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A cross-sectional analysis of perinatal depressive symptoms among Punjabi-speaking women: are they at… Sanghera, Raman; Wong, Sabrina T; Brown, Helen Jul 22, 2015

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RESEARCH ARTICLE Open AccessA cross-sectional analysis of perinatal depressivesymptoms among Punjabi-speaking women:are they at risk?Raman Sanghera1, Sabrina T. Wong2* and Helen Brown3AbstractBackground: Depression is the leading cause of disability for childbearing women. We examined three specificresearch questions among Punjabi-speaking women residing in the Fraser Health Authority: 1) What are the prevalencerates of prenatal depressive symptoms? 2) Do Punjabi-speaking women have a higher likelihood of reportingdepressive symptoms compared to English-speaking women after controlling for age, level of education and financialworries, and 3) Given the same level of exposure to level of education and financial worries, do Punjabi-speakingwomen have the same likelihood of reporting depressive symptoms?Methods: Data originated from the Fraser Health Authority prenatal registration database consisting of pregnantwomen (n = 9684) who completed a prenatal registration form between June 2009 and August 2010; 9.1 % indicatedspeaking Punjabi. The Whooley Depression Screen measured depressive symptoms. Chi-square tests and logisticmultiple regression were used to examine the rates of reporting depressive symptoms among Punjabi-speakingwomen compared to English-speaking women.Results: Punjabi-speaking women are at a higher risk for perinatal depressive symptoms. Women needing aninterpreter were more likely to report prenatal depressive symptoms compared to English-speaking women. Allregistrants who reported financial worries had four and a half times the odds of reporting depressive symptoms. Theimpact of financial worries was significantly greater in the English-speaking women compared to the Punjabi-speakingwomen needing an interpreter.Conclusion: Using an established screening device, Punjabi-speaking women were found to be at higher risk forprenatal depressive symptoms.Keywords: Pregnancy, South Asian, Ethnicity, Health disparity, Immigrant, Canada primary health care, publichealthBackgroundDepression is the leading cause of disability for childbearingwomen [1]. The term ‘perinatal’ depression encompassesprenatal and/or postpartum depression within the first year,which often arises during pregnancy and extends intothe postpartum period [1]. The exact cause of perinataldepression remains unclear, though evidence suggeststhat depression in pregnancy is positively associated withpostpartum depression [2–5]. Past work also indicates thatperinatal depression results from a combination of bio-logical and psychosocial factors. A history of mental illnessor anxiety, the lack of social support, and stressful lifeevents are the strongest predictors of depression withinthe perinatal period [4–7]. Poor marital relationship,socioeconomic status, obstetric complications, and inparticular, migration experience have also been shownto influence the onset of depressive symptoms inwomen in the perinatal period [6–10].There are not only detrimental impacts of perinataldepression to women and new mothers but also on in-fants [2, 6]. Depression during pregnancy is positively* Correspondence: Sabrina.wong@nursing.ubc.ca2University of British Columbia School of Nursing and Centre for HealthServices and Policy Research, Co-Director of BC node of the CanadianPrimary Care Sentinel Surveillance Network, T201 2211 Wesbrook Mall,Vancouver, BC V6T 2B5, CanadaFull list of author information is available at the end of the article© 2015 Sanghera et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Sanghera et al. BMC Pregnancy and Childbirth  (2015) 15:151 DOI 10.1186/s12884-015-0568-2associated with fetus growth delays, preeclampsia, andpremature delivery [1]. Neonates born to mothers ex-periencing depression may have low birth weights, be lessresponsive to stimulation and have low vagal tone [2, 6].The reported prevalence of perinatal depression tendsto vary widely because of the manner in which the de-pression is defined, how the depression is diagnosed,characteristics of the population being studied, and theperiod of time being considered [11]. Generally preva-lence rates for both prenatal and postpartum depressionare similar, with a commonly reported estimate of 13 %[3, 6, 7, 12, 13]. Rates of depression appear higher inimmigrant women when compared to Canadian-bornwomen [14–17]. Stewart [16] and Sword [17] found thatimmigrant women were more likely to report depressivesymptoms. Similarly, Collins, Zimmerman, & Howard[18] and Fung & Dennis [19] determined that immigrantwomen had a high risk of depression with a prevalencerange of 24 to 42 %.Until recently, perinatal depression was typically viewedas a Western phenomenon. Recent research, however,indicates depression associated with childbirth has det-rimental consequences for women and families frommany nations and cultures [3]. In British