Postpartum depression

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Postpartum depression
Classification and external resources
Specialty Psychiatry
ICD-10 F53.0
ICD-9-CM 648.4
DiseasesDB 10921
MedlinePlus 007215
eMedicine med/3408
Patient UK Postpartum depression
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Postpartum depression (PPD), also called postnatal depression, is a type of clinical depression which can affect both sexes after childbirth. Symptoms may include sadness, low energy, changes in sleeping and eating patterns, reduced desire for sex, crying episodes, anxiety, and irritability. While many women experience self-limited, mild symptoms postpartum, postpartum depression should be suspected when symptoms are severe and have lasted over two weeks. In about 1 to 2 per 1,000, postpartum depression results in postpartum psychosis.[1]

Although a number of risk factors have been identified, the causes of PPD are not well understood. Hormonal change is hypothesized to contribute as one cause of postpartum depression. The emotional effects of postpartum depression can include sleep deprivation, anxiety about parenthood and caring for an infant, identity crisis, a feeling of loss of control over life, and anxiety due to lack of support from a romantic or sexual partner.[2] Many women recover with treatment such as a support group, counseling, or medication.[3][4]

Studies report prevalence rates among women from 5% to 25%, but methodological differences among the studies make the actual prevalence rate unclear. Among men, in particular new fathers, the incidence of postpartum depression has been estimated to be between 1% and 25.5%.[5] In the United States, postpartum depression is one of the leading causes of the murder of children less than one year of age which occurs in about 8 per 100,000 births.[6][7]

Signs and symptoms

Symptoms of PPD can occur any time in the first year postpartum.[8] These symptoms include, but are not limited to:

Onset and duration

Postpartum depression usually begins between two weeks to a month after delivery.[11] Recent studies have shown that fifty percent of postpartum depressive episodes actually begin prior to delivery.[12] Therefore, in the DSM-5, postpartum depression is diagnosed under "depressive disorder with peripartum onset", in which "peripartum onset" is defined as anytime either during pregnancy or within the four weeks following delivery. PPD may last several months or even a year.[13] Postpartum depression can also occur in women who have suffered a miscarriage.[14]

Parent-infant relationship

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect child development. Postpartum depression may lead mothers to be inconsistent with childcare.[15] Children of mothers with PPD have been found to have higher rates of emotional problems, behavioral problems, psychiatric diagnoses (such as oppositional defiant disorder and conduct disorder), and hyperactivity.[16][17]

In rare cases, or about 1 to 2 per 1,000, the postpartum depression appears as postpartum psychosis which may adversely affect the infant's health.[1] In these, or among women with a history of previous psychiatric hospital admissions,[18] infanticide may occur. In the United States, postpartum depression is one of the leading causes of annual reported infanticide incidence rate of about 8 per 100,000 births.[6][19]

Causes

The cause of PPD is not well understood. Hormonal changes, genetics, and major life events have been hypothesized as potential causes.

Evidence suggests that hormonal changes may play a role. Hormones which have been studied include estrogen, progesterone, thyroid hormone, testosterone, corticotropin releasing hormone, and cortisol.[20]

Fathers, who are not undergoing profound hormonal changes, can also have postpartum depression.[21] The cause may be distinct in males.

Profound lifestyle changes that are brought about by caring for the infant are also frequently hypothesized to cause PPD. However, little evidence supports this hypothesis. Mothers who have had several previous children without suffering PPD can nonetheless suffer it with their latest child.[22] Additionally, most women experience profound lifestyle changes with their first pregnancy, yet most do not suffer PPD.[citation needed]

Risk factors

While the causes of PPD are not understood, a number of factors have been suggested to increase the risk:

Of these risk factors, formula-feeding, a history of depression, and cigarette smoking have been shown to have additive effects.[24]

These above factors are known to correlate with PPD. This correlation does not mean these factors are causal. Rather, they might both be caused by some third factor. Contrastingly, some factors almost certainly attribute to the cause of postpartum depression, such as lack of social support.[27]

Not surprisingly, women with fewer resources indicate a higher level of postpartum depression and stress than those women with more financial resources. Rates of PPD have been shown to decrease as income increases.[28] Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing risk of PPD. Single mothers of low income may have fewer resources to which they have access while transitioning into motherhood.

