development [108]. Thus, infant temperament has been measured by asking mothers about their perception of their infant’s characteristics and behaviors. Maternal perceptions of infant temperament are of paramount importance since their beliefs about the attributes of the infant affect how they care for their child and their rearing practices. It is also of great relevance to understanding the appropriateness of the about her infant's behaviors, which may be by their personality [42].
• There was perceived differences in infant temperament and the presence of depression and are not altered by the presence of family support or childcare stress. There were significant differences between the two groups of mothers’ ratings of infant temperament at 2 and 6 months of age, with depressed mothers rating their infants as more difficult than non-depressed mothers [109].
• A study with 55 women was found that maternal perception of difficult infant temperament was strongly related to mothers' level of postpartum depression [110]. In addition, the indirect influence of infant temperament on depression was found through the mediation of maternal self-efficacy. The direct relationship between a difficult infant temperament and maternal depression is thought to be based on multiple reasons, such as the aversive stimulus of infant crying; ambivalence toward the infant, resulting in guilt and self-dislike; unmet expectations as to the infant's nature; and life-style strains due to the care of a difficult infant [110].
• In societies today, son preference has been well-documented especially in Asian country including Vietnam [11]. Male bias can be detected in countries with a high sex ratio that indicates purposeful intervention regarding the selection gender of children through prenatal gender determination or selective abortions especially the gender of second children. Besides that, socioeconomic status also affects family preferences for male children and desired family composition [11].
• There are numerous studies that reported the sex of the infant is associated with postpartum depression. A study about the association of birth of girls with postpartum depression [111] reported that the birth of a girl child was related to increased maternal postpartum depression. Similar, a study was conducted in China, the prevalence of postpartum depression was double in women who delivered a girl as opposed to a boy [112]. The marital tensions and family were created by the negative reactions of family members to a female child that was the onset of postpartum depression. Many mothers who blamed for giving birth to a girl felt shame and low self-esteem, which in turn leads to being less interested in the child of the mother that contributes to postpartum depression [112].
• 3. Environmental factors
• Social support refers to the social resources that one perceives to be available to them, or that are actually provided to them, from those within his or her social network [113]. The two types of social support that receive the most attention in the mental health literature are emotional support and instrumental support [113]. Emotional support refers to demonstrations of love, esteem, empathy, and encouragement and lets an individual know that he or she is valued [113]. Besides that, instrumental support is comprised of the things that others physically do or provide in order to assist you, such as help with babysitting or household chores [113,114]. The most commonly used measures of social support in the mental health literature are measures of perceived support primarily [115] because the effects of perceived support are stronger and consistently beneficial for mental health [113]. Various epidemiological studies have identified that having a positive and causal relationship between social support and mental health, particularly major depression and the major etiological factors of postpartum depression are the absence of social support from partner, family, or friends and presence of stressful life events. Social support has been shown to play a beneficial role in reducing the risk of postpartum depression [116].
• With regarding to postpartum depression, a woman’s family structure and the sources of support available in her social network may in large part shape the beneficence she gains from social support. A family is a primary network of supportive relationships [113], and may influence which sources of support are most relevant to a woman's mental health after giving birth. Family members and a woman's intimate partner are cited as both the most important sources of social support and the most available sources of support following childbirth [117]. In many circumstances, intimate partner support appears to be uniquely beneficial to postpartum mental health. Support from an intimate partner has been found to be a consistent and significant protective factor for postpartum depression [118]. Support from a partner is most important to maternal well-being and mothers who were satisfied with their partner support experienced less overt signs of depression six weeks after birth [119]. A sudy of Turkish women revealed lack of support from the husband was a significant factor in the development of postpartum depression among [120]. Besides that low social support and high levels of stress and anxiety are linked to fear of childbirth [121,122] which leads to negative childbirth experiences and in turn an increased risk of postnatal depression. Social support is important in relieving the negative effects of stress experienced by mothers proceeding and following childbirth, it has the primary influence of reducing depressive symptoms in mothers postpartum [119].
• The women experiencing postpartum depression that is provided social support and counseling by health provider visit their home had a much more rapid improvement in their emotional health. In addition, emotional support from husbands, friends and practical help, taking care baby have been proposed to help decrease physical and emotional complications associated with postpartum depression [120].
• Maternal partner relationship status is the most commonly studied predictor of postpartum depression that including legal marital status, cohabiting, and the presence of any partnership relationship with the baby’s father [123-129]. A population-based study of marital and cohabitation status found that being unmarried and not cohabiting conferred risk for postpartum depression at five to nine months [123]. A representative cohort study of more than 4,000 largely poor and ethnic-minority urban women [124] found that married women had lower rates of postpartum depression at one year postpartum in comparison with cohabiting but unmarried women cohabiting women, in turn, had lower rates of postpartum depression than did women who were non-cohabiting, and those not in a relationship with the baby’s father had the highest rates of postpartum depression. A study about partner relationship quality [125] found that low partner relationship quality was associated with postpartum depression at 12-15 months even after controlling for perinatal depression. Support of husband, intimate partner, or family member is one of the most influential social factors of postpartum depression. Poor intimate relationships or marital dissatisfaction are considered as the strongest risk factors for postpartum depression consisting of may not confide in her husband; lack of support financially to the family; no assist with household tasks and taking care of the baby; an alcohol or drug abuse husband [126]. Moreover, a lack of familial support is also an important predictor of postpartum depression. If the mother receives useful family support, they will feel comfortable, increasing perceived self-efficacy and maternal role in taking care of children. A study in China reported that a good relationship with the mother-in-law and maternal marital satisfaction can significantly reduce the risk of postpartum depression [127].
• C. Research framework
• 1. Transactional model of stress and coping
• The transactional theory of stress and coping was s special tool in stress and coping research that was developed by Lazarus and Folkman [128]. According to this theory, stress was a transactional specific process that was associated between person and environment. Each individual evaluated continuously stimuli in their environment and a stressful response depended on the appraisal of the stressful agent and their ability to cope with the stressor. The transactional model of stress and coping explained why each individual reacts in a different way to the same stressor. This appraisal process created the cognitive and behavior changing and when the stressors such as loss or harm, threaten, challenges were appraised, the coping strategies were happened to manage or solve this change directly. Coping processes created a change in the relationship between the person and environment and outcomes were evaluated as success or unsuccess base on their own ability to cope with the stressor [128].
• The assumptions of this model are that stressors are understood as the changes of a person with the environment. These transactions are mediated by the impact of internal or external stressors. According to Lazarus and Folkman [128] primary appraisal, secondary appraisal, coping efforts, and outcomes of coping are considered the main concept of the model.
• Primary appraisal is the individual’s evaluation of a potentially threatening event when they faced with a stressor and defines the significance of appraisals to the well-being of a person. The primary appraisal can be distinguished by three kinds: benign-positive appraisals, irrelevant appraisals, and a stressful event.
• Benign-positive appraisals are the positive effect to maintain or enhance the well-being of a person. The satisfied emotions such as happiness, love, joy, peacefulness are the characteristics of benign-positive appraisals. Irrelevant appraisals are evaluated when carrying no implications for the well-being of a person. Both these appraisals do not create negative emotions or the need for the next coping actions. Stressful event appraisals include harm/loss, threat, or challenge events. Harm/loss appraisals refer to harm or damage and provoke negative emotions such as injury, illness, self-efficacy, or loss of a loved person. Threat appraisals refer to anticipate harms or losses which occurred or not yet occurred. Challenge appraisals differ from harm or threat appraisals because they refer to the potential or gain inherent. Excitement and eagerness are pleasurable emotions of challenge appraisals. Each individual evaluates the situation to decide whether it is relevant to you, furthermore gives appraisals whether stress events are motivational or stressful, obstructing goal achievement and evaluating the cause of the stress [128].
• In terms of postpartum depression in this present study, this concept would help us to understand the awareness of maternal role of an individual mother who is experienced postpartum depression. Moreover, an appraisal of threat about maternal role strain may result in maladaptive maternal role experience. Besides that, if maternal role strain was considered an appraisal challenge it may lead to a more adaptive maternal role experience by positive mother's behavior during the postpartum period.
• When people face an agent causing stress, the second appraisal is determined, which is an individual’s appraisals of internal or external coping resources and coping strategies for dealing with the agent causing stress [129]. Secondary appraisal occurs when a transaction in the primary appraisal is considered a stressful event and related to the cognitive process through this process each individual evaluates and identifies the individual's coping options such as self-efficacy, situational variables such as social support, and the coping styles [130]. Moreover, it will also help us understand that the social support resources, perceived self-efficacy coping and family level coping resources are appropriate to Vietnamese postpartum women.
• When the agents of stress happen at primary appraisal and demanding attempts to resolve and manage at the secondary appraisals, coping processes are performed which we call coping efforts. Coping efforts are the processes that mediate to interact between a primary appraisal and secondary appraisals of each individual. According to the transactional model of stress and coping theory, the objectives of coping efforts are to control the agents of stress directly and to attend to emotional responses as a consequence of the stressful event, which we call problem-focused coping and emotion-focused coping [128]. Problem-focused coping is utilized to find out the agent causing stress with the environment and trying to manage or solve that agent whereas emotion-focused coping is used to regulate emotion about the agent causing stress by changing the feelings and thoughts oaf each individual. The coping resources include psychological and socioeconomic status to control the needs from the agents of stress, health and morale, positive beliefs, problem-solving skills, social supports, and financial resources that can facilitate an individual’s coping efforts [128]. In this present study, coping effort not only helps us to understand the efforts of coping with postpartum depression used by Vietnamese women but also to explore how women manage their problems during the postpartum period. Besides that, we can understand what kind of women's thoughts and feelings when facing postpartum depression.
• Outcomes of coping are results that related to emotional well-being, functional wellbeing status, health behaviors. The outcome of a person’s coping efforts combine with new information from the environment is the result of new appraisals or re-appraisals that determining whether the coping efforts have been successful [128]. The way of coping effects outcomes of coping. Positive coping way refers to the stability of personality characteristics and social support that regulate the coping abilities and perceptions of each individual [131]. This concept will help us to understand the way Vietnamese women perceive an agent of stress can influence their outcome of coping. Besides that, the outcome of coping will help us to understand the feelings of the mother, her maternal role, and the general health behaviors of the mother during the postpartum period. Outcomes of coping will guide us whether the mother's behaviors are positive or negative behavior to approach or avoid or find out the nursing solutions from health care professionals.
• Figure1. Transactional model of stress and coping.
• 2. Conceptual framework
• In terms of postpartum depression in this study, the management of maladaptive emotion-focused coping may be related to increasing the prevalence of postpartum depression, and the issue of whether or not appraisal processes may predict postpartum depression requires further investigation. Moreover, investigated whether mediating effect of maternal role strain on the relationship between self-efficacy, social support, infant temperament, and postpartum depression. Thus, according to concepts of the transactional model of stress and coping model, we drew and developed a conceptual framework that is suitable for the concepts of this study. This theory provided a foundation for exploring the relationships between the agent causing postpartum depression such as general, maternal, depression-related characteristics, maternal role strain, self-efficacy, infant temperament, maternal social support, and postpartum depression. The concepts were shown in figure 2.
• Stressors are experienced as an appraisal of the situation we face ourselves. In this study the impact of stressors are considered the primary appraisals, the researchers used three different questionnaires to find out the agents of stress in an environment which were a self-developed questionnaire of the researcher that consisted of general demographic, maternal characteristics, and depression related characteristics as well as infant temperament which evaluated the perception of mother about infant temperament. With regard to secondary appraisal, this study included the following two related measures: the first, self-efficacy which evaluated the confidence ability of an individual, the second, social support which assessed the support to which an individual feels powerful enough to deal the demands of work activity. The relationship between variables in the secondary appraisals and postpartum depression was complemented in this study by a mediating effect of maternal role strain. The outcome of coping was results that determine whether or not postpartum depression. Coping efforts included problem-focused coping and emotion-focused coping. In terms of problem-focused coping was considered positive coping which leads to normal mental health but not postpartum depression. Lack of emotional resources is likely to lead to negative coping mechanisms which also affected postpartum depression.
• Figure2. Conceptual framework of the study.
• III. RESEARCH METHODS
• A. Study design
• The research design of this study was a correlational descriptive research design
• B. Sample and setting
• 1. Sampling strategies
• Purposive convenience sampling was used for this study. Data was collected with mothers to give vaccination enrolled in 12 community health centers in Hue city on vaccination day from January 20 to May 26 in 2020.
• Inclusion and exclusion criteria are below.
• Inclusion criteria: All of the mothers over 18 years old who were in the previous four weeks to six months after giving birth. Mothers with only for first birth were recruited into the study. In addition, mothers spoke and read the Vietnamese language and were willing to participate in the study.
• Exclusion criteria: Mother under 18 years were excluded and the mother who experienced a birth before, death of a newborn or had an infant with a congenital disability. In addition, postpartum women who were diagnosed with types of mental health disorders or depression at the time of research were excluded.
• This range was chosen as the "postpartum" period typically refers to less than 6 months based on the systematic review of the literature on measuring postpartum depression. Moreover, in Vietnam, after giving birth, women do not have to go to work, they are allowed to rest at home for 6 months and this is the period that affects the psychology of women when they start with a new life to taking care of the baby. Therefore that's the reason we chose all of the mothers over 18 years old who were in four weeks to six months after giving birth.
• 2. Sample size
• The number of estimated subjects was calculated by using G-power analysis 3.1.9.4. According to the Linear Regression power analysis, with eight predictor variables in the model including postpartum depression, self-efficacy, social support, maternal role strain, infant temperament, general characteristics, maternal characteristics, depression-related characteristics, a sample size of 160 observations would achieve 95% power at a 0.05 significance level. With 20% attrition, the goal was to obtain a sample of 190 women who were recruited for the main survey. Additionally, 20 participants were recruited for the pilot test in this study. Finally, 210 subjects participated in this study.
• A total of 231 mothers were contacted and eligible of which 190 were recruited. All the mothers completed questionnaires, hence data collection all questionnaires were included in the analysis, resulting in a total of 190.
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• 3. Setting of the study
• The recruitment of participants was randomized to Hue city. Thua Thien Hue province had 1 city, 2 towns, and 6 districts. Hue city is divided into 27 administrative zones called precinct where has 2 big hospitals Hue central hospitals, and Hue university hospitals, having over 500 beds. Of the 27 precincts in Hue city, 12 precincts were randomly selected by taking the Huong River as the central location including six precincts from the Northern side of Huong River and six from the South. Precincts far from Huong River under 5km were chosen. The health station in each commune establishes a list of the first time mother who was from four weeks to six months in the postpartum period. All mothers on this list were invited to participate in the study.