Columbia(BC), Canada one in five women are estimated to ex-perience significant depression related to pregnancy andchildbirth; [1] Immigrant women are at a high risk forperinatal depression due to numerous stressors associ-ated with migration and acculturation [15–17]. Limitedresearch has been undertaken to understand the pres-ence of perinatal depressive symptoms, specificallyamong Punjabi-speaking women living in Canada. Thus,it is unknown whether these women are at a higher riskfor prenatal depression than their English-speakingcounterparts.The purpose of this study was to gain a better under-standing of perinatal depressive symptoms among Punjabi-speaking women, all of whom are assumed to be SouthAsian. We examined three specific research questionsamong Punjabi-speaking women residing in the FraserHealth Authority (FHA): 1) What are the prevalencerates of prenatal depressive symptoms? 2) Do Punjabi-speaking women have a higher likelihood of reportingdepressive symptoms than English-speaking womenafter controlling for level of education and financialworries? and 3) Given the same level of exposure tolevel of education and financial worries, do Punjabi-speaking women have the same likelihood of reportingdepressive symptoms?MethodsWe used a cross-sectional descriptive study design andcompleted secondary analyses of a database registered inthe Best Beginnings program. Pregnant South Asianwomen, those who self-identify as being associated withany southern part of Asia or South Asian group, [20]were the group of interest given that individuals fromIndia account for the largest proportion of all SouthAsian immigrants in Canada [21]. One of the mostdensely populated areas of FHA, British Columbia is thecity of Surrey, where India is the most common countryof birth and Punjabi is the most common languagespoken at home next to English among immigrants [21].Speaking Punjabi was taken to be an indicator of beingSouth Asian in this study since this is the most commonregion of immigrants’ birthplace within Surrey. Surreyhas the largest live birth rate in the entire Fraser HealthAuthority; South Asian immigrants account for a largeproportion of these births [22–24].ParticipantsThe Best Beginnings Program located in the FHA pro-vides public health services for pregnant and postpartumwomen and babies up to two years of age [25]. Womenwho register for this program self-report whether theyspeak Punjabi or another language the most. Given thesmall number of women who reported speaking anyother South Asian language, those who were included inour study were: Punjabi- and English-speaking who reg-istered for the Best Beginnings Program by completing aprenatal registration form. We examined two groups ofPunjabi-speaking women; one group included pregnantwomen who spoke Punjabi and indicated they requiredan interpreter and the other group were pregnantwomen who were Punjabi-speaking but did not indicatea need for an interpreter. We also included English-speaking pregnant women who did not indicate a needfor an interpreter. Our rationale for the English-speakinggroup was that regardless of ethnicity, this group wouldcontain women who were more accustomed to living inCanada.Best beginnings databaseThe prenatal database was developed using informationcollected in the Best Beginnings registration form whichincludes self-reported information on depressive symp-toms, level of education, financial worries, and tobaccouse. Roughly 40 % of pregnant women registered for theprogram throughout FHA. However, the registrationrates varied widely from one health unit to another withregistration rates being higher in areas where existingprenatal registration programs were in place. In the FHAwhere the majority of Punjabi-speaking women live (Sur-rey) the registration rate is closer to 70 %. This higherregistration rate reflects the comprehensive nature of theprenatal registration program in this jurisdiction. Onaverage, women registered at 27 weeks gestation andonly 15 % registered prior to 20 weeks [26].Sanghera et al. BMC Pregnancy and Childbirth  (2015) 15:151 Page 2 of 7Screening for depressive symptoms was measuredusing the Whooley Depression Screen. Primary languageand need for interpreter was also assessed. The prenatalregistration form is completed through a local healthunit, physician office, local hospital, or online at anytime during a woman’s pregnancy. Punjabi translationsof the form were available upon request. The purpose ofthe registration form was to identify pregnant womenwho could be at risk for depression, tobacco exposure,and other potential vulnerabilities (e.g. financial need)[26]. All completed prenatal registration forms were sentto health units for determination of follow-up by publichealth nurses (PHNs).We conducted a secondary analysis of the 2009-2010FHA prenatal registration database. The data from theprenatal registration forms was entered into a regionaldatabase developed by Fraser Health specialists [26].During this time period, approximately 9684 womencompleted the prenatal registration form. We comparedthe prenatal database to Fraser