DOI: 10.1111/j.1471-0528.2010.02660.

x
Epidemiology
www.bjog.org

Perinatal complications increase the risk of

postpartum depression. The Generation R Study
EA Blom,a,b PW Jansen,b FC Verhulst,b A Hofman,c H Raat,d VWV Jaddoe,a,e M Coolman,f
EAP Steegers,f H Tiemeierc,d
a
The Generation R Study Group b Department of Child and Adolescent Psychiatry c Department of Epidemiology d Department of Public
Health e Department of Paediatrics f Department of Obstetrics and Gynaecology, Division of Obstetrics and Perinatal Medicine, Erasmus MC
University Medical Center Rotterdam, Rotterdam, the Netherlands
Correspondence: Dr H Tiemeier, Department of Child & Adolescent Psychiatry, Erasmus MC – Sophia, PO Box 2060, 3000CB Rotterdam,
the Netherlands. Email h.tiemeier@erasmusmc.nl

Accepted 8 June 2010. Published Online 4 August 2010.

Objective To examine whether specific pregnancy and delivery
complications are risk factors for postpartum depression.
Design A prospective longitudinal study.
Setting Rotterdam, the Netherlands.
Population A cohort of 4941 pregnant women who enrolled in
the Generation R Study.
Methods Information on perinatal complications was obtained
from the midwife and hospital registries or by questionnaire.
Logistic regression analyses were used to calculate the risk of
postpartum depression for the separate perinatal complications.
Main outcome measures Postpartum psychiatric symptoms were
assessed 2 months after delivery using the Edinburgh postnatal
depression scale.
Results Several perinatal complications were significantly
associated with postpartum depression, namely: pre-eclampsia
(adjusted OR, aOR 2.58, 95% CI 1.30–5.14), hospitalization
during pregnancy (aOR 2.25, 95% CI 1.19–4.26), emergency
caesarean section (aOR 1.53, 95% CI 1.02–2.31), suspicion of fetal
distress (aOR 1.56, 95% CI 1.08–2.27), a medically indicated
delivery provided by an obstetrician (aOR 2.43, 95% CI 1.56–
3.78), and hospital admission of the baby (aOR 1.45, 95% CI
1.10–1.92). Unplanned pregnancy, thrombosis, meconium-stained
amniotic fluid, and Apgar score were not associated with
postpartum depression after adjustment for confounding factors,
such as pre-existing psychopathological symptoms and
sociodemographic characteristics. The risk of postpartum
depression increased with the number of perinatal complications
women experienced (P < 0.001).
Conclusions We showed that several pregnancy and delivery
complications present a risk for women’s mental health in the
postpartum period. Obstetricians, midwives, general practitioners,
and staff at baby well clinics should be aware that women who
experienced perinatal complications—especially those with a
number of perinatal complications—are at risk for developing
postpartum depression.
Keywords Complications, delivery, depression, postpartum, preg-
nancy, risk factors.

Please cite this paper as: Blom E, Jansen P, Verhulst F, Hofman A, Raat H, Jaddoe V, Coolman M, Steegers E, Tiemeier H. Perinatal complications increase
the risk of postpartum depression. The Generation R Study. BJOG 2010;117:1390–1398.

nise in postpartum women. If postpartum depression is left

Introduction
Many women experience depressive symptoms during the
postpartum period, ranging from mild complaints such as
‘maternity blues’ to clinically diagnosed postpartum depres-
sion. The prevalence of postpartum depression in the
general population is estimated at around 10%, with most
cases manifesting themselves in the first 3 months postpar-
tum.1,2 The diagnosis is, however, often missed by health-
care professionals3 because some symptoms of depression
according to the diagnostic criteria4 are difficult to recog-
untreated it can persist for months to years,1 and may
severely affect women’s health and psychosocial wellbe-
ing.5,6 In addition, there is ample evidence that postpartum
depression is associated with disturbances in the behavioural
and cognitive development of offspring.5,7,8
Previous research reported that low socio-economic
background, ethnic minority status, and a young age are
associated with a higher risk of postpartum depression.5,9–
13
Furthermore, various epidemiological studies identified
social and psychological risk factors, such as stress, marital

