Factors influencing adherence to psychological intervention referrals: a study of 35,390 women who screened positive for postpartum depression between 2016 and 2020 in Shenzhen, Southern China

Factors influencing adherence to psychological intervention referrals: a study of 35,390 women who screened positive for postpartum depression between 2016 and 2020 in Shenzhen, Southern China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Factors influencing adherence to psychological intervention referrals: a study of 35,390 women who screened positive for postpartum depression between 2016 and 2020 in Shenzhen, Southern China Dadong Wu, Siqi Chen, Siyuan Liu, Jiayi Zhang, Guanglin Zhao, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6502238/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Aug, 2025 Read the published version in Scientific Reports → Version 1 posted 14 You are reading this latest preprint version Abstract Background Postpartum Depression (PPD) is a significant public health issue in China. Despite the launch of a universal PPD screening and intervention programme in Shenzhen, Southern China, there remains a substantial gap between the number of women who screened positive and were referred for psychological interventions and those who actually presented at mental health institutions for further evaluation and treatment. To inform enhancements of the programme, this study sought to understand the factors influencing adherence to intervention referrals among women with positive PPD screening results. Methods Using a retrospective study design, data from the programme management information system was analysed. The sample comprised 35,390 women who gave births in Shenzhen and screened positive for PPD between January 2016 and December 2020. Chi-square test and stepwise logistic regression were employed to determine factors affecting intervention uptake, with a p -value of less than 0.05 indicating statistical significance. Results The study found that although referral messages were given to 85.9% of women with positive PPD screening results, only 16.1% of them received psychological interventions. High school education (OR = 1.266, 95% CI: 1.1602 ~ 1.38), anxiety (OR = 1.126, 95% CI: 1.048 ~ 1.210) and depressive symptoms (OR = 1.054, 95% CI: 0.968 ~ 1.145) during pregnancy, as well as bottle (OR = 1.368, 95% CI: 1.218 ~ 1.535) and mixed feeding (OR = 1.110, 95% CI: 1.043 ~ 1.181) were positively associated with treatment engagement. Conversely, women with high level of depressive symptoms after childbirth (OR = 0.892, 95% CI: 0.836 ~ 0.953), and temporary (OR = 0.860, 95% CI: 0.800 ~ 0.924) or floating residence (OR = 0.628, 95% CI: 0.550 ~ 0.713) were less likely to seek mental health support. Conclusions This study is, to date, the largest quantitative investigation of its kind in China. It contributes to a better understanding of the factors influencing intervention-seeking behaviours among women who screened positive for PPD. The main findings underline the necessity for tailored interventions that cater to the specific needs and circumstances of different groups of women. It is crucial to encourage treatment engagement through strategies such as psychoeducation, addressing stigma, and providing supportive resources. Health sciences/Diseases/Psychiatric disorders/Depression Health sciences/Health care/Public health/Population screening Postpartum depression Psychological intervention Referral uptake Influencing factor Perinatal care China Figures Figure 1 Background Postpartum depression (PPD) is one of the most common complications of childbearing, affecting approximately one in six (17.2%) women after childbirth worldwide [ 1 ]. This disorder encompasses a range of mental, emotional and behavioural symptoms, often beginning within the first a few weeks after delivery and lasting up to one year [ 2 ]. If left untreated, PPD can lead to negative health consequences in both the women and their offspring [ 3 ], ranging from mild symptoms such as low mood and anxiety to more severe outcomes such as recurrent or chronic depression, postpartum psychosis [ 4 ], and cognitive and behavioural disorders in the children [ 5 , 6 ]. Moreover, women with severe PPD are at higher risk of committing suicide and infanticide [ 7 , 8 ]. It has been reported that PPD-related suicides account for up to 20% of all postpartum deaths [ 9 ]. As such, PPD has emerged as a critical public health problem warranting research and resource attention. Studies have shown that screening for PPD, followed by diagnosis and appropriate management for those who detected positive, can effectively reduce the burden of this disorder [ 10 , 11 ]. Over the past decade, there has been a growing movement to integrate depression screening into routine postnatal care [ 12 – 15 ]. In 2020, the National Health Commission of China issued the first guideline for the prevention and treatment of perinatal depression, which emphasises the integration of PPD screening into routine postpartum home visits and the provision of mental health support for women identified at high risks [ 16 ]. However, despite high coverage of PPD screening at some local levels, the acceptance of psychological interventions among women with positive screening results remains low (ranging from 1 in 248 women to 19%) [ 13 , 17 ]. Identifying factors that influence PPD intervention acceptance can help enhance the efficacy of routine screening [ 18 ] and support the implementation of the national guideline. Given China’s significant burden of PPD due to the enormous population size, understanding these factors is crucial for improving the mental health outcomes of millions of women and their families. The existing literature on factors influencing PPD intervention uptake largely comprises qualitative studies. In a thematic synthesis of such literature, Hadfield et al. identified common barriers to those with positive PPD screening results seeking and receiving further support. These include the perception that the services might not be helpful, reluctance to take antidepressant medication due to concerns over side effects, the internalised stigma related to PPD, and a general lack of knowledge about the disease [ 19 ]. Another review found that healthcare providers’ influences, such as responses to the women’s emotional and practical needs, may also interfere with their decision to seek psychological treatment [ 20 ]. However, these reviews were limited to studies conducted in high-income countries with healthcare systems that differ significantly from those in China, which hampers the generalisability of the conclusions. Furthermore, there is a noticeable dearth of large-scale, quantitative studies in this realm, underscoring the necessity for robust, data-driven research in diverse settings to better understand the nuances of intervention-seeking behaviours among postpartum women. In China, studies focusing on factors affecting PPD intervention uptake are limited. Gong et al. qualitatively surveyed 161 women who declined treatments, of which 128 (79.5%) believed they could manage their depressive symptoms on their own while 142 (88.2%) turned to their family members for support [ 17 ]. Another qualitative inquiry involving 46 women with positive PPD screening results found that the women’s adherence to referral recommendations was influenced by their understanding of the disease, perceived necessity for help, attitudes towards healthcare providers, and the support they received from their families [ 21 ]. Yet, mirroring global studies, these investigations are qualitative in nature, carrying inherent limitations like small sample sizes and limited representativeness. Moreover, these studies overlooked some important factors, such as the women’ sociodemographic characteristics, history of mental illness, childbirth experiences, and infant-related factors, which could significantly shape their help-seeking behaviours [ 20 , 22 ]. To bridge the gaps mentioned above, a retrospective study was conducted using routine data from a government-funded universal PPD screening and intervention programme in Shenzhen Municipality, Southern China. Initiated in 2013, this programme offers free depression screening to all women who give birth in Shenzhen, regardless of their resident status, during routine postpartum home visits (held between 2 and 6 weeks after delivery). Depressive symptoms are measured using a well validated Chinese version of the Edinburg Postnatal Depression Scale (EPDS) [ 23 , 24 ], with cut-off scores of 10 and 13 for mild and high levels of symptoms, respectively. These scores are utilised as they are internationally accepted indicators and have been widely tested in China [ 24 , 25 ]. As required by the programme guideline [ 26 ], women with mild depressive symptoms (EPDS score 10 ~ 13) are referred to clinical psychology departments within municipal or district-level maternal and child health institutes for further evaluation and consultation, while women with high-level symptoms (EPDS score > 13) are referred to the municipal psychiatric specialty hospital or psychiatric departments within general hospitals for diagnosis and treatment. All women who screen positive are followed up for at least 4 weeks. The home visits and referrals are arranged by the local community health service centers (CHSCs) where the women live. Since its inception, the programme has screened 170,000 to 180,000 postpartum women annually, maintaining a coverage rate of approximately 80% [ 13 ]. Utilising the programme data, this study aimed to ascertain the actual proportion of women who screened positive for PPD receiving psychological interventions, as well as to identify potential factors associated with adherence to intervention referrals. Given the dearth of large-scale quantitative evidence, the findings will provide important insights into the efficacy of existing PPD screening programmes and inform the development of strategies to improve treatment engagement, thereby reducing the burden of PPD on affected women and their families. Methods Study population A retrospective study was conducted on women who gave birth in a public or private hospital in Shenzhen between January 1 st , 2016 and December 31 st , 2020 and were detected positive for PPD during postpartum home visits (EPDS score≥10). For this study, a total of 36,598 women were eligible and their