Studies have also shown a correlation between a mother’s race and postpartum depression. For race, African American mothers have been shown to have the highest risk of PPD at 25%, while Asians had the lowest at 11.5%, after controlling for social factors such as age, income, education, marital status, and baby’s health. The PPD rates for American Indians, Caucasian and Hispanic women fell in between.[28]

Sexual orientation[29] has also been studied as a risk factor for PPD. In a 2007 study conducted by Ross and colleagues, lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample. It was found that lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale scores than did the heterosexual women in the sample.[29] These higher rates of PPD in lesbian/bisexual mothers may reflect less social support, particularly from their families of origin and additional stress due to homophobic discrimination in society.[30]

Violence

A meta-analysis reviewing research on the association of violence and postpartum depression showed that violence against women increases the incidence of postpartum depression.[31] About one-third of women throughout the world will experience physical and/or sexual violence at some point in their lives.[32] Violence against women occurs in conflict, post-conflict, and non-conflict areas.[32] It is important to note that the research reviewed only looked at violence experienced by women from male perpetrators, but did not consider violence inflicted on men or women by women. Further, violence against women was defined as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women”.[31] Psychological and cultural factors associated with increased incidence of postpartum depression include family history of depression, stressful life events during early puberty or pregnancy, anxiety or depression during pregnancy, and low social support.[29][31] Violence against women is a chronic stressor, so depression may occur when someone is no longer able to respond to the violence.[31]

Evolutionary psychology

Research suggests that PPD is a functional component of human reproductive decision-making, supporting the notion that PPD allows mothers to reduce investment in their offspring when resources are limited.[33]

Human infants require an extraordinary degree of care. Lack of support and insufficient investment from fathers and/or other family members increase the costs that are borne by mothers, whereas infant health problems reduce the evolutionary benefits to be gained.[33] If ancestral mothers did not receive enough support from fathers or other family members, they may not have been able to afford to raise the new infant without harming any existing children, or damaging their own health (nursing depletes mothers' nutritional stores, placing the health of poorly nourished women in jeopardy).

For mothers suffering inadequate social support or other costly and stressful circumstances, negative emotions directed towards a new infant could serve an important evolved function by causing the mother to reduce her investment in an unaffordable infant, thereby reducing her costs. Numerous studies support the correlation between postpartum depression and lack of social support or other childcare stressors.[23][33] Kruckman, using observations from anthropological field work, suggests that supportive rituals and knowledge, if projected to the mother in a meaningful and sincere fashion, can affect the hypothalamus, pituitary and adrenal function and the production of endocrine signal molecules, and reduce the expression of anxiety or panic in postpartum women.[34][35]

Mothers with postpartum depression can unconsciously exhibit fewer positive emotions and more negative emotions toward their children, are less responsive and less sensitive to infant cues, less emotionally available, have a less successful maternal role attainment, and have infants that are less securely attached; and in more extreme cases, some women may have thoughts of harming their children.[23][36][37][38][39][40][41][42][43][44] In other words, most mothers with PPD are suffering some kind of cost, like inadequate social support, and consequently are mothering less.[improper synthesis?]

In this view, mothers with PPD do not have a mental illness, but instead cannot afford to take care of the new infant without more social support, more resources, etc. Treatment should therefore focus on helping mothers get what they need.[33][45]

Diagnosis

Criteria

The common term, postpartum depression, no longer exists as a diagnosis in the DSM-4, nor the DSM-5. In the DSM-5, postpartum depression would be diagnosed as a "depressive disorder with peripartum onset". Peripartum onset is defined as starting anytime during pregnancy or within the four weeks following delivery. There is no longer a distinction made between depressive episodes that occur during pregnancy or those that occur after delivery.[46] Nevertheless, the majority of experts continue to diagnose postpartum depression as depression with onset anytime within the first year after delivery.[25]

The criteria required for the diagnosis of postpartum depression are the same as those required to make a diagnosis of non-childbirth related major depression or minor depression. The criteria include at least five of the following nine symptoms, within a two-week period:[46]

  • Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day or the observation of a depressed mood made by others
  • Loss of interest or pleasure in activities
  • Weight loss or decreased appetite
  • Changes in sleep patterns
  • Feelings of restlessness
  • Loss of energy
  • Feelings of worthlessness or guilt
  • Loss of concentration or increased indecisiveness
  • Recurrent thoughts of death, with or without plans of suicide