1390 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

conflict, maternal perfectionism, antenatal depression or
anxiety, and lack of social support.5,9,11,14,15 Although
numerous studies have described these sociodemographic
and psychosocial determinants, little research has investi-
gated whether complications during pregnancy or delivery
predict postpartum depression. Moreover, the few studies on
this topic reported contradicting results. Whereas some
studies found no perinatal risk factors for postpartum
depression,12,16–18 another study characterised obstetric com-
plications as modest but significant risk factors.13 The latter
study, however, examined a composite score of obstetric
complications, making it difficult to identify which specific
complications predict postpartum depression.
Within a large birth cohort study in the Netherlands we
studied a wide range of specific perinatal complications as
risk factors for postpartum depression. Several of these
complications are, to our knowledge, studied for the first
time.
Methods
Design and study population
This study was embedded in the Generation R Study, a
multi-ethnic population-based cohort from fetal life
onwards. It has previously been described in detail.19
Briefly, all women living in Rotterdam, the Netherlands,
with an expected delivery date between April 2002 and Jan-
uary 2006 were eligible for participation. Assessments
included physical examinations and questionnaires during
and after pregnancy. The Medical Ethical Committee of the
Erasmus Medical Center, Rotterdam, approved the study.
Written informed consent was obtained from all partici-
pants.
Full consent for the postnatal phase of the Generation R
Study was obtained from 7295 women. Women with miss-
ing data on the Edinburgh postnatal depression scale
(EPDS), either because of logistic problems at our research
centre (14% received no questionnaire, n = 1051) or
because of non-response (17.9%, n = 1303), were excluded.
In total, 4941 women were included in the analyses. As
some women had missing data on one or more perinatal
complications (maximum 14% per complication), the
number of women included in the separate analyses varies
per complication studied.
Outcome measures
Postpartum psychiatric symptoms were assessed 2 months
after delivery with the EPDS, a widely used self-report scale
that has been validated for the Dutch population.20,21 The
EPDS assesses symptoms of postpartum depression in the
previous week and comprises ten statements, each with
four possible answers on a scale ranging from ‘no, not at
all’ (0) to ‘yes, quite often’ (3). The EPDS sum score ranges
ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
Perinatal risk factors of postpartum depression
from 0 to 30, with higher scores indicating more depressive
symptoms. We classified women with a score of more than
12 as having postpartum depression. Previous research
indicated that this cut-off score has a sensitivity of over
80% and a specificity of 95% for identifying women with
clinically diagnosed postpartum depression in a community
sample.22
Determinants
The present study examined a wide range of perinatal com-
plications as risk factors (indicated in italics) for postpar-
tum depression. Information on the following
complications was obtained from midwife and hospital reg-
istries (these complications were prospectively and rou-
tinely registered for all women). Pre-eclampsia and
pregnancy-induced hypertension were defined according to
the criteria described by the International Society for the
Study of Hypertension in Pregnancy.23 Pregnancy-induced
hypertension was diagnosed if previously normotensive
women had a systolic blood pressure ‡ 140 mmHg and/or
a diastolic blood pressure ‡ 90 mmHg after 20 weeks of
gestation; if they additionally had proteinuria (‡300 mg/
24 hour) they were diagnosed as pre-eclamptic. Gestational
diabetes was diagnosed according to Dutch midwifery and
obstetric guidelines using the following criteria: random
glucose level > 11.1 mmol/l or a glucose level > 7.0 mmol/l
after fasting, both in the absence of previously diagnosed
diabetes. Suspicion of fetal distress was diagnosed on the
basis of a fetal blood sample with a pH < 7.20 or a deviat-
ing cardiotocogram (e.g. repetitive decelerations, loss of
variability, or increased baseline fetal hart rate). Type of
delivery was divided into four categories: (1) spontaneous
delivery; (2) instrumental delivery (including expression,
forceps, and vacuum extraction); (3) elective caesarean sec-
tion; (4) emergency caesarean section. Location of the
delivery was either at home or in hospital. Although rela-
tively uncommon in most Western countries, in the Neth-
erlands approximately 30% of pregnant women give birth
at home.24 This is the result of the Dutch system of obstet-
ric care that is based on risk management. Women with
low-risk pregnancies remain in primary care and may choose
whether they want to deliver at home or in hospital: mid-
wives provide the delivery in both places. Pregnant women
with one or more risk factors (ranging from suspicion of
low fetal weight to an innate heart defect of the mother)
get a medical indication for secondary care, which is pro-
vided by obstetricians in hospital. We categorised location
of delivery as follows: (1) hospital delivery provided by an
obstetrician; (2) hospital delivery provided by a midwife;
(3) delivery at home provided by a midwife. Although the
location of the delivery might not be a perinatal complica-
tion in itself, it may be associated with postpartum depres-
sion as it is a proxy for complications during pregnancy
1391
 Blom et al.
and delivery. Information on meconium-stained amniotic
fluid (yes, no), Apgar score at 5 minutes after delivery
(below seven; seven or higher), and birthweight of the child
(<2500 g; ‡2500 g) was also obtained from routine mid-
wife and hospital registry records. Gestational age was
determined by fetal ultrasound examination conducted at
our research centre.25 Birth was classified as preterm if it
occurred before 37 weeks of gestation.
The following perinatal risk factors were obtained by
questionnaire. Upon enrolment, women reported whether
or not the pregnancy was planned. At 30 weeks of gestation,
women answered a question about whether they had been
admitted to hospital for more than 24 hours during the first
two trimesters of pregnancy. Two months after delivery,
the women reported retrospectively on the prevalence
of thrombosis during pregnancy, and whether or not
their baby was admitted to hospital in the first week after
delivery.
Covariates
Based on the literature, we considered the following non-
obstetrical factors as possible confounders in the associa-
tion between perinatal complications and postpartum
depression: maternal educational level, ethnicity, age, and
general psychopathological symptoms, as well as family
income and family functioning.4,8–13 Information on educa-
tional level, ethnicity, and age was obtained by question-
naire upon enrolment. Educational level, defined by the
highest attained education, was divided into four catego-
ries, ranging from low to high. We categorised ethnicity as:
‘Dutch’, ‘other Western’, and ‘non-Western’. The question-
naire at 30 weeks of gestation included questions about
income, family functioning, and general psychopathological
symptoms. Family income was defined by the total net
monthly income of the household, and was categorised as
‘<1200 euros’, ‘1200–2000 euros’, and ‘>2000 euros’. Fam-
ily functioning during pregnancy was measured by the
‘general family functioning’ measure of the McMaster fam-
ily assessment device.26 This scale consists of 12 statements
about support and stress within the family: higher scores
represent poorer family functioning. Psychopathological
symptoms during pregnancy, like anxiety, depression, so-
matisation, hostility, and psychoticism, were assessed using
the brief symptom inventory. The sum score of the 53
items indicates general psychopathology, with higher scores
representing more symptoms.27 We consciously chose to
adjust for general psychopathological symptoms and not
only for depression, because anxiety during pregnancy is
also a risk factor for postpartum depression. Results were,
however, essentially unchanged if corrected for depressive
symptoms instead of general psychopathological symptoms
(data not shown, adjustment for both scales not feasible
because of colinearity).
1392 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
Statistical analyses
All analyses were performed using the Statistical Package of
Social Sciences v15.0 for Windows (SPSS Inc., Chicago, IL,
USA). Chi-square tests were used to describe the associa-
tion of general population characteristics (categorical vari-
ables) and perinatal risk factors with postpartum
depression. The relationship between continuous popula-
tion characteristics and postpartum depression was
described with analysis of variance (ANOVA; normally dis-
tributed variables) or Kruskal–Wallis (non-normally dis-
tributed variables) tests. Using logistic regression analyses
we calculated odds ratios (ORs) for the risk factors that
were significantly associated with postpartum depression, as
indicated by the chi-square tests. The associations were
controlled for possible confounding factors. Missing data
on the confounding factors were replaced by the median
(categorical variables or non-normally distributed continu-
ous variables) or the mean (normally distributed continu-
ous variables). In the multivariable regression analyses, we
firstly calculated ORs adjusted for family functioning and
general psychopathological symptoms of the mother, as we
considered these covariates to be important potential con-
founding factors. Additionally, the ORs were adjusted for
sociodemographic covariates, which may be confounding
factors but could also be anteceding factors, i.e. sociodemo-
graphic factors causing depression through their association
with pregnancy complications. Finally, we calculated a risk
score per participant by summing the number of perinatal
risk factors that were significantly associated with postpar-
tum depression in the fully adjusted analyses. We examined
the association between the number of perinatal risk factors
and risk of postpartum depression with logistic regression
analyses.
Non-response analyses
For the non-response analyses, women with missing data
on the EPDS were compared with women who filled out
the EPDS. Women with missing data (n = 2266) reported
more general psychopathological symptoms (F-test = 12;
df = 1; P = 0.001), poorer family functioning (F-test = 12;
df = 1; P = 0.001), and a lower family income (v2
test = 42; df = 2; P < 0.001) than women who completed
the EPDS. They were also more likely to be educated to a
lower level (v2 test = 227; df = 3; P < 0.001), to be of non-
Western origin (v2 test = 181; df = 2; P < 0.001), and
younger (F-test = 109; df = 1; P < 0.001).
Results
The characteristics of the study population are presented in
Table 1. Of the 4941 women, 396 (8%) had postpartum
depression. These women reported more psychopathological
symptoms (P < 0.001) and poorer family functioning during
 Perinatal risk factors of postpartum depression