• C. Instruments
• In order to establish the representative nature of the sample, a range of background data was obtained. Participants provided contact details and information on demographics such as age completed educational level and occupational status, income, and obstetric history.
• 1. General, maternal, depression-related characteristics
• The survey consisted of the variables found to be significant predictors of postpartum depression in the literature. It is divided into 3 sub-demographic sections: general characteristics section, maternal characteristics section, and depression related characteristics section.
• The general characteristics section included basic questions regarding age, religion, marital status, education level and professional occupation of the mother and her husband, relationship with her husband, relationship with her mother in law and stressful life events.
• The maternal characteristics section included some items of postpartum pertaining to paid maternity leave, mode delivery, the gender of baby, feeling with baby’ gender, gestational age, baby’s current health, weight at birth, the person giving care support.
• Depression related characteristics the section included 2 short questions of previous mental health such as the history of mental health including depression of mother and family members with depression.
• 2. Self-efficacy
• The perceived self-efficacy scale is used to measure the level of self-efficacy in early parenting of mothers [36]. This self-report tool consists of 25-items about prenatal and postpartum mother's expectations and her perceived self-efficacy in tasks such as taking care of her babies, maternal role, and relationship with their husband. Mothers assess their confidence on a rating scale from 0 (cannot do) to 10 (certain can do) that the most closely in their ability which a mother perform. For examples of the first and second statements of the perceived self-efficacy scale are "I will be able to manage the feeding of my baby and "I will be able to manage the responsibility of my baby"'. Each statement begins with the prefix "I will" when evaluating in the pregnancy period and in the postpartum period, the prefix was changed into "I can". The total score is calculated by summing the rating on each statement. The perceived self-efficacy scale has been validated for use during pregnancy and postpartum [36,132]. According to Reece [36] the Cronbach's alpha for perceived self-efficacy was 0.91 when evaluated at one month postpartum and 0.86 at three months postpartum. Similarly, Reece and Harkless [132] reported that Cronbach’s alpha for perceived self-efficacy during pregnancy and in the postpartum period were respectively 0.92 and 0.97. The Cronbach’s alpha coefficient of the perceived self-efficacy scale in this study was 0.96.
• 3. Social support
• The social support level was measured by the maternity social support scale. The maternity social support scale represents the social factors that have a correlation with postpartum depression. The social support factors include a poor relationship with friends, lack of family support; deficiency of help from husband; conflict with husband; feeling controlled by husband, and feeling unloved by the husband. The social support factors were combined in six items and self-report with a five-point Likert scale [38]. The score of two-statements "There is a conflict with my husband" and "I feel controlled by my husband" are reversed scored. To score the maternity social support, each item is summed and the total is 30, with scores classified into 3 groups: low support with a total score from 6 to 18, medium support with a total scores from 19 to 24, and adequate support with a total score above 24 [38]. The maternity social support scale is simple to administer, useful to prenatal evaluation, and gives an opportunity for the health care professionals to start developing research [38]. Maternity social support scale was chosen to be used in the current study because it assesses levels of support women receive from their husbands, families, and friends as well as assesses women's relationships with their husbands. The Cronbach’s alpha for the maternity social support scale during pregnancy and at six to eight weeks postpartum was 0.90 and at six months postpartum was 0.89 [133]. Cronbach’s alpha coefficient of the maternity social support scale in this study was 0.60.
• 4. Maternal role strain
• The concept of maternal role strain is an important issue to study because the mothering role is closely tied to a woman’s sense of identity. Maternal role strain was measured by 20 items, Likert scale, which were translated and adapted to this study by reviewing the tools of Bae [40], which tapped general feelings of physical fatigue, economic burden, and sleep disturbance. Items were adjusted slightly to reflect multiple roles associated with the maternal role. Mothers were asked to assess the degree to which they agreed with various statements on a 4-point scale ranging from 1 (not at all), 2 (rarely), 3 (sometimes), and 4 (always). To score the maternal role strain scale, all Items are summed and divided by the total item number to calculate a mean score, with higher scores indicating higher levels of role strain. Internal consistency coefficient Cronbach's alpha was 0.92 [40]. The Cronbach’s alpha coefficient of the maternal role strain scale in this study was 0.92.
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• 5. Infant temperament
• There are many instruments to measure the infant temperament however no method is unified. The most commonly researched temperament of the infant was “difficult temperament”, with its original formulation and longitudinal research presented and conducted by Thomas, Chess, and Birch [134]. In this study, we used the difficult infant temperament scale to measure the relationship between the behavior of mother and infant temperament and this scale could be created items to reflect how the mothers experienced or sharing her experience and report the behavioral characteristics of a difficult infant when mother took care of them. Besides that, evaluate the difficulties related to coping with a difficult infant [135].
• Infant temperament was measured by asking mothers about their perception of their infant’s behaviors characteristics and with an 8 items questionnaire and was developed by Macedo [42]. The respondent options varied from 1 (never) to 6 (always). To score the difficult infant temperament scale, all the items were summed by the total 8 response scores and divided by the total item number to identify the mean of difficult infant temperament score. A high score is related to a more difficult infant temperament and perceived by the mother. The final infant temperament scale revealed a very good internal consistency Cronbach alpha coefficient was 0.88 [42]. The Cronbach’s alpha coefficient of the difficult infant temperament scale in this study was 0.91.
• 6. Postpartum depression
• The degree of postpartum depression was measure by using the EPDS and developed by Cox, Holden, and Sagovsky [34]. It was used by primary care health professionals to screen mothers for postpartum depression. The EPDS was used to detect depression as a screening tool. The EPDS includes ten items self-report questionnaire in which women are asked to rate how they have felt in the previous 7 days. The ten questions of EPDS is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool [136].
• The respondent options ranged from 0 to 3 according to the increasing severity of the depressive symptoms. The total score is calculated by adding each score of 10 items. The value of the score can range from 0 to 30 [137]. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity and if she always looks at item 10, maybe she will have suicidal thoughts. A cutoff point of 12/13 was used to define the presence of postpartum depressive symptoms (without postpartum depressive symptoms: EPDS ≤12 points/with postpartum depressive symptoms: EPDS ≥13) [34]. Researchers have used varying EPDS cut-off scores depending on the population they are studying. The utility of the EPDS lies in its ability to measure depressive mood symptoms after birth, as it is not intended to diagnosis pathology [34]. The EPDS has been verified with a sensitivity of 88.0% and specificity of 92.5% [34]. EPDS has been used widely in many studies of postpartum depression and validated in many languages including Vietnam with satisfactory sensitivity and specificity. According to many studies, EPDS had high internal consistency, with a Cronbach’s α ranging from 0.87 to 0.93 [138,139]. In this study, we used the Vietnamese version of the EPDS that was translated, validated, and researched in Vietnam [14]. The Cronbach’s alpha-reliability coefficient for internal consistency was 0.75. The Cronbach’s alpha coefficient of the EPDS in this study was 0.89.
• 7. Vietnamese translation
• In order to apply the research instruments to Vietnamese women, instruments in the present study were translated into Vietnamese to minimize barriers of assessment with Vietnamese participants. The entire translation process was carried out using a committee approach. The whole English version questionnaires were translated into Vietnamese, back-translated into English, then having a meeting, discussion and the expert committee reviewed and gave the final version.
• Firstly, the whole English version questionnaires were translated by two bilingual persons who were proficient in both English and Vietnamese. One is a researcher and the other is a professional Vietnamese translator. Because the EPDS version was validated and used widely in Vietnam, there was no need to translate it again. Other instruments that had not previously validated in Vietnam were back-translated into English to ensure accuracy.
• Secondly, the whole Vietnamese versions were back-translated by one translator who is an English teacher in a university and had blinded the original English questionnaire. Then the back-translated English version and the original English version were compared about the grammar of sentences and meaning.
• Third, the expert committee was established including four Vietnamese experts who are a nurse, a midwife, a psychiatrist, and a researcher. All the Vietnamese experts had more than 5 years of clinical experience and a nurse who graduated from Thailand, a psychiatrist who graduated from Australia. The expert committee reviewed whether the translated measurements ensure content validity and each item was relevant, clear, and easy of understanding for native speakers. The measurements were modified and supplemented according to expert advice.
• D. Data collection
• Data collection process was showed in figure 3
• 1. Research assistant training
• Five nurses who had a clinical career over 3 years collected the data with researchers as an assistant researcher. In order to train them, a 2-hours meeting was held before and after the pilot-test. At the first meeting, the researcher explained the purpose, theoretical framework of the research, informed consent, other ethical principles, and procedure of the study. Then, researcher assistants practiced the questionnaire on each other and discussed to clarify each item of the questionnaire. In the second meeting, with the result of the pilot-test, the researcher and 5 assistant researchers discussed and revised the measurement according to the participants' comments.
• 2. Pilot study
• Before starting data collection for the major study, the instruments were piloted to examine whether the questions were acceptable to Vietnamese women in the community, check whether the items were comprehended, and determined the time required to complete each instrument and if any questions needed to be altered, difficult to understand, or too long, after receiving the data collectors’ feedback, the research and consultancy council will discuss and the questionnaire was revised again.
• The questionnaire was pre-tested with 20 postpartum women in a community health center, in Hue City (Vinh Ninh). The community health center randomly selected for the pre-test was not invited to participate in the main study to avoid bias factor. The researcher and 5 nursing staff were trained to do this survey. Data collectors recorded the time of the questionnaire took asked the respondents for feedback on the survey. Then, the second meeting was held to discuss and revise the measurement according to the participants' comments.
• It was found the meantime for the survey was 45 minutes. It took more time than the expected time but they responded positively to the questionnaire. Women think the benefits of the questionnaire gave them the knowledge of their own health or their infant’s health. Hence women would often ask more about these topics when the questionnaire was surveyed and finished. Besides that, some data collectors reported some women could not answer the questions such as income "the average family income per month" This might be they could not know the income of every member of the family. Therefore research decided to ask about the income of the mother.
• 3. Survey procedure
• The researcher and 5 research assistants implemented data collection by a face-to-face interview through the questionnaires which were translated, modified, and supplemented according to expert advice.
• Data collection was scheduled on monthly immunization days when mothers come for follow-up visits and bring their infants to the community health centers. As the study was conducted in conjunction with each commune health centers, health station staffs were available to support participants.
• The data collectors approached all the target mothers at the child follow-up room after immunization and asked if they would like to answer an interview. If women said they agreed. The data collectors explained the purpose of the study, and get the participation agreement. A survey was set up at the community health center and took from 25 to 40 minutes.
• Figure 3. Flow chart of data collection.
• E. Ethical consideration
• To protect the human dignity and rights of all participants, the study conducted after approval of the Human Research Ethics Committees of Inje University Korea (INJE201906011001-UE001), Hue University of Medicine and Pharmacy (H2019/466). Throughout the study, all efforts were made to maintain the respect and dignity of research participants, and cause them no harm.
• Before performing the survey, participants received verbal information and in writing about the nature and purposes of the research clearly and were notified of their right not to participate, ability to withdraw at any time without explanation, and to not answer any questions as they wish. Therefore, participation was completely voluntary and that refusal or withdrawal at any stage of the interview without result in any penalty. All the data were used for the purpose of the study. Participants were required to sign a consent form before the interview.
• When the interviews were held at the commune health center, if women had any questions about their health or infant health, or became emotionally distressed, the health station staff could assist them. Participants received reimbursement of 50.000Vnd (2 USD). These amounts were given as a reimbursement for costs associated with participation but were too small to be considered an inducement.
•  
• F. Data analysis
• The statistical package program (SPSS 25.0) was used to analyze data. Statistical significance was accepted by p-values of less than 0.05. The statistical analysis methods were used in this study as follows:
• 1) Descriptive statistics were given below as mean, the standard deviation for interval variables, and frequency, the percentage for categorical variables.
• 2) Independent t-test or One-way ANOVA test was applied to examine the differences in postpartum depression according to the general, maternal and depression-related characteristics. Scheffé test was used for Post hoc test.
• 3) Pearson’s correlation analysis was performed to estimate correlations among self-efficacy, social support, infant temperament, maternal role strain, and postpartum depression.
• 4) Multiple linear regressions were conducted to identify the predicting factor of postpartum depression.
• 5) To check the assumption of linearity in the model, Skewness and Kurtosis were applied to define whether the variables analyzed in this study showed a normal distribution or not normal distribution. Normality was accepted by Skewness < 2 and Kurtosis < 7 for each variable [140].
• 6) Cronbach's alpha was used to assess the internal consistency of the research instruments for the EPDS, perceived self-efficacy scale, maternal role strain scale, maternity social support scale, and difficult infant temperament scale.
• 7) The mediating effect of maternal role strain on the relationship between self-efficacy, social support, infant temperament and postpartum depression were tested. Mediation was tested by simple and a series of multiple regressions and using the method was described by Baron and Kenny [141], which includes three steps:
• In the first step, the relationship between the independent variables (self-efficacy, social support, infant temperament) on the mediating variable (maternal role strain) was estimated and required a significant effect on the mediating variable.
• In the second step, estimated the relationship between the independent variables on the dependent variable (postpartum depression), and this relationship had to impact a significant effect on the dependent variable.
• In the third step, the mediating variable had to have a significant impact on the independent variables, and decreasing the effect of the independent variable on the dependent variable which was estimated in the second step.
• Finally, mediation occurs if, in this final equation, the relationship between the independent and dependent variables became non-significant which means the mediating variable was considered a full mediating effect on this relationship. However, if the independent variables were significant with dependent variables, the mediating variable was considered a partial mediating effect on this relationship.
• The Sobel test was used to identify the statistical significance of a mediation effect and was developed by Sobel [142].
• V. RESULTS
• 1. Participants’ characteristics
• 1.1. General characteristics of participants
• General characteristics of participants were showed in Table 1
• Participants ranged in age from 18 to 43, the minimum age was 18 (as required by the research) and the maximum age was 43. The mean age of mother was 27.7 years (SD=4.5). In terms of religion, nearly a half (42.1%) of the women followed some kind of religion, mostly Buddhism and Christianity. The mother's education status was accomplished years of education and measured as a continuous variable based on the level of attended education. The results of the mother's education status are presented in Table 1. Overall, over half of the women had achieved high education (59.0%) having a college, university, or postgraduate degree. Just 11.6% (n=22) of mothers had finished secondary school. A further 29.5% (n=56) of them had completed high school. Husband's education status was lower education than her, 52.1% of them achieving a diploma at college, university, or postgraduate. All the women were married (100.0%). In terms of mother occupation, most of the mother 82.1% (n=156) worked in a job and were in paid salary but 10.0% (n=19) of them took time off from a job after pregnancy and 15 mothers who had unstable occupation. But nearly all their husbands were currently employed (97.9%, n=186), only 2.1% (n=4) of mother had husbands who were not. The occupations of mother and their husbands are outlined in Table 1.