Health Profiles to exam-ine whether the pregnant women in the database wassimilar to the women in Fraser Health. Women whoprimarily spoke Punjabi made up 9 % of the prenatalregistration data compared to 7 % of the population livingin Fraser Health [22]. Among the prenatal registrants,15.2 % indicated worrying about finances, while the FraserHealth census data [22] reported that 14.3 % of its resi-dents are low income. Eleven percent of prenatal regis-trants reported some high school, which is lower than theFraser Health census data, [22] where 17 % reported theyhave completed less than high school.VariablesThe independent variable of interest was Punjabi- versusEnglish-speaking. The confounding variables included:age, level of education (some high school, high school,some college or university, college or university), and fi-nancial worries. The dependent variable of interest waspresence of depressive symptoms as measured by theWhooley Depression Screen. This screen is a reliableand valid measure consisting of two questions: “Duringthe past month have you often been bothered by feelingdown, depressed or hopeless?” and “During the pastmonth have you often been bothered by little interest orpleasure in doing things?” Research indicates these twoquestions address mood and interests, are as likely to beeffective in detecting depressive symptoms compared toother depressive symptom screening tools, and are feas-ible for routine use in routine health care [27, 28]. Thetool is only used for screening purposes and not a diag-nostic instrument for depression [27, 28].The Whooley Depression Screen is a two-item screen-ing tool considered to be simple, quick, and efficient forscreening for depressive symptoms during pregnancy[28]. Whooley et al., [28] compared the validity of theWhooley Depression Screen to six previously validatedinstruments including two types of the Centre for Epi-demiological Studies Depression Scale (CES-D), two formsof the Beck Depression Inventory (BDI), the Medical Out-come Study (MOS), and the Symptom-Driven DiagnosticSystem for Primary Care (SDSS-PC). These two questionsare considered separate items; a negative response to bothquestions on the screening tool indicates that depression ishighly unlikely [28], A positive response to either one ofthese items in the Whooley Depression Screen indicatesthe presence of depressive symptoms. The calculatedsensitivity of 96 % and specificity of 57 % was based onself-report [28].Data analysisWe conducted a power analysis using the statistical pro-gram R, version 2.15, to determine sample size adequacyfor detecting a statistically significant difference in pre-natal depressive symptoms between Punjabi- and English-speaking women. Based on an effect size of 0.35, [15, 29]our sample size for the Punjabi-speaking (n = 887) andEnglish-speaking (n = 7423) groups provided a power of 1in a two-tailed test at a significance level of 0.05. Punjabi-speaking women were divided into two groups: those whoindicated they needed an interpreter and those who didnot. A combination of parametric (e.g., analysis of vari-ance) and non-parametric (e.g., Chi-square) tests was usedto examine if there were differences between the groups.We conducted a series of logistic regressions to examinewhether the statistically significant association betweenlanguage and presence of depressive symptoms was atten-uated by age, level of education, and financial worries. TheStatistical Package for Social Sciences (SPSS), version 20,was used for the analyses. The University of BritishColumbia Behavioural Ethics Research Ethics Board andFraser Health Research Ethics Board approved of allprocedures.ResultsThe characteristics of the Punjabi- and English-speakingprenatal registrants are summarized in Table 1. English-speaking registrants were significantly older than thePunjabi-speaking registrants and the Punjabi-speakingregistrants with an interpreter (p < 0.05). A significantdifference was found in the reported level of educationbetween the three groups (X2 = 563.32, p < 0.001). Manymore Punjabi-speaking women needing an interpreterhad not completed high school compared to those whowere English-speaking (43 % versus 10 %, respectively).Almost three-quarters (74.5 %) of the English-speakingwomen reported to have partially or fully completedsome college or university, compared to 36 % ofPunjabi-speaking women needing an interpreter. ASanghera et al. BMC Pregnancy and Childbirth  (2015) 15:151 Page 3 of 7similar percentage of women in both the Punjabi-speaking women needing an interpreter and the English-speaking group reported having financial worries.Table 2 shows that the two Punjabi-speaking groupsreported a higher prevalence of depressive symptomscompared to the English-speaking group (X2 = 47.50, p= 0.001). Significantly more women needing an inter-preter reported depressive symptoms than the Punjabi-speaking and English-speaking women. Even aftercontrolling for age, level of education, and financialworries, the women needing an interpreter had twicethe likelihood of reporting depressive symptoms com-pared with their