VIETNAM NATIONAL UNIVERSITY HA NOI
UNIVERSITY OF EDUCATION

TEP PHARIN

POSTPARTUM DEPRESSION IN CAMBODIA WOMEN

MASTER’S THESIS IN PSYCOLOGY

HANOI, VIETNAM: April, 2016


VIETNAM NATIONAL UNIVERSITY HA NOI
UNIVERSITY OF EDUCATION

TEP PHARIN

POSTPARTUM DEPRESSION IN CAMBODIA WOMEN

MASTER’S THESIS IN PSYCOLOGY
Major: Clinical psychology of children and adolescents
Code: Pilot

Supervisor: Prof. Dr. Bahr Weiss
Dr. Tran Thanh Nam

HANOI, VIETNAM: April, 2016


SUPERVISOR’S RESEARCH SUPERVISION
STATEMENT

TO WHOM IT MAY CONCERN

Name of program: Master‟s degree of Art in Clinical Psychology, specialize in
Child and
Adolescent Clinical Psychology.
Name of candidate: Tep Pharin
Title of research: Post-partum depression in Cambodia women
This is to certify that the research carried out for the above titled master„s
thesis was completed by the above named candidate under my direct supervision.
This thesis material has not been used for any other degree. I played the following
part in the preparation of this thesis:

Supervisor (s)…………………………….
Date………………………………………


ABSTRACT
Cambodia is one of the developing countries where postpartum depression
has a high predictive rate. Unfortunately, there is no data on postpartum depression.
This study was the first study which explored the rate of postpartum depression and
anxiety in women in Cambodia. According to GAD -7 measures, 26% of our
participants had moderate and severe anxiety. According to EPDS, 30% of our
participants had moderate and severe depression. The rate of anxiety and depression
among our participants are very high. Therefore, policy makers, researchers, health
practitioners should pay more attention to the issues in order to improve the life of
women and their infants. There should be more research into these issues in order to
have a better understand of these issues. Particularly, the next research should
include more women, expand the age‟s ranges of participants as well as the
geographic of the participant in order to achieve a more representative sample.



TABLE OF CONTENTS
ABSTRACT .............................................................................................................. iv
Table of Contents ........................................................................................................v
ACKNOWLEDGEMENT ........................................................................................ vi
1.1 Background and Rationale of the Research .......................................................1
1.2 Research Problem ..............................................................................................2
1.3 Research Objectives...........................................................................................3
1.4 Scope of the Research ........................................................................................3
1.5 Significance of the Research .............................................................................4
PART II - LITERATURE REVIEW ..........................................................................5
2.1 What is postpartum depression? ........................................................................5
2.2 Measures of Postpartum Depression .................................................................5
2.3 Prevalence of postpartum depression around the world ....................................6
2.4 Effect of post-partum depression on the child. ..................................................8
2.4 Risk factors in postpartum depression: ..............................................................9
PART III - RESEARCH METHODOLOGY ...........................................................13
3.1 Sample and data collection ..............................................................................13
3.2 Instrument and Scales ......................................................................................13
3.3Ethics ................................................................................................................15
3.4 Data Analysis ...................................................................................................16
PART IV - RESULTS ...............................................................................................17
4.1 Demographic characteristics ............................................................................17
4.2 Preliminary analyses: Mean levels of variables ..............................................19
4.3 Primary analyses: Prediction of postpartum depression, and anxiety .............24
PART V - DISCUSSION ..........................................................................................27
PART VI - CONCLUSION AND RECOMMENDATION .....................................32
6.1 Conclusion: ......................................................................................................32
6.2 Recommendations ............................................................................................33

REFERENCES ..........................................................................................................35


ACKNOWLEDGEMENT
I would first like to thank my thesis advisors Dr. Bahr Weiss and Dr. Nam
Tran who always provided patient and insightful responses whenever I ran into a
trouble spot or had a question about my research or writing. His guidance helped
me in all the time of research and writing of this thesis. I could not have imagined
having a better advisor and mentor for my Ph.D study.
I would also like to acknowledge The University of Education, Vietnam
National University and well as National Institutes of Health give me a chance to
participate in their wonderful Master program. Without they precious training it
would not be possible to conduct this research.
Finally, I must express my very profound gratitude to my parents and to my
husband for providing me with unfailing support and continuous encouragement
throughout my years of study and through the process of researching and writing
this thesis. This accomplishment would not have been possible without them. Thank
you.