Table 1. General population characteristics

Total study population Edinburgh postnatal depression scale

n* % % Normal % Clinically
(n = 4545) high (n = 396)

Population characteristics
Parity (% nullipara) 4869 57.9 58.1 55.6
Twin birth (% yes) 4941 1.1 1.1 1.8
Gender (% boys) 4887 49.7 49.4 53.5
Psychosocial wellbeing characteristics
General psychopathological symptoms, score (range)** 4078 0.13 (0.00–3.04) 0.13 (0.00–2.73) 0.39 (0.00–3.04)*****
Family functioning, score (range)*** 4046 1.42 (1.00–4.00) 1.42 (1.00–4.00) 1.50 (1.00–3.42)*****
Sociodemographic characteristics
Age mother, years (±SD) 4941 31.0 (4.8) 31.1 (4.7) 29.7 (5.7)*****
Education level mother
High (%) 1438 29.1 30.4 14.1*****
Mid-high (%) 1349 27.3 27.2 28.5*****
Mid-low (%) 1359 27.5 27.0 33.3*****
Low (%) 795 16.1 15.4 24.0*****
Ethnicity mother
Dutch (%) 3107 62.9 64.8 40.4*****
Other Western (%) 924 18.7 18.8 17.9****
Non-Western (%) 910 18.4 16.4 41.7*****
Family income
>2000 euros (%) 3731 75.5 77.2 56.1*****
1200–2000 euros (%) 665 13.5 12.9 19.7*****
<1200 euros (%) 545 11.0 9.9 24.2*****

