Journal of Affective Disorders 108 (2008) 147 – 157

www.elsevier.com/locate/jad

Research report
Antenatal risk factors for postnatal depression:
A large prospective study
Jeannette Milgrom a,b,⁎, Alan W. Gemmill b , Justin L. Bilszta c , Barbara Hayes d ,
Bryanne Barnett e , Janette Brooks f , Jennifer Ericksen b , David Ellwood g , Anne Buist h
a
Department of Psychology, School of Behavioural Science, University of Melbourne, Victoria, Australia
b
Parent–Infant Research Institute, Department of Clinical & Health Psychology, Austin Health, Victoria, Australia
c
Department of Psychiatry, University of Melbourne and Austin Health, Victoria, Australia
d
School of Nursing, Midwifery and Nutrition, James Cook University, Townsville, Australia
e
School of Psychiatry, University of New South Wales and Sydney South West Area Health Service, New South Wales, Australia
f
School of Psychology, Edith Cowan University and State Perinatal Mental Health Unit, Western Australia
g
Australian National University Medical School, Australian Capital Territory, Australia
h
Austin Health & Northpark Hospital, Victoria, Australia
Received 7 June 2007; received in revised form 11 October 2007; accepted 11 October 2007
Available online 18 December 2007

Abstract

Background: This study measured antenatal risk factors for postnatal depression in the Australian population, both singly and in
combination. Risk factor data were gathered antenatally and depressive symptoms measured via the beyondblue National Postnatal
Depression Program, a large prospective cohort study into perinatal mental health, conducted in all six states of Australia, and in
the Australian Capital Territory, between 2002 and 2005.
Methods: Pregnant women were screened for symptoms of postnatal depression at antenatal clinics in maternity services around
Australia using the Edinburgh Postnatal Depression Scale (EPDS) and a psychosocial risk factor questionnaire that covered key
demographic and psychosocial information.
Results: From a total of 40,333 participants, we collected antenatal EPDS data from 35,374 women and 3144 of these had a score N 12
(8.9%). Subsequently, efforts were made to follow-up 22,968 women with a postnatal EPDS. Of 12,361 women who completed
postnatal EPDS forms, 925 (7.5%) had an EPDS score N12. Antenatal depression together with a prior history of depression and a low
level of partner support were the strongest independent antenatal predictors of a postnatal EPDS score N 12.
Limitations: The two main limitations of the study were the use of the EPDS (a self-report screening tool) as the measure of depressive
symptoms rather than a clinical diagnosis, and the rate of attrition between antenatal screening and the collection of postnatal follow-up data.
Conclusions: Antenatal depressive symptoms appear to be as common as postnatal depressive symptoms. Previous depression,
current depression/anxiety, and low partner support are found to be key antenatal risk factors for postnatal depression in this large
prospective cohort, consistent with existing meta-analytic surveys. Current depression/anxiety (and to some extent social support)
may be amenable to change and can therefore be targeted for intervention.
Crown Copyright © 2007 Published by Elsevier B.V. All rights reserved.

Keywords: Postnatal depression; Antenatal risk factors; Anxiety

⁎ Corresponding author. 300 Waterdale Road, PO Box 5444, Heidelberg West, Victoria 3081, Australia. Tel.: +61 3 9496 4496; fax: +61 3 9496 4148.
E-mail addresses: jeannette.milgrom@austin.org.au, barbara.frazer@austin.org.au (J. Milgrom).

0165-0327/$ - see front matter. Crown Copyright © 2007 Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2007.10.014
148 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157
1. Introduction
There is now a considerable literature on risk factors
for both antenatal and postnatal depression and an
extensive list of variables significantly associated with
postnatal depressive symptoms (Roberston et al., 2004).
These encompass a wide range of socio-demographic,
psychiatric, biological, medical and personal factors
which are thoroughly reviewed by Pope (2000). There
have been several meta-analyses and systematic reviews
of the subject (Beck, 1996; O'Hara and Swain, 1996;
Beck, 2001; Roberston et al., 2004) and, briefly, the
main variables of interest can be summarised as follows:
1.1. Demographic and socio-economic factors
Maternal age (both younger and older) has been
associated with postnatal depressive symptoms (Pope,
2000; Rubertsson et al., 2003). Lower socio-economic
status tends to raise the risk (e.g. Patel et al., 2002) as
does lower educational attainment (e.g. Tammentie et al.,
2002).