PART I - INTRODUCTION
1.1 Background and Rationale of the Research
In modern society, the role of women is increasing, leading to more of a focus
on issues surrounding them. Among the issues, health, especially mental health is
getting more attention from policy makers, researchers, and practitioners. Mental
health becomes an important issue for woman because improving mental health
improves the quality of life for the woman as well as their functioning in society.
According to The National Institute of Mental Health (2015), woman are faced with
many mental health problems, common ones being anxiety, bipolar disorder, attention
deficit hyperactivity disorder, borderline personality disorder, eating disorders,

postpartum depression, depression, and schizophrenia. Among these problems,
postpartum depression is known as one of the most common mental health issues in
mothers and prenatal woman (Hanlon 2013).
Women with postpartum depression experience depression symptoms: sadness,
worries, withdraws, and thoughts harming themselves and their children. Postpartum
depression is different from other kinds of depression because its symptoms start to
develop within one year after the mother gives birth. Because postpartum happens
during a critical time, its effects go beyond the common effects of general depression,
creating significant consequences for the suffering mothers and their children. While
having a baby should be a happy time, postpartum depression makes the mothers suffer
sadness. After giving birth, the mothers need to cover from the labor, experiencing
postpartum depression symptoms prevents them from recovering normally and adds
another burden for them to cope with. The symptoms of postpartum depression also
prevent the suffering mothers from completing their duties with their children, thus
affecting their childrens‟ development. Additionally, its symptoms are opposite from
the typical feelings of new mothers. Instead of being happy to have a baby and feeling
1


skilled enough to take care of their children, Bilszta, Ericksen et al. (2010) showed
evidence that woman suffering from postpartum depression have some belief and fear
that prevent them from seeking help, making the effects of the issues even heavier
Postpartum depression is well known in developed countries. O'hara and Swain
(1996) did a meta-analysis of 59 studies. The total participants were 12,810, and their
analysis showed that the prevalence of postpartum depression was 13%. Gavin, Gaynes
et al. (2005) did a more recent systematic review that showed that the frequency of
postpartum depression was 19.2% with 7.1% for major depression and 12.2% for
minor depression. Two large studies done in Europe recently both predicted that the
occurrence of postpartum depression is about 9.2% to 9.6% (Navarro, García-Esteve et
al. 2008, Banti, Mauri et al. 2011). Although the rates vary between these studies, they

show that the prevalence of postpartum depression is quite significant among woman.
Like many other mental health issues, postpartum depression is not getting as
much attention in developing countries as it is in developed countries. In their recent
review the data of postpartum depression in low and middle income country, Parsons,
Young et al. (2012) conclude that much less is known about this issue in developing
countries compared to what has been determined in the high income countries. Among
available data, the rate of postpartum depression in developing countries varies from
4.9% (Nepal) to 33% (Vietnam). Southeast Asia has a significant rate of postpartum
depression: 11.5% (Malaysia), 13.3% (Thailand), 16.3%, and 33% (Vietnam). Besides
having a high rate, most postpartum depression, like other maternal depression,
remains undiagnosed and untreated in middle and low income countries. Therefore,
greater attention needs to be paid to postpartum depression in developing countries.
1.2 Research Problem
Cambodia is one of the developing countries where postpartum depression has a
high predictive rate. Unfortunately, there is no data on postpartum depression. As a
Cambodian woman, I believe that Cambodian woman carry a lot of burdens during the
2


time surrounding the birth of a baby. Culture beliefs and practices could put more
stress during the postpartum time for mothers. First, the society is hierarchical, woman
have “double duty” both working and taking care of the family (Ebihara, Mortland et
al. 1994) thus, woman undergo a lot of stress and pressure. The Khmer has a proverb
"num min thom cheang nil" meaning that parents know to choose who to married
better than a child (Ebihara, Mortland et al. 1994). Many married couples in Cambodia
are still arranged, which leads to potential problems including an unhappy married life,
thus reducing the support the women have during their postpartum time. White (2004)
also pointed out some potential harmful traditional practices including a high salt diet
during the postpartum period, drinking Khmer medicines infused in rice wine while
roasting, labor work at home (delivery the child at home). In order to have better