Differential diagnosis

Postpartum blues

Postpartum blues, commonly known as "baby blues" is a transient postpartum mood disorder characterized by milder depressive symptoms than postpartum depression. This type of depression accounts for about 80% of all post partum depression.[47] Symptoms typically resolve within two weeks. Symptoms lasting longer than two weeks are a sign of more serious depression.[48]

Psychosis

Postpartum psychosis is a separate mental health disorder which is sometimes erroneously referred to as postpartum depression. It is less common than PPD, and it involves the onset of psychotic symptoms that may include thought disturbances, hallucinations, delusions and/or disorganised speech or behaviour. The prevalence of postpartum psychosis in the general population is 1–2 per 1,000 childbirths. However, the rate is 100 times higher in women with bipolar disorder or a previous history of postpartum psychosis. Bipolar disorder and, to a lesser extent, schizophrenia, have elevated prevalences in postpartum psychosis.[49] Previous research looked at the relationship between childbirth and postpartum psychosis. Using data on 54,000 births over a 12-year period, researchers found that psychiatric admissions were seven times more likely in the first 30 days after childbirth than in the pre-pregnancy period. Additionally, among women who developed postpartum psychosis after childbirth, 72%–80% had bipolar disorder or schizoaffective disorder and 12% had schizophrenia. Indicators of a possible bipolar diagnosis include a history of missed or misdiagnosed mood episodes, any previous mania or hypomania, and a family history of bipolar disorder or postpartum psychosis.[49]

Treatment for postnatal psychosis is essential; it will not go away without medical attention.[8]

Screening

In the US, the American College of Obstetricians and Gynecologists suggests healthcare providers consider depression screening for perinatal women.[50] Additionally, the American Academy of Pediatrics recommends pediatricians screen mothers for PPD at 1-month, 2-month and 4-month visits.[51] However, many providers do not consistently provide screening and appropriate follow-up.[50] For example, in Canada, Alberta is the only province with universal PPD screening. This screening is carried out by Public Health nurses with the baby's immunization schedule.

The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression.[52] If the new mother scores 13 or more, she likely has PPD and further assessment should follow.[52]

Prevention

A 2013 Cochrane review found evidence that psychosocial or psychological intervention after childbirth helped reduce the risk of postnatal depression.[53][54] These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy.[53]

A major part of prevention is being informed about the risk factors, and the medical community can play a key role in identifying and treating postpartum depression. Women should be screened by their physician to determine their risk for acquiring postpartum depression. Also, proper exercise and nutrition appear to play a role in preventing postpartum, and depressed mood in general.

Treatment

A variety of treatment options exist for PPD, and treatment may include a combination of therapies. If the cause of PPD can be identified, treatment should be aimed accordingly. If a woman with PPD does not feel she is being taken seriously, or is being recommended a treatment plan with which she is not comfortable, she may wish to seek a second opinion.[8]

Non-pharmacologic therapy

Both individual social and psychological interventions appear effective in the treatment of PPD.[55] Other forms of therapy, such as group therapy and home visits, are also effective treatments.[8] Internet-based cognitive behavioral therapy has been developed and tested, and has shown promising results with lower negative parenting behavior scores in those who participated. It is unclear if acupuncture, massage, bright lights, or taking omega-3 fatty acids are useful.[56] .

Medication

There is evidence which suggests that selective serotonin reuptake inhibitors (SSRIs) are effective treatment for PPD.[57] However, the quality of the evidence is low given it is based on very few studies and patients. It remains unclear which antidepressants are most effective for treatment of PPD, and for whom antidepressants would be a better option than non-pharmacotherapy.[57] A recent study has found that adding sertraline, a specific SSRI, to psychotherapy does not appear to confer an additional benefit.[58]

Epidemiology

Postpartum depression is found across the globe, with rates varying from 11% to 42%.[59]

Mothers

According to the National Institutes of Mental Health, studies show that the childbearing years are when a woman is most likely to experience depression in her lifetime. Approximately 15% of all women will experience postpartum depression following the birth of a child.[60]