electronic records were exported from the programme management information system. After ensuring completeness and logistic accuracy, 35,390 (96.7%) were included in the analysis. With China's hospital delivery rate exceeding 99% [27] and Shenzhen’s universal programme maintaining a high depression screening rate of 80% among all postpartum women [13], this sample was viewed as representative of those with positive PPD screening results in the city. This study was approved by the Medical Ethics Committee of Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University [SFYLS[2024]004]. All methods were performed in accordance with the relevant guidelines and regulations. Data collection By 2020, the universal programme had successfully extended its coverage to all 647 communities across the 10 districts of Shenzhen. Designated health workers from the CHSCs bore the primary responsibilities for conducting routine postpartum home visits and follow-ups. During the home visits, they assisted postpartum women in evaluating their own depressive symptoms using the EPDS and gathered information on the women's sociodemographic, psychological, perinatal and neonatal care through a pre-designed questionnaire. Women who screened positive were then given referral messages (including alerts about their depression risks and the necessity of receiving psychological interventions, address of psychology or psychiatric departments, and links of appointment registration) and followed up with by phone over a period of four weeks. The phone calls aimed to collect information on whether they had sought mental health support, which institute they had visited, what psychological interventions they had received, and whether their depressive symptoms had increased or decreased. This information was then validated by cross-referencing with the women’s medical records at psychology/psychiatric departments in the programme management information system. All women were informed prior to the screening that their data might be used for research and publication purposes, and they had the right to withdraw from the study at any time. Written consent was obtained from each woman before enrolment. Data from the postpartum home visits and follow-ups, along with information on the women’s intervention uptake, were manually entered into the programme management information system and double-checked for accuracy. Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University was responsible for coordinating the programme. To enhance programme implementation and data quality, the hospital organised periodic trainings for relevant CHSC health workers and conducted quality controls by randomly sampling and checking individual case records within the information system. For the purpose of this study, the original data was exported by authorised personnel, adhering strictly to the programme’s data privacy and security protocols. Access to the study database was restricted to the authors only. Assessment of potential influencing factors The study collected data on a range of variables relating to the sociodemographic, psychological, obstetric and neonatal characteristics of postpartum women. These factors, potentially affecting psychological intervention acceptance, were identified through literature review [20, 22] and expert consultation, and were mostly assessed using single questions. Sociodemographic characteristics encompassed maternal age, education level (junior school and below, high school, bachelor’s degree, and master’s degree or higher), resident status (permanent resident, temporary resident – with a residence card, and floating population – without a residence card), family structure (nuclear family, living with parents, and living with parents-in-law), and annual family income in Chinese yuan (CNY) (below 120,000, 120,000~240,000, above 240,000). Psychological characteristics included level of depressive symptoms (EPDS score 10~13 and EPDS score>13), recent stressful life events (such as divorce, job loss, serious illness, or death of family members), family history of mental illness, and previous history of psychological issues. The women were specifically asked whether they had been tested positive for depressive and anxiety symptoms during pregnancy. Obstetric characteristics included the women’s gravidity, parity, gestational age at delivery, and mode of delivery (vaginal delivery and caesarean delivery). Neonatal characteristics encompassed the presence of multiple births, Apgar score ("7~10" and "0~6") and birth weight (low birth weight, normal, and high birth weight) of the infants, as well as their feeding patterns (breast, mixed, and bottle-fed). Measurement of adherence to intervention referrals Adherence to psychological Intervention referrals was determined based on whether the women’s visits to psychology or psychiatric departments were recorded in the programme management information system or not. Statistical analysis The statistical analysis in this study utilised R version 4.0.2. Referral and intervention rates were calculated by dividing the number of women with positive PPD screening results by the number of referral messages offered and the number of women who presented at psychology or psychiatric departments, respectively. The trend of variables was assessed using the trend χ 2 , and statistical significance was determined with a p -value of less than 0.05. Descriptive analysis was conducted to examine the frequency of each of the possible influencing factors in the study population. A chi-square test was then used to determine any differences between women who adhered to intervention referrals and those who did not, with a p -value of less than 0.05 considered statistical significance. As age is the only continuous variable, it was categorised into four groups for Chi-square test: 16~20, 21~27, 28~34, and ≥35. Variables that showed significant differences were further analysed using stepwise logistic regression to estimate Odds ratio (OR) and 95% Confident interval (95% CI), with a p -value for removal set at 0.05. In establishing the logistic regression model, the first level of each ordered categorial variable was used as the reference. Unordered categorical variables (i.e., family structure and feeding pattern) were converted into dummy variables while those living in nuclear families and those using bottle feeding as the reference categories, respectively. Results Basic information Among the 35,390 postpartum women studied, 30,408 (85.9%) were given referral messages and followed up, while only 5,712 (16.1%) sought further interventions. Figure 1 shows that the percentage of women who received referral messages increased from 74.1% in 2016 to 97.2% in 2020 ( χ 2 =1090.908, p <0.001). However, the uptake rate for psychological interventions remained relatively low, despite an overall increasing trend ( χ 2 =1656.943, p <0.001). The following univariate and multivariate analyses only pertain to women who have records of follow-ups. Sociodemographic characteristics of women who adhered to intervention referrals The average age of the 30,408 women who received referral messages was 28.3 (standard deviation: 4.6, range: 16~50). As shown in Table 1, most of them (87.9%) were aged between 21 and 35. Regarding educational attainment, 35.0% had finished high school, and 46.4% had a bachelor’s degree or higher. The majority of the women held either permanent (29.5%) or temporary residence (61.4%) in Shenzhen, while 9.1% were part of the floating population. Nearly four-fifths (78.0%) reported an annual family income between CNY 120,000 and CNY 240,000. Half (49.0%) lived in nuclear families, while 38.8% lived with parents-in-law. Women with a high school education ( χ 2 =49.662, p <0.001) and permanent residence ( χ 2 =59.730, p <0.001) were more likely to adhere to referral recommendations. There was no statistically significant difference between those with different ages, economic statuses, and family structures. Psychological characteristics of women who adhered to intervention referrals Table 1 indicated that 34.2% of the women experienced high-level depressive symptoms (EPDS score>13), and 34.3% had some extents of anxiety symptoms in the postpartum period. Additionally, 6.8% reported recent stressful life events, while 1.0% and 0.9% reported a family history and personal previous history of mental illness, respectively. The proportion of women with higher EPDS scores undergoing psychological interventions was lower than those with lower EPDS scores ( χ 2 =59.730, p =0.025). Women with anxiety ( χ 2 =59.730, p <0.001) or depressive symptoms ( χ 2 =16.905 p <0.001) during pregnancy were more likely to adhere to PPD intervention referrals than those without. There was no statistically significant difference between women with experiences of stressful life events, a family or previous history of mental illness, and those without. Obstetric characteristics of women who adhered to intervention referrals The majority of women had been pregnant once (39.8%) or twice (31.3%), and had given birth to one child (56.7%) or two children (37.4%). Most women (88.2%) delivered between 37 and 41 gestational weeks. Table 1 revealed that women who were pregnant for three or more times were more likely to seek psychological interventions ( χ 2 =9.737, p =0.021). However, no statistical significance was found between different parity, gestational age, and delivery mode groups. Neonatal characteristics of women who adhered to intervention referrals According to Table 1, 2.1% of the women had multiple births. Of the infants, 99% had Apgar scores between 7 and 10, indicating good health. Additionally, 90.5% had normal birth weights, 6.4% had low birth weights, and 3.1% were classified as large for gestational age. About half (56.2%) of the infants were breastfed, while 37.3% received mixed feeding. Statistical analysis indicated a significant correlation between feeding pattern and the women’s adherence to referral advice ( χ 2 =38.477, p <0.001). Women who used bottle feeding and mixed feeding were more likely to seek psychological support compared to women who exclusively breastfed. However, no significant association was found between different numbers of fetuses, Apgar scores, and birth weights. Table 1 Univariate analysis of factors influencing adherence to intervention referrals among women who screened positive for PPD Variable