1.2. Psychological and psychiatric factors
Both a familial and personal history of depression are
consistently reported risk factors (O'Hara and Swain, 1996;
Pope, 2000; Johnstone et al., 2000) as are depression and
anxiety in pregnancy (Barnett and Parker, 1986; Bergant
et al., 1999; Beck, 2001; Matthey et al., 2003; Heron et al.,
2004).
Personality and psychological factors including neu-
roticism, introversion (Verkerk et al., 2005) perfection-
ism (Dimitrovsky et al., 2002) dysfunctional cognitive
style, high interpersonal sensitivity (Boyce et al., 1991),
attributional style (Cutrona, 1983; Demyttenaere et al.,
1995; Milgrom and Beatrice, 2003; Faisal-Cury et al.,
2004) and low self-esteem (Ritter et al., 2000) have been
associated with postnatal depression, as have traumatic
experiences such as abuse (Buist, 1998).
1.3. Stressful life events
High scores on “current life events” scales are asso-
ciated with postnatal depression (Eberhard-Gran et al.,
2002; Dennis et al., 2004) and may interact with vul-
nerability factors (O'Hara et al., 1991). Important
stressors include negative life events and stressful events
associated with pregnancy and childbirth (Eberhard-Gran
et al., 2002). Two or more stressful life events in the year
prior to pregnancy predict depression in early pregnancy
and the postpartum (Rubertsson et al., 2005).
1.4. Social support
Low levels of both antenatal and postnatal social
support are significant risk factors (Brugha et al., 1998;
Honey et al., 2003a). Of particular relevance are partner
support, availability of people to depend on during
pregnancy and the early postpartum, and a woman's
relationships with her own parents (Pope, 2000), but not
necessarily the absolute size of her social network
(Brugha et al., 1998).
1.5. Obstetric and biological factors
History of miscarriage and pregnancy termination are
associated with postnatal depression (e.g. Pope, 2000;
Roberston et al., 2004). Studies of other obstetric factors
have shown mixed results (Johnstone et al., 2000). Various
biophysical and hormonal correlates are also known (e.g.
Harris et al., 1996; Ingram et al., 2003; Glover and
Kammerer, 2004).
Based on such risk factors there have been various
attempts to construct and validate “predictive” indices
capable of forecasting the development of postnatal
depression in advance (e.g. Braverman and Roux, 1978;
Cooper et al., 1996; Posner et al., 1997; Beck, 2002;
Honey et al., 2003b; Austin et al., 2005; Webster et al.,
2006). In general, such antenatal instruments have not
been developed using diagnostic criteria for depression
and have limited positive predictive value for future
postnatal depression (most were reviewed by Austin and
Lumley, 2003). However, three existing meta-analytic
studies yield a core list of six risk factors for postnatal
depression which exert substantial effects and are
readily measurable, namely antenatal depression,
antenatal anxiety, major life events, low social support
levels, depression history and low self-esteem (Beck,
1996; O'Hara and Swain, 1996; Beck, 2001). Some of
these risk factors (particularly antenatal depression and
anxiety) are amenable to intervention in their own right,
irrespective of future depression.
One aim of the beyondblue National Postnatal Depres-
sion Program was to collect such information prospectively
from a large and representative sample of the Australian
antenatal population. We measured both the occurrence
and strength of association with postnatal depression of an
array of demographic and psychosocial variables, includ-
ing most of these six key risk factors. The data generated
are presented in the final report of this public health
initiative, available at http://beyondblue.org.au. Elsewhere
(Buist et al., 2008) we give a detailed breakdown of the
prevalence of postnatal depressive symptomatology across
Australia, which is consistent with existing Australian data
 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157
(from 7–15% e.g. Boyce, 2003; Austin et al., 2005;
Milgrom et al., 2005) and with international research
(Gavin et al., 2005). Here, we focus on examining the
relative importance of the key antenatal risk factors
identified by screening a large primary care cohort.