Fathers

In the past, developmentalists have underestimated the importance of a father's interactions with the child in early development.[16] However, researchers have recently found that father involvement in early life has significant effects on subsequent child development. These studies include infants' exposure to paternal depression and its repercussions on the child's development.[61]

Research on postpartum depression have mostly focused on mothers, but studies have shown that fathers also pose a risk of experiencing postpartum depression, though a lower prevalence than in mothers.[61] Compared to mothers, fathers face lower levels of anxiety towards fatherhood and typically take part less in direct care for the child, reducing their susceptibility to PPD.[62] In addition, researchers have depicted a positive correlation between maternal postnatal depression and paternal depression, most likely due to factors such as marital satisfaction, a strong predictor for PPD.[61] Some studies propose that maternal depression plays a causal role in the development of postnatal depression in fathers.[61]

Furthermore, the prevalence of PPD in fathers inversely correlates with socioeconomic status, in which the PPD in fathers increased as socioeconomic status declined.[62] Similarly, unemployed fathers also demonstrated greater vulnerability to developing PPD.[62]

Several negative development outcomes in children have been associated with paternal depression. In a cross-sectional study, pre-school children, three to five years of age, who faced paternal depression as infants developed increased behavioral problems relating to conduct and hyperactivity.[16] In other words, paternal depression in early life places the child at a higher risk for developing behavioral issues, especially in early childhood.[61] The results of the study also indicated a higher incidence of behavioral problems, as a result of paternal postpartum depression, in boys than in girls.[16] Generally, boys more sensitively responded to the father's parenting, explaining the increased tendency of the boys to develop behavioral issues.[16]

The study proposes several explanations for the development of behavioral issues. Similar to maternal depression, fathers experiencing depression find it more difficult to care for their children and to fulfill their roles and responsibilities in the family. As a result, early interaction between the father and the child may decrease.[16] Also, indirect causes of depression, such as marital stress and tension, could also be a factor in the increase in behavior problems.[16]

Prevention and treatment for parental postnatal depression follow the same guidelines as in maternal depression. Awareness through consulting services by doctors and nurses of postpartum depression, baby care, and the attachment and relationship between the parents and the child will provide fathers with the necessary information to avoid depression.[62]

Society and culture

Malay culture holds a belief in Hantu Meroyan; a spirit that resides in the placenta and amniotic fluid.[63] When this spirit is unsatisfied and venting resentment, it causes the mother to experience frequent crying, loss of appetite, and trouble sleeping, known collectively as "sakit meroyan". The mother can be cured with the help of a shaman, who performs a séance to force the spirits to leave.[64] Some cultures believe that the symptoms of postpartum depression or similar illnesses can be avoided through protective rituals in the period after birth. Chinese women participate in a ritual that is known as "doing the month" in which they spend the first 30 days after giving birth resting in bed, while the mother or mother-in-law takes care of domestic duties and childcare. In addition, the new mother is not allowed to bathe, wash her hair, leave the house, or be blown by the wind.[65]