Referral received (N=30,408) n (%) Adherence (N=24,696) n (%) Non-adherence (N=5,712) n (%) χ 2 p Sociodemographic characteristics Maternal age 16~20 755 (2.5) 611 (2.5) 145 (2.5) 0.399 0.940 21~27 12,670 (41.7) 10,273 (41.6) 2,397 (42.0) 28~34 14,040 (46.2) 11,417 (46.2) 2,622(45.9) ≥35 2,943 (9.7) 2,395 (9.7) 548 (9.6) Education level Junior school and below 5,667 (18.6) 4,737 (19.2) 930 (16.3) 49.662 <0.001 High school 10,634 (35.0) 8,431 (34.1) 2,203 (38.6) Bachelor’s degree 13,008 (42.8) 10,622 (43.0) 2,386 (41.8) Master’s degree or higher 1,098 (3.6) 905 (3.7) 193 (3.4) Resident status Permanent resident 8,969 (29.5) 2,387 (28.9) 388 (32.2) 59.730 <0.001 Temporary resident 18,664 (61.4) 15,180 (61.5) 3,484 (61.0) Floating population 2,775 (9.1) 7,129 (9.6) 1,840 (6.8) Economic status Below CNY 120,000 1,137 (3.8) 931 (3.9) 206 (3.6) 5.337 0.069 CNY 120,000~240,000 23,201 (78.0) 18,821 (78.2) 4,380 (77.2) Above CNY 240,000 5,398 (18.2) 4,310 (17.9) 1,088 (19.2) Family structure Nuclear family 14,583 (49.0) 11,869 (49.3) 2,714 (47.9) 4.952 0.084 With parents 3,635 (12.2) 2,949 (12.2) 686 (12.1) With parents-in-law 11,529 (38.8) 9,259 (38.5) 2,270 (40.0) Psychological characteris tics EPDS score 10~13 20,018 (65.8) 16,185 (65.5) 3,833 (67.1) 4.997 0.025 >13 10,390 (34.2) 8,511 (34.5) 1,879 (32.9) Anxiety during pregnancy No 19,489 (65.7) 15,959 (66.5) 3,530 (62.3) 35.261 <0.001 Yes 10,189 (34.3) 8,052 (33.5) 2,137 (37.7) Depression during pregnancy No 23,640 (79.6) 19,242 (80.1) 4,398 (77.6) 16.905 <0.001 Yes 6,045 (20.4) 4,779 (19.9) 1,266 (22.4) Stressful life events No 27,583 (93.2) 22,322 (93.2) 5,261 (93.2) <0.001 0.976 Yes 2,019 (6.8) 1,635 (6.8) 384 (6.8) Family history of mental illness No 29,340 (99.0) 23,754 (99.0) 5,586 (98.7) 3.788 0.052 Yes 305 (1.0) 233 (1.0) 72 (1.3) Previous history of mental illness No 29,438 (99.1) 23,828 (99.1) 5,610 (98.9) 1.783 0.182 Yes 267 (0.9) 207 (0.9) 60 (1.1) Obstetric characteris tics Gravidity 1 11,980 (39.8) 9,731 (39.8) 2,249 (39.7) 9.737 0.021 2 9,429 (31.3) 7,576 (31.0) 1,853 (32.7) 3 4,983 (16.6) 4,109 (16.8) 874 (15.4) ≥4 3,721 (12.3) 3,021 (12.4) 691 (12.2) Parity 1 16,969 (56.7) 13,776 (56.7) 3,193 (56.7) 0.122 0.941 2 11,205 (37.4) 9,091 (37.4) 2,114 (37.5) ≥3 1,766 (5.9) 1,439 (5.9) 327 (5.8) Gestational age at delivery <37 1,331 (4.4) 1,080 (4.4) 251 (4.4) 0.144 0.931 37~41 26,807 (88.2) 21,779 (88.2) 5,028 (88.0) ≥42 22,70 (7.5) 1,837 (7.4) 433 (7.6) Mode of delivery Vaginal delivery 19,474 (64.0) 15,879 (64.2) 3,595 (62.9) 3.668 0.055 Cesarean delivery 10,934 (36.0) 8,817 (35.7) 2,117 (37.1) Neonatal characteris tics Multiple births No 2,9764 (97.9) 24,173 (97.9) 5,591 (97.9) 1 <0.001 Yes 644 (2.1) 523 (2.1) 121 (2.1) Feeding pattern Breast 16,648 (56.2) 13,656 (56.9) 2,992 (53.0) 38.477 <0.001 Mixed 11,067 (37.3) 8,855 (36.9) 2,212 (39.2) Bottle 1,920 (6.5) 1,478 (6.2) 442 (7.8) Apgar score 7~10 30,083 (99.0) 24,438 (99.0) 5,645 (98.9) 0.500 0.479 0~6 302 (1.0) 240 (1.0) 62 (1.1) Birth weight Low birth weight 1,948 (6.4) 1,574 (6.4) 374 (6.5) 0.252 0.881 Normal 27,530 (90.5) 22,368 (90.6) 5,162 (90.4) Giant baby 930 (3.1) 754 (3.0) 176 (3.1) Multivariate analysis of factors influencing adherence to intervention referrals The stepwise logistic regression model included all seven variables demonstrating significant differences between women who adhered to intervention referrals and those who did not. As shown in Table 2, six potential determinants of adherence were identified. First, women with high school education were 1.266 times (95% CI: 1.1602~1.38) more likely to accept referral advice compared to women with junior school education or below. However, women with a bachelor’s degree (OR=0.966, 95% CI: 0.880~1.061) or a master’s degree or higher (OR=0.892, 95% CI: 0.741~1.070) were less likely to seek professional support. Second, temporary (OR=0.860, 95% CI: 0.800~0.924) and floating residents (OR=0.628, 95% CI: 0.550~0.713) were less likely to adhere to intervention referrals compared to permanent residents. Third, women experiencing high-level depressive symptoms were less likely to seek mental health services (OR=0.892, 95% CI: 0.836~0.953) than women with mild symptoms. Fourth, women with anxiety and depressive symptoms during pregnancy were 1.126 times (95% CI: 1.048~1.210) and 1.054 times (95% CI: 0.968~1.145) more likely to accept intervention referrals, respectively, compared to women without. Lastly, in terms of infant feeding patterns, bottle feeding and mixed feeding women were 1.368 (95% CI: 1.218~1.535) 1.107 and 1.110 (95% CI: 1.043~1.181) times more likely to follow referrals, respectively, compared to breastfeeding women. Table 2 Multivariate analysis of factors influencing adherence to intervention referrals β p OR 95% CI Education level Junior school and below - - - - High school 0.236 <0.001 1.266 1.160~1.382 Bachelor’s degree -0.034 0.474 0.966 0.880~1.061 Master’s degree or higher -0.114 0.222 0.892 0.741~1.070 Resident status Permanent resident - Temporary resident -0.151 <0.001 0.860 0.800~0.924 Floating population -4.660 13 -0.114 <0.001 0.892 0.836~0.952 Gravidity 1 - - - - 2 0.068 0.056 1.071 0.998~1.149 3 -0.073 0.107 0.930 0.850~1.016 ≥4 0.016 0.746 1.016 0.920~1.120 Feeding pattern Breast - - - - Mixed 0.104 0.001 1.110 1.043~1.181 Bottle 0.313 <0.001 1.368 1.218~1.535 Discussion This study on factors affecting adherence to psychological interventions among 35,390 women who screened positive for PPD is, to data, the largest quantitative investigation of its kind in China. Using routine data from a municipal universal PPD screening and intervention programme in Shenzhen, the study revealed that although referral messages were given to 85.9% of women with positive PPD screening results, only 16.1% of them received psychological interventions between 2016 and 2020. The screening-intervention gap finding is consistent with findings reported in published studies. Byatt et al.’s systematic review has found that, without intervention, the proportion of postpartum women seeking mental health support for positive depression screenings is only 22% on average (range: 14%~33%) [ 28 ], which is lower than the rates observed in other major disease screening programmes such as colon cancer [ 29 ]. Thombs et al. pointed out that a low coverage rate of psychological intervention can significantly reduce the effectiveness of universal PPD screening, ultimately affecting the overall prevention and treatment outcomes [ 18 ]. These findings highlight the importance of increasing adherence to intervention referrals among women with positive PPD screening results and improving access to mental health services more broadly. The reasons for the low psychological intervention rate among women who tested positive for PPD are multifaceted. Existing literature cites various reasons such as time constraints, transient improvements in mood [ 30 – 32 ], viewing postpartum depressive symptoms as normal and not necessitating intervention [ 33 , 34 ], and the impracticality of attending in-person counselling with an infant [ 35 ]. In the context of China, specific factors may explain this low uptake. The current mental health resources are seriously inadequate, with only 0.1 psychiatric hospitals or psychiatric departments in general hospitals, 2.2 psychiatrists, and 5.4 psychiatric nurses (including community mental health workers) per 100,000 people. These figures are far lower than those in high-income countries such as the United States and Japan [ 36 ]. Multiple studies have shown that poor accessibility to mental health services is a major barrier to the uptake of psychological interventions among women with positive PPD screening results [ 19 , 37 – 39 ]. Many women abandon seeking help due to concerns about high treatment costs, inconvenient transportation, and stigmatisation [ 40 , 41 ]. Conversely, most women who screened positive only have temporary or mild depressive symptoms and only need simple mental health support rather than having to visit professional institutions [ 42 ]. The statistical analysis revealed that the women’s adherence to intervention referrals was influenced by various sociodemographic, psychological, obstetric, and neonatal factors. Those with a high school education were more likely to accept psychological interventions compared to those with higher education levels. This finding aligns with existing evidence that women with higher education levels in Shenzhen are at higher risk of postpartum depression [ 43 ]. It is inferred that women with lower education levels might face fewer time constraints and career pressures than women with higher education levels, facilitating their access to treatment [ 44 ]. Furthermore, women who suffered anxiety and depressive symptoms during pregnancy might be more likely to seek support due to heightened awareness of their mental health status and existing contact with professionals, making the transition to depression treatments more seamless [ 45 ]. Regarding feeding pattern, women who adopted bottle or mixed feeding methods might have more time and flexibility for seeking psychological interventions compared to those who exclusively breastfeed. Bottle-feeding allows for the sharing of caregiving responsibilities with other family members, potentially reducing maternal stress and providing more opportunities for women to seek help. Some women might choose not to breastfeed due to pre-existing mental health conditions [ 46 ], which might also explain a higher intervention adherence in this group. This study revealed that women with higher EPDS scores, indicative of high level of depressive symptoms, were less likely to seek mental health support. The debilitating symptoms of severe depression, including extreme fatigue or feelings of worthlessness, could hinder treatment-seeking [ 20 ]. Additionally, cognitive impairments caused by PPD, such as difficulties in concentration, decision-making, and memory [ 4 ], could pose substantial barriers to accessing professional support. Furthermore, fears of social judgement or self-stigmatisation might exacerbate the women’s hesitancy to use mental health services [ 47 ]. Remarkably, it was observed that women with temporary or floating residence were less likely to adhere to intervention referrals compared to women with permanent residence. This could be attributed to the lack of stable access to local healthcare services and