understanding about postpartum depression, our study aims to be the first study to
investigate the rate of and the risk factors surrounding postpartum depression among
Cambodian women. The results of the study will provide information to policy makers
and practitioners to improve the lives of mothers in Cambodia.
1.3 Research Objectives
The aims of this research study are (1) To assess the incidence of postpartum
depression in Cambodian women; (2) To identify risk factors for postpartum
depression in Cambodian women; (3) To assess at the relationships among factors
related to postpartum depression in Cambodian women.
1.4 Scope of the Research
Very little research has been conducted on postpartum depression in Cambodia.
This research study will be focused on a sample of 50 women in a single district on the
province of Kandal (Mukh Kampul district) in Cambodia. Research was collected
during a 1-month time frame in May 2015.This research study will focus on the
potential risk factors of postpartum depression in Cambodian women. The main target
group consists of 50 mothers who delivered their babies in the period of 3 to 6 months.
3


1.5 Significance of the Research
Even though the sample of this study is small, it is the first data collected on
postpartum depression in rural areas in Cambodia. This data allows an estimate on the
prevalence and the seriousness of postpartum depression in Cambodia. The result,
therefore, could make policy makers pay more attention to the issue. This data also
tries to provide an understanding of some risk factors for postpartum depression.
Understanding these risk factors would help practitioners in implementing prevention
and intervention strategies to help the postpartum women.

4



PART II - LITERATURE REVIEW
2.1 What is postpartum depression?
Postpartum depression (PPD) is a type of clinical depression that occurs after a
woman gives birth. It also called postnatal depression. Its symptoms include the same
symptoms as other forms of depression, such as sadness, anhedonia, low self-esteem,
changes in eating and sleeping habits, lack of energy, reduced interest in sex, and
irritability. Although the majority of women who experience PPD have mild symptoms
postpartum that disappear over the course of several weeks after birth, postpartum
depression can be severe and last a number of months. PDD often begins within the
first few weeks after giving birth, but research studies have found that about half of
cases of PDD actually begin prior to giving birth (Chen et al., 2008; Yonkers et al.,
2001).

According to the American Psychiatric Association Diagnostic Statistical

Manual of Mental, Fifth Edition (DSM-5), post-partum depression is defined as a
major or minor depressive episode affecting women within four weeks after childbirth
but it is commonly believed by clinicians and researchers to occur anytime within the
first year postpartum (APA, 2013).
2.2 Measures of Postpartum Depression
The mostly widely used measure to assess postpartum depression is the
Edinburgh Postpartum Depression Scale. It has been used in many research studies and
many countries around the world. It was first developed by Scottish health centers in
Edinburgh and Livingston. It has 10 items that are rated with a 0, 1, 2, 3 Likert scale on
the severity of the PPD symptoms. The total score is calculated by adding up the points
together from the total of 10 questions. In addition, the Postpartum Depression
Screening Scale (PPDS) (Beck & Gable, 2000) is sometimes used to screen for PPD.
The PPDS is a longer questionnaire than the EPDS. It contains containing 35items and
produces 7 subscales. These subscales include disturbance in (1) Sleeping and Eating;

5


(2) Anxiety / Insecurity, (3) Emotional Lability, (4) Mental Confusion, (5) Loss of Self,
(6) Guilt and shame, (7) Suicidal Thoughts. The PPDS is generally considered a valid
questionnaire, but the EPDS is more often used because the EPDS is shorter.
2.3 Prevalence of postpartum depression around the world
The nature, prevalence and determinants of mental health problems in women
during pregnancy and in the year after giving birth have been thoroughly investigated
in high-income countries. O'hara and Swain (1996) did a meta-analysis of 59 studies.
The total participants were 12,810. Their analysis showed that the prevalence of
postpartum depression was 13%. Among the59 studies, 31 studies used interviewbased methods, and 29 studies used self-report measures. The overall prevalence of
postpartum depression via the self-report measure was 14%. Gavin, Gaynes et al.
(2005) conducted a more recent systematic review, covering literature up to 2003, and
they only looked at studies that used interview-based assessment. This review showed
that the rate for postpartum depression were 19.2% with 7.1% for major depression and
12.2% for minor depression. There are no further systematic reviewsto date, however,
there is some new data. Two large studies done in Europe recently both predicted that
the prevalence of postpartum depression is about 9.2% to 9.6% (Gaynes, Gavin et al.
2005, Banti, Mauri et al. 2011). It is noticeable that the rate of postpartum depression
varies from 9.2% to 19.2%. The most important factors that contribute to this variety is
the difference in diagnostic criteria, especially the time period. O'hara and Swain
(1996) consider the postpartum period to be up to the first eight weeks after the
delivery while the review of Gaynes includes the first 12 weeks. Despite all the
differences in rates, this data confirms that the rate of postpartum depression in high
income countries is quite significant.
A systematic review have shown that in these settings, about 10% of pregnant
women and 13% of those who have given birth. 2 experience some type of mental