2. Methods
2.1. Recruitment and screening
Recruitment and screening were conducted by mid-
wives during routine visits to maternity hospital
antenatal clinics throughout every state of Australia
and in the Australian Capital Territory (ACT). Ethics
approval was obtained on a hospital-by-hospital basis.
Pregnant women were given a Plain Language State-
ment and the purpose of the Program was explained
verbally. All participants gave written, informed con-
sent. The only specific inclusion criterion was a basic
ability to read and understand written English. There
were no exclusion criteria. At the same visit women
received a resource booklet “Emotional Health During
Pregnancy and Early Parenthood” and had the oppor-
tunity to discuss the screening result with their midwife.
Women with elevated EPDS scores, women who ac-
knowledged thoughts of self-harm, and any women
about whom midwives had concerns, were encouraged
and assisted to access appropriate referral pathways.
2.2. Data collection tools
Participants answered questions designed to elicit
psychosocial, mood and demographic data. A 33-item,
self-report psychosocial risk factor questionnaire
(PSRFQ) included questions on both demographic and
psychosocial variables. The content of the PSRFQ was
decided by consensus among the authors after review
and discussion of the literature and includes some items
derived from the Pregnancy Risk Questionnaire (Austin
et al., 2005). Areas covered included: age, country of
birth, main language spoken, family income, occupa-
tion, level of education, previous psychiatric conditions,
current emotional/psychological difficulties, major life
events in the past year, availability of emotional/prac-
tical supports, level of daily hassles, relationship with
mother and partner, and past history of abuse (sexual,
physical and emotional). Some questions were phrased
to elicit categorical responses e.g. Question 22 asked
“Have you ever been diagnosed with one of the fol-
lowing psychiatric or psychological conditions?” Pos-
sible responses were None, Minor Depression, Major
Depression, Anxiety, Other. Responses to other ques-
149
tions were either arranged on Likert-type scales or were
binary, e.g. Question 29(g) asked “In general, would
you say that you usually want everything to be just right
or perfect?” with possible responses Yes or No.
Participants also completed the Edinburgh Postnatal
Depression Scale (EPDS: Cox et al., 1987). This self-
rated instrument comprises 10 statements relating to
symptoms of depression and anxiety with four possible
responses for each. The EPDS was developed specifically
to screen for symptoms of postnatal depression: it cannot
provide a diagnosis. It has been validated for antenatal use
and in many languages, is in widespread use internation-
ally (Cox and Holden, 2003) and is deliberately brief,
simple and nonreliant on somatic symptoms. The EPDS
has good acceptability among both depressed and
nondepressed women (Gemmill et al., 2006). For a cut-
off score of N 12 a recent Australian study found 85% and
71% sensitivity and specificity respectively and 82%
overall accuracy for identifying major and minor depres-
sion in the postnatal period (Milgrom et al., 2005). As
pointed out previously (Milgrom et al., 2005) such test
performance statistics will vary between populations and
must be interpreted carefully.
In services where screening/assessment protocols
were already established and could not be altered (e.g. in
New South Wales as part of the Integrated Perinatal Care
program) some data (such as EPDS, education and
income) were not always obtained.
2.3. Postnatal follow-up
Women were asked to complete a second EPDS as
close as possible to the 6th week postpartum. This
postnatal follow-up was largely achieved via postal return
of questionnaires collated into standard hospital discharge
paperwork and/or child health records. A system of follow-
up reminders was implemented to maximize returns. In
some sites, mostly in Western Australia (WA) a follow-up
EPDS was completed at postnatal visits with Maternal and
Child Health Nurses. In South Australia (SA) research
midwives collected both antenatal and postnatal data. In
New South Wales (NSW) some 17,365 of the women
surveyed in pregnancy were not available for follow-up in
the postnatal period (existing procedures could not be
changed). Thus, a total of 22, 968 women were available
for postnatal follow-up. Fig. 1 gives an overview of the
numbers of PSRFQ and EPDS records collected.
2.4. Statistical analysis
There were two aims of the analysis. First, to generate
univariate odds ratios (ORs) associated with potential
150 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157

Fig. 1. Overview of data collected. ⁎Psychosocial data were collected from 40,333 participants. At some sites with existing screening practices,
psychosocial data were collected but no antenatal EPDS record was obtainable. Similarly, at some sites where antenatal psychosocial and/or EPDS
data were collected, no postnatal follow-up was feasible.