• Mother were asked how about was their relationship with their family members based on a Likert scale with four choices "Excellent", "Good", "Fair" and "Poor". The majority of participants (81.5%, n=155) said that their relationship with their husband was good and excellent, and 34 mothers had a fair relationship with her husband, only one mothers had a poor relationship with her husband. Almost all 67.9% (n=129) of the mothers said that they had good and excellent relationships with their mother-in-law. Participants were asked about the stressful life event, 31.6% (n=60) of mothers said that they have at least a stressful life events during the past six months such as finances, change the relationship, move the house, or loss of a relative.
•  
• Table 1. General Characteristics of Participants (N = 190)
• Characteristics Categories n (%) or M±SD
• Age group (years) ≤ 24
• 25 – 34
• ≥ 35
• 40 (21.1)
• 136 (71.6)
• 14 (7.4)
• 27.7 ± 4.5
• Religion Yes
• No 80 (42.1)
• 110 (57.9)
• Mother’s educational status Secondary school
• High school
• College
• University/Postgraduate 22 (11.6)
• 56 (29.5)
• 44 (23.2)
• 68 (35.7)
• Mother’s occupation Yes
• No
• 156 (82.1)
• 34 (17.9)
• Husband’s educational status Secondary school
• High school
• College
• University/Postgraduate 26 (13.7)
• 65 (34.2)
• 39 (20.5)
• 60 (31.6)
• Husband’s occupation Yes
• No 186 (97.9)
• 4 (2.1)
• Relationship with her husband Excellent
• Good
• Fair/Poor
• 66 (34.7)
• 89 (46.8)
• 35 (18.5)
• Relationship with mother in law Excellent
• Good
• Fair/Poor
• 38 (20.0)
• 91 (47.9)
• 61 (32.1)
• Stressful life events Yes
• No 60 (31.6)
• 130 (68.4)
• M=mean; SD= standard deviation
• 1.2. Maternal characteristics of participants
• Maternal characteristics of participants were summarized in Table 2.
• Of 156 the mothers who worked, over half 53.2% (n=101) of mother received paid maternity leave, and 46.8% of them did not receive paid maternity leave including 17.9% of mothers (n=34) who did not have a stable occupation. The mothers received paid maternity leave, who worked for the government, a private business, a large company. The women who did not receive paid maternity leave had freelance work, small business, or housework. In terms of mode delivery, 56.9% (n=108) of women had cesarean section and eighty-two women (43.1%) had a vaginal delivery. Almost all mothers for the first birth had a happy feeling with baby’ gender, only one mother had moderate feeling with gender of baby. Regarding gender of infant, 57.9% (n=110) of mothers gave birth to a male baby and 46.1% (n=80) of them gave birth to a female baby. 97.9% (n=186) of babies were over 2500g and 93.2% (n=177) of the mothers described their children as healthy, and 6.8% (n=13) of mothers described their children as moderate or less than moderate but only one case described their children less than moderate but did not need to go hospital. Most women (88.4%) listed their mother and mother-in-law as their main career during postpartum, only one mother did not receive any giving care support and take care by herself. Regarding gestational age, 91.6% of mothers who had a baby were delivered from 38 weeks to the under 42 weeks.
• Table 2. Maternal Characteristics of Participants (N=190)
• Characteristics Categories n (%)
• Paid maternity leave Yes
• No
• No occupation 101 (53.2)
• 55 (28.9)
• 34 (17.9)
• Mode delivery Vaginal delivery
• Caesarean section 82 (43.1)
• 108 (56.9)
• Gender of baby Male
• Female 110 (57.9)
• 80 (42.1)
• Feeling with baby’s gender Very happy
• Happy/Moderate 105 (55.3)
• 85 (44.7)
• Gestational age (week) < 38 or ≥ 42
• 38 ~ < 42 16 (7.4)
• 174 (91.6)
• Baby’s current health Healthy
• Moderate/less than moderate 177 (93.2)
• 13 (6.8)
• Weight at birth (g) < 2500
• ≥ 2500 4 (2.1)
• 186 (97.9)
• Person giving care support Mother
• Mother-in-law
• Husband
• Friend/ Relatives
• None 129 (67.9)
• 39 (20.5)
• 18 (9.5)
• 2 (1.6)
• 1 (0.5)
•  
• 1.3. Depression related characteristics of participants
• Depression related characteristics of participants were showed in Table 3.
• Mothers were asked whether they had ever been a psychiatric facility. Overall, 3.7% of the sample (n=7) had been treated for mental health including depression, and 1.6% of the mother said that had family members with depression.
• Table 3. Depression related Characteristics of Participants (N = 190)
• Characteristics Categories n (%)
• History of mental health Yes
• No 7 (3.7)
• 183 (96.3)
• Family member with depression Yes
• No 3 (1.6)
• 187 (98.4)
• 2. The level of self-efficacy, social support, infant temperament, maternal role strain and postpartum depression
• The level of self-efficacy, social support, infant temperament, maternal role strain and postpartum depression were summarized in Table 4.
• The mean score of self-efficacy was 201.86 (SD=26.79, from 100 to 250). In this study, over half (54.2%) of mothers who had self-efficacy score higher than the mean score.
• The mean score of social support was 25.25 (SD=2.82, from 18 to 30). Of the 190 mothers studied, 120 women (63.2%) scored > 24 (high support), only 1.1% (n=2) of women scored less than 19 (low support) and 68 mothers (35.8%) reported moderate support which scored from 19 to 24.
• The mean score of infant temperament was 18.45 (SD=7.36, from 8 to 40). Of 190 mothers studied, 76 mothers (40.0%) scored higher than the mean score.
• The mean score of maternal role strain was 41.53 (SD=11.71, from 20 to 69). And 48.9% of mother who had maternal role strain score higher than the mean score.
• The mean score of postpartum depression was 8.09 (SD=5.93). We used a cut-off point 13 or above on the EPDS. Based on the cut-off point, women who scored 13 and more the EPDS were categorized as probable depression while women scored less than 13 on the EPDS were identified as possible depression. Of those surveyed, 18.9% (36 women) reported postpartum depression had a score of 13 or above the EPDS, whereas, 81.1% (n=154) of them were found normal with a score of less than 13 in EPDS scale.
• Table 4. Level of Self-efficacy, Social Support, Infant Temperament Maternal Role Strain and Postpartum Depression of Participants (N = 190)
• Name scale M±SD Min Max Range
• Self-efficacy 201.86 ± 26.79 100 250 0 - 250
• Social support 25.25 ± 2.82 18 30 6 - 30
• Infant temperament 18.45 ± 7.36 8 40 8 - 48
• Matenal role strain 41.53 ± 11.71 20 69 20 - 80
• Postpartum depression 8.09 ± 5.93 0 22 0 - 30
• M=mean; SD=standard deviation
• 3. Differences in postpartum depression according to the general characteristics
• The differences in postpartum depression according to the general characteristics were summarized in Table 5.
• Postpartum depression was measured by EPDS of all the participants was significantly different in mother’s occupation (t=-2.86, p=.005), relationship with her husband (F=5.91, p=.003), stressful life events (t=2.94, p=.004). Post-hoc analysis revealed that postpartum depression as defined by an EPDS ≥ 12 of the mothers with fair or poor relationship with her husband was the most and there was no statistically significant differences between the mother of group with excellent and good relationship with her husband. Besides that, there were no statistically significant differences in postpartum depression according to age, religion, mother and her husband’s education status, husband’s occupation, and relationship with mother in law.
• Table 5. Postpartum Depression according to General Characteristics (N=190)
• Characteristic Categories M±SD t or F p
• Scheffé
• Age (years) ≤ 24
• 25 – 34
• ≥ 35 8.23 ± 5.70
• 8.15 ± 6.01
• 7.07 ± 6.03
• 0.22
• .500
• Religion Yes
• No 8.43 ± 5.88
• 7.85 ± 5.97 0.66
• .507
• Mother’s educational status Secondary school
• High school
• College
• University/
• Postgraduate
• 8.95 ± 4.66
• 8.50 ± 6.41
• 8.11 ± 5.67
• 7.46 ± 6.09
• 0.50
• .682
• Mother’s occupation Yes
• No 7.53 ± 5.90
• 10.68 ± 5.40 -2.86
• .005
• Husband’s educational status Secondary school
• High school
• College
• University/
• Postgraduate
• 10.54 ± 4.66
• 7.85 ± 6.07
• 7.64 ± 6.20
• 7.58 ± 5.95 1.75 .157
• Husband’s occupation Yes
• No 8.01 ± 5.91
• 11.75 ± 6.29 -1.25
• .213
• Relationship with husband Excellenta
• Goodb
• Fair/Poorc 7.12 ± 5.61
• 7.63 ± 5.88
• 11.09 ± 5.80
• 5.91
• .003
• a,b<c
• Relationship with mother in law Excellent
• Good
• Fair/Poor 8.08 ± 5.14
• 7.32 ± 5.93
• 9.25 ± 6.26
• 1.94
• .145
• Stressful life events Yes
• No 9.92 ± 6.07
• 7.25 ± 5.68 2.94
• .004
• M=mean; SD=standard deviation
• 4. Differences in postpartum depression according to maternal characteristics and depression related characteristics
• Differences in postpartum depression according to maternal characteristics and depression related characteristics were summarized in Table 6 and Table 7.
• Postpartum depression according to EPDS score were significantly different in paid maternity leave (F=6.83, p=.001), and gestational age (t=3.32, p=.001) and history of mental health (t=3.86, p<.001). In term paid maternity leave included mothers who did not receive and received paid maternity leave during postpartum and mothers who did not have an occupation. The result showed that mothers who had no an occupation and did not receive paid maternity leave had the highest the mean of postpartum depression. Women gave a birth from 38 weeks to under 42 weeks was less postpartum depression than women delivered baby under 38 weeks or over 42 weeks. Women who had gone a psychiatric facility had higher postpartum depression than women who had never had history of mental health. In addition, there were no statistically significant differences in postpartum depression according to mode delivery, gender of baby, feeling with baby’s gender, baby’s current health, person giving care support, and family member with depression. The results are summarized in Table 6 and Table 7.
• Table 6. Postpartum Depression according to Maternal Characteris (N=190)
• Characteristic Categories M±SD t or F p
• Scheffé
• Paid maternity leave Yesa
• Nob
• No occupationc 6.69 ± 6.21
• 8.87 ± 5.13
• 10.68 ± 5.40 6.83
• .001
• a,b<c
• Mode delivery Vaginal delivery
• Caesarean section 7.41 ± 6.41
• 8.60 ± 5.50 -1.37
• .172
• Gender of baby Male
• Female 8.23 ± 5.66
• 7.90 ± 6.31 0.37
• .708
• Feeling with baby’s gender Very happy
• Happy/Moderate 7.68 ± 5.82
• 8.60 ± 6.05
• -1.06
• .287
• Gestational age (week) < 38 or ≥42
• 38 ~ < 42 12.69 ± 6.36
• 7.67 ± 5.72 3.32
• .001
• Baby’s current health Healthy
• Moderate/Less than moderate 7.84 ± 5.92
• 11.46 ± 5.06
• 1.02
• .309
• Weight at birth (g) < 2500
• ≥ 2500 11.67 ± 6.50
• 8.07 ± 5.91 0.12
• .721
• Person giving care support Mother
• Mother in law
• Husband or herself 8.28 ± 5.76
• 6.97 ± 6.18
• 8.95 ± 6.41 0.99
• .374
• M=mean; SD=standard deviation
• Table 7. Postpartum Depression according to Depression related Characteristics (N=190)
• Characteristic Categories M±SD t p
• History of mental health Yes
• No 16.29 ± 4.57
• 7.78 ± 5.75 3.86
• <.001
• Family member with depression Yes
• No 12.00 ± 4.58
• 8.03 ± 5.93 1.15
• .250
• M=mean; SD=standard derivation
• 5. Correlations between self-efficacy, social support, infant temperament, maternal role strain and postpartum depression.
• The correlations between self-efficacy, social support, infant temperament, maternal role strain and postpartum depression were summarized in Table 8.
• Analyses were used to identify variables that were significantly correlated with together. The correlation analysis showed that the social support was a significantly positive correlation with the self-efficacy (r=.32, p<.001). Whereas the infant temperament had a significant, negative correlated with the self-efficacy (r=.14, p=.047) and social support (r=-.26, p<.001). The maternal role strain was not only a significantly positive correlation with the self-efficacy (r =-.34, p<.001) and the social support (r=-.42, p<.001) but also negative correlation with the infant temperament (r=.40, p<.001). In addition, postpartum depression and the self-efficacy (r=-.15, p=.030), postpartum depression and the social support (r=-.38, p<.001) showed a significant negative correlation, but postpartum depression showed a significant and positive correlation with the infant temperament (r=.40, p<.001) and the maternal role strain (r=.59, p<.001).
• Table 8. Correlations between Self-efficacy, Social Support,
• Infant Temperament, Maternal Role Strain and Postpartum Depression (N=190)
• Name scale Self-efficacy Social support Infant temperament Maternal role strain
• r (p)
• Social support .32
• (<.001)
• Infant temperament -.14
• (.047) -.26
• (<.001)
• Maternal role strain -.34
• (<.001) -.42
• (<.001) .40
• (<.001)
• Postpartum depression -.15
• (.030) -.38
• (<.001) .40
• (<.001) .59
• (<.001)
• 6. Predictors of postpartum depression
• The predictors of postpartum depression were summarized in Table 9.
• Multiple regression was calculated to identify predictors of postpartum depression based on the significant variables, which included the self-efficacy, social support, infant temperament, maternal role strain, relationship with her husband, stressful life events, paid maternity leave, gestational age, and history of mental health.
• The results showed that the predictors of postpartum depression were paid maternity leave (β=-.16, p=.004), gestational age (β=.15, p=.005), history of mental health (β=-.19, p=.002), the self-efficacy (β=.12, p=.031), and the maternal role strain (β=.47, p<.001). Moreover, there were not significant predictors of postpartum depression consisting social support, infant temperament, relationship with her husband, stressful life events. The overall model fit was adj.R2=.46, indicating that the significant predictors, namely paid maternity leave, gestational age, history of mental health, the self-efficacy, and the maternal role strain explain 46% of the variance.