6



disorder, most commonly depression or anxiety.3 Social, psychological and biological
etiological factors interact, but their relative importance is debated.
Mental health issues in general get much less attention in developing countries
than in developed ones. The mental health of women who have just given birth living
in low- and lower-middle-income countries has received less research attention, in part
because greater concern has been focused on preventing deaths related to pregnancy.
Parsons, Young et al. (2012) reviewed data on postpartum depression in middle and
low income countries and concluded that much less is known about this issue
compared to what has been found in the high income countries. However, this issue
might have a strong impact on the lives of women in middle and low income countries
as it has been suggested that in low resource countries women are less likely to
experience post-partum mental problems due to the support from social and traditional
cultural practices used during and after pregnancy. As the result, postpartum depression
is now attracted great attention (Hanlon 2013).
Among available data, Fisher et al. (2012) recently conducted a meta-analysis
that examined the prevalence of PPD in LMIC. They identified 47 studies in LMIC that
had assessed post-partum depression. They conducted a meta-analysis to review the
studies, and found that the overall rate of postnatal depression was 20%, significantly
higher than the 13% rate in high income countries (Fisher et al., 2012). It is noticeable
that most of the studies that were included in Fisher‟s review recruited people through
health care/ health facility centers. This population is less likely to represent woman in
the middle and low income countries where woman have limited access to health care.
In another review, Villegas, McKay et al. (2011) look at the data in rural area in both
developed and developing countries. Their data suggested that the overall rate of
postpartum depression was 27.0%. The rate of postpartum depression for rural woman
in developing countries is significantly higher than in developed countries (31.3% vs
21.5%). No Southeast Asian countries were included in this review. The last review
7



was from Parsons and colleagues in 2012. These authors showed that the rate of
postpartum depression in developing countries varied from 4.9% (Nepal) to the highest
at 33% (Vietnam). Southeast Asia has quite a significant rate of postpartum depression:
11.5% (Malaysia), 13.3% (Thailand), 16.3%, 33% (Vietnam).
2.4 Effect of post-partum depression on the child.
Research has found that there are a number of negative outcomes associated
with a mother‟s post-partum depression and child functioning. These include low birth
weight, child behavior problems, children‟s somatic complaints, learning difficulties in
school, a poor growth trajectory, and emotional mental health problems (Zuckerman
&Beardslee, 1987). Research in England has shown that postpartum depression can
increase the risk of infant death from Sudden Infant Death Syndrome. As they become
older, children of depressed mothers are more likely to be depressed themselves
(James, & Blackmore,2002).

However, as a mother‟s depression improves, the

situation for the child also improves.
Behavioral Development. Mothers with PDD often pay less attention and are
less responsiveness to their children. They also are role models for negative mood and
emotions and problem solving. Longitudinal studies that have compared behaviors of
mothers with and without PPD, and their children‟s outcomes have found that children
with mothers with PPD were less likely to set behavioral limits with their children and
less likely to implement behavioral consequences if they did set limits to follow
through if they did set limits (Kochanska et al., 1987). Children of mothers appeared
more passively oppositional, and have less develop age-appropriate autonomy
(Kuczynsk et al., 1990). Children of mother‟s with PPD are more likely to negatively
respond to friendly approaches from other children, less likely to engage in physical
play or creative play than children of mothers without PDD.