antenatal risk factors for postnatal depressive symptoms
(EPDS score N 12). Second, to arrive at a simple, robust
model for describing these data via multivariate logistic
regression analysis: we did not attempt to develop an
antenatal predictive tool with which to forecast the future
onset of postnatal depression.
Computations were executed in SPSS 14 and in SAS.
3. Results
Forty thousand, three hundred and thirty three
(40,333) pregnant women were recruited across
Australia (Fig. 1). Of these, an antenatal EPDS was
recorded for 35,374 (87.7%) and 3144 had scores N12
(8.9%). The largest number of women was from NSW
(21,285) reflecting both the largest state population in
Australia and the antenatal procedures already
established when the program began. Antenatal
screening was also well established in WA (4840).
Elsewhere, we successfully introduced screening de
novo resulting in the recruitment of large numbers in
Victoria (5079), Queensland (4041) and SA (3355).
Smaller numbers were recruited from the ACT (984)
and Tasmania (749), the territory and state with the
smallest populations.
A detailed overview of the national demographic
data is available at http://beyondblue.org.au/postnatal-
depression. The sample appeared reasonably represen-
tative of the Australian childbearing population.
Briefly, 74% of women were Australian-born, similar
to the 2004 national average of 76.9% (Laws et al.,
2006). The largest non-Australian-born groups were
those from Asia (8%) and New Zealand/Oceania (5%).
The study sample included 611 women (1.7%) from
Australia's Aboriginal and Torres Strait Islander
peoples. The mean age of pregnant women was
30.3 years (SD = 5.6) close to the 2004 national ave-
rage of 29.7 (Laws et al., 2006). The mean stage of
pregnancy was 25.1 weeks (SD = 9.0) with a mean of
2.5 pregnancies and 1.1 children. Eighty six percent of
women had six years of secondary education, and
22.4% had Bachelor degrees or higher. The sample was
predominantly public sector, with 1114 women from
private hospitals and 255 at a birth centre, representing
only 3% of the total sample, compared to 31% of
women who birthed privately in Australia in 2004
(Laws et al., 2006). Women from rural, regional and
remote centres numbered 2517 (6.5%).
Of the 35,374 women who completed an antenatal
EPDS, only 22,968 were available for postnatal follow-up
 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157 151

Table 1
Demographic antenatal risk factors
Variable Responses (N) a EPDS N 12 b OR (95% CIs) p-value
Age (years) 12,034
b21 40/257 2.71 (1.89–3.88) b.001
21–25 164/1642 1.63 (1.33–1.99) b.001
26–30 233/2316 1.11 (.93–1.33 .26
31–35 270/4237 1 –
36–40 146/2032 1.14 (.92–1.40) .23
N40 47/550 1.37 (.99–1.90) .06
Indigenous Australians 12,361
Nonindigenous 897/12,139 1 –
Indigenous 28/222 1.81 (1.21–2.70) b.01
Country of birth 10,907
Australia 633/8591 1 –
Elsewhere 174/2316 1.02 (.85–1.22) .81
Main language spoken 11,920
English 854/11,402 1 –
Other 42/518 1.09 (.79–1.50) .60
Higher Education 9536
None 528/6243 1 –
Diploma or above 186/3293 .65 (.54–.77) b.001
Family income (AUS$) 8494
b$20,000 137/962 1 –
$20–60,000 337/4648 .47 (.38–.58) b.001
N$60,000 140/2884 .31 (.24–.39) b.001
Marital Status 11,970
Spouse/de facto 694/10,250 1 –
No spouse/de facto 203/1720 1.84 (1.56–2.17) b.001
Antenatal medical problems 10,370
No 419/4425 1 –
Yes 366/5945 1.59 (1.38–1.84) b.001
Home location 11,803
Urban 764/10,444 1 –
Rural 120/1359 1.23 (1.00–1.50) b.05
Number of children 10,458
0 301/4162 1 –
1 271/3991 .93 (.79–1.11) .44
2 124/1541 1.12 (.90–1.40) .30
N2 94/764 1.80 (1.41–2.30) b.001
Trimester of pregnancy 11,152
1 31/516 1 –
2 178/2189 .79 (.55–1.15) .23
3 629/8447 1.10 (.93–1.31) .28
Univariate odds ratios (ORs) with 95% confidence intervals (CIs) for demographic variables, in respect of elevated postnatal EPDS. All reference
categories have ORs = 1.
a
Number of postnatal EPDS scores for which responses to this question are available.
b
Number of cases in this category with an elevated postnatal EPDS / number of cases in this category.