• Table 9. Predictors of Postpartum Depression (N = 190)
• Variables B SE β t p
• Paid maternity leave -1.30 0.44 -.16 -2.91 .004
• Relationship with husband -0.01 0.48 -.01 -0.01 .986
• Gestational age 3.33 1.16 .15 2.87 .005
• Stressful life events 0.96 0.72 .07 1.34 .181
• History of mental health -5.97 1.90 -.19 -3.14 .002
• Self-efficacy 0.02 0.01 .12 2.17 .031
• Social support -0.26 0.13 -.12 -1.93 .055
• Infant temperament 0.06 0.05 .08 1.32 .186
• Maternal role strain 0.23 0.03 .47 7.16 <.001
• R2=0.48 Adj.R2=0.46, F=19.16, p<.001
• Adj.R2 =Adjusted R2
• Durbin-Watson=1.349; Tolerance=.653~.956; VIF=1.046~1.532
• Dummy variables=Paid maternity leave (reference=yes); Relationship with husband (reference=exellent); Gestational age (reference=<38 or ≥42weeks); Stressful life events (reference=yes); History of mental health (reference=yes).
• 7. The mediating effect on postpartum depression
• In order to determine whether the first three conditions of Baron and Kenny were met in terms of research variables, the correlation coefficients between the variables were seen [141]. Considering the mediator maternal role strain between self- efficacy, social support, infant temperament and postpartum depression, before the mediator variable analysis, the correlation coefficients between variables were calculated. As shown in Table 8, the relationship of all variables appears to be significant. Therefore, mediator variable analysis was conducted.
• The mediating effects of maternal role strain on the relationship between self-efficacy, social support, infant temperament and postpartum depression were showed in Table 10 and figure 4.
• 7.1. Mediating effects of maternal role strain on the relationship between self-efficacy and postpartum depression.
• In the first step, a simple regression analysis was conducted regarding examining the mediating effect of maternal role strain and the result of the first step found that decreased self-efficacy was also associated with a higher score of maternal role strain and significantly (β=-.34, p<.001). The result of the analysis in the second step showed that self-efficacy had a negative and significant effect on postpartum depression (β=-.15, p=.029).In the third step, multiple regression of the dependent variable on the mediating variable - controlling for the independent variable was conducted. In this study, postpartum depression was entered as the dependent variable, and self-efficacy and maternal role strain were entered as predictor variables, a positive association between maternal role strain and postpartum depression was found controlling for the self-efficacy (β=.61, p<.001). In other words, the maternal role strain effective factor appears as a full mediator of the relationship between self-efficacy and postpartum depression. The Sobel test confirmed the mediating effect of maternal role strain (Z=-4.48, p<.001).
• 7.2. Mediating effects of maternal role strain on the relationship between maternal social support and postpartum depression.
• In the first and the second step, the simple regression analysis conducted to examine the mediating role of maternal role strain showed that the pattern of association between social support and maternal role strain among women was observed, those in the lower social support reported maternal role strain higher and significantly (β=-.42, p<.001). The result of second step lower maternal social support was associated with an increased depressive symptom score and significantly (β=-.38, p<.001). In the third step, postpartum depression was entered as the dependent variable, and social support and maternal role strain were entered as predictor variables, the result showed that both social support and maternal role strain exerted a significant effect on postpartum depression was found controlling for maternal social support (β=.52, p<.001) and (β=-.16, p=.009). Hence, maternal role strain as a partial mediator of the relationship between maternal social support and postpartum depression. The Sobel test confirmed the mediating effect of maternal role strain (Z=-5.02, p<.001).
• 7.3. Mediating effects of maternal role strain on the relationship between infant temperament and postpartum depression.
• In the first step, a simple regression analysis was conducted regarding examining the mediating effect of maternal role strain and the result of the first step found that infant temperament impacted a significant effect on the maternal role strain (β=0.40, p<.001). The result of the analysis in the second step showed that infant temperament had a positive relationship with depressive symptoms that means higher difficult infant temperament was associated with a higher postpartum depression (β=.40, p<.001). In the third step, both infant temperament, as an independent variable, and maternal role strain, as the mediator, entered the regression model, with the postpartum depression as a dependent variable. The results indicated that this relationship was significant. Infant temperament (β=.19, p=.001) and maternal role strain (β=.51, p< .001) were significant predictive variables of postpartum depression explaining 38% of the variance. In other words, maternal role strain is a partial mediating effect of the relationship between infant temperament and postpartum depression. Finally, the Sobel test found that the mediating effect of the maternal role the strain on the relationship between infant temperament and postpartum depression was significant (Z = 4.87, p<.001).
• Table 10. Mediating Effect of Maternal Role Strain on the Relationship between Self-Efficacy, Social Support,
• Infant Temperament and Postpartum Depression (N = 190)
• Step Independent variable Dependent variable B SE β t p Adj.R2 F (p) Sobel test
• Z p
• 1 Self-efficacy Maternal role strain -.15 .03 -.34 -5.07 <.001 .12 25.79 (<.001)
• 2 Self-efficacy Postpartum depression -.03 .01 -.15 -2.19 .029 .02 4.80 (.029)
• 3 Self-efficacy Postpartum depression .01 .01 .05 0.86 .388 .35 50.97 (<.001) -4.48 <.001
• Maternal role strain .31 .03 .61 9.73 <.001
• 1 Social support Maternal role strain -1.74 .27 -.42 -6.36 <.001 .17 40.51 (<.001)
• 2 Social support Postpartum depression -.81 .14 -.38 -5.76 <.001 .15 33.19 (<.001)
• 3 Social support Postpartum depression -.35 .13 -.16 -2.63 .009 .37 55.73 (<.001) -5.02 <.001
• Maternal role strain .26 .03 .52 8.16 <.001
• 1 Infant temperament Maternal role strain .64 .10 .40 6.09 <.001 .16 37.13 (<.001)
• 2 Infant temperament Postpartum depression .32 .05 .40 6.09 <.001 .16 37.12 (<.001)
• 3 Infant temperament Postpartum depression .15 .05 .19 3.15 .001 .38 58.07 (<.001) 4.87 <.001
• Maternal role strain .25 .03 .51 8.13 <.001
• Figure 4. Mediating effect of maternal role strain on the relationship between self-efficacy, social support, and infant temperament and postpartum depression.
• V. DISCUSSION
• This section discussed the findings related to the literature and some additional findings. This research was not only focused on elucidating the prevalence and predictors of postpartum depression, but also verified the mediating effect of the maternal role strain on postpartum depression that was insufficiently performed in Vietnam so far. The outcome of the research emphasized the importance of reducing the risk factors of postpartum depression in order to promote a healthy life for mothers, creating good conditions for the growth and development of the newborn, and seeking effective interventions for postpartum depression in Vietnamese women.
• 1. Prevalence of postpartum depression and the level of self-efficacy, social support, infant temperament, maternal role strain
• In this study, using the standardized EPDS for measuring postpartum depression, the prevalence of probable postpartum depression or being at risk for clinical depression was the EPDS score at or above cut-off of 13 points. The existing study found that 18.9% (n=36) of women surveyed had EPDS score at or greater cut-off of 13 points or probable postpartum depression. The prevalence of probable postpartum depression was different in different researches even though also using the EPDS scale and cut-off of 13 because they conducted their researches on women at various times after giving birth. This prevalence is similar to the finding reported in other studies conducted in Danang, Vietnam was 19.3% [12], and some Asian countries such as Nepal [143], Philippines [144], and less than the incidence reported in Saudi Arabia [25], and southeast Nigeria [24], but higher than the rate presented in the developed countries [145,146]. The finding of the study was slightly higher than the other study that could be due to the survey time to 24 weeks after childbirth. The other studies were limited to 4 weeks postpartum may reflect only maternal blue symptoms which were a transient depressive stage rather than actual depression. The variation within postpartum depression prevalence may be concerned with many factors such as the mothers’ characteristics, the different cut-off, multi-social and multi-cultural factors, sample size, and methods. Postpartum depression is an illness related to cultural, economic, and social issues; hence the studies conducted in places with various cultural and social backgrounds will have a different prevalence of postpartum depression. The findings could be influenced by the research design and the period during which the research was conducted within the first year after giving birth. Moreover, the EPDS as a tool reports prevalence at a point in time rather than the incidence of ongoing depression.
• The finding of this study found that only over half (54.2%) of mothers had a self-efficacy score higher than the mean score. Self-efficacy refers to the mother believes in her abilities to organize and executing particular behavior, and achieving a specific goal [35]. A low self-efficacy score of a mother could be due to first-time mother parenting. Most postpartum women need to both recover their strength and look after their babies during the postpartum period which is a new and heavy maternal role. In this early postpartum transition period, the new roles could cause considerable pressure in effectively parenting, making them lose their confidence, and finally resulting in low self-efficacy [147].
• Regarding the incidence of social support, in this study, 63.2% of mothers received high support and only 2 mothers scored less than 19 which means low support. According to Vietnamese culture, most first-time mothers returned to their own mother’s house for months following giving birth, especially in the first three months, this is called the confinement periods. Husband and own parents are usually the main sources of social support for a mother in the postpartum period. Support from family is the most important and useful especially husband support, it may make the mother feel comfortable and increasing maternal competence. However, the family relationship may also cause pressure and challenges for them. In this study, 2 mothers had a conflict with a husband that could make the mother receive less support and the mother would feel specifically vulnerable and have negative emotions.
• In this study, infant temperament was measured by perceptions of the mother. Of 190 mothers studied, 76 mothers (40.0%) of temperamentally difficult infants scored higher than the mean score. Infant temperament reflected the way mother's experience and reported the behavioral characteristics of a difficult infant in the clinical. Mothers of temperamentally difficult infants were a significant risk factor for postpartum depression in the first months [148]. In this study, the possible reasons for the prevalence of mothers who had high temperamentally difficult infants could be due to the less interest in their maternal role and lack an understanding relative to other mothers. With a difficult infant, the mother faced the reaction of the infant including crying vigorously for long periods of time, and difficult to comfort or calm down. These were pressures for first-time mothers. Thus, maternal perceptions of infant temperament and maternal role are of paramount importance, which affected how mothers care for and rearing practices their child.
• The prevalence of maternal role strain reported in this study was relatively high (48.9%) which indicated mothers had not adapted to the transition role in the motherhood process. Adaptation to motherhood consists of a series of maternal behaviors and emotions [149], if the maternal duties were not be fulfilled and the mother did not enjoy interacting with her child that was contributed to maternal role strain Perceived maternal role strain had a positive effect on the degree of difficulty of the transition to parenthood. In this study, the possible reasons for high maternal role strain prevalence could be due to parenting strain-child and financial strain. According to Vietnamese culture, the husband made main responsible for the economy in the family, the woman is often economically dependent on her husband meanwhile raising a child was an important task and costs a lot of money. Not receiving support from husbands and not having independent earnings can therefore increase the maternal role strain.
• 2. Factors associated with postpartum depression
• Our findings indicated that postpartum depression according to the general characteristics, the mean score of mothers with stable occupation was higher than of those who had unstable jobs (10.68 vs 7.53). Many research that was similar results to our study, was found that the role a woman’s occupation status related to the development of depressive symptoms and the women who worked outside of the home may be a protective factor for postpartum depression [150-152]. In addition, a research conducted in India [153] determined that a significant association between postpartum depression and occupation of postpartum mothers. In Vietnam, there have strong policies promoting equal gender, that means both men and women have opportunities for working. This means that if a mother did not have a stable occupation outside of the home, or freelances or unemployed, she could not do financial contributions to her family and hence become economically dependent on her husband that increased the risk of postpartum depression.
• Postpartum depression is a situation that affects the relationship with everyone close to the person who is suffering. There is international consensus that a woman’s relationship with their husband is one of the most influential social factors of postpartum depression. In this study, the majority of women stated that their relationship with their husbands was very excellent (34.7%) and good (46.8%). The postpartum depression according to a relationship with her husband, the mean score of mothers with a fair or poor relationship with her husband was the most. That means women who had a fair or poor relationship with their husbands, higher risk factors for postpartum depression. The results found in this study were similar to those found in Murray et al’s study [11]. Commonly factors that lead to a fair or poor husband relationship in this study may be having a husband who does not assist to take care of their baby or doing household tasks and provide for a financial family or having a husband with alcohol.
• Regarding other stressful events in their lives, 31.6% (n = 60) of women said that they had experienced another stressful life events. Stressful life events are reported in many studies as a predictor of postpartum depression. A study conducted in Riyadh, Saudi Arabia [25] about the prevalence and predictors of postpartum depression reported that having a high percentage of surveyors with stressed life event was the situation of the general population of Riyadh residents and stressful life events were the strongest predictor of postpartum depression. In the present study, the mean score of women who had experienced another stressful life event was higher than those who had never stressful life events. Because the mother’s body underwent a series of changes during the process of pregnancy and parturition, the presence of stressful life events may be a trigger for developing postpartum depression. Further, after giving birth, mothers will have many challenges and new responsibilities that she must cope with, and being stressed by other problems will be easily increased postpartum depression. When women were asked what these stressful life events were as a multiple-choice question, the most commonly concerned problems worried about finances, a lack of money, and unstable occupation or unemployment. The findings of the current study are similar to many other types of research which also report that women who have financial problems are more likely to develop postpartum depression [154]. Other stressors included healthy infants, anxious about how to take care of the baby. Finally, some other stressors examined by women were being too busy, doing housework, a fair or poor relationship with their husband, and having a husband drinks alcohol.
• After giving birth, child-rearing is the main task, and mothers must spend a lot of time taking care of their newborn child. According to the labor code of Vietnam, women who are working for the government are entitled to 6 months paid maternity leave [155]. If they do not have independent income or paid maternity leave, it will increase the financial burden on their family. In the present study, due to 156 women having an occupation that means 156 women were asked about paid maternity leave, only 101 of those received paid maternity leave. The majority of women in this study who received paid maternity leave worked for the government, some of them worked for a large company, a private company or business and 55 women did not receive paid maternity leave because of freelances. Besides that, 34 women did not receive paid maternity during the postpartum period because they did not have a job during the pregnancy period. The result of this study was found that paid maternity leave was related to postpartum depression symptoms. The results of the current study here were similar to the study by Aitken et al [156], and study in Australian [157]. Paid maternity leave had effected to positively maternal mental health. For most women and families, paid maternity leave may relieve some of the burdens around taking care of the baby and affording time off work.