English-speaking counterparts (Table 3).Prenatal registrants who reported financial worries were4.5 times more likely to report depressive symptoms. Reg-istrants with an incomplete high school education weretwo times more likely to report depressive symptoms thanthose registrants who had completed their post-secondaryeducation.We conducted a logistic regression of Punjabi-speakingwomen who needed an interpreter (Table 4) in order toexamine whether the presence of age, level of education,and financial worries was associated with the reportingof depressive symptoms. Our results suggest that thosereporting financial worries were two times more likelyof also reporting depressive symptoms. Educationallevel had no statistically significant association in thereporting of depressive symptoms in the interpreter group;however, the point-estimates indicate that education on allthree levels is still associated with the reporting of depres-sive symptoms within this group. The point estimates aresuggestive of associations that are almost similar, if notstronger, in magnitude, than the English-speaking womengroup (Table 5). Those who have only completed highschool graduation appeared to have almost 2.5 times theodds of reporting depressive symptoms than those whohad graduated from college.Financial worries was the strongest associated factorin the reporting of depressive symptoms among theEnglish-speaking women. The impact of financial wor-ries was significantly greater in the English-speakingwomen compared to the Punjabi-speaking women withinterpreter group. English-speaking women reportingfinancial worries had 5 times the likelihood of reportingdepressive symptoms. In addition, within this group,education was significantly associated with the reportingof depressive symptoms. Notably, English-speaking womenwho had completed only partial high school educationhad more than twice the odds of reporting depressivesymptoms than those who had completed post-secondaryeducation.Table 2 Depressive symptoms in fraser health prenatal registrantsPunjabi-speaking withinterpreter n = 556 n (%)Punjabi-speakingn = 331 n (%)English-speakingn = 7423 n (%)Yes* 109 (20.6) 42 (13.1) 799 (10.8)Note. *p < 0.05Table 1 Characteristics of prenatal registrantsPunjabi-speakingwith interpretern = 556Punjabi-speakingn = 331English-speakingn = 7423Age: mean (sd)* 29.0 (4.5) 29.1 (4.2) 29.6 (5.2)Education: n (%)*Some high school 196 (42.6) 80 (28.8) 667 (9.6)High schoolgraduation100 (27.7) 45 (16.2) 1112 (15.9)Some college/university67 (14.6) 51 (18.3) 1688 (24.2)College/universitygraduation97 (21.1) 102 (36.7) 3506 (50.3)Financial worries:n (%)*81 (15.3) 28 (8.9) 1151 (15.6)Note. *p < .0.05Table 3 Factors associated with depressive symptoms in FraserHealth Prenatal RegistrantsFactor Odds ratio (95 % CIs)Ethnic/Language groupPunjabi-speaking with interpreter* 1.99 [1.54-2.59]Punjabi-speaking 1.29 [0.88-1.90]English-speaking (ref) 1Age 0.97 [0.98-1.01]Financial worriesYes* 4.57 [3.90-5.35]No (ref) 1EducationSome high school* 2.03 [1.62-2.05]High school graduation* 1.29 [1.04-1.60]Some college/university* 1.35 [1.11-1.63]College/university graduation (ref) 1Note. *p < 0.05Table 4 Factors associated with depressive symptoms inPunjabi-speaking with Interpreter WomenFactor OR (95 % CIs)Age 1.03 [0.98-1.09]Financial worries* 2.06 [1.17-3.61]EducationSome high school 1.49 [0.76-2.92]High school graduation 1.96 [0.94-4.08]Some college/university 1.67 [0.74-3.79]College/university graduation (ref) 1Note. *p < 0.05Sanghera et al. BMC Pregnancy and Childbirth  (2015) 15:151 Page 4 of 7DiscussionThis study is one of the few Canadian studies to investigateperinatal depressive symptoms among Punjabi-speakingwomen. The findings suggest that pregnant South Asianwomen who are Punjabi-speaking are at a higher risk forexperiencing perinatal depressive symptoms. Unique to thisstudy are the findings that being a Punjabi-speaking womanwith poor English language skills is strongly associated withself-reporting of depressive symptoms compared to beingan English-speaking woman. Our findings are similar tostudies completed in countries that suggest immigrantwomen are at a higher risk of prenatal depression thannon-immigrant women [21–23]. It is likely that the womenneeding an interpreter are more recent immigrants toCanada who still hold strong cultural beliefs and values as-sociated with their country of origin, India.Depression in pregnancy is highly prevalent in immi-grant women without social support [30, 31]. The processof migration and the associated impacts of language, gen-der and cultural environments intersect to create circum-stances that increase the risks for perinatal depression forthese women [10, 31]. Migrating to Canada for SouthAsian women can lead to a separation of social supportsand cultural norms such as the lack of support from theirmothers and female relatives. Moreover, the increaseddependency on their spouses and inability to financiallycontribute to the family could also be additional riskfactors for developing depressive symptoms [31].Financial uncertainties in