See also

References

  1. 1.0 1.1 Seyfried and Marcus (2003), Postpartum mood disorders, International Review of Psychiatry, Vol. 15, No. 3 , pp. 231-242
  2. "Diseases and Conditions Postpartum depression". /www.mayoclinic.org. Mayo Clinic. Retrieved 21 November 2014. More than one of author-name-list parameters specified (help); |first1= missing |last1= in Authors list (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  3. Kinnaman, Gary & Jacobs, Richard. Seeing in the Dark. Michigan: Baker Publing Group, 2006.[page needed]
  4. "Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes". Agency for Health Care Research and Quality.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  5. Paulson, James F. (2010). "Focusing on depression in expectant and new fathers: prenatal and postpartum depression not limited to mothers". Psychiatry Times. 27 (2).<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  6. 6.0 6.1 Pearlstein et al. (2009), Postpartum depression, American journal of obstetrics and gynecology, 200(4), pp. 357-364
  7. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 The Boston Women's Health Book Collective: Our Bodies Ourselves, pages 489–491, New York: Touchstone Book, 2005
  9. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  10. WebMD: Understanding Post Partum Depression http://www.webmd.com/depression/postpartum-depression/understanding-postpartum-depression-basics
  11. Postpartum Depression from Pregnancy Guide, by Peter J. Chen, at Hospital of the University of Pennsylvania. Reviewed last on: 10/22/2008
  12. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  13. Canadian Mental Health Association > Post Partum Depression Retrieved on June 13, 2010
  14. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  15. Field, T (Feb 2010). "Postpartum depression effects on early interactions, parenting, and safety practices: A review". Infant Behavior and Development. 33, 1-6.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  16. 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  17. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  18. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  19. Porter and Gavin (July 2010), Infanticide and Neonaticide: A Review of 40 Years of Research Literature on Incidence and Causes, Trauma Violence & Abuse, vol. 11, no. 3, pp. 99-112
  20. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  21. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  22. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  23. 23.00 23.01 23.02 23.03 23.04 23.05 23.06 23.07 23.08 23.09 23.10 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  24. 24.0 24.1 24.2 24.3 McCoy SJ, Beal JM, Shipman SB, Payton ME, Watson GH (April 2006). "Risk factors for postpartum depression: a retrospective investigation at 4-weeks postnatal and a review of the literature". J Am Osteopath Assoc. 106 (4): 193–8. PMID 16627773. <templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  25. 25.0 25.1 25.2 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  26. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  27. The causal role of lack of social support in PPD is strongly suggested by several studies, including O'Hara 1985, Field et al. 1985; and Gotlib et al. 1991.
  28. 28.0 28.1 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  29. 29.0 29.1 29.2 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value). Cite error: Invalid <ref> tag; name "Ross" defined multiple times with different content
  30. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  31. 31.0 31.1 31.2 31.3 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  32. 32.0 32.1 Western, Deborah (2013-01-01). A Conceptual and Contextual Background for Gender-Based Violence and Depression in Women. New York: Springer New York. pp. 13–22. ISBN 978-1-4614-7531-6.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  33. 33.0 33.1 33.2 33.3 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  34. Kruckman, Laurence (1999). "Rituals as Prevention: The Case of Postpartum Depression". In Heinze, Ruth-Inge. The Nature and Function of Rituals: Fire from Heaven. Greenwood Publishing. pp. 213–28. ISBN 978-0-89789-663-4.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  35. Kruckman, L. "A Renewed Call for a Biocultural Understanding of Postpartum Depression Etiology," paper presented at the Max Planck Institute International Symposium, "Postpartum Dysphoria & Depression: Anthropological, Ethnopsychiatric & Evolutionary Dimensions" Reimers Stiftung, Bad Homburg, Germany, 2000.
  36. Beck 1995[verification needed]
  37. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  38. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  39. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  40. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  41. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  42. Jennings et al. 1999[verification needed]
  43. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  44. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  45. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  46. 46.0 46.1 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington, VA: American Psychiatric Association. 2013.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  47. http://www.webmd.com/depression/postpartum-depression/understanding-postpartum-depression-basics
  48. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  49. 49.0 49.1 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  50. 50.0 50.1 "Screening for Depression During and After Pregnancy". American College of Obstetricians and Gynecologists, Committee Opinion. February 2010.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  51. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  52. 52.0 52.1 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  53. 53.0 53.1 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  54. PubMed Health. "Preventing postnatal depression". National Center for Biotechnology Information. Retrieved 30 May 2013.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  55. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  56. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  57. 57.0 57.1 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  58. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  59. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  60. Chasse, J[verification needed]
  61. 61.0 61.1 61.2 61.3 61.4 Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).
  62. 62.0 62.1 62.2 62.3 Sehran, Nilufer; Ege, Emel; Ayranci, Unal; Kosgeroglu, Nedime (2011). "Prevalence of postpartum depression in mothers and fathers and its correlates". Journal of Clinical Nursing.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  63. Laderman, Carol (1987). Wives and midwives : childbirth and nutrition in rural Malaysia (1st pbk. ed.). Berkeley: University of California Press. p. 202. ISBN 9780520060364.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  64. McElroy, Ann; Townsend, Patricia K., eds. (2009). "Culture, Ecology, and Reproduction". Medical Anthropology in Ecological Perspective. pp. 217–66. ISBN 978-0-7867-2740-7.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  65. Lua error in Module:Citation/CS1/Identifiers at line 47: attempt to index field 'wikibase' (a nil value).

External links