• Gestational age assessment means figuring out the number of weeks of mother’s pregnancy. A full-term pregnancy is usually from 38 weeks to 42 weeks. If the gestational age is outside this period, it is called a preterm or late gestation. The result of the present study, the mean score of women gave birth from 38 weeks to under 42 weeks was less postpartum depression than women delivered a baby under 38 weeks or over 42 weeks. Our study showed that there was a positive association between gestational age and postpartum depression, which meant that as gestational age under 38 weeks of over 42 weeks increased, the incidence of postpartum depression actually increased. The results of this study were similar to a systematic review study [158] and Zhou et al [159]. Gestational age at delivery was a significant predictor of postpartum depression at 6 weeks postpartum after accounting for admission to hospital during pregnancy [158]. The other study in Northwest Ethiopia [160], women giving birth less than 36 weeks of gestational age were two times than that of those giving birth at 36 or more weeks of gestational age. The findings of the study might be due to the uncertainty of the mother about the survival of the newborn and doubts or anxiety about her capacity to cope with the care of an ill newborn child or abnormal child.
• Regarding depression-related characteristics in the present study, among the women were asked, only 3 of them had family members who experienced a mental illness history include depression. In addition, 3.7% (n=7) of the women reported that she had been treated for mental illness problems including depression. Moreover, the finding found that the previous history of mental disorders was associated with postpartum depression symptoms, but we did not find a relationship between the women who had family members with depression and the development of postpartum depression. A study conducted in Southern Ethiopia [161] also found that a previous history of mental health including depression in the study women was related to 3.54 times of odds compared to participants without a history of previous mental health. Besides that, a study postnatal depression in central Vietnam [11] only 1.2% of the women had been attended a psychiatric facility and treated for a psychiatric illness, including two living in urban areas and three from rural areas. In contrast, these findings of our study did not correspond to some of the studies reported by Mengstu, Haymonot, Eyerusalem [160], and Leodoro et al [144]. These differences may be related to the difficulties in determining and diagnosing a positive previous history of mental health. It requires women to be aware that they have been experienced from depression in previous pregnancies or after giving birth and they are willing to reveal this information. However, Vietnamese women are not aware of general depression during pregnancy or after childbirth. Besides that, they are not screened or diagnosed as an illness by many health services. Mothers also rarely participate in mental health screening because of lack of knowledge about perinatal mental health, limited opportunities for screening, and being afraid of stigmatization if diagnosed.
• 3. Correlations between self-efficacy, social support, infant temperament, maternal role strain and postpartum depression.
• The research found that self-efficacy and postpartum depression have a significant negative correlation that means high self-efficacy is a protective factor, making reduction postpartum depression. Maternal self-efficacy referred to mothers’ confidence in their ability to perform roles related to care for their baby, or in relation to more holistic perceptions about being a mother [162]. Role and duties involved in taking care of a child were critically important tasks associated with motherhood and posed a great challenge and pressure to a first-time mother. Our findings are in accordance with the report of a longitudinal study [163] and Law et al [164] that indicated the first-time mothers' depressive symptoms peaked, and maternal self-efficacy was weakest, at 3 weeks postpartum and the low self-efficacy of postpartum women is an important factor for postpartum depression.
• The research demonstrates that social support and postpartum depression have a significant negative correlation. This means a lower degree of social support were associated with a higher incidence of postpartum depression in the postpartum period which is in accordance with previous studies [25,32,165]. Mothers who received a high degree of support from husband, family, and friends were related to lower experience postpartum depression. Compared to mothers receiving a high degree of support, the rate of postpartum depression was high nearly twice and nearly four times with mother receiving a medium and low level of support [166]. In this study, with a new role and task, postpartum women were vulnerable and the occurrence of negative events, the negative emotions appear thus the support from husband played an important role in preventing and developing postpartum depression.
• The research reported that infant temperament and postpartum depression have a significant positive correlation. This result means that the difficulty of infant temperament is an important dimension of women's experience in the first months after giving birth. Our findings are in accordance with the other study [167,168]. In this study, this correlation may be that the woman whose infants are temperamentally difficult may have emotional conflict toward the infant, resulting in resentful and disappointed feelings. The infant cried excessively or poor infant sleep prolonged time that may affect caring for an infant of mother and cause of maternal stress and depression because her infant did not look like the infant in their mind during pregnancy.
• The research demonstrates that maternal role strain and postpartum depression have a significant positive correlation that means higher levels of maternal role strain were related to higher rates of postnatal depression in the postpartum period. Role strain refers to the emotional reaction of mothers to the subjective stressful postpartum experience. Role strain is created when a woman holds being a mother's status but she cannot do this role every day. After giving birth mothers must adapt to their motherhood and for fitting to a new task, the mother should overcome and cope with these stresses properly. This role strain affected serious psychological of postpartum mothers that may lead to postpartum depression
• 4. Influencing factors of postpartum depression
• Postpartum depression can obstruct the maternal-infant relationship, thus, influencing adversely infant development and having a part in the mother's sense of shame and guilt. In spite of postpartum depression was recovered, the negative interaction relationship formed during the early critical period may impact on children’s later development. However, maternal remission can affect positively the children. Therefore, early detection and management of the disorder should be prioritized during postnatal care, especially for mothers at risk. In this study a multiple linear regression was calculated to predict postpartum depression based on the significant variables including mother’s occupation, relationship with her husband, stressful life events, paid maternity leave, gestational age, history of mental health, and the self-efficacy, social support, infant temperament, and maternal role strain. However, mothers who had no a job did not receive paid maternity leave, both mother’s occupation paid maternity leave variables were significant effect on postpartum depression hence we combined two variables into a new variable including 3 categories mother say yes or no in paid maternity leave and mother did not have a job. Maternal self-efficacy is concerned with the mother’s awareness of her effectiveness as a mother. It is strongly associated between maternal feelings and the extent of her self-confidence, and the perception of her competence in performing tasks associated with caring for their baby [30]. Tasks associated with caring for her baby are as critically important tasks as related to motherhood. Maternal feelings of self-efficacy are related to a number of adaptive parental outcomes, including lower postpartum depression symptoms [148]. In contrast, low self-efficacy is associated with depression, anxiety, and reduced efforts at coping with problems in their life. Maternal self-efficacy at 3 weeks postpartum was a negative significant predictor of 3-week levels of, and also positively significant predicted reduction in stress later [164].
• Recently, in Vietnam, few studies have investigated an association between maternal self-efficacy and postpartum depression [11]. In the present study maternal self-efficacy was associated with the development of postpartum depression symptoms. Women who reported score 13 and more in the EPDS were more likely to be low self-efficacy. Postpartum depression obstructs the ability of the mother caring for her infant and to build confident skills in specific parenting tasks, such as feeding, diapering, and play interactions between mother and infant [75]. Vietnamese women had experienced low self-efficacy in the current study may affect their ability to implement special functions relevant to caring for newborns. This may be a result of poor antenatal preparation for parenting and a low level of postpartum social support. Low self-efficacy maybe increase Vietnamese women's levels of anxiety and stress which in turn may increase their risk of developing postpartum depression.
• The maternal role is one of the most basic and important roles played by women during their lifetime and having a socially meaningful role, in many cultures, it determines women’s identity, value, and place in society [71]. The process of becoming a mother requires extensive physical, psychological, socialwork. The result of this study found that maternal role strain had been association with postpartum depressive symptoms. This finding is most likely to be associated with parenting strain child and financial strain during the postpartum period. The first-time mothers face tremendous challenges as she undergoes this transition. In Vietnam, after giving birth, women are entitled to 6 months maternity leave, if they do not have independent income or paid maternity leave, they will increase worried about their financial security and have higher levels of role strain. Thus, the more support from social, family, and husband, the less maternal role strains the first-time mothers felt. Besides that, mothers who reported that lack of knowledge and not have enough time taking care of the baby they may tend to be displayed more depressive symptoms. Hence, there is a need for the development of interventions that addresses maternal role strain, depressive symptoms, and enhancement of social support among first-time mothers.
• Three strong predictors of demographic variables and developing postpartum depression in this study were gestational age, new-paid maternity leave, and a history of mental health. Happiness, without illness and preterm infants, may prevent the development of postpartum depression. Mothers of infants born preterm have higher rates of postpartum depression from 28.0% to 40.0% [158]. The relationship between maternal and infant may be adversely affected by a women’s depressive state. According to the global literature research, gestational age is a predictor of postpartum depression. A systematic review about preterm and low-birth-weight infants, four of the six studies reported either significantly increased depression prevalence or mean depression scores in mothers of preterm infants in the first postpartum year [158]. Therefore, preterm infants of depressed mothers are at increased risk for developmental problems including both their prematurity and their mother’s mental health status [169]. Paid maternity leave is an important aspect for employed mothers during the postpartum period and paid maternity leave has positive maternal mental health effects [11]. The main task of the mother at this time was taking care of the child, if the mother did not receive paid maternity leave, she could increase the financial burden to her family. Therefore paid maternity leave policies enacted and effective were supported mothers who had independent earnings and did not dependent economically on her husband. Besides that, mothers who had no stable job outside or doing housework need to receive financial assistance from her husband and family that help the mother reduce stress and depression during the postpartum period. The third predictor of demographic variables and developing postpartum depression in this study was a history of mental health. According to the literature review [88,94], by asking pregnant women about their previous mental illness, we can define most of the women at high risk for postpartum depression. However, that is a clinical challenge to predict which women will have experienced depression for the first time during the postpartum period [96]. It may be difficult to identify depression for any new mother in giving and caring for a new baby. Women believe that their mood and anxiety symptoms due to losing sleep or to the stress of caring for a new baby [170]. Many women with their first episode of depression during the postpartum period do not get treatment. It may be quite difficult to predict reliably which women with no history of mental health will develop postpartum depression, it is necessary to screen all women for postpartum depression, in addition, having education program for all women about the signs and symptoms of mood disorders in the postpartum period.
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• 5. The mediating effect on postpartum depression
• 5.1. Mediating effects of maternal role strain on the relationship between self-efficacy and postpartum depression.
• The study explored an important but under-researched topic on paternal postpartum influence on postpartum depression. In spite of the emerging evidence on the potential harm of self-efficacy on postpartum depression [163,164], the role of maternal role strain is still largely unknown. In this study, the theoretical model in which self-efficacy was linked to postpartum depression symptoms through their effects on maternal role strain proved to account for the data quite adequately.
• According to our research, a novel finding of this study is that maternal role strain played the key role of mediator in the relationship between self-efficacy and postpartum depression among postpartum women in Thua Thien Hue province, Vietnam. In the current study, the mean score of self-efficacy of the mother was 201.86 in which over half (54.2%) of mothers who had self-efficacy score higher than the mean score that means an increase in the level of self-efficacy has a positive effect on health behavior and symptom control. Because the physiological and psychological changes during the postpartum period, the cultural beliefs and practices of postpartum women affected how they evaluated themselves and were satisfied with their roles. Therefore, these results suggest that the special needs of postpartum women regarding taking care of herself and their babies were needed and supported appropriately enough especially increasing maternal self-efficacy in the early postpartum period. This support should deal with their emotional, status needs, and role as a mother. It helps to improve the mother's self confidence and increase the level of perceived self-efficacy. Education for mothers, social support, clarifying expectations, and making available structured peer support were the effective strategies that help new mothers perceive to be effective for improving maternal self-efficacy in the early stages of motherhood [31].
• Higher postpartum depression was associated with lower levels of self-efficacy and with higher maternal role strain. Postpartum depression showed the strongest association with maternal role strain, followed by self-efficacy. In this study, self-efficacy and maternal role strain were also a predictor factor of postpartum depression, this result was similar to the findings of previous studies [30,164]. Moreover, the findings showed that decreasing the mother's self-efficacy total score was associated with a higher score of maternal role strain and significantly (β=-.34, p<.001). Maternal self-efficacy is related to adaptive maternal outcomes including the transition to motherhood easily, lower postpartum depression, and satisfaction with social support. Some studies reported that greater feelings of maternal self-efficacy are associated with greater maternal competence and skill in specific tasks, such as self-care, feeding, diapering, and play interactions with infants [30]. Besides that, low self-efficacy is associated with higher maternal role strain and reduced efforts to cope with taking care of baby and problems in life. Perceived self-efficacy is an important indicator in the successful transition to being become a mother, and the maternal role is an important factor that has been associated with positive maternal behavior. Maternal self-efficacy plays an important role in increasing and promoting the abilities of mothers to implement their tasks and reducing strain in the maternal role [30].
• The current study reported that maternal role strain showed a full mediating effect on the relationship between self-efficacy and postpartum depression. In other words, rather than directly affecting postpartum depression, self-efficacy affected maternal role strain, which in turn affected postpartum depression. This finding is consistent with the results of a previous study reporting that self-efficacy in postpartum women decreased their levels of maternal role strain, which in turn decreased postpartum depression [30]. As maternal role strain is an essential predictor that determines postpartum depression, this factor is more important than psychological and physical health, life experiences, social interactions, and demographic factors. Maternal role strain is also known to be a key factor that assists with mother adaptation, improves her caring for the infant and her maternal role performance. Therefore, nursing intervention strategies focusing on decreasing the degree of maternal role strain are extremely important to prevent the negative effects of decreasing the degree of self-efficacy on postpartum depression. To date, in Vietnam, no study investigated the mediating effect of maternal role strain on the perceived self-efficacy and postpartum depressive symptoms. Most of the studies identified that had examined the mediation role of maternal role strain on this relationship were conducted in Korea and the US. It may be argued that in this thesis used effectively the approach in capturing the contributions of maternal role strain on perceived self-efficacy and postpartum depressive symptoms relationship.
• 5.2. Mediating effects of maternal role strain on the relationship between maternal social support and postpartum depression.
• In contrast to the mediating effects of maternal role strain on the relationship between self-efficacy and postpartum depression, maternal role strain as a mediator factor in maternal social support and postpartum depression relationship was a partial mediating effect on this relationship. In other words, maternal social support not only had direct effects on postpartum depression but also had indirect effects mediated by maternal role strain.
• One clear implication of these results is that maternal social support is an important dimension of experienced women in the months following giving birth. A lack of postpartum social support had been demonstrated to be an important modifiable risk factor for postpartum depression [171]. The postpartum period is an important time that the mother is needed to provide extra support by social, family members, in many developing societies. The decline of social support might an important having a part in factor to be higher rates of postpartum depression [32]. Mothers who were dissatisfied with support from their husbands were at increased risk for postpartum depression in the first five months after delivery. According to a cultural perspective study in China, the main sources of social support are from their own mothers and mothers-in-law; emotional support from their husbands, informational support from their friends, physicians [154]. The result of the present study found a strong association between maternal social support and the development of postpartum depression. In Vietnamese culture, after childbirth, women have to spend in confinement for at least 100 days they will receive social support from members of her family and/or her husbands’ family. After this period, the social support from her family or her husbands’ family will decrease or not be available and the new mothers have to get back their responsibilities in taking care of their children, their houses in addition to looking after themselves. This might increase their levels of stress and increase their risk of developing postpartum depression.