(see Methods). Of these, 12,361 (53.8%) completed a
postnatal EPDS (Fig. 1) with 925 (7.5%) scoring N12.
This group of 12,361 women comprised: 4109 from WA;
3046 from Victoria; 2175 from SA; 1318 from NSW; 751
from Queensland; 520 from the ACT and 442 from
Tasmania. Postnatal response rates were very similar
irrespective of whether women had scored above or
below the EPDS cut-off at antenatal screening (Fig. 1).
3.1. Univariate regression models
The binary outcome was elevated postnatal EPDS
(Yes versus No) using a cut-off of N12. Logistic regres-
sion models were constructed for each explanatory
variable and univariate odds ratios (ORs) with 95% con-
fidence limits and p-values obtained (Tables 1 and 2). For
demographic variables in Table 1 some multiple-response
152 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157

Table 2
Psychosocial antenatal risk factors
Variable Responses (N) a EPDS N 12 b OR (95% CIs) p-value
Elevated antenatal EPDS 12,266
≤ 12 584/11,136 1 –
N12 332/1130 7.52 (6.45–8.76) b.001
History of abuse 10,777
No 530/9068 1 –
Yes 277/1709 3.12 (2.67–3.64) b.001
Major life events in past year 10,963
No 214/4967 1 –
Yes 608/6016 2.50 (2.13–2.93) b.001
Practical/emotional supports 10,144
Available 705/9880 1 –
None 45/264 2.67 (1.92–3.72) b.001
Perfectionism 10,445
Not perfectionist 266/5474 1 –
Perfectionist 498/4971 2.18 (1.87–2.54) b.001
Antenatal emotional problems 9544
None 285/7108 1 –
Antenatal anxiety 107/841 3.49 (2.76–4.41) b.001
Antenatal depression 110/596 5.42 (4.27–6.88) b.001
Antenatal depression with anxiety 113/391 9.73 (7.59–12.48) b.001
Antenatal eating disorder difficulty 6/39 4.35 (1.81–10.47) b.01
Accepting pregnancy 34/330 2.75 (1.89–4.00) b.001
Other (unspecified) 34/183 5.46 (3.69–8.08) b.001
Level of daily hassles 10,033
Moderate 340/3459 1 –
Low 255/5831 .42 (.35–.50) b.001
High 146/743 2.24 (1.81–2.76) b.001
Early-life emotional support from own mother 10,991
Moderate 157/1731 1 –
Low 213/1851 1.30 (1.05–.162) b.05
High 438/7409 .63 (.52–.76) b.001
Previous psychiatric conditions 9853
None 372/7538 1 _
History of minor depression 146/1021 3.21 (2.62–3.94) b.001
History of major depression 73/384 4.52 (3.43–5.96) b.001
History of anxiety 48/325 3.34 (2.41–4.61) b.001
History of depression with anxiety 90/373 6.13 (4.73–7.94) b.001
Other 32/212 3.42 (2.32–5.06) b.001
Univariate odds ratios (ORs) with 95% confidence intervals (CIs) for psychosocial variables in respect of elevated postnatal EPDS. All reference
categories have ORs = 1.
a
Number of postnatal EPDS scores for which responses to this question are available.
b
Number of cases in this category with an elevated postnatal EPDS / number of cases in this category.

options were reduced to binary or trinary codings to
obtain simple ORs.