Values are percentages, except for continuous, non-normally distributed variables [median score (100% range)] and continuous normally distrib-
uted variables [mean (standard deviation)].
*Some data were missing: parity (n = 72), gender (n = 54), general psychopathological symptoms (n = 863), family functioning (n = 895), educa-
tion level (n = 229), ethnicity mother (n = 171), and family income (n = 672).
**Measured with the brief symptom inventory.
***Measured with Family Assessment Device.
****P < 0.01, *****P < 0.001 for normal score versus clinically high score on EPDS; v2 tests for categorical variables, ANOVA for continuous nor-
mally distributed variables, or Kruskal–Wallis test for continuous non-normally distributed variables.

pregnancy (P < 0.001). Women with postpartum depression
were also younger (P < 0.001), were more often educated to
a lower level (P < 0.001), and were more often of non-Wes-
tern origin (P < 0.001) than women with no postpartum
depression. The mean age of all pregnant women in the study
population was 31.0 years (SD = 4.8); depressed women
were on average 29.7 years old (SD = 5.7).
The frequencies of perinatal complications among
depressed and non-depressed women are presented in
Table 2. In total, ten perinatal complications were signifi-
cantly associated with a high prevalence of postpartum
depression. For these complications, univariate regression
analyses were used to calculate the corresponding unad-
justed ORs for the risk of having postpartum depression
(first column of Table 3). Secondly, we adjusted the associ-
ation between perinatal complications and postpartum
depression for maternal general psychopathological symp-
toms and family functioning (second column of Table 3).
Thrombosis, meconium-stained amniotic fluid, and Apgar
score at 5 minutes were no longer significantly associated
with postpartum depression after this adjustment. Finally,
we additionally adjusted these analyses for sociodemo-
graphic covariates (third column in Table 3). The following
risk factors remained significantly associated with an
increased risk of postpartum depression: pre-eclampsia
(aOR 2.58, 95% CI 1.30–5.14), hospitalization during preg-
nancy (aOR 2.25, 95% CI 1.19–4.26), emergency caesarean
section (aOR 1.53, 95% CI 1.02–2.31), suspicion of fetal
distress (aOR 1.56; 95% CI 1.08–2.27), delivery in a hospi-
tal provided by an obstetrician or by a midwife (aOR 2.43,
95% CI 1.56–3.78; aOR 2.23 95% CI 1.38–3.62, respec-
tively), and hospital admission of the baby (aOR 1.45, 95%
CI 1.10–1.92). The relationship between unplanned preg-
nancy and postpartum depression was explained by both

ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 1393
 Blom et al.

Table 2. Frequencies of perinatal complications by score on the Edinburgh postnatal depression scale

Perinatal complications Edinburgh postnatal depression scale

Normal (n = 4545) Clinically high (n = 396)

Unplanned pregnancy (% yes) 21.1 (n = 871) 36.2 (n = 121)***

Pre-eclampsia (% yes) 1.4 (n = 59) 3.2 (n = 12)**
Pregnancy induced hypertension (% yes) 4.0 (n = 169) 3.8 (n = 14)
Gestational diabetes (% yes) 0.6 (n = 28) 1.0 (n = 4)
Thrombosis (% yes) 0.6 (n = 27) 2.1 (n = 8)**
Hospitalization during pregnancy (% yes) 1.8 (n = 70) 4.4 (n = 14)**
Type of delivery
Spontaneous delivery (%) 70.0 (n = 2879) 69.8 (n = 252)
Instrumental delivery (%) 18.0 (n = 742) 15.2 (n = 55)
Elective caesarean section (%) 5.1 (n = 208) 4.7 (n = 17)
Emergency caesarean section (%) 6.9 (n = 285) 10.2 (n = 37)*
Suspicion of fetal distress (% yes) 7.7 (n = 338) 10.8 (n = 42)*
Meconium-stained amniotic fluid (% yes) 14.8 (n = 646) 18.8 (n = 72)*
Location of delivery
At home, provided by midwife (%) 17.9 (n = 808) 6.3 (n = 25)***
Hospital, provided by midwife (%) 22.2 (n = 1004) 27.4 (n = 108)***
Hospital, provided by obstetrician (%) 59.9 (n = 2708) 66.2 (n = 261)***
Preterm birth (% yes) 4.6 (n = 207) 6.1 (n = 24)
Low birthweight (% yes) 3.9 (n = 168) 3.6 (n = 13)
Apgar score of <7 at 5 minutes (% yes) 0.8 (n = 37) 2.4 (n = 9)**
Hospital admission of the baby (% yes) 16.5 (n = 731) 22.2 (n = 86)**