• Moreover, the pattern of association between maternal social support and maternal role strain among women tin this study was observed, those in the lower maternal social support reported maternal role strain higher and significantly (β=-.42, p<.001). These findings were consistent with previous research. A study about current status and future direction of depression [46] showed that social support created the good conditions for the transition to motherhood, and the positive support of husband and family, increases parenting competence and decreases maternal role strain. Social support looks like a barrier that protects the mother against stressful life events and to cope with the difficulties in life. Social support is an important source, which adaptive the mother’s emotional needs. In addition, it decreases maternal role strain and increases maternal behaviors that enable to respond to the mother to the child’s needs and creates a positive interaction between the mother and the infant. Furthermore, social support has been associated positively with mother-infant attachment, and maternal self-efficacy, however, it has a negative relationship with postpartum depression. On the other hand, providing social support is suitable for the mother’s needs that might lead to better adaptation to the maternal role [82]. To date, Vietnam had a few studies about maternal social support during the postpartum period, especially the confinement period. Having strong social support especially support her husband and family for the first-time mother during the postpartum period is universally recognized as a positive factor to reduce postpartum depression [11]. During this period that mothers cope with many difficult problems and starting with a new relationship with a maternal role which reaches to the maternal role strain. Hence more social support will be decreased the risk of the maternal role strain, resulting in decreasing the risk of postpartum depression symptoms.
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• 5.3. Mediating effects of maternal role strain on the relationship between infant temperament and postpartum depression.
• Similar to the mediating effects of maternal role strain on the relationship between maternal social support and postpartum depression, maternal role strain as a mediator factor in infant temperament and postpartum depression relationship was a partial mediating effect on this relationship. In other words, infant temperament not only had direct effects on postpartum depression but also had indirect effects mediated by maternal role strain.
• Difficult infant temperament is characterized by negative behavior, emotion, and health of baby, such as crying, fussiness, sleep problems, unpredictability, and unadaptable ability. It was associated with difficulties in the early mother-infant bonding and the development of infants' behavioral problems. Difficult infant temperament not only has been related to maternal mental health during pregnancy [33] but also is a risk factor for the development of postpartum depression. Mothers with postpartum depressive symptoms tend to have more negative perceptions of their infants’ behavior; feel less confident about their maternal efficacy and be less satisfied with the experience of motherhood. According to a current study, difficult infant temperament correlated with postpartum depression. This finding is consistent with findings from previous researches [148,168]. For example, Della Vedova’s study noted that higher scores of the postpartum state were a predictor of increased temperamental difficulties at three months old of the infant [148]. Another study found that women with postpartum depression reported their infants as being more difficult temperament at two and six months of age [168]. In Vietnam, a low-income country, the dearth of studies about child temperament, the mother-child relationship, and given the implications for the quality of life of the mother and the socio emotional development of the infant even though scientific evidence has shown the need to research this problem. Hence psychological interventions are needed due to these women may require assistance with emotional adaptation in the transition to motherhood and in learning new strategies to care for infants who may be difficult.
• In this study we also found that, there was a positive significant relationship between infant temperament and maternal role strain. To better understand maternal role strain, it is important to consider the infant temperament as an integral piece of this relationship. Although the contribution of infant temperament to the maternal role is little, evidence supports its contribution. Rode and Kiel found that infant temperament affects the strongest on a maternal role with additional significant impacts of postpartum depression [172]. Pridham, Lin, and Brown examined two factors which contribute to maternal caregiving evaluation, including both postpartum depression and infant temperament [173]. Results reported both of these contribute to caregiving evaluation, such that higher levels of depression and more difficult infant temperament had been associated with more negative caregiving evaluations.
• However, no study among postpartum Vietnamese women was associated with this problem. The finding of the present study is suitable for the small part of previous researches about the contribution of maternal role strain in explaining infant temperament differences in postpartum depression symptoms. However, differences in the measurement infant temperament scale, Vietnamese cultural and social backgrounds as well as in research methods, postpartum period, and data analysis techniques make a direct comparison between studies difficult.
• 6. Limitations
• Although the study contributes to a further comprehensive understanding of postpartum depression and self-efficacy, social support, infant temperament and maternal role strain, shortcomings in this project are inevitable due to its scope.
• In terms of its overall scope, the study is limited by the nature of the small cross-sectional study design and heterogeneous sample. The data gathered in this survey is self-reported questionnaires rather than clinical assessments and structured interviews. Hence it may not set up causal inferences. Follow-up research may not be done because this is not a longitudinal study. The survey is to only participants who lived in Hue city. Thus, it is not generalizable to all women in Vietnam.
• Aditionally, using a simple mediation model in this study has unadequate permission for the finding out the effects of other mediators that are omitted from the model.
• Fortunately, the research examining these relationships will have the advantage of using larger samples, including physiological variables and objective measures of social support, self-efficacy, maternal role strain, postpartum depression, and infant temperament. A tighter test about influencing of these constructs on each other would be repeated to assess and confirm the developmental processes in the model.
• 7. Implications
• The study findings have implications for nursing education, nursing practice and nursing research.
• 7.1. Implication for nursing education
• The result of this study is neccesary for nursing education to indicate the usefulness of the mediation model in describing the Postpartum Depression Predictor Model. The model includes predictor factors which examine both the hypothesized indirect and direct effects rather than focusing on individual pathways. The knowledge from this study is very useful not only in guiding practice to students who will become nurses in the future but also re-training to senior nurses for the intervening with postpartum women. Furthermore, a public education program about prenatal postpartum care, transform role of mothers, health care and screen mental health should be implemented by medical staff and other maternity workers.
• 7.2. Implication for nursing practice
• The implications for nursing practice are very important to the nurses practicing in hospital as well as to home care nurses. In the hospital, the nurses help postpartum women to avoid adding strain by a good attitude such as friendliness and attentive observation and try to help mothers and babies as much as possible. Careful explanation and consultation of the problems are for those who may face after giving birth or stressful causes at the out-patient departments. On the other hand, community health nurses or social worker should connect organizations to conduct home visits to follow up the mother's health and screen postpartum depression during the confinement period because postpartum women are afraid of going out and to approach postpartum services for themselves and their infants. Finding from this study also suggests that a decrease in social support, decrease perceived self-efficacy may lead to strain in the maternal role and cause the women at high-risk postpartum depression. Thus, both nurses in hospital and in community should be aware of how to help the mother to increase their feeling of self-efficacy, to receive the support from social support and her family so that they are alble to deal with difficult infant temperament in clinics and aware the ways that her husband and family involved to support them during the postpartum period.
• 7.3. Implication for nursing research
• The implications for nursing research in the future are mentioned in this study, too. Future qualitative studies including self-efficacy, maternal role strain, and infant temperament are carried out by in-deep questionnaires. Quantitative research about abortion, chronic disease by multiple-choice are also recommended. Besides, this study should be replicated by using large samples, various geographical locations, and times of postpartum or mothers who face chronic illnesses such as diabetes mellitus or hypertension. On the other hand, it is necessary to conduct research about the nursing interventions or guidelines for nursing practice to enhance health promotion behaviors as well as decrease or prevent postpartum depression symptoms.
•  
• VI. CONCLUSIONS
• A. Conclusion
• The purpose of the current study was to examine the relationship and predict postpartum depression for Vietnamese women. It also identified the role of the maternal role strain degree mediator effects between the degree of self-efficacy, infant temperament, social support, and postpartum depression symptoms.
• 1. The existing study found that all women surveyed, the prevalence of probable postpartum depression which had EPDS score at or greater cut-off of 13 points was 18.9% (n=36).
• 2. The result showed that there was a significant relationship between postpartum depression and mother’s occupation (t=-2.86, p=.005), relationship with her husband (F=5.91, p=.003), Stressful life events (t=2.94, p=.004), paid maternity leave (F=6.83, p=.001), and gestational age (t=3.32, p=.001) and history of mental health (t=3.86, p<.001).
• 3. Postpartum depression was significantly negatively correlated with self-efficacy (r=-.15, p=.030), and social support (r=-.38, p<.001) and significantly positively correlated with infant temperament (r=.40, p<.001) and maternal role strain (r=.59, p<.001).
• 4. The finding also found that paid maternity leave (β=-.16, p=.004), gestational age (β=.15, p=.005), history of mental health (β=-.19, p=.002), the self-efficacy (β=.12, p=.031), and the maternal role strain (β=.47, p<.001) were significant predictors. The overall model fit was adj.R2= .46, indicating that the significant predictors, namely paid maternity leave, gestational age, history of mental health, the self-efficacy, and the maternal role strain explain 46% of the variance.
• 5. This study demonstrated that maternal role strain had a full mediating effect on the relationship between self-efficacy and postpartum depression. Besides that maternal role strain was also a partial mediating effect on the relationship between maternal social support, and infant temperament and postpartum depression among postpartum women.
•  
• B. Recommendations
• From the results of this study, a number of recommendations for further research should recognize as follow:
• Conducting the longitudinal studies following women from pregnancy to the postpartum period and/or to the first birthday of the child to examine the change in a maternal role, maternal mood, and growth, development of the child
• Future interventions research for mothers who are experienced or at risk for postpartum depression may consider as an instrument to assess self-efficacy, social support, maternal role strain, and infant temperament. Furthermore, adopt various instruments and measurement methods to analyze the effect of mediator variables on postpartum depression.
• Establish a screen for depression programs and early intervention to find out the early effects of postpartum depression and reduce its potential harm.
• An investigation to the acceptance of screening programs for prenatal and postpartum depression and acceptable treatment methods including counseling and using medications.
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• APPENDICES
• Appendix 1 Approval letter from IRB at Inje University, Korea
• Appendix 2: Approval letter from IRB at Hue University of Medicine and Pharmacy, Vietnam (English version)
• Appendix 3: Approval letter from IRB at Hue University of Medicine and Pharmacy, Vietnam (Vietnamese versison)
• Appendix 4: Approval letter for using survey
• A. Appoval letter for using Difficult infant temperament Scale
• B. Appoval letter for using maternal role strain Scale
• C. Appoval letter for using Perceveid Self-efficacy Scale
• Appendix 5 Informed consent
• A. Informed consent (English version)
• Information to Consider Before Taking Part in this Research Study
• Researchers at the Inje University, Korea study many diseases and health problem. To do this, we need the help of people who agree to take part in a research study. This form tells you about this research study. We are asking you to take part in a research study that is called: “DETERMINING THE PREDICTOR OF DEPRESSION FOR POSTPARTUM IN VIETNAM”.The person who is in charge of this research study is Nguyen Thi Phuong Thao, Ph.D. Candidate Student Nursing faculty, Inje University, South Korea. This person is called the Principal Investigator. However, other research staff may be involved and can act on behalf of the person in charge.
• The research will be done at 12 community health centers in Hue city, Vietnam
• The purpose of this study will to identify risk factors and predicts postpartum depression. This study is conducted for the following specific purposes according to the necessity of research:
• The benefit of this study includes an evaluation of your depression status. If depression is found, referral to appropriate resources may be made and the survey takes about 20 minutes and after the interview, you will receive 50.000 VND as compensation for your time. You are free to choose to participate in the study. You may refuse to participate without any loss of benefit which you are otherwise entitled to. You may also refuse to answer some or all the questions if you don’t feel comfortable with those questions. If you decide during the study that you do not want to participate, you can withdraw at any time. There will be no penalty or loss of benefits you are entitled to receive if you stop taking part in this study.
• We must keep your study records private and confidential; however, certain people may need to see your study records such as the research team, including the Principal Investigator, study coordinator, research nurses, and all other research staff. The information gained from this research will be used to make recommendations for best practice and will offer insights into the findings of the emotion earliest symptoms and predict the factors of postpartum depression. The results of the study may also lead to further studies into postpartum depression. Please do not hesitate to contact me if you need further information
• Name: NGUYEN THI PHUONG THAO
• Address: Nursing faculty, Hue University of Medicine and Pharmacy
• Phone: [phone], email: [e-mail]
• Thank you for your participation.
• Participant’s statement
• I certify that I understand the foregoing, that I have been given a satisfactory answer to my inquiries concerning study procedures and other matters and that I have been advised that I am free to withdraw my consent and to discontinue participation in this study at any time without prejudice. I understand that by signing this form. I am agreeing to take part in the research. I have received a copy of this form to take with me.
• ………………………………………………. …………………………………………………. Signature of Participant Date Signature of the researcher Date
• B. Informed consent (Vietnamese version)
• Kính gửi Bà/ Chị. .............,
• Tên tôi là Nguyễn Thị Phương Thảo. Tôi là nghiên cứu sinh về điều dưỡng tại Khoa Điều dưỡng, Trường Đại học Inje Hàn Quốc. Tôi đang tiến hành một đề tài nghiên cứu để hoàn thành khóa học trong chương trình Tiến sỹ Điều Dưỡng. Đề tài nghiên cứu của tôi là “Xác định các yếu tố dự báo trầm cảm sau sinh tại Thành phố Huế”. Tôi muốn mời chị tham gia trong nghiên cứu này bằng cách kể cho tôi những yếu tố liên quan xảy ra đối với chị trong khoảng thời gian 6 tháng sau khi chị sinh
• Trước khi chị quyết định có tham gia trong nghiên cứu, điều quan trọng là chị hiểu rõ mục đích của đề tài nghiên cứu và chị sẽ được yêu cầu làm gì. Xin vui lòng dành thời gian để đọc thông tin sau đây và thảo luận về nó với những người khác nếu chị muốn. Dựa trên cơ sở đó chị quyết định có hay không tham gia. Nếu chị quyết định tham gia, chị sẽ được đưa ra bản cung cấp thông tin này để giữ lại. Chị sẽ được yêu cầu ký vào phiếu chấp thuận tham gia nghiên cứu. Chị có thể thay đổi quyết định của chị tại bất kỳ thời điểm nào và rút ra từ nghiên cứu này mà không cần đưa ra một lý do.
• Mục đích của nghiên cứu này là xác định các dự đoán cho trầm cảm sau sinh. Tôi muốn hỏi những câu hỏi về những gì liên quan đến chị, suy nghĩ của chị, cảm xúc, tâm trạng của chị cũng như tình huống, sự kiện, địa điểm và con người liên quan đến chị sau khi sinh. Kết quả và kiến thức của nghiên cứu này sẽ tăng cường các điều dưỡng cung cấp chăm sóc thích hợp cho những bà mẹ sau sinh để đối phó hiệu quả hơn với những yếu tố nguy cơ về trầm cảm sau sinh nhằm cải thiện chất lượng cuộc sống sau này của họ.