Most variables showed statistically significant effects
in the directions expected from previous research and
from clinical experience. For example, among demo-
graphic factors, the socio-economic indicators of higher
income and better education were both associated with
lower odds of elevated postnatal EPDS scores, whilst
psychosocial variables such as low practical and emo-
tional supports, antenatal anxiety, and previous depres-
sion history were all associated with higher odds. Not
surprisingly, elevated antenatal EPDS (N 12) was itself a
strong predictor of an elevated postnatal EPDS. Women
without an elevated antenatal EPDS had just 18% of
the risk of women with an elevated antenatal EPDS
(Relative Risk = 0.18). Put another way, women with an
elevated antenatal EPDS were 5.6 times more likely to
have an elevated postnatal score.
3.2. Multivariate logistic regression model
There were 12,361 postnatal EPDS scores. To facilitate
modeling, the multiple-response variables antenatal emo-
tional problems and previous psychiatric conditions were
 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157
Table 3
Adjusted odds ratios (ORs) from the multiple logistic regression model
(N = 7797)
Risk factor OR (95% CIs)
Antenatal EPDS score 1.18 (1.15–1.21)
Previous psychiatric condition 1.70 (1.39–2.07)
Antenatal emotional problems 1.39 (1.12–1.73)
Level of daily hassle 1.17 (0.89–1.55)
High versus moderate
Minimal versus moderate 0.79 (0.64–0.97)
Perfectionism 1.26 (1.04–1.52)
Partner support
High versus moderate 0.68 (0.51–0.89)
Minimal versus moderate 0.99 (0.66–1.47)
No partner versus moderate 0.62 (0.34–1.12)
recoded in binary form. Sequential selection procedures
were used to arrive at a statistical best-fit regression model.
Backward elimination resulted in a model that retained
only antenatal EPDS, perfectionism and family income
(education, level of daily hassles and language spoken at
home were the last three terms to be removed). The
forward selection process yielded a model with antenatal
EPDS, language spoken at home, education, family
income and perfectionism. From clinical considerations
and from existing literature, antenatal EPDS, previous
psychiatric condition, antenatal emotional problems and
partner support were thought to be important. Therefore
the following terms were all fit: antenatal EPDS, antena-
tal emotional problems, previous psychiatric condition,
level of daily hassles, perfectionism, partner support,
education, family income and language spoken at home.
Only 6997 cases could be fit in this model (due to
missingness) and the area under the ROC curve was 0.805.
The model fit was maximized by omitting family income,
education and language spoken at home, which allowed
utilization of 7797 observations and gave an area under the
ROC curve of 0.810. Expressed in logits, the regression
equation is:
logitðelevated postnatal EPDSÞ
¼ 3:864 þ 0:166⁎antenatal EPDS
þ antenatal emotional problems
þ 0:530⁎previous psychiatric condition
þ 0:160⁎high hassles  0:238⁎no hassles
þ 0:230⁎perfectionism
þ 0:393⁎high partner support  0:477⁎no partner:
These parameter estimates correspond to the adjusted
ORs in Table 3, and represent the independent effects of
each explanatory variable when all others are controlled
for. The variables antenatal EPDS, previous psychiatric
condition and antenatal emotional problems had the
153
highest significance values, each increasing the odds of
an elevated postnatal EPDS. Similarly, perfectionism
exerted a significant effect. Whilst a high level of partner
p-value support had a significantly risk-reducing effect, there
b.0001 was no detectable shift in odds due to having minimal
b.0001 support or to having no partner (ORs not significantly
b.01
different from 1). Likewise, there was a risk-reducing
.26
effect of minimal levels of daily hassles but no detect-
b.05 able increase in odds due to high levels.
b.05
4. Discussion
b.01
.95
.11 This study provides a very large, cross-sectional
snapshot of the occurrence and relative importance of an
array of antenatal risk factors for postnatal depression in
a prospective community sample recruited in primary
care. Most of the core risk factors for postnatal depres-
sion identified in previous meta-analytic surveys exert
significant effects in this single, large cohort. Six of our
variables map directly (or very closely) to five items on
this core list (the same five identified as the strongest
risk factors by Roberston et al., 2004) namely: antenatal
depression, antenatal anxiety, major life events, practi-
cal/emotional support, partner support and previous
depression history — all six have substantial univariate
odds ratios associated with them.