*P < 0.05, **P < 0.01, ***P < 0.001 for normal versus clinically high score on the EPDS with v2 tests.

psychosocial wellbeing and sociodemographic characteris-
tics: the OR was reduced by 79% from 2.12 to 1.24.
Finally, Table 4 shows the association between the number
of perinatal complications per participant and the risk of
postpartum depression. The sum score was based on the
perinatal complications that remained significantly associ-
ated with postpartum depression in the fully adjusted analy-
ses (see also third column Table 3). The majority of the
participants (n = 3579, 74%) had none or just one complica-
tion, whereas only 6% of the participants experienced three
or more complications. The risk of postpartum depression
increased with a higher number of perinatal complications
(P < 0.001, tested by including the number of risk factors
per participant as a continuous variable in the model). Next
to an accumulation of perinatal complications, psychopatho-
logical symptoms during pregnancy are an important risk
factor for the development of postpartum depression. Low
educational level and non-Western ethnicity were also inde-
pendently associated with postpartum depression.
Discussion
This population-based study showed that various complica-
tions during pregnancy and delivery predicted postpartum
depression in women 2 months after giving birth. Women
who experienced more than two perinatal complications
are especially at high risk of developing postpartum depres-
sion. Some perinatal factors, e.g. meconium-stained amni-
otic fluid, were associated with later postpartum
depression, but these associations were explained by prena-
tal psychosocial wellbeing and the sociodemographic char-
acteristics of the mother.
The strengths of the present study are the large number of
women participating, the population-based design, and the
availability of detailed information on numerous perinatal
risk factors. We measured risk factors prospectively and rou-
tinely, which limits potential bias of diagnosing more peri-
natal complications in women at risk for postpartum
depression than in women with a low risk of postpartum
depression. Retrospective measurements have potentially
limited previous research, and might explain the differences
between our findings and other studies.12,13,18 A final
strength of the study is that we controlled for several possi-
ble confounding factors. Previous studies reported associa-
tions between pregnancy complications and postpartum
depression that were only marginally adjusted, and thus may
have resulted from confounding factors.12,18,28,29 We showed
the extent of confounding, as several perinatal complications
were initially associated with postpartum depression, but
these relations were explained by sociodemographic and

1394 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
 Perinatal risk factors of postpartum depression

Table 3. Perinatal complications and the risk of postpartum depression

Perinatal complications n Univariate Analyses adjusted Analyses additionally

analyses* for prenatal adjusted for
psychosocial socio-demographic
wellbeing** characteristics***

OR (95% CI) P OR (95% CI) P OR (95% CI) P

Unplanned pregnancy (yes) 4454 2.12 (1.68–2.68) <0.001 1.38 (1.06–1.80) 0.02 1.24 (0.94–1.64) 0.1
Pre-eclampsia (yes) 4647 2.40 (1.28–4.50) 0.007 2.63 (1.33–5.21) 0.005 2.58 (1.30–5.14) 0.007
Thrombosis (yes) 4876 3.51 (1.58–7.78) 0.002 2.38 (0.99–5.74) 0.05 1.74 (0.71–4.27) 0.2
Hospitalization during pregnancy (yes) 4236 2.56 (1.43–4.60) 0.002 2.44 (1.29–4.61) 0.006 2.25 (1.19–4.26) 0.01
Type of delivery
Spontaneous delivery 3131 Reference Reference Reference
Instrumental delivery 797 0.85 (0.63–1.15) 0.3 1.01 (0.73–1.40) 0.9 1.07 (0.77–1.49) 0.7
Elective caesarean section 225 0.93 (0.56–1.56) 0.8 0.94 (0.53–1.66) 0.8 0.99 (0.56–1.75) 0.9
Emergency caesarean section 322 1.48 (1.03–2.14) 0.04 1.49 (0.99–2.23) 0.05 1.53 (1.02–2.31) 0.04
Suspicion of fetal distress (yes) 4793 1.46 (1.04–2.04) 0.03 1.55 (1.07–2.24) 0.02 1.56 (1.08–2.27) 0.02
Meconium-stained amniotic fluid (yes) 4746 1.33 (1.02–1.74) 0.04 1.12 (0.83–1.52) 0.5 1.09 (0.80–1.48) 0.6
Location delivery
At home, provided by midwife 833 Reference Reference Reference
Hospital, provided by midwife 1112 3.48 (2.23–5.42) <0.001 2.69 (1.68–4.30) <0.001 2.23 (1.38–3.62) 0.001
Hospital, provided by obstetrician 2969 3.12 (2.05–4.73) <0.001 2.70 (1.74–4.18) <0.001 2.43 (1.56–3.78) <0.001
Apgar score of <7 at 5 minutes (yes) 4743 2.85 (1.36–5.94) 0.005 2.27 (0.96–5.35) 0.06 2.21 (0.92–5.31) 0.08
Hospital admission of the baby (yes) 4828 1.45 (1.12–1.86) 0.004 1.42 (1.08–1.88) 0.01 1.45 (1.10–1.92) 0.009