• Chị sẽ được yêu cầu để hoàn thành một bảng câu hỏi về đặc điểm dân số xã hội như tuổi tác, tình trạng hôn nhân, nền giáo dục, tình trạng việc làm, tiền sử sản khoa… bên cạnh đó người tham gia nghiên cứu còn hoàn thành các bảng câu hỏi dự đoán các yếu tố trầm cảm sau sinh qua các thang đo về trầm cảm sau sinh của Edinburg, thang đo “nhận thức về khả năng tự làm được của bản thân”, thang đo “Sự căng thẳng trong vai trò làm mẹ”, thang đo “Sự hỗ trợ về mặt xã hội” và thang đo “Tính khí khó chịu của trẻ sơ sinh”. Tôi sẽ phỏng vấn chị khoảng 20 phút, hoặc cho đến khi chị muốn dừng lại. Sau cuộc phỏng vấn, chị sẽ nhận được 50.000 VND.
• Chị có thể từ chối tham gia mà không có bất kỳ tổn thất lợi ích mà chị đang được hưởng. Chị cũng có thể từ chối trả lời một số hoặc tất cả các câu hỏi nếu chị không cảm thấy thoải mái với những câu hỏi đó. Nếu trong quá trình nghiên cứu mà chị quyết định không muốn tham gia, chị có thể rút bất cứ lúc nào. Quyết định này sẽ không ảnh hưởng đến cuộc sống của chị trong bất kỳ hoàn cảnh nào.
• Thông tin thu được từ nghiên cứu này sẽ được đảm bảo bí mật và được sử dụng để đưa ra các khuyến nghị cho thực hành tốt nhất đồng thời cung cấp cái nhìn sâu hơn, những phát hiện sớm nhất về những cảm xúc những triệu chứng của trầm cảm. Kết quả của nghiên cứu cũng có thể dẫn đến các nghiên cứu trong tương lai về các yếu tố dự đoán trầm cảm sau sinh. Xin đừng ngần ngại liên hệ với tôi nếu chị cần thêm thông tin theo địa chỉ sau:
• Bà: Nguyễn Thị Phương Thảo
• Khoa Điều dưỡng Trường Đại học Y Dược Huế, Việt Nam
• Điện thoại: [phone]. Email: [e-mail]
• Cám ơn sự quan tâm của chị. Trân trọng.
• Sự đồng ý của người tham gia nghiên cứu.
• Tôi xác nhận rằng tôi hiểu rõ những điều đã đề cập ở trên, tôi đã được đưa ra câu trả lời thỏa đáng đối với các thắc mắc liên quan đến qui trình nghiên cứu và các vấn đề khác và tôi đã được thông báo rằng tôi được tự do từ chối tham gia và từ bỏ trở thành đối tượng nghiên cứu trong nghiên cứu này tại bất kỳ thời điểm nào mà không có ý kiến. Theo bản cam đoan này, Tôi đồng ý tham gia vào nghiên cứu này.
• Ngày…. tháng ….năm….. Ngày….. tháng ….năm ….
• Nhà nghiên cứu Người tham gia nghiên cứu
• Appendix 6: Surveys instruments for the study
• A. DEMOGRAPHICS (English version)
• 1. GENERAL CHARACTERISTICS
• First I will ask you some basic questions about your family, education, employment
• 1. How old are you? (dd/mm/yyyy)
• ( / / )
• 2. Do you have a religion?
• 1) Yes, 2) No
• 3. What is the final educational level that you have achieved?
• 1) Primary School graduate 2) Middle School graduate 3) High school graduate
• 4) College graduate 5) University graduate 6) Master graduate 7) Doctoral graduate
• 4. What is your current marriage situation?
• 1) Married 2) Widowed 3) Divorced
• 4) Separated 5) Never Married
• 5. Do you have an occupation?
• 1) Yes 2) No 3) Take time off from a job after pregnancy
• 6. The average family income per month in Vietnam Dong
• ( ) Vietnam Dong
• 7. What is the final education status of husband?
• 1) Primary School graduate 2) Middle School graduate 3) High school graduate
• 4) College graduate 5) University graduate 6) Master graduate 7) Doctoral graduate
• 8. Is your husband employed?
• 1) Yes 2) No
• 9. How is the relationship between you and your husband?
• 1) Very good 2) Good 3) Mixed 4) Difficult 5) Very difficult
• 10. How is the relationship between you and your mother-in-law?
• 1) Very good 2) Good 3) Mixed 4) Difficult 5) Very difficult
• 11. Stressful life events in the last year. (Please tick ALL that apply)
• 1) Financial problems 2) Changing relationships 3) Change home
• 4) Death in any of women relatives 5) Not applicable 6) Other (please mention)
• 2. POSTPARTUM CHARACTERISTICS
• 1. Have you received paid maternity leave?
• 1) Yes 2) No
• 2. How was your baby delivered?
• 1) Normal vaginal delivery 2) Vaginal delivery with forceps
• 3) Caesarean section without labor 4) Caesarean after labor stated
• 3. What is your baby’s gender?
• 1) Girl
• 2) Boy
• 4. How did you feel about the baby being a boy/girl?
• 1) Very happy 2) Happy 3) Mixed 4) Unhappy 5) Very unhappy
• 5. What weeks did you deliver your baby?
• 1) ≤ 37 weeks 2) 38 – 42 weeks 3) ≥ 42 weeks
• 6. What is your baby’s current health condition?
• 1) Healthy 2) moderate 3) Not healthy
• 7. How many grams of baby weights after giving birth?
• 1) < 2500g 2) ≥ 2500g
• 8. Who helped to take care for you and baby during postpartum?
• 1) Mother 2) Mother-in law 3) Husband
• 4) Relative or friend 5) Nobody
• 3. DEPRESSION RELATED CHARACTERISTICS
• 1. Have you ever been diagnosed with depression?
• 1) Yes 2) No
• 2. Has your family member ever been diagnosed with depression?
• 1) Yes 2) No
• B. DEMOGRAPHICS (Vietnamese version)
• 1. ĐẶC ĐIỂM CHUNG
• Đầu tiên tôi sẽ hỏi chị một số câu hỏi cơ bản về gia đình, giáo dục, việc làm và thu nhập….
• 1. Chị bao nhiêu tuổi ? ...........
• 2. Chị có tôn giáo không?
• 1) Có 2) Không
• 3. Trình độ học vấn của chị là gì?
• 1) Tiểu học 2) Trung học cơ sở 3) Trung học 4) Cao đẳng 5) Đại học 6) Thạc sĩ 7) Tiến sĩ
• 4. Tình hình hôn nhân hiện tại của chị là gì?
• 1) Kết hôn 2) Góa phụ 3) Ly hôn
• 4) Ly thân 5) Chưa kết hôn
• 5. Chị có nghề nghiệp không?
• 1) Có 2) Không 3) Dành thời gian nghỉ việc sau khi mang thai
• 6. Thu nhập trung bình của gia đình mỗi tháng tại Việt Nam?
• ( ) Việt Nam đồng
• 7. Tình độ học vấn của chồng chị là gì?
• 1) Tiểu học 2) Trung học cơ sở 3) Trung học 4) Cao đẳng
• 5) Đại học 6) Thạc sĩ 7) Tiến sĩ
• 8. Chồng chị có đi làm không?
• 1) Có 2) Không
• 9. Mối quan hệ giữa chị và chồng chị như thế nào?
• 1) Rất tốt 2) Tốt 3) Bình thường
• 4) Không tốt 5) Rất không tốt
• 10. Mối quan hệ giữa chị và mẹ chồng chị như thế nào?
• 1) Rất tốt 2) Tốt 3) Bình thường
• 4) Không tốt 5) Rất không tốt
• 11. Các sự kiện cuộc sống căng thẳng trong năm qua. (Vui lòng đánh dấu tất cả những gì đã trãi qua)
• 1) Vấn đề tài chính 2) Thay đổi mối quan hệ 3) Thay đổi nhà
• 4) Tử vong của bất kỳ người thân nào 5) Không có căng thẳng 6) Khác
• 2. ĐẶC ĐIỂM TRONG THỜI KỲ HẬU SẢN
• 1. Trong thời kỳ nghĩ thai sản chị có nhận được lương không?
• 1 Có 2 Không
• 2. Em bé của bạn được sinh như thế nào?
• 1) Âm đạo bình thường 2) Âm đạo bình thường kết hợp với Forceps
• 3) Sinh mổ khi chưa chuyển dạ. 4. Sinh mổ khi bắt đầu chuyển dạ
• 3. Giới tính của bé là gì?
• 1) Con trai 2) con gái
• 4. Bạn cảm thấy thế nào khi bé là con trai / bé gái?
• 1) Rất hạnh phúc 2) Hạnh phúc 3) Hỗn hợp 4) Không hạnh phúc 5) Rất không hạnh phúc
• 5. Tuần nào bạn sinh em bé?
• 1) Dưới 37 tuần 6 ngày 2) Từ 38-42 tuần 3) Trên 42 tuần
• 6. Bé nặng bao nhiêu gram sau khi sinh?
• 1) < 2500g 2) ≥2500g
• 7. Tình trạng sức khỏe hiện tại của bé như thế nào?
• 1) Khỏe mạnh 2) Vừa phải 3) Không khỏe mạnh
• 8 Ai là người giúp chị chăm sóc trẻ trong thời kỳ hậu sản?
• 1) Mẹ ruột 2) Mẹ chồng 3) Chồng
• 4) Họ hang hoặc bạn bè 5) Không có
• 3. TRẦM CẢM LIÊN QUAN ĐẾN ĐẶC ĐIỂM CHUNG CỦA BÀ MẸ
• 1. Chị đã bao giờ được chẩn đoán mắc bệnh tâm thần bao gồm trầm cảm chưa?
• 1) Có 2) Không
• 2. Thành viên gia đình của chị đã bao giờ được chẩn đoán mắc bệnh trầm cảm không?
• 1) Có 2) Không
• C. Edinburgh Postnatal Depression Scale (EPDS) (English version)
• As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.
• 1. I have been able to laugh and see the funny side of things.
• a) As much as I always could
• b) Not quite so much now
• c) Definitely not so much now
• d) Not at all
• 2. I have looked forward with enjoyment to things.
• a) As much as I ever did
• b) Rather less than I used to
• c) Definitely less than I used to
• d) Hardly at all
• 3. I have blamed myself unnecessarily when things went wrong.
• a) Yes, most of the time
• b) Yes, some of the time
• c) Not very often
• d) No, never
• 4. I have been anxious or worried for no good reason.
• a) No, not at all
• b) Hardly ever
• c) Yes, sometimes
• d) Yes, very often
• 5. I have felt scared or panicky for not a very good reason.
• a) Yes, quite a lot
• b) Yes, sometimes
• c) No, not much
• d) No, not at all
• 6. Things have been getting on top of me.
• a) Yes, most of the time I haven't been able to cope at al
• b) Yes, sometimes I haven't been coping as well as usual
• c) No, most of the time I have coped quite well
• d) No, I have been coping as well as ever
• 7. I have been so unhappy that I have had difficulty sleeping.
• a) Yes, most of the time
• b) Yes, sometimes
• c) Not very often
• d) No, not at all
• 8. I have felt sad or miserable.
• a) Yes, most of the time
• b) Yes, quite often
• c) Not very often
• d) No, not at all
• 9. I have been so unhappy that I have been crying.
• a) Yes, most of the time
• b) Yes, quite often
• c) Only occasionally
• d) No, never
• 10. The thought of harming myself has occurred to me.
• a) Yes, quite often
• b) Sometimes
• c) Hardly ever
• d) Never
• D. Edinburgh Postnatal Depression Scale (Vietnamese version)
• Thang Cấp Trầm Cảm Hậu Sản Edinburgh
• Vì bà vừa sinh con nên chúng tôi muốn biết bà cảm thấy thế nào. Xin đánh dấu vào câu trả lời phù hợp nhất với cảm giác của bà trong 7 ngày qua chứ không phải chỉ cảm giác của bà trong ngày hôm nay. Trong thí dụ dưới đây, “X” có nghĩa là “Tôi hầu như lúc nào cũng cảm thấy vui vẻ trong suốt tuần qua.”
• Xin trả lời các câu hỏi sau đây theo cách trên.
• Trong 7 ngày qua:
• 1. Tôi có thể cười và thấy được khía cạnh khôi hài của sự việc
• ____ Vẫn như trước
• ____ Ít hơn
• ____ Chắc chắn là ít hơn
• ____ Không bao giờ
• 2. Tôi đã hân hoan đón nhận mọi việc
• ____ Vẫn như trước
• ____ Ít hơn trước
• ____ Chắc chắn là ít hơn trước
• ____ Gần như là không có
• 3. Tôi đã tự đổ lỗi cho mình khi chuyện xảy ra không như ý mà lẽ ra thì không nên thế
• ____ Có, rất thường xuyên
• ____ Có, thỉnh thoảng
• ____ Không thường lắm
• ____ Không, không bao giờ
• 4. Tôi đã lo âu hoặc lo ngại một cách vô lý
• ____ Không, không bao giờ
• ____ Hầu như không bao giờ
• ____ Có, đôi khi
• ____ Có, rất thường
• 5. Tôi đã cảm thấy sợ hãi hoặc hốt hoảng một cách vô lý
• ____ Có, khá nhiều
• ____ Có, đôi khi
• ____ Không, không nhiều
• ____ Không, không bao giờ
• 6. Mọi việc đã trở nên quá sức chịu đựng của tôi
• ____ Có, tôi hầu như không đối phó nổi
• ____ Có, đôi khi tôi không thể đối phó được hiệu quả như mọi khi
• ____ Không, tôi hầu như đã đối phó được khá hiệu quả
• ____ Không, tôi vẫn đối phó hiệu quả như mọi khi
• 7. Tôi đã buồn bực đến mức bị khó ngủ
• ____ Có, hầu như lúc nào cũng vậy
• ____ Có, đôi khi
• ____ Không thường lắm
• ____ Không, không bao giờ
• 8. Tôi đã cảm thấy buồn hoặc khổ sở
• ____ Có, hầu như lúc nào cũng vậy
• ____ Có, khá thường
• ____ Không thường lắm
• ____ Không, không bao giờ
• 9. Tôi đã buồn bực đến mức phải khóc
• ____ Có, hầu như lúc nào cũng vậy
• ____ Có, khá thường
• ____ Chỉ thỉnh thoảng
• ____ Không, không bao giờ
• 10. Tôi đã từng nghĩ đến chuyện tự hại bản thân
• ____ Có, khá thường
• ____ Thỉnh thoảng
• ____ Hầu như không bao giờ
• ____ Không bao giờ
• E. PERCEIVED SELF-EFFICACY SCALE (PSES) (English version)
• The following statements describe what some postpartum mothers believe about their abilities to take care of their infants. After reading each statement, please circle the number that you feel most closely describes how you feel about yourself in relation to parenting. These are a statement about beliefs, so there are not right or wrong answers.