contextWorrying about finances was significantly associatedwith reporting depressive symptoms in pregnancy. Ourresults are somewhat surprising since previous studieson prenatal depression have found immigrant womenare more likely to have a low income compared toCanadian-born women [14, 15]. More work needs to becompleted since financial uncertainties affect both English-and Punjabi-speaking women’s reports of depressive symp-toms. What is known is that financial uncertainties cannegatively affect the mental health of immigrants [15, 32];in FHA many of these immigrants could be Punjabi-speaking women, whom often experience employmentchallenges and economic insecurities throughout theimmigration period [33].Employment is often a challenging adjustment forPunjabi-speaking women, since many may not haveworked in their country of origin, relying on men to bethe primary income earners [32]. In Canada thesewomen may have to work outside the home and areoften still expected to fulfill culture-specific gender roleswithin the home. Patriarchal practices within the familycan result in greater stress and responsibility forPunjabi-speaking women, [34–36] increasing their riskfor depression during the sensitive perinatal period.Since their income is necessary for the household, manywomen are reluctant to take leave for self-care [32].Male partners may also be forced to work strenuouslyand may be unavailable for support to their wives duringthe prenatal and postpartum periods. Some women alsoface pressure to save their earnings to sponsor theirspouse or other family members who remain in theircountry of origin. These circumstances illustrate howthe cultural context of women’s lives can be shaped bythe intersection of patriarchal practices, marital relation-ships, and economic realities of new immigrant womenand their families. These dynamics affect the lives ofwomen in specific ways during pregnancy. These findingsindicate that depressive symptoms in pregnancy couldprovide an entry point for beginning to address the vari-ous factors in promoting health pregnancy outcomes.Reporting being worried about finances also had astrong association with the reporting of prenatal depres-sive symptoms among English-speaking women, espe-cially compared to the Punjabi-speaking women needingan interpreter. Past work suggests that socio-economicstatus, regardless of language spoken, is associated withdepressive symptoms in perinatal depression [6, 12].Education in contextIn the overall regression model of the entire sample ofprenatal registrants, the association of education withthe reporting of depressive symptoms was statisticallysignificant. In the separate regression analysis; however,education was not statistically associated with prenataldepressive symptoms in the Punjabi-speaking with inter-preter group, which may be attributed to a smaller sam-ple size and a lack of heterogeneity in the educationlevels within this group. Nonetheless the results suggestthat women with less education are more likely to reportdepressive symptoms in pregnancy. Certainly, the oppor-tunities for obtaining employment are lower for thosewho have less education and cannot speak English; fi-nances, as a consequence, are more likely to be a con-cern for these women. The affiliation to their homecountry’s culture may be stronger for those who indicateTable 5 Factors associated with depressive symptoms inEnglish-Speaking WomenFactor OR (95 % CIs)Age 1.00 [0.98-1.01]Financial worries* 5.03 [4.25-5.94]EducationSome high school* 2.47 [1.92-3.17]High school graduation 1.24 [0.94-4.08]Some college/university* 1.37 [1.12-1.67]College/university graduation (ref) 1Note. *p < 0.05Sanghera et al. BMC Pregnancy and Childbirth  (2015) 15:151 Page 5 of 7a need for an interpreter, likely because they are morerecent immigrants to Canada [37]. Thus, cultural affili-ation should be analyzed in conjunction with migration[38]. Language spoken inside and outside the home canalso be linked to the progressive integration into thecommunity at large [37].LimitationsThe results of this study should be interpreted with cau-tion. The data are cross-sectional and do not offerinsight into the nature of perinatal depression over timeor the timing of depressive symptoms among thesewomen. Although the data captures one of the largestsamples of Punjabi-speaking pregnant women in Canada,the findings have limited generalizability since only datafrom FHA is included and the precise proportion of preg-nant women living in Fraser Health at the time who wereregistered in the Best Beginnings program is unknown.The secondary data are from 2009 to 2010; after thisperiod, no central database was available. The prenatalregistration form is a self-report form and the screeningis completed on self-report measures. Some Punjabi-speaking women may have misunderstood the WhooleyDepression Screen questions since depressive symptomswithin the South Asian culture is often somatised, andphysical distress may be combined with mental distress[38]. The two questions of the tool have not been vali-dated in Punjabi-speaking women. Moreover, the