Furthermore, the multivariate model confirms that most
of the core risk factors (or factors closely related to them)
are exerting strong, statistically independent effects on the
risk of developing symptoms of postnatal depression in the
Australian population. Specifically, antenatal EPDS score,
previous psychiatric condition, and antenatal emotional
problems exert the strongest effects and increase the odds
of postnatal depressive symptoms, independent of all other
factors. The core risk factors of depression history and
antenatal anxiety are closely reflected by our variables
previous psychiatric condition and antenatal emotional
problems respectively. A history of major/minor depression
and antenatal anxiety are the most important categories
encompassed by these two variables in terms of both
frequency and associated risk (Table 1). Similarly, adequate
levels of social support (as measured here by partner
support) showed a clear protective effect, lowering the
odds of an elevated postnatal EPDS score independent of
all other factors. The variable perfectionism was a
significant, independent risk factor and has been linked
with high maternal anxiety (Barnett and Parker, 1986).
Whilst self-esteem has been identified as a core risk factor
previously, it may also reflect broader characteristics such
as those associated with perfectionism (e.g. Church et al.,
2005). These could make some women uniquely vulner-
able to the often unremitting, inflexible and unpredictable
154 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157
stressors of parenthood (e.g. night time crying, unsettled
behaviour). Although we found a strong univariate
association of major life events with postnatal depressive
symptoms, this was not established as an independently
operating risk factor. Nevertheless, the significant effect of
level of daily hassles in the multivariate model indicates
that a nonstressful antenatal environment has some
protective role postnatally. This is distinct from the findings
of Da Costa et al. (2000) who found an association of
antenatal hassles only with antenatal depressive symptoms.
The sample came mostly from public hospitals.
Variation in socio-economic variables still had a detect-
able influence on the risk of depressive symptomatology.
The socio-economic indicator variables family income
and education were significantly associated with ele-
vated postnatal EPDS scores and their exclusion from
the final multivariate regression was partly to allow an
increased sample size. Our finding of elevated odds of
postnatal depressive symptoms among Australian indi-
genous women may mark the first published estimate of
this risk and seems consistent with the poorer overall
health profile of the Aboriginal and Torres Strait Islander
peoples, relative to the wider Australian population
(Australian Institute of Health and Welfare, 2006). The
possible resilience of women aged between 26 and
40 years (the majority in our sample) is interesting. We
find increased odds on either side of this category, so that
the profile of risk appears U-shaped with respect to
maternal age. Although the increase in odds for the 40-
plus age group is marginally insignificant, both younger
and older maternal age have been reported as risk factors
previously (references in Pope, 2000). The study has some
particular strengths. It is possibly the largest community-
wide, prospective risk factor study into perinatal depres-
sion yet conducted. Along with the relatively extensive list
of data collected, this has allowed robust, contempora-
neous estimates of multiple risk factors.
The main limitations of the study also reflect, to some
extent, its size and scope. First, because it is a screening tool
the EPDS has well known limitations (Cox and Holden,
2003) and can neither diagnose depression nor establish
prevalence accurately. For example, Eberhard-Gran et al.
(2001) provide a careful meta-analytical re-exploration of
the test performance of the EPDS. They show that many
published predictive value estimates are inflated, because
they are measured in higher prevalence populations.
However, the diagnostic interviewing of our entire cohort
was impractical to attempt. EPDS scores are used here, as
elsewhere (e.g. Evans et al., 2001) as a surrogate measure
of variation in postnatal depressive symptomatology. A
second limitation was that not all pregnant women
participated and not all were actively followed-up in the
postpartum. Consequently, just over half of those followed-
up responded (although response rate was similar between
those who scored above and below EPDS cut-off at
antenatal screening). Third, given the need to integrate a
single screening regimen across many time-pressured
antenatal health care settings, the psychosocial data
collection instruments themselves were limited.
Despite these limitations, the estimates of core risk
factors are both robust and consistent with existing re-
search. Indeed, that antenatal depression, antenatal anxi-
ety, a history of depression and poor partner support are
key risk factors for postnatal depressive symptomatology
is not new a information (O'Hara and Swain, 1996; Beck,
2001; Roberston et al., 2004). What is perhaps more
surprising, is that antenatal care practices in many
countries do not include routine investigation and man-
agement of current symptoms of emotional difficulty.