socio-economic challenges like unstable housing or employment [ 48 ]. Limited awareness of available mental health resources may also factor into their decreased treatment engagement [ 49 ]. The utilisation of routine data from a universal PPD screening and intervention programme helped enhance quality of evidence [ 50 ], offering a significant advancement over previous, predominantly qualitative, studies based on smaller samples. The findings are likely more reflective of the reality given the high PPD screening and referral rates in Shenzhen. However, limitations do exist. First, given that adherence to Intervention referrals was determined by the women’s electronic records at psychological/psychiatric departments within maternal and child health institutions or general hospitals, this study may have overlooked women who sought help at private or online mental health institutions. This could lead to an underestimation of the actual rate of intervention uptake. Second, the retrospective study design limits the ability to infer causality or temporal relationships between the variables studied. Third, the study was conducted in Shenzhen, a large and affluent city in China, limiting the generalisability of findings to rural areas or other parts of the country where mental health resources may be less accessible and cultural attitudes towards mental health may differ. Fourth, the study focused solely on the women’s adherence to intervention referrals, excluding other crucial aspect of PPD management such as quality of interventions, treatment adherence, and treatment outcomes. The findings of this study have important implications for PPD management in China. The large gap between the number of women who screened positive and those who received psychological interventions indicates an urgent need for improvement in the follow-up of PPD screening. This could involve strategies to encourage treatment engagement, such as psychoeducation, on-site counselling, addressing stigma, and providing supportive resources for help-seeking [ 28 , 31 ]. The various factors identified to influence the uptake of treatment referrals highlight the necessity of tailoring interventions to the specific needs and circumstances of different groups of women. For instance, more support might be needed for women with high-level depressive symptoms, women with temporary or floating residence, and women with higher education levels. Considering that most women who screened positive for PPD only have temporary or mild symptoms, how to fully utilise limited mental health resources to construct a comprehensive intervention strategy that is personalised, equitable, destigmatised, and capable of effectively increasing the overall psychological intervention rate and sustaining implementation remains a challenging task at the current stage. Conclusion In conclusion, this study reveals the complex interplay of sociodemographic, psychological, obstetric, and neonatal factors influencing adherence to psychological intervention referrals among women who screened positive for PPD in Shenzhen, China. It highlights the critical gaps in treatment engagement, particularly among women with high level of depressive symptoms, temporary or floating residence, higher education levels, and those who breastfeed. The findings underscore the need for a more personalised, comprehensive, and destigmatised approach to PPD management, which addresses the specific needs and circumstances of different groups of women. While the study advances our understanding of the factors influencing PPD intervention-seeking behaviours, further research is needed to develop and test strategies to increase intervention uptake and improve mental health outcomes among postpartum women in China. Abbreviations PPD Postpartum depression EPDS Edinburg Postnatal Depression Scale CHSC Community health service center CNY Chinese yuan OR Oddis ratios CI Confidence interval Declarations Ethics approval and consent to participate. This study was approved by the Medical Ethics Committee of Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University [SFYLS[2024]004]. Written consent was obtained from all woman before their enrolment. Consent to publication. Not applicable. Availability of data and materials. The datasets generated and analysed during the current study are not publicly available due to the data protection policies of Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, but are available from the corresponding author upon reasonable request. Competing interests. The authors declare no competing interests. Funding. This study was supported by the National Natural Science Foundation of China [72374096], Shenzhen Science and Technology Program [JCYJ20230807120309020], Shenzhen Key Laboratory of Maternal and Child Health and Diseases [ZDSYS20230626091559006], and the Research Fund of Shenzhen Maternity and Child Healthcare Hospital [FYA2022001]. Authors’ contributions. D.W. conceptualised the study and prepared the manuscript. S. C. carried out the statistical analysis. S. L. and J. Z. undertook the literature review and made contributions to the manuscript. G. Z. was responsible for managing the programme management information system and assisted in data export. L. J. coordinated the PPD screening and intervention programme. J. H. provided valuable comments on the manuscript. All authors have reviewed and given approval for the final version of the article. Acknowledgements. The authors would like to express their gratitude to Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University for the coordination and support of this study. They also acknowledge the dedicated health workers involved in the PPD screening and intervention programme in Shenzhen. Furthermore, they extend their appreciation to all the postpartum women who consented to participate, making this study possible. 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Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK. BMJ Open 2019. 9, e024803. Chen, H.; Wang, J.; Ch'ng, Y.C.; Mingoo, R.; Lee, T.Ong, J. Identifying mothers with postpartum depression early: integrating perinatal mental health care into the obstetric setting. ISRN Obstet Gynecol 2011. 2011, 309189. Kim, J.J.; La Porte, L.M.; Corcoran, M.; Magasi, S.; Batza, J.Silver, R.K. Barriers to mental health treatment among obstetric patients at risk for depression. Am J Obstet Gynecol 2010. 202, 312.e1-5. Bhat, A.; Nanda, A.; Murphy, L.; Ball, A.L.; Fortney, J.Katon, J. A systematic review of screening for perinatal depression and anxiety in community-based settings. Arch Womens Ment Health 2022. 25, 33-49. Wu, D.; Jiang, L.Zhao, G. Additional evidence on prevalence and predictors of postpartum depression in China: A study of 300,000 puerperal women covered by a community-based routine screening programme. J Affect Disord 2022. 307, 264-270. Wang, P.S.; Angermeyer, M.; Borges, G.; Bruffaerts, R.; Tat Chiu, W.; G, D.E.G.; et al. Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry 2007. 6, 177-85. Dennis, C.L.; Falah-Hassani, K.Shiri, R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry 2017. 210, 315-323. Cooklin, A.R.; Amir, L.H.; Nguyen, C.D.; Buck, M.L.; Cullinane, M.; Fisher, J.R.W.; et al. Physical health, breastfeeding problems and maternal mood in the early postpartum: a prospective cohort study. Arch Womens Ment Health 2018. 21, 365-374. Barney, L.J.; Griffiths, K.M.; Jorm, A.F.Christensen, H. 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08:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6502238/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6502238/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-17281-x","type":"published","date":"2025-08-25T15:58:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84711499,"identity":"6ecc8e57-10d2-452b-8eca-0621569ab863","added_by":"auto","created_at":"2025-06-16 13:25:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48583,"visible":true,"origin":"","legend":"\u003cp\u003eReferral and psychological intervention rates of women who screened positive for postpartum depression in Shenzhen, 2016-2020\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6502238/v1/1b7b52d25fed7edeca40e882.png"},{"id":90345708,"identity":"b61895c3-be72-44bf-9307-5d3642689531","added_by":"auto","created_at":"2025-09-01 16:10:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1171347,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6502238/v1/536fb348-83a5-4d09-b630-16196ca0a615.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors influencing adherence to psychological intervention referrals: a study of 35,390 women who screened positive for postpartum depression between 2016 and 2020 in Shenzhen, Southern China","fulltext":[{"header":"Background","content":"\u003cp\u003ePostpartum depression (PPD) is one of the most common complications of childbearing, affecting approximately one in six (17.2%) women after childbirth worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This disorder encompasses a range of mental, emotional and behavioural symptoms, often beginning within the first a few weeks after delivery and lasting up to one year [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. If left untreated, PPD can lead to negative health consequences in both the women and their offspring [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], ranging from mild symptoms such as low mood and anxiety to more severe outcomes such as recurrent or chronic depression, postpartum psychosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and cognitive and behavioural disorders in the children [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, women with severe PPD are at higher risk of committing suicide and infanticide [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It has been reported that PPD-related suicides account for up to 20% of all postpartum deaths [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. As such, PPD has emerged as a critical public health problem warranting research and resource attention.