Values are odds ratios and estimate the risk of having postpartum depression for the perinatal complications indicated in the first column.
*Univariate analyses.
**Adjusted for general psychopathological symptoms, measured with the brief symptom inventory, and family functioning, measured with the
family assessment device.
***Adjusted for general psychopathological symptoms, family functioning, maternal ethnicity and age, education level mother, and family
income.

prenatal psychosocial features. However, our thorough con-
trol for possible confounding factors may have led to an
overadjustment of the associations, as some sociodemo-
graphic variables, e.g. educational level, may partly act as
preceding factors in the relationship between perinatal com-
plications and postpartum depression.
Some other limitations must also be discussed. The par-
ticipants in this study represent a selection towards a more
healthy population.30 Our non-response analyses showed
that the EPDS data was more complete for highly educated,
Western women. This resulted in an under-representation
of the most disadvantaged groups, who are most at risk of
postpartum depression.4,8–10,12 If similar effects were pres-
ent in these disadvantaged women, our results would be an
underestimation of the true associations. It is less likely
that the selection led to spurious findings. Secondly, despite
our large study population, the prevalence of some perina-
tal complications was rather low, and may have limited our
power. Finally, a limitation of our study is that the EPDS
was developed to screen for clinically relevant symptoms of
postpartum depression, rather than for postpartum depres-
sion itself. However, EPDS scores correspond closely to
clinical diagnoses, and are commonly used as a measure of
postpartum depression.22
We showed that various pregnancy and delivery compli-
cations predicted postpartum depression in women. Several
mechanisms may explain these associations. Firstly, we hy-
pothesise that the association between pre-eclampsia and
postpartum depression may be caused by physical and hor-
monal changes. For example, serotonin levels in the blood
are known to be increased in women with pre-eclampsia.31
This might lead to decreased levels of serotonin in the
brain, thereby causing depressive symptoms.32
Another possible mechanism mediating the studied rela-
tionship is physical health. Women who had pregnancy
complications or a troubled delivery, as indicated by an
emergency caesarean section and fetal distress, are more
likely to experience physical morbidity in the postpartum
period.33 Physical morbidity can lead to higher rates of
postpartum depression, as poor health is a well-known
stressor because of pain, tiredness and limitations.
Thirdly, psychological mechanisms might underlie the
association between complications and postpartum depres-
sion. Most women have particular expectations about their

ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 1395
 Blom et al.

Table 4. Number of perinatal complications and the risk of postpartum depression (adjusted for prenatal psychosocial wellbeing and
sociodemographic characteristics)

Variables included in the analyses n (total n = 4835)* OR (95% CI) P

Number of perinatal complications**

0 770 Reference
1 2809 2.36 (1.45–3.83) 0.001
2 956 2.93 (1.75–4.93) <0.001
3 241 4.55 (2.46–8.40) <0.001
4 or 5 59 5.47 (2.25–13.3) <0.001
General psychopathological symptoms (per score point) 4835 9.73 (7.19–13.2) <0.001
Family functioning (per score point) 4835 1.28 (0.99–1.66) 0.056
Age mother (per year) 4835 1.01 (0.99–1.04) 0.252
Education level mother
High 1438 Reference
Mid–high 1349 1.29 (0.85–1.94) 0.230
Mid–low 1359 1.44 (1.00–2.08) 0.051
Low 795 1.83 (1.28–2.59) 0.001
Ethnicity mother
Dutch 3107 Reference
Other Western 924 1.12 (0.82–1.54) 0.476
Non-Western 910 2.14 (1.61–2.85) <0.001
Family income
>2000 euros 3731 Reference
1200–2000 euros 665 1.15 (0.83–1.61) 0.408
<1200 euros 545 1.19 (0.86–1.63) 0.291

*Participants with missing information on three or more perinatal complications (n = 106) were excluded from these analyses.
**The following perinatal complications were used to calculate the sum score: pre-eclampsia, hospitalization during pregnancy, type of delivery,
suspicion of fetal distress, location of delivery, and hospital admission of the baby.