Cognitive and Academic Development. There is an association between
maternal PDD and attention deficit/hyperactivity disorder (ADHD). In a study
8


conducted by Lesesne et al. (2003), 9,529 mother-child dyads were assessed, and a
moderately large correlation was found between maternal depression in ADHD, even
after adjusting for the child‟s age, sex, race, household income and type of family
structure. Other studies using large samples have found similar effects of PDD on child
cognitive development. Studies on large samples all agree on the negative impact of
maternal postpartum depression on a child‟s cognitive development. Early experience
with a depressed mother predicts of reduced cognitive functioning. In a study by Sharp
et al (1995), children of depressed mothers showed a decrease on standardized tests of
intellectual ability, particularly in regard to abstract intelligence. Other aspects of
cognitive development, such as language functioning, also have been shown to be
affected negatively by maternal post-partum depression.
Thus, research shows that maternal post-partum depression can have serious
effects on the child‟s development. It also has shown that these effects may persist into
adolescence.
2.4 Risk factors in postpartum depression:
Risk factors of a disease are any biological, cultural, or social features of a
person that would heighten the probability of experiencing the disease (WHO 2016).
On the other hand, a protective factor is one that decreases the risk of developing a
disease. In order to determine risk factors, epidemiologists use statistics to determine the
correlation between the existence of the disease and factors contributing to it. It is
important to emphasize that risk factors are not the causes of the disease. However,
they could provide hypotheses for the etiology ofit. In other words, some risk factors
could be the cause of the disease, but the relationships have not been proven. To some
extent, risk factors are used in screening tests if they are strongly associated with the
disease (Wald, Hackshaw et al. 1999).

Etiology of Postpartum Depression. Currently, there are two models that
explain the etiology of postpartum depression. The first is the hormone withdraw
9


model, which focuses on the biological aspect. The second is the cognitive model,
which focuses on stressful factors in life. The hormone withdraw model proposes that
postpartum depression is mainly caused by the fact that steroid hormones, estradiol and
progesterone, change dramatically during the postpartum period (O'hara and McCabe
2013). The cognitive behavior model proposes that stressful events during postpartum
period cause depression (O'Hara, Rehm et al. 1982). However, there is little evidence
to support both of the theories, and the mechanism behind how postpartum depression
develops is still unknown (O'hara and McCabe 2013).
Risk factors. O'hara and Swain (1996) did the first meta-analysis on
epidemiology research in postpartum depression, containing 59 studies with 12,810
subjects. Their meta-analysis found the following risk factors for the development of
postpartum depression: social class, life stressors during pregnancy, marital problems,
lack of support from their partner during pregnancy, and previous mental health
problems, particularly depression and anxiety. A more recent review, from Stewart,
Robertson et al. (2003) which is covered 14,000 subjects, identified a broader picture
of risk factors. The same risk factors that were identified in the first review remained
the strongest risk factors: depression and anxiety during pregnancy, previous history of
depression, stressful life events during of the early puerperium, and low levels of social
support. The moderate risk factors were high levels of childcare stress, low self-esteem,
neuroticism, and infant temperament (Stewart, Robertson et al. 2003). The moderate
risk factors seem to focus on the stressors that occur after the pregnancy apart from low
self-esteem. Small predictors were pregnancy problems, relationship problems,
negative thoughts, and social class (Stewart, Robertson et al. 2003). This recent review
also pointed out that the following factors were not the risk factors for postpartum
depression: age, ethnicity, education level of the mother, and the gender of the child

(Stewart, Robertson et al. 2003). There are significant differences between the two
meta-analyses. For example, social class was a strong risk factor in the first review, but
10


it was only small risk factors in the more recent review. It should be noticed that the
two meta-analyses were done in different times, the second review was done in 2004
while the first review was done in 1996. With an 18 year difference, some factors could
change the way they affect the mothers. For example: low social class in the first
review could mean bad situations like hunger, but low social class in the second review
could mean that the mother used aid money from the government. Despite these
differences, the meta-analyses converge on some core themes, moderate to strong risk
factors of postpartum depression are: depression (history or during the pregnancy),
postpartum blues (short depression after delivery), anxiety during pregnancy, low selfesteem, neuroticism, stressful live events including childcare problems, marital
problems, and a lack of social support. Modest risk factors are: unwanted pregnancy,
medical problems during pregnancy, social class (SES), married status (single), and a
challenging infant O'hara and McCabe (2013).
Risk factors in low and middle income countries. Most of the meta-analysis
were based on data from high income countries, therefore, their findings may not
reflect the situation in middle and low income countries (O'hara and McCabe (2013).
Fisher et al. (2012) conducted a meta-analysis that only focused on data from middle
and low income countries to identify the risk factors for common mental disorders
during the perinatal period. Common mental disorders were: depressive, anxiety,
adjustment, and somatic disorders. They found the risk factors: social and economic
status, problems in couple relationships, lack of social support from family and
communities, problems with health including reproductive health, history of mental
health problems, and infant characteristics. Coast, Leone et al. (2012) pointed out that
most of the research focused on individual levels of the risk factors while the role of
neighborhoods, communities, and locations were ignored. The points of Coast, Leone
et al. (2012) are very important for research in Southeast Asian since neighborhoods,