speci-ficity of the tool suggests there is a 57 % potential tomisclassify women’s depressive symptoms. The prenatalregistration forms also did not assess for the presence ofpre-existing mental illnesses; hence, it is unknownwhether these depressive symptoms arose in the perinatalperiod or were due in part to recurrent and untreated de-pression or other mental illnesses. Finally, in the case ofthe English as a primary language group, it is likely thatthis group included other ethnic/cultural backgroundsand second generation immigrants that have their ownvulnerabilities to depression.Despite these limitations, the study findings suggestthat through screening, targeting, and accounting for thesocial determinants, nurses and other healthcare pro-viders could work towards the overall prevention andearly treatment of depressive symptoms with Punjabi-speaking pregnant women. The findings suggest that aprenatal registration database that contains intersectingdimensions of language, culture, migration, education,and financial concerns maintained by a health authoritycould assist in identifying women who may be at risk fordeveloping ill health. Obtaining data on language andmigration in addition to other social determinants ofhealth is important for developing gender and culturallysensitive public health interventions to reduce the healthdisparities in different groups. In particular, close attentionmust be given to the reporting of financial worries, inde-pendent of language spoken. Based on identified risk fac-tors, public health nurses and other health professionalscould work on developing stronger collaborations to meetthe mental healthcare needs of Punjabi-speaking women.These findings provide some evidence of the need toallocate more targeted resources and funds for preventiveand treatment options for populations who speak Englishas a second language. More work is needed to examinewhat tools and programs are needed to identify and sup-port Punjabi-speaking women’s mental health care needs.ConclusionUsing an established screening device, Punjabi-speakingwomen were found to be at higher risk for prenatal de-pressive symptoms. Further studies are needed to explorethe prevalence of perinatal depression among Punjabi-speaking and additional groups of South Asian immigrantwomen with additional validated instruments. New re-search should continue to evaluate the effectiveness of de-pression screening measures for women in the perinatalperiod to determine which measures are more culturallysensitive for a given population group and setting.This study provides insight into the context of depres-sive symptoms in pregnancy for Punjabi-speaking women.Additional longitudinal studies would be needed to exam-ine maternal and fetal outcomes and to consider theprocess of perinatal depression during pregnancy andinto the postpartum period. Further examination of theintersecting risk factors and their relation to the recov-ery process of perinatal depression may reveal valuablefindings about the reproductive mental healthcare needsof women.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsRS was the lead investigator, having conceptualized, obtained permission touse the data, analyzed the data, and wrote up the results. SW and HB wereinvolved in all parts of the study. All authors contributed substantively towriting this manuscript. All authors read and approved the final manuscript.Authors’ informationRaman Sanghera RN, BScN, MSN: Public Health Nurse, Newton Public HealthUnit.Sabrina T. Wong, RN, PhD: Professor, University of British Columbia School ofNursing and Centre for Health Services and policy research. Co-director, BCnode of the Canadian Primary Care Sentinel Surveillance Network.Helen Brown, RN, PhD: Associate Professor, University of British ColumbiaSchool of Nursing.AcknowledgementsWe would like to thank Fraser Health Authority for assistance with the datapreparation, Joseph Puyat, MSc for statistical consultation and Leena Chaufor assistance with formatting. Lastly, thank you to the UBC School ofNursing, BC Nurses’ Union and Fraser Health Authority for assisting with thefunding of this research project.Sanghera et al. BMC Pregnancy and Childbirth  (2015) 15:151 Page 6 of 7Author details1Fraser Health Authority, Public Health Nurse, Newton Public Health Unit,#200 7337 137th Street, Surrey, BC V3W 1A4, Canada. 2University of BritishColumbia School of Nursing and Centre for Health Services and PolicyResearch, Co-Director of BC node of the Canadian Primary Care SentinelSurveillance Network, T201 2211 Wesbrook Mall, Vancouver, BC V6T 2B5,Canada. 3University of British Columbia School of Nursing, T149-2211Wesbrook Mall, Vancouver, BC V6T 2B5, Canada.Received: 6 September 2014 Accepted: 27 May 2015References1. BC reproductive mental health program: BC Women’s Hospital and HealthCentre. Addressing Perinatal Depression: A Framework for BC’s HealthAuthorities. Vancouver, Canada; 2006:1–40.2. Field T. Prenatal depression effects on early development: a review. InfantBehav Dev. 2011;34:1–14.3. 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