pregnancy, delivery, and postpartum period. Sudden life
events, like a complex delivery or hospitalisation of the
baby, lead to worries and feelings of disappointment and
failure.4,8,10,13 This may affect a woman’s ability to adapt in
the postpartum months, and cause her to experience
depressive symptoms.
Finally, personality differences might explain that women
with a hospital delivery have a higher risk of developing
postpartum depression. We hypothesise that personality
characteristics are associated with both choice of place of
delivery and risk of postpartum depression. Presumably,
women delivering at home are optimistic and self-confi-
dent, as they rely on having positive delivery outcomes,
whereas it is known that self-confident women have a
lower risk of postpartum depression as compared with neu-
rotic women.5,8,14
partum depression. Hence, further research is needed to
confirm our findings. These studies should have a prospec-
tive design and consist of a large study population.
The detection and treatment of postpartum depression is
important for both mothers and their children. It is impor-
tant that obstetricians, midwives, general practitioners, and
staff at baby clinics are aware of the substantially increased
risk of postpartum depression associated with complicated
pregnancies, difficult deliveries, and health problems of
babies in the neonatal period. These healthcare workers
must be particularly attentive for depressive symptoms in
women who experienced a number of perinatal complica-
tions.
Disclosure of interests
There are no potential conflicts of interest.

Conclusions
Only a few studies have previously examined the relation-
ship between perinatal complications and postpartum
depression. To our knowledge, this was the first time that
suspicion of fetal distress, meconium-stained amniotic
fluid, and thrombosis were studied as risk factors of post-
Contribution to authorship
All authors have significantly contributed to this scientific
work and approved the final version of the manuscript.
EAB performed the data analyses and wrote the manu-
script. PWJ was involved in the design of the paper, super-
vised the data analyses, and co-wrote the manuscript. FCV
and HT were involved in the conception of the project,