\u003c/p\u003e \u003cp\u003eStudies have shown that screening for PPD, followed by diagnosis and appropriate management for those who detected positive, can effectively reduce the burden of this disorder [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Over the past decade, there has been a growing movement to integrate depression screening into routine postnatal care [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In 2020, the National Health Commission of China issued the first guideline for the prevention and treatment of perinatal depression, which emphasises the integration of PPD screening into routine postpartum home visits and the provision of mental health support for women identified at high risks [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, despite high coverage of PPD screening at some local levels, the acceptance of psychological interventions among women with positive screening results remains low (ranging from 1 in 248 women to 19%) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Identifying factors that influence PPD intervention acceptance can help enhance the efficacy of routine screening [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and support the implementation of the national guideline. Given China\u0026rsquo;s significant burden of PPD due to the enormous population size, understanding these factors is crucial for improving the mental health outcomes of millions of women and their families.\u003c/p\u003e \u003cp\u003eThe existing literature on factors influencing PPD intervention uptake largely comprises qualitative studies. In a thematic synthesis of such literature, Hadfield et al. identified common barriers to those with positive PPD screening results seeking and receiving further support. These include the perception that the services might not be helpful, reluctance to take antidepressant medication due to concerns over side effects, the internalised stigma related to PPD, and a general lack of knowledge about the disease [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another review found that healthcare providers\u0026rsquo; influences, such as responses to the women\u0026rsquo;s emotional and practical needs, may also interfere with their decision to seek psychological treatment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, these reviews were limited to studies conducted in high-income countries with healthcare systems that differ significantly from those in China, which hampers the generalisability of the conclusions. Furthermore, there is a noticeable dearth of large-scale, quantitative studies in this realm, underscoring the necessity for robust, data-driven research in diverse settings to better understand the nuances of intervention-seeking behaviours among postpartum women.\u003c/p\u003e \u003cp\u003eIn China, studies focusing on factors affecting PPD intervention uptake are limited. Gong et al. qualitatively surveyed 161 women who declined treatments, of which 128 (79.5%) believed they could manage their depressive symptoms on their own while 142 (88.2%) turned to their family members for support [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Another qualitative inquiry involving 46 women with positive PPD screening results found that the women\u0026rsquo;s adherence to referral recommendations was influenced by their understanding of the disease, perceived necessity for help, attitudes towards healthcare providers, and the support they received from their families [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Yet, mirroring global studies, these investigations are qualitative in nature, carrying inherent limitations like small sample sizes and limited representativeness. Moreover, these studies overlooked some important factors, such as the women\u0026rsquo; sociodemographic characteristics, history of mental illness, childbirth experiences, and infant-related factors, which could significantly shape their help-seeking behaviours [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo bridge the gaps mentioned above, a retrospective study was conducted using routine data from a government-funded universal PPD screening and intervention programme in Shenzhen Municipality, Southern China. Initiated in 2013, this programme offers free depression screening to all women who give birth in Shenzhen, regardless of their resident status, during routine postpartum home visits (held between 2 and 6 weeks after delivery). Depressive symptoms are measured using a well validated Chinese version of the Edinburg Postnatal Depression Scale (EPDS) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], with cut-off scores of 10 and 13 for mild and high levels of symptoms, respectively. These scores are utilised as they are internationally accepted indicators and have been widely tested in China [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. As required by the programme guideline [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], women with mild depressive symptoms (EPDS score 10\u0026thinsp;~\u0026thinsp;13) are referred to clinical psychology departments within municipal or district-level maternal and child health institutes for further evaluation and consultation, while women with high-level symptoms (EPDS score\u0026thinsp;\u0026gt;\u0026thinsp;13) are referred to the municipal psychiatric specialty hospital or psychiatric departments within general hospitals for diagnosis and treatment. All women who screen positive are followed up for at least 4 weeks. The home visits and referrals are arranged by the local community health service centers (CHSCs) where the women live. Since its inception, the programme has screened 170,000 to 180,000 postpartum women annually, maintaining a coverage rate of approximately 80% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUtilising the programme data, this study aimed to ascertain the actual proportion of women who screened positive for PPD receiving psychological interventions, as well as to identify potential factors associated with adherence to intervention referrals. Given the dearth of large-scale quantitative evidence, the findings will provide important insights into the efficacy of existing PPD screening programmes and inform the development of strategies to improve treatment engagement, thereby reducing the burden of PPD on affected women and their families.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy population\u003c/h2\u003e\n\u003cp\u003eA retrospective study was conducted on women who gave birth in a public or private hospital in Shenzhen between January 1\u003csup\u003est\u003c/sup\u003e, 2016 and December 31\u003csup\u003est\u003c/sup\u003e, 2020 and were detected positive for PPD during postpartum home visits (EPDS score\u0026ge;10). For this study, a total of 36,598 women were eligible and their electronic records were exported from the programme management information system. After ensuring completeness and logistic accuracy, 35,390 (96.7%) were included in the analysis. With China\u0026apos;s hospital delivery rate exceeding 99% [27] and Shenzhen\u0026rsquo;s universal programme maintaining a high depression screening rate of 80% among all postpartum women [13], this sample was viewed as representative of those with positive PPD screening results in the city. This study was approved by the Medical Ethics Committee of Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University [SFYLS[2024]004]. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eBy 2020, the universal programme had successfully extended its coverage to all 647 communities across the 10 districts of Shenzhen. Designated health workers from the CHSCs bore the primary responsibilities for conducting routine postpartum home visits and follow-ups. During the home visits, they assisted postpartum women in evaluating their own depressive symptoms using the EPDS and gathered information on the women\u0026apos;s sociodemographic, psychological, perinatal and neonatal care through a pre-designed questionnaire. Women who screened positive were then given referral messages (including alerts about their depression risks and the necessity of receiving psychological interventions, address of psychology or psychiatric departments, and links of appointment registration) and followed up with by phone over a period of four weeks. The phone calls aimed to collect information on whether they had sought mental health support, which institute they had visited, what psychological interventions they had received, and whether their depressive symptoms had increased or decreased. This information was then validated by cross-referencing with the women\u0026rsquo;s medical records at psychology/psychiatric departments in the programme management information system. All women were informed prior to the screening that their data might be used for research and publication purposes, and they had the right to withdraw from the study at any time. Written consent was obtained from each woman before enrolment.\u003c/p\u003e\n\u003cp\u003eData from the postpartum home visits and follow-ups, along with information on the women\u0026rsquo;s intervention uptake, were manually entered into the programme management information system and double-checked for accuracy. Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University was responsible for coordinating the programme. To enhance programme implementation and data quality, the hospital organised periodic trainings for relevant CHSC health workers and conducted quality controls by randomly sampling and checking individual case records within the information system. For the purpose of this study, the original data was exported by authorised personnel, adhering strictly to the programme\u0026rsquo;s data privacy and security protocols. Access to the study database was restricted to the authors only.