• 1. I can be able to manage the feeding of my baby.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 2. I can be able to manage the responsibility of my baby.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 3. I can always be able to tell when my baby is hungry.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 4. I can be able to deal effectively with the baby when he/she cries for “no reason”
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 5. I can be able to tell when my baby is sick.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 6. I can be able to tell when to add different food items to my baby’s diet.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 7. I can be able to manage my household as well as before while caring for the baby.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 8. When I think the baby is sick, I can be able to take his/her temperature accurately.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 9. I can be able to give my baby a bath without him/her getting cold or upset.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 10. I can work without my concerns about working or not working once the baby arrives.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 11. I can be able to keep my baby from crying.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 12. I can be able to maintain my relationship with my husband during this year.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 13. I can be able to meet all the demands placed on me once the baby here.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 14. I can easily be able to get the baby and myself out for a visit to Early Childhood Health Centre.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 15. I can have good judgment in deciding how to care for the baby.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 16. I can be able to make the right decisions for my baby.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 17. I can be able to get the baby on a good night-time routine.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 18. I can be able to give the baby the attention he/she needs.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 19. I can be able to hire a baby sitter when I need one.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 20. I can be able to tell what my baby likes and dislikes.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 21. I can be able to sense my baby’s mood.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 22. I can be able to show my love for my baby.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 23. I can be able to calm my baby when he/she is upset.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 24. I can be able to support my baby during stressful times.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• 25. I can be able to stimulate my baby by playing with him/her.
• Cannot
• do Moderately
• certain can do certain
• can do
• 0 1 2 3 4 5 6 7 8 9 10
• F. PERCEIVED SELF-EFFICACY SCALE (PSES) (Vietnamese version)
• THANG ĐO CẢM NHẬN VỀ KHẢ NĂNG TỰ LÀM ĐƯỢC
• Các phát ngôn sau mô tả điều mà các bà mẹ sau sinh tin về khả năng chăm sóc con của họ. Sau khi đọc mỗi phát ngôn sau, vui lòng khoanh tròn số mà chị cảm thấy mô tả đúng nhất cảm giác về bản thân khi làm mẹ. Những phát ngôn này thiên về lòng tin, vì vậy không có câu trả lời đúng hoặc sai.
• 1. Tôi có thể cho con tôi ăn.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 2. Tôi có thể chịu trách nhiệm về con tôi.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 3. Tôi có thể luôn có thể biết được khi nào con tôi đói.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 4. Tôi có thể xử lý hiệu quả khi con tôi “bỗng nhiên” khóc.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 5. Tôi có thể biết được khi nào con tôi đau.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 6. Tôi có thể biết được khi nào cần thêm thức ăn khác vào chế độ ăn của con tôi.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 7. Tôi có thể quản lý gia đình tôi tốt như trước đây trong lúc chăm sóc con tôi.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 8. Khi tôi cảm nhận con tôi đau, tôi có thể đo nhiệt độ cho bé một cách chính xác.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 9. Tôi có thể tắm cho con tôi mà không để con lạnh hoặc khó chịu.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 10. Tôi có thể làm việc mà không quan tâm sẽ làm việc hay không làm việc nữa khi sinh con ra.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 11. Tôi có thể giữ cho con tôi không khóc.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 12. Tôi có thể duy trì mối quan hệ với chồng tôi trong năm này.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 13. Tôi có thể đáp ứng tất cả yêu cầu đặt ra cho tôi khi tôi có con.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 14. Tôi có thể đưa con tôi đến Trung tâm Sức khỏe Trẻ nhỏ một cách dễ dàng.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 15. Tôi có thể nhận định sáng suốt trong việc quyết định cách chăm sóc con.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 16. Tôi có thể đưa ra quyết định đúng đắn cho con tôi.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 17. Tôi có thể tập cho con thói quen đi ngủ đúng giờ vào buổi tối.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 18. Tôi có thể quan tâm trẻ khi trẻ cần.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 19. Tôi có thể thuê người giữ trẻ khi tôi cần.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 20. Tôi có thể biết con tôi thích gì hoặc không thích gì.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 21. Tôi có thể cảm nhận được tâm trạng của con tôi.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 22. Tôi có thể biểu hiện tình yêu thương của mình dành cho con.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 23. Tôi có thể làm cho con tôi bình tĩnh khi con khó chịu.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 24. Tôi có thể hỗ trợ con tôi trong những lúc căng thẳng.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• 25. Tôi có thể khơi dậy sự hào hứng của con tôi bằng cách chơi với con.
• Không thể
• làm được Có thể làm được Chắc chắn có thể làm được
• 0 1 2 3 4 5 6 7 8 9 10
• G. MATERNITY SOCIAL SUPPORT SCALE (MSSS) (English version)
• Now I will read the statements about perceived support from family, from friends and from a significant other. As I read each statement, please tell me how you feel about the support you have right now.
• H. MATERNITY SOCIAL SUPPORT SCALE (Vietnamese version)
• THANG ĐO VỀ MỨC ĐỘ HỖ TRỢ THAI PHỤ VỀ MẶT XÃ HỘI
• Bây giờ tôi sẽ đọc những phát ngôn sau về hỗ trợ từ gia đình, bạn bè và những người quan trọng khác. Khi tôi đọc từng câu, chị vui lòng cho biết hiện tại chị cảm thấy chị được hỗ trợ như thế nào.
• Phát ngôn Luôn luôn Phần lớn thời gian Đôi khi Hiếm khi Không bao giờ
• Tôi có những người bạn tốt luôn giúp đỡ tôi
• 5
• 4
• 3
• 2
• 1
• Gia đình tôi luôn ủng hộ tôi 5 4 3 2 1
• Chồng tôi giúp đỡ tôi rất nhiều 5 4 3 2 1
• Tôi có mâu thuẫn với chồng tôi 1 2 3 4 5
• Tôi cảm thấy bị chồng kiểm soát 1 2 3 4 5
• Tôi cảm thấy được chồng tôi yêu thương 5 4 3 2 1
• I. DIFFICULT INFANTS TEMPERAMENT (English version)
• In the statements below, indicate how certain you are about the perception of their infant's characteristics and behaviors. Please choose by a tick mark (√) only one for each item that you think about your infant's characteristics and behaviors. The meaning of your choice is as follows:
• 1 = Almost never 4 = Nearly always
• 2 = Never 5 = Always
• 3 = Nearly never to always 6 = Almost always
• Statements 1 2 3 4 5 6
• Has your baby been having feeding problems? 1 2 3 4 5 6
• Has your baby been having sleeping problems? 1 2 3 4 5 6
• Has your baby been giving you bad nights? 1 2 3 4 5 6
• Has your baby been difficult to raise? 1 2 3 4 5 6
• Does your baby have difficulties falling asleep at bedtime? 1 2 3 4 5 6
• Is your baby irritable or fussy? 1 2 3 4 5 6
• Does your baby cries excessively? 1 2 3 4 5 6
• Is your baby difficult to comfort or calm down? 1 2 3 4 5 6
• I. DIFFICULT INFANTS TEMPERAMENT (Vietnamese version)
• TRẺ SƠ SINH CÓ TÍNH KHÍ KHÓ CHỊU
• Đối với các câu hỏi dưới đây, chị vui lòng cho biết mức độ chắc chắn của chị về sự cảm nhận tính cách và hành vi của con chị ở độ tuổi sơ sinh. Vui lòng chỉ đánh dấu  vào một phương án nói về tính cách và hành vi của con chị ở độ tuổi này. Các phương án có ý nghĩa như sau:
• 1 = Hầu như không bao giờ
• 2 = Không bao giờ
• 3 = Gần như không bao giờ cho đến mức Luôn luôn
• 4 = Gần như luôn luôn
• 5 = Luôn luôn
• 6 = Mọi lúc
• Câu hỏi 1 2 3 4 5 6
• Con chị có gặp vấn đề về ăn uống không? 1 2 3 4 5 6
• Con chị có gặp vấn đề về ngủ không? 1 2 3 4 5 6
• Con chị có làm chị có những đêm mệt mỏi không? 1 2 3 4 5 6
• Con chị có khó nuôi không? 1 2 3 4 5 6
• Con chị có khó ngủ lúc vào giờ đi ngủ hay không? 1 2 3 4 5 6
• Con chị có cáu kỉnh hay la om sòm không? 1 2 3 4 5 6
• Con chị có khóc quá to không? 1 2 3 4 5 6
• Con chị có khó an ủi hay khó dỗ dành không? 1 2 3 4 5 6
• K. MATERNAL ROLE STRAIN (English version)
• In the statements below, indicate how certain you are about your experience from caring for a child. Please choose by a tick mark (√) only one for each item that you think about your feeling. The meaning of your choice is as follows:
• 1 = Not at all 2 = Rarely
• 3 = Sometime 4 = Always
• Statements 1 2 3 4
• 1. The economic burden has increased 1 2 3 4
• 2. I feel emotional and feel anxious. 1 2 3 4
• 3. I am tired and physically exhausted because of many things. 1 2 3 4
• 4. The future plan that we had before birth was changed. 1 2 3 4
• 5. The housekeeping is not as clean as before. 1 2 3 4
• 6. I get interference from the parents in law about baby care. 1 2 3 4
• 7. Less contact with people. 1 2 3 4
• 8. I am dissatisfied with my appearance change. 1 2 3 4
• 9. I do not give enough care and affection to my husband. 1 2 3 4
• 10. I can not eat in moderation because of my baby. 1 2 3 4
• 11. My personal life has been reduced. 1 2 3 4
• 12. My husband shows too much interest only to the baby. 1 2 3 4
• 13. Sometimes I want to get rid of the responsibility to raise the baby. 1 2 3 4
• 14. I can not sleep at night because of my baby. 1 2 3 4
• 15. I do not know what to do for baby development. 1 2 3 4
• 16. I am worried whether I am a good parent. 1 2 3 4
• 17. I am worried about more the responsibility for the baby. 1 2 3 4
• 18. Everyday regular activities at home are interrupted. 1 2 3 4
• 19. It takes too much time and effort to care for a baby. 1 2 3 4
• 20. Baby is young and can not go out 1 2 3 4
• L. MATERNAL ROLE STRAIN (Vietnamese version)
• SỰ CĂNG THẲNG TRONG VAI TRÒ LÀM MẸ
• Trong những phát ngôn dưới đây, chị vui lòng cho biết mức độ chắc chắn của chị về trải nghiệm từ việc chăm sóc con cái như thế nào. Vui lòng chỉ đánh dấu  vào một phương án mô tả cảm nhận của chị.
• Các phương án có ý nghĩa như sau:
• 1 = Không có 2 = Hiếm khi
• 3 = Thỉnh thoảng 4 = Luôn luôn
• Phát ngôn 1 2 3 4
• 1. Gánh nặng kinh tế gia tăng. 1 2 3 4
• 2. Tôi cảm thấy xúc động và lo lắng. 1 2 3 4
• 3. Tôi cảm thấy mệt và kiệt sức về mặt thể chất vì nhiều vấn đề. 1 2 3 4
• 4. Kế hoạch tương lai của chúng tôi trước khi sinh con đã thay đổi. 1 2 3 4
• 5. Nhà cửa không còn sạch sẽ như trước. 1 2 3 4
• 6. Tôi bị ba mẹ chồng can thiệp về việc chăm sóc con cái. 1 2 3 4
• 7. Ít giao tiếp với mọi người. 1 2 3 4
• 8. Tôi không hài lòng với thay đổi ngoại hình của tôi. 1 2 3 4
• 9. Tôi không chăm sóc và yêu thương chồng đủ. 1 2 3 4
• 10. Tôi không thể ăn uống điều độ vì bận chăm sóc con. 1 2 3 4
• 11. Đời sống riêng tư của tôi giảm sút. 1 2 3 4
• 12. Chồng tôi dành quá nhiều quan tâm cho con. 1 2 3 4
• 13. Thỉnh thoảng tôi muốn bỏ hết trách nhiệm để nuôi con. 1 2 3 4
• 14. Tôi không thể ngủ vào ban đêm vì con tôi. 1 2 3 4
• 15. Tôi không biết làm gì để con tôi phát triển. 1 2 3 4
• 16. Tôi lo lắng không biết tôi có phải là người mẹ tốt hay không. 1 2 3 4
• 17. Tôi lo lắng về trách nhiệm đối với con tôi. 1 2 3 4
• 18. Các hoạt động thường nhật trong gia đình bị ngắt quãng. 1 2 3 4
• 19. Việc chăm sóc con tốn quá nhiều thời gian và công sức. 1 2 3 4
• 20. Con còn nhỏ và tôi không thể ra ngoài. 1 2 3 4
• Appendix 7: Community health centers in Hue
• ①Phu Nhuan community health center, 158 Nguyen Hue Street, Phu Nhuan Ward, Hue city, Thua Thien Hue province, Vietnam.
• ②Phu Hoi community health center, 03 Ton Duc Thang Street, Phu Hoi Ward, Hue city, Thua Thien Hue province, Vietnam.
• ③An Dong community health center, 73 Dang Van Ngu Street, An Dong Ward, Hue city, Thua Thien Hue province, Vietnam.
• ④Xuan Phu community health center, 123 Nguyen Lo Trach Street, An Dong Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⓹ Vinh Ninh community health center, 89 Phan Dinh Phung Street, Vinh Ninh Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⑥An Cuu community health center, 314 Phan Chu Trinh, An Cuu Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⑦Thuan Thanh community health center, 22 Dang Thai Than Street, Thuan Thanh Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⑧Thuan Loc community health center, 21 Truong Han Sieu Street, Thuan Loc Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⑨Thuan Hoa community health center, 155 Nguyen Trai Street, Thuan Hoa Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⑩Tay Loc community health center, 5 Thai Phien Street, Tay Loc Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⑪Phu Thuan community health center, 93 Tang Bat Ho Street, Phu Thuan Ward, Hue city, Thua Thien Hue province, Vietnam.
• ⑫Phu Hoa community health center, 98 Phan Dang Luu Street, Phu Hoa Ward, Hue city, Thua Thien Hue province, Vietnam.