There may be many reasons for this, including a stronger
awareness of identifying and treating postnatal difficulties
(despite antenatal symptoms being at least as common:
Evans et al., 2001; Bennett et al., 2004; Gavin et al., 2005).
A related reason may be a perception that in the absence of
a reliable “predictive index” capable of forecasting the
onset of future postnatal depression, there is not enough to
be gained in investigating antenatal problems. Although
substantial questions relating to when and how to best
screen for, identify, treat or prevent perinatal depression
remain (Nylen et al., 2005) our results serve as a reminder
of several viable reasons that better identification of an-
tenatal emotional problems is particularly worthwhile.
First, antenatal depression and anxiety are debilitating and
distressing conditions and are therefore important to treat
in their own right. Second, there is substantial evidence
that antenatal emotional problems are associated with
obstetric complications including premature delivery
(Hedegaard et al., 1993; Copper et al., 1996; Dunkel-
Schetter, 1998; Chung et al., 2001; Dole et al., 2001) and
intra-uterine growth restriction (Wadhwa et al., 1993).
Antenatal stress and anxiety can also impact on foetal
neurodevelopment resulting in adverse cognitive and
behavioural outcomes (Lou et al., 1994; Glover and
O'Connor, 2002; O'Connor et al., 2002a,b; O'Connor
et al., 2003; Van den Bergh et al., 2005). It is currently an
open question whether treatment of antenatal depression
and anxiety can ameliorate such problems.
Finally, there may be some preventative benefit for
individual ‘high risk’ women and for symptomatic
women who are treated for antenatal anxiety and dep-
ression. For example, an existing meta-analysis of inter-
ventions to prevent postnatal depression (Dennis and
Creedy, 2004) found no detectable treatment effect
across 15 studies but illustrates that these approaches
 J. Milgrom et al. / Journal of Affective Disorders 108 (2008) 147–157
constitute a ‘mixed bag’ both in terms of the types of
interventions attempted (some involve very broad,
generalised supports/education) and in terms of the tar-
get populations (sometimes general antenatal popula-
tions). Interestingly, studies that targeted ‘high risk’
(nonsymptomatic) individuals yielded the most promis-
ing results and no such randomised controlled study has
yet assessed an indicated treatment approach in an
antenatal sample of symptomatic women. For such sub-
groups of pregnant women, the protective benefits of
active management of major risk factors such as levels of
social support and/or treatment for antenatal depression
and anxiety may be worth fuller exploration. Optimising
the identification of those individuals who might benefit
most will require ongoing knowledge of the relationships
between key risk factors in the relevant populations.
In conclusion, most of the core risk factors for post-
natal depression (antenatal depression, antenatal anxi-
ety, major life events, low social support levels and
depression history) are operating in this single, large,
prospective cohort. Currently, whilst postnatal depres-
sion can be neither reliably forecast nor prevented, some
form of antenatal screening/assessment focussed on
psychiatric history, current emotional problems and so-
cial supports is likely to benefit many pregnant women
in terms of their immediate and future well-being.
Role of funding source
Funding for this study was provided by beyondblue and beyond-
blue had an initial role in general study design but had no further role in
collection, analysis and interpretation of data; in writing the manuscript
and in the decision to submit the manuscript for publication.
Conflict of interest
No conflict declared.
Acknowledgement
The work was funded by a generous grant from
beyondblue and would not have been possible without
the involvement of the 40,333 women and all of the
midwives and other health professionals who took part
in the beyondblue National Postnatal Depression Pro-
gram. Our thanks go to all of the supporting organisa-
tions for providing time and resources for their staff to
screen women and to be involved in education and
training. The PSRFQ included questions derived from
an existing questionnaire (now published in Austin
et al., 2005) with the permission of its senior author
M. Austin. Bronwyn Leigh kindly shared results of a
literature review and had input to the first draft of the
introduction. Some of the statistics reported were gene-
rated by Statistical Revelations.
155
Sheryl Pope. Our co-researcher Sheryl Pope passed
away before this work was complete. At earlier stages, she
contributed much to this study, as well as to many others
during a fruitful career. At the final stage of this work
therefore, we wish to acknowledge Sheryl's enduring
contribution to perinatal mental health research.
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