\u003c/p\u003e\n\u003ch2\u003eAssessment of potential influencing factors\u003c/h2\u003e\n\u003cp\u003eThe study collected data on a range of variables relating to the sociodemographic, psychological, obstetric and neonatal characteristics of postpartum women. These factors, potentially affecting psychological intervention acceptance, were identified through literature review [20, 22] and expert consultation, and were mostly assessed using single questions. Sociodemographic characteristics encompassed maternal age, education level (junior school and below, high school, bachelor\u0026rsquo;s degree, and master\u0026rsquo;s degree or higher), resident status (permanent resident, temporary resident \u0026ndash; with a residence card, and floating population \u0026ndash; without a residence card), family structure (nuclear family, living with parents, and living with parents-in-law), and annual family income in Chinese yuan (CNY) (below 120,000, 120,000~240,000, above 240,000). Psychological characteristics included level of depressive symptoms (EPDS score 10~13 and EPDS score\u0026gt;13), recent stressful life events (such as divorce, job loss, serious illness, or death of family members), family history of mental illness, and previous history of psychological issues. The women were specifically asked whether they had been tested positive for depressive and anxiety symptoms during pregnancy. Obstetric characteristics included the women\u0026rsquo;s gravidity, parity, gestational age at delivery, and mode of delivery (vaginal delivery and caesarean delivery). Neonatal characteristics encompassed the presence of multiple births, Apgar score (\u0026quot;7~10\u0026quot; and \u0026quot;0~6\u0026quot;) and birth weight (low birth weight, normal, and high birth weight) of the infants, as well as their feeding patterns (breast, mixed, and bottle-fed).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eMeasurement of adherence to intervention referrals\u003c/h2\u003e\n\u003cp\u003eAdherence to psychological Intervention referrals was determined based on whether the women\u0026rsquo;s visits to psychology or psychiatric departments were recorded in the programme management information system or not.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eThe statistical analysis in this study utilised R version 4.0.2. Referral and intervention rates were calculated by dividing the number of women with positive PPD screening results by the number of referral messages offered and the number of women who presented at psychology or psychiatric departments, respectively. The trend of variables was assessed using the trend \u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e, and statistical significance was determined with a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05. Descriptive analysis was conducted to examine the frequency of each of the possible influencing factors in the study population. A chi-square test was then used to determine any differences between women who adhered to intervention referrals and those who did not, with a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05 considered statistical significance. As age is the only continuous variable, it was categorised into four groups for Chi-square test: 16~20, 21~27, 28~34, and \u0026ge;35. Variables that showed significant differences were further analysed using stepwise logistic regression to estimate Odds ratio (OR) and 95% Confident interval (95% CI), with a \u003cem\u003ep\u003c/em\u003e-value for removal set at 0.05. In establishing the logistic regression model, the first level of each ordered categorial variable was used as the reference. Unordered categorical variables (i.e., family structure and feeding pattern) were converted into dummy variables while those living in nuclear families and those using bottle feeding as the reference categories, respectively.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eBasic information\u003c/h2\u003e\n\u003cp\u003eAmong the 35,390 postpartum women studied, 30,408 (85.9%) were given referral messages and followed up, while only 5,712 (16.1%) sought further interventions. Figure 1 shows that the percentage of women who received referral messages increased from 74.1% in 2016 to 97.2% in 2020 (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=1090.908, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001). However, the uptake rate for psychological interventions remained relatively low, despite an overall increasing trend (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=1656.943, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001). The following univariate and multivariate analyses only pertain to women who have records of follow-ups.\u003c/p\u003e\n\u003ch2\u003eSociodemographic characteristics of women who adhered to intervention referrals\u003c/h2\u003e\n\u003cp\u003eThe average age of the 30,408 women who received referral messages was 28.3 (standard deviation: 4.6, range: 16~50). As shown in Table 1, most of them (87.9%) were aged between 21 and 35. Regarding educational attainment, 35.0% had finished high school, and 46.4% had a bachelor\u0026rsquo;s degree or higher. The majority of the women held either permanent (29.5%) or temporary residence (61.4%) in Shenzhen, while 9.1% were part of the floating population. Nearly four-fifths (78.0%) reported an annual family income between CNY 120,000 and CNY 240,000. Half (49.0%) lived in nuclear families, while 38.8% lived with parents-in-law. Women with a high school education (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=49.662, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) and permanent residence (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=59.730, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) were more likely to adhere to referral recommendations. There was no statistically significant difference between those with different ages, economic statuses, and family structures.\u003c/p\u003e\n\u003ch2\u003ePsychological characteristics of women who adhered to intervention referrals\u003c/h2\u003e\n\u003cp\u003eTable 1 indicated that 34.2% of the women experienced high-level depressive symptoms (EPDS score\u0026gt;13), and 34.3% had some extents of anxiety symptoms in the postpartum period. Additionally, 6.8% reported recent stressful life events, while 1.0% and 0.9% reported a family history and personal previous history of mental illness, respectively. The proportion of women with higher EPDS scores undergoing psychological interventions was lower than those with lower EPDS scores (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=59.730, \u003cem\u003ep\u003c/em\u003e=0.025). Women with anxiety (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=59.730, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) or depressive symptoms (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=16.905\u003cem\u003e\u0026nbsp;p\u003c/em\u003e\u0026lt;0.001) during pregnancy were more likely to adhere to PPD intervention referrals than those without. There was no statistically significant difference between women with experiences of stressful life events, a family or previous history of mental illness, and those without.\u003c/p\u003e\n\u003ch2\u003eObstetric characteristics of women who adhered to intervention referrals\u003c/h2\u003e\n\u003cp\u003eThe majority of women had been pregnant once (39.8%) or twice (31.3%), and had given birth to one child (56.7%) or two children (37.4%). Most women (88.2%) delivered between 37 and 41 gestational weeks. Table 1 revealed that women who were pregnant for three or more times were more likely to seek psychological interventions (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=9.737, \u003cem\u003ep\u003c/em\u003e=0.021). However, no statistical significance was found between different parity, gestational age, and delivery mode groups.\u003c/p\u003e\n\u003ch2\u003eNeonatal characteristics of women who adhered to intervention referrals\u003c/h2\u003e\n\u003cp\u003eAccording to Table 1, 2.1% of the women had multiple births. Of the infants, 99% had Apgar scores between 7 and 10, indicating good health. Additionally, 90.5% had normal birth weights, 6.4% had low birth weights, and 3.1% were classified as large for gestational age. About half (56.2%) of the infants were breastfed, while 37.3% received mixed feeding. Statistical analysis indicated a significant correlation between feeding pattern and the women\u0026rsquo;s adherence to referral advice (\u003cem\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=38.477, \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001). Women who used bottle feeding and mixed feeding were more likely to seek psychological support compared to women who exclusively breastfed. However, no significant association was found between different numbers of fetuses, Apgar scores, and birth weights.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eUnivariate analysis of factors influencing adherence to intervention referrals among women who screened positive for PPD\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferral received (N=30,408)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherence (N=24,696)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-adherence (N=5,712)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026chi;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003echaracteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eMaternal age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16~20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e755 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e611 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e145 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.940\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21~27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12,670 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,273 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,397 (42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28~34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14,040 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11,417 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,622(45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,943 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,395 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e548 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJunior school and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,667 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,737 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e930 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e49.662\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,634 (35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8,431 (34.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,203 (38.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13,008 (42.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,622 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,386 (41.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,098 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e905 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e193 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eResident status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePermanent resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8,969 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,387 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e388 (32.