1396 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology

designing the paper, and provided financial and material
support. HT supervised the drafting of the manuscript,
whereas FCV revised the manuscript critically. HR was
involved in the conception of the project and revised the
manuscript significantly. AH and VWVJ were involved in
the conception of the project, provided financial and mate-
rial support, and helped to improve the manuscript. MC
was responsible for data gathering and revised the manu-
script critically. EAPS was involved in the conception of
the project, supervised the data gathering, and helped
improve the text.
Details of ethics approval
The Medical Ethical Committee of the Erasmus Medical
Center, Rotterdam, approved the study (MEC 198.1782/
2001/31 and MEC 217.595/2002/202). Written informed
consent was obtained from all participants.
Funding
The first phase of the Generation R Study was made possi-
ble by financial support from: Erasmus MC – University
Medical Centre Rotterdam; Erasmus University Rotterdam;
and the Netherlands Organization for Health Research and
Development (ZonMW). The present study was supported
by an additional grant from the Netherlands Organization
for Health Research and Development (ZonMW ‘‘Geestk-
racht’’ programme 10.000.1003). PWJ was financially sup-
ported by grant 602 from the Sophia Foundation for
Medical Research SSWO.
Acknowledgements
The Generation R Study is conducted by the Erasmus MC –
University Medical Center Rotterdam in close collaboration
with the Erasmus University Rotterdam, School of Law and
Faculty of Social Sciences; the Municipal Health Service Rot-
terdam area, Rotterdam; the Rotterdam Homecare Founda-
tion, Rotterdam; and the Stichting Trombosedienst &
Artsenlaboratorium Rijnmond (STAR), Rotterdam. We
gratefully acknowledge the contribution of the participating
pregnant women and their partners, general practitioners,
hospitals, midwives, and pharmacies in Rotterdam. j
References
1 Cooper PJ, Campbell EA, Day A, Kennerley H, Bond A. Non-psy-
chotic psychiatric disorder after childbirth. A prospective study of
prevalence, incidence, course and nature. Br J Psychiatry
1988;152:799–806.
2 Buultjens M, Liamputtong P. When giving life starts to take the life
out of you: women’s experiences of depression after childbirth. Mid-
wifery 2007;23:77–91.
3 American Psychological Association. Diagnostic and Statistical Man-
ual of Mental Disorders: DSM-IV-TR, 4th edn, text revision. Washing-
ton, DC: American Psychological Association, 2000.
ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
Perinatal risk factors of postpartum depression
4 Beck CT. Postpartum depression: it isn’t just the blues. Am J Nurs
2006;106:40–50; quiz 50-1.
5 Beck CT. Predictors of postpartum depression: an update. Nurs Res
2001;50:275–85.
6 Murray L, Cooper P. Effects of postnatal depression on infant devel-
opment. Arch Dis Child 1997;77:99–101.
7 Ramchandani PG, Stein A, O’Connor TG, Heron J, Murray L, Evans
J. Depression in men in the postnatal period and later child psycho-
pathology: a population cohort study. J Am Acad Child Adolesc Psy-
chiatry 2008;47:390–8.
8 Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk fac-
tors for postpartum depression: a synthesis of recent literature. Gen
Hosp Psychiatry 2004;26:289–95.
9 Tannous L, Gigante LP, Fuchs SC, Busnello ED. Postnatal depression
in Southern Brazil: prevalence and its demographic and socioeco-
nomic determinants. BMC Psychiatry 2008;8:1.
10 Milgrom J, Gemmill AW, Bilszta JL, Hayes B, Barnett B, Brooks J,
et al. Antenatal risk factors for postnatal depression: a large pro-
spective study. J Affect Disord 2008;108:147–57.
11 Onozawa K, Kumar RC, Adams D, Dore C, Glover V. High EPDS
scores in women from ethnic minorities living in London. Arch
Womens Ment Health 2003;6(Suppl 2):S51–5.
12 Warner R, Appleby L, Whitton A, Faragher B. Demographic and
obstetric risk factors for postnatal psychiatric morbidity. Br J Psychia-
try 1996;168:607–11.
13 O’Hara MW, Swain AM. Rates and risk of postnatal depression:
meta-analysis. Int Rev Psychiatry 1996;8:37–54.
14 Verkerk GJ, Denollet J, Van Heck GL, Van Son MJ, Pop VJ. Person-
ality factors as determinants of depression in postpartum women:
a prospective 1-year follow-up study. Psychosom Med
2005;67:632–7.
15 Soderquist J, Wijma B, Thorbert G, Wijma K. Risk factors in preg-
nancy for post-traumatic stress and depression after childbirth. BJOG
2009;116:672–80.
16 Boyce PM, Todd AL. Increased risk of postnatal depression after
emergency caesarean section. Med J Aust 1992;157:172–4.
17 Nielsen FormanD, Videbech P, Hedegaard M, Dalby Salvig J, Secher
NJ. Postpartum depression: identification of women at risk. BJOG
2000;107:1210–7.
18 McCoy SJ, Beal JM, Saunders B, Hill EN, Payton ME, Watson GH.
Risk factors for postpartum depression: a retrospective investigation.
J Reprod Med 2008;53:166–70.
19 Jaddoe VW, van Duijn CM, van der Heijden AJ, Mackenbach JP,
Moll HA, Steegers EA, et al. The Generation R Study: design and
cohort update until the age of 4 years. Eur J Epidemiol
2008;23:801–11.
20 Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression.
Development of the 10-item Edinburgh Postnatal Depression Scale.
Br J Psychiatry 1987;150:782–6.
21 Pop VJ, Komproe IH, van Son MJ. Characteristics of the Edinburgh
Post Natal Depression Scale in The Netherlands. J Affect Disord
1992;26:105–10.
22 Murray L, Carothers AD. The validation of the Edinburgh Post-natal
Depression Scale on a community sample. Br J Psychiatry
1990;157:288–90.
23 Brown MA, Lindheimer MD, de Swiet M, Van Assche A, Moutquin
JM. The classification and diagnosis of the hypertensive disorders of
pregnancy: statement from the International Society for the Study of
Hypertension in Pregnancy (ISSHP). Hypertens Pregnancy
2001;20:IX–XIV.
24 Anthony S, Amelink-Verburg MP, Jacobusse GW, Pal-de Bruin KM.
De thuisbevalling in Nederland 1995–2002 [Home deliveries in the
1397
 Blom et al.
Netherlands 1995-2002]. In: Leven. Stichting Perinatale Registratie
Nederland, Bilthoven, 2005.
25 Verburg BO, Steegers EA, De Ridder M, Snijders RJ, Smith E,
Hofman A, et al. New charts for ultrasound dating of pregnancy
and assessment of fetal growth: longitudinal data from a popula-
tion-based cohort study. Ultrasound Obstet Gynecol 2008;31:
388–96.
26 Byles J, Byrne C, Boyle MH, Offord DR. Ontario Child Health Study:
reliability and validity of the general functioning subscale of the
McMaster Family Assessment Device. Fam Process 1988;27:97–104.
27 de beurs E. Brief Symptom Inventory, Handleiding. The Netherlands:
Leiden, 2004.
28 Josefsson A, Angelsioo L, Berg G, Ekstrom CM, Gunnervik C, Nordin
C, et al. Obstetric, somatic, and demographic risk factors for post-
partum depressive symptoms. Obstet Gynecol 2002;99:223–8.
1398 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
29 Dennis CL, Janssen PA, Singer J. Identifying women at-risk for post-
partum depression in the immediate postpartum period. Acta Psychi-
atr Scand 2004;110:338–46.
30 Center for Research and Statistics (COS). Kerncijfers Rotterdam 2005
[Basic demographic data Rotterdam 2005], Center for Research and
Statistics, Rotterdam, 2005.
31 Bolte AC, van Geijn HP, Dekker GA. Pathophysiology of preeclamp-
sia and the role of serotonin. Eur J Obstet Gynecol Reprod Biol
2001;95:12–21.
32 Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow
DR. Effects of gonadal steroids in women with a history of postpar-
tum depression. Am J Psychiatry 2000;157:924–30.
33 Borders N. After the afterbirth: a critical review of postpartum health
relative to method of delivery. J Midwifery Womens Health
2006;51:242–8.