communities, and locations have important roles in the culture, although it is difficult
11


to assess these factors. Besides risk factors, Fisher, Mello et al. (2012) also identified
protective factors: more years of education, having a stable job, having an employed
partner, belonging to the ethnic majority group, and traditional postpartum care from a
trusted person.

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PART III - RESEARCH METHODOLOGY
3.1 Sample and data collection
The sample in this study consisted of 50 women who had given birth in the last
3 – 6 months. Sampling involved the convenience sampling technique. In order to
obtain the sample, women‟s names were obtained by contacting village chiefs in the
Mukh Kampus district of Cambodia‟s Kandal province. The researchers also received
names of women in this district who had given birth recently at the local hospital in the
district. Individual interviews were completed by trained student research assistants
who were current students at the Department of Psychology at the Royal University of
Phnom Penh. All women participants in the study were interviewed in their home.
Each interview took approximately one hour to complete and followed the interview
protocol described next.
3.2 Instrument and Scales
The research interview questionnaire was designed to measure post-partum
depression (PPD) as well as some potential factors that may relate to PPD in women
today.

Demographic items were included such as age, years of education, number of


children, employment status, health ratings and experiences of domestic violence.
Post-Partum Depression. In order to measure Post-Partum Depression (PPD)
the Edinburgh Postnatal Depression Scale 1 (EPDS; Cox, Holden & Sagoysky, 1987)
was used. This test was developed in 1987 and has been used extensively as a measure
of PPD in many different countries and cultures and translated into numerous
languages. For example, the EPDS has been translated into languages such as Chinese
(Wang, Guo, Lau, Chan, Kin, Yin, & Chen, 2009), Chichewa (Stewart, Umar,
Tomenson & Creed, 2013), Portuguese (Matijasevich, et al., 2014), and Iranian
(Montazeri, Torkan, & Omidvari (2007). The EPDS includes 10 questions that are each
rated on a four-point scale. When scored, there is a maximum score of 30 for this test.
13


A score of 13 or more is considered to be a significant 'case' of postnatal depression,
while scores of 10 to12 represent 'borderline' and 0 to 9 'not depressed.' Like other
portions of the research interview, this scale was translated in the Khmer language
before data collection.
Marital Satisfaction: The abbreviated Dyadic Adjustment Scale (Sabourin,
Valois & Lussier, 2005) was included to measure the quality of the relationship the
women have with their spouse. This scale has a total of six questions about how often
the women in agreement with her partner. One example item states “We (myself and
my partner) have enjoyable conversations”. Each question is rated on a 6-point scale
ranging from “we always agree” to “we always disagree”. Higher scores (we always
agree) are scored with 5 points and “we always disagree” responses are scored as 0
points. A higher average score on these six-questions suggests better adjustment and
quality in the primary relationship.
General Life Satisfaction: Participants were also asked to rate their current
happiness level (on a 7-point scale) and completed the 5-item Satisfaction with Life
Scale (Deiner, Emmons, Larson, & Griffin, 1985). This scale measures how satisfied a

person is with their life with questions such as “In most ways my life is close to ideal”
and “The condition of my life is excellent”. Respondents are asked to rate each item
for agreement a 7-point scale ranging from 1 (strongly disagree) to 7 (strongly agree)
so that a higher average score represents higher satisfaction with life. This scale has
been translated into many languages and used in many different cultures. This scale
was

previously

translated

into

Khmer

and

can

be

accessed

at

www.internal.psychology.illinois.edu/~ediener/Documents/SWLS_Khmer.pdf.
Anxiety. Anxiety was assessed by the Generalized Anxiety Disorder – (GAD-7)
scale. The GAD-7 is a widely used questionnaire that assesses anxiety. The test was
designed with seven items that assess symptoms that are aversive. Each question has
four choices on the Likert scale, from 0 to 3, and total points range from 0-21