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e59.730\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTemporary resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18,664 (61.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15,180 (61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,484 (61.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFloating population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,775 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7,129 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,840 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eEconomic status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBelow CNY 120,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,137 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e931 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e206 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e5.337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCNY 120,000~240,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23,201 (78.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18,821 (78.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,380 (77.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbove CNY 240,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,398 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,310 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,088 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eFamily structure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNuclear family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14,583 (49.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11,869 (49.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,714 (47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e4.952\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWith parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,635 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,949 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e686 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWith parents-in-law\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11,529 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9,259 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,270 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;characteris\u003c/strong\u003e\u003cstrong\u003etics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eEPDS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10~13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20,018 (65.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16,185 (65.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,833 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,390 (34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8,511 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,879 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety during pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19,489 (65.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15,959 (66.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,530 (62.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e35.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,189 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8,052 (33.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,137 (37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDepression during pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23,640 (79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19,242 (80.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,398 (77.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e16.905\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6,045 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,779 (19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,266 (22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eStressful life events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27,583 (93.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22,322 (93.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,261 (93.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.976\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,019 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,635 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e384 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFamily history of mental illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29,340 (99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23,754 (99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,586 (98.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e3.788\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e305 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e233 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePrevious history of mental illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29,438 (99.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23,828 (99.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,610 (98.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e267 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e207 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eObstetric\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003echaracteris\u003c/strong\u003e\u003cstrong\u003etics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11,980 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9,731 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,249 (39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e9.737\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9,429 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7,576 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,853 (32.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,983 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4,109 (16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e874 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,721 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,021 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e691 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16,969 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13,776 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,193 (56.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.941\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11,205 (37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9,091 (37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,114 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,766 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,439 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e327 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eGestational age at delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,331 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,080 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e251 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.931\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37~41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26,807 (88.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21,779 (88.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,028 (88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22,70 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,837 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e433 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVaginal delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19,474 (64.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15,879 (64.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3,595 (62.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e3.668\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCesarean delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,934 (36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8,817 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,117 (37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeonatal characteris\u003c/strong\u003e\u003cstrong\u003etics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMultiple births\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,9764 (97.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24,173 (97.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,591 (97.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e644 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e523 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e121 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eFeeding pattern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16,648 (56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13,656 (56.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,992 (53.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e38.477\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11,067 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8,855 (36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2,212 (39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBottle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,920 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,478 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e442 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eApgar score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7~10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30,083 (99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24,438 (99.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,645 (98.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.479\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0~6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e302 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e240 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eBirth weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow birth weight\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,948 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,574 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e374 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0.881\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27,530 (90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22,368 (90.