14


points. Subjects with 0-4 are considered to not have anxiety, from 5-9 are considered
mild anxiety, from 10-14 anxiety medium, from 15 points or more is considered severe
anxiety.
Predictors of Postpartum Depression Inventory. This scale assesses factors
that are hypothesize or that have been found to be related to postpartum depression.
These include economic status, self-esteem, anxiety and depression before birth, social
support from the spouse, family, and friends, stressful life events, and stress in caring
for children.
Traditional Practices Questionnaire. This questionnaire assesses culturally
specific traditions that follow childbirth in Cambodia. As these cultural traditions may
be related to the development of postpartum depression, the many traditions were
explored by the interviewer in both closed and open-ended questions. For example, a
list of traditional practices included taking traditional herbal medicines, maintaining a
special diet, or engaging in daily practices such as avoiding drinking cold water,
placing rice bags on the abdomen, or lying near a fire. Further questions were asked
about the purpose of these practices.
All of the scales were collected into a single interview questionnaire and
translated into Khmer.

Both the English and Khmer versions of the interview

questionnaire are presented in Appendix 1.
3.3 Ethics
All of the participants in this study were asked to volunteer their time to answer
the questions of the interviewers. No one was coerced to answer the questions, and if
they became tired or no longer wished to answer the questions, they were told that they
may stop the interview at any time. The data collected was stored in a safe location

and no names are attached to the responses so that all data are analyzed by group, and
no data is associated with the names of the individuals. The study was approved by the
Human Research Board at the Vietnam National University.
15


3.4 Data Analysis
Data were entered in the SPSS version 21 for Window. SPSS and SAS were
used to analyze the data.

16


PART IV - RESULTS
4.1 Demographic characteristics
Because this study focused on women, the gender of all participants was female.
Table 1 presents the demographics for the sample. The women ranged in age from 19
years old to 34 years old, with a mean of about 26 years of age. There was also a wide
range of education, ranging from completing the 2nd grade to completing two years of
college, with the mean years of education being about 7 (i.e., the average participant in
this study did not enter junior high school). Almost all of the women were married
(96%). The average monthly income of the women was $129 and the average monthly
income of their partner (all women were living with a partner) was $176. Two thirds
of the women reported that their overall health was “good” with 20% reporting less
than “good” health. Most women were either employed (48%) or housewives (36%)
with only 12% unemployed and looking for a job.
The average number of children in the household was about 2.8, and the target
child was on average about 5 months old when the interview was conducted. Almost
2/3 of the women (64%) reported that their partner had a significant problem with
alcohol, drugs, or gambling, and 14% reported that they had been physically abused

and 2% reported that they had been sexually abused by their partner in the last year.

17


Table 1 – Demographic Characteristics
Characteristic

Mean (SD) [Min - Max] / %

Age: Years

25.93 (3.86) [19 – 34]

Education: Years

7.09 (2.75 [2 – 14]

Marital Status
Married

96%

Divorced

4%

Number people in house

6.18 (2.65) [3 – 12]


Monthly income: US $

128.52 (46.02) [40-200]

Overall health
Excellent %

2%

Very Good %

6%

Good %

66%

Fair %

14%

Poor %

6%

Employment status
Employed outside home %

48%


Housewife %

36%

Unemployed, want job %

12%

Unemployed, don‟t want job %

2%

Number of children – Mean (SD) [Min- Max]

2.82 (1.00) [1 – 5]

Target child age: Months – Mean (SD) [Min- Max]

4.88 (1.20) [3– 6]

Partner: Employment status of
Employed outside home

100%

Partner: Monthly income: US $

175.58 (85.50) [40 – 550]


Partner has alcohol, drug, or gambling problem %

64%

Past year, partner physically abused %

14%

Past year, partner sexually abused %

2%

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4.2 Preliminary analyses: Mean levels of variables
Overall, participants reported on the Dyadic Adjustment Scale that they were
“happy” with their relationship, average=3.08 (with 2=A Little Unhappy, 3=Happy,
4=Very Happy).

Participants reported that they almost always agreed with their

partner about what they wanted from their life and family (Item #1, average=4.00),
what was important to them individually and as a family (Item #2, average=4.08), and
on the amount of time they spent together (Item #3, average=4.02). They also reported
that they had an enjoyable conversation between several times a week (Item #4,
average=3.64), and calmly discussed something (Item #5, average=3.36) and worked
together on a family matter (Item #6, average=3.02) once or twice a week.

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