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,162 (90.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGiant baby\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e930 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e754 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e176 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eMultivariate analysis of factors influencing adherence to intervention referrals\u003c/h2\u003e\n\u003cp\u003eThe stepwise logistic regression model included all seven variables demonstrating significant differences between women who adhered to intervention referrals and those who did not. As shown in Table 2, six potential determinants of adherence were identified. First, women with high school education were 1.266 times (95% CI: 1.1602~1.38) more likely to accept referral advice compared to women with junior school education or below. However, women with a bachelor\u0026rsquo;s degree (OR=0.966, 95% CI: 0.880~1.061) or a master\u0026rsquo;s degree or higher (OR=0.892, 95% CI: 0.741~1.070) were less likely to seek professional support. Second, temporary (OR=0.860, 95% CI: 0.800~0.924) and floating residents (OR=0.628, 95% CI: 0.550~0.713) were less likely to adhere to intervention referrals compared to permanent residents. Third, women experiencing high-level depressive symptoms were less likely to seek mental health services (OR=0.892, 95% CI: 0.836~0.953) than women with mild symptoms. Fourth, women with anxiety and depressive symptoms during pregnancy were 1.126 times (95% CI: 1.048~1.210) and 1.054 times (95% CI: 0.968~1.145) more likely to accept intervention referrals, respectively, compared to women without. Lastly, in terms of infant feeding patterns, bottle feeding and mixed feeding women were 1.368 (95% CI: 1.218~1.535) 1.107 and 1.110 (95% CI: 1.043~1.181) times more likely to follow referrals, respectively, compared to breastfeeding women.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eMultivariate analysis of factors influencing adherence to intervention referrals\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% \u003cem\u003eCI\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJunior school and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.160~1.382\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.880~1.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.741~1.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eResident status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePermanent resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTemporary resident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.800~0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFloating population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-4.660\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.628\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.550~0.713\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety during pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.048~1.210\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDepression during pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.969~1.145\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eEPDS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10~13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.836~0.952\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.998~1.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.850~1.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.920~1.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eFeeding pattern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBreast\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.043~1.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBottle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.218~1.535\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study on factors affecting adherence to psychological interventions among 35,390 women who screened positive for PPD is, to data, the largest quantitative investigation of its kind in China. Using routine data from a municipal universal PPD screening and intervention programme in Shenzhen, the study revealed that although referral messages were given to 85.9% of women with positive PPD screening results, only 16.1% of them received psychological interventions between 2016 and 2020. The screening-intervention gap finding is consistent with findings reported in published studies. Byatt et al.\u0026rsquo;s systematic review has found that, without intervention, the proportion of postpartum women seeking mental health support for positive depression screenings is only 22% on average (range: 14%~33%) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], which is lower than the rates observed in other major disease screening programmes such as colon cancer [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Thombs et al. pointed out that a low coverage rate of psychological intervention can significantly reduce the effectiveness of universal PPD screening, ultimately affecting the overall prevention and treatment outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These findings highlight the importance of increasing adherence to intervention referrals among women with positive PPD screening results and improving access to mental health services more broadly.\u003c/p\u003e \u003cp\u003eThe reasons for the low psychological intervention rate among women who tested positive for PPD are multifaceted. Existing literature cites various reasons such as time constraints, transient improvements in mood [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], viewing postpartum depressive symptoms as normal and not necessitating intervention [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], and the impracticality of attending in-person counselling with an infant [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In the context of China, specific factors may explain this low uptake. The current mental health resources are seriously inadequate, with only 0.1 psychiatric hospitals or psychiatric departments in general hospitals, 2.2 psychiatrists, and 5.4 psychiatric nurses (including community mental health workers) per 100,000 people. These figures are far lower than those in high-income countries such as the United States and Japan [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Multiple studies have shown that poor accessibility to mental health services is a major barrier to the uptake of psychological interventions among women with positive PPD screening results [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Many women abandon seeking help due to concerns about high treatment costs, inconvenient transportation, and stigmatisation [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Conversely, most women who screened positive only have temporary or mild depressive symptoms and only need simple mental health support rather than having to visit professional institutions [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe statistical analysis revealed that the women\u0026rsquo;s adherence to intervention referrals was influenced by various sociodemographic, psychological, obstetric, and neonatal factors. Those with a high school education were more likely to accept psychological interventions compared to those with higher education levels. This finding aligns with existing evidence that women with higher education levels in Shenzhen are at higher risk of postpartum depression [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. It is inferred that women with lower education levels might face fewer time constraints and career pressures than women with higher education levels, facilitating their access to treatment [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Furthermore, women who suffered anxiety and depressive symptoms during pregnancy might be more likely to seek support due to heightened awareness of their mental health status and existing contact with professionals, making the transition to depression treatments more seamless [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Regarding feeding pattern, women who adopted bottle or mixed feeding methods might have more time and flexibility for seeking psychological interventions compared to those who exclusively breastfeed. Bottle-feeding allows for the sharing of caregiving responsibilities with other family members, potentially reducing maternal stress and providing more opportunities for women to seek help. Some women might choose not to breastfeed due to pre-existing mental health conditions [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], which might also explain a higher intervention adherence in this group.\u003c/p\u003e \u003cp\u003eThis study revealed that women with higher EPDS scores, indicative of high level of depressive symptoms, were less likely to seek mental health support. The debilitating symptoms of severe depression, including extreme fatigue or feelings of worthlessness, could hinder treatment-seeking [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Additionally, cognitive impairments caused by PPD, such as difficulties in concentration, decision-making, and memory [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], could pose substantial barriers to accessing professional support. Furthermore, fears of social judgement or self-stigmatisation might exacerbate the women\u0026rsquo;s hesitancy to use mental health services [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Remarkably, it was observed that women with temporary or floating residence were less likely to adhere to intervention referrals compared to women with permanent residence. This could be attributed to the lack of stable access to local healthcare services and socio-economic challenges like unstable housing or employment [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Limited awareness of available mental health resources may also factor into their decreased treatment engagement [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe utilisation of routine data from a universal PPD screening and intervention programme helped enhance quality of evidence [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], offering a significant advancement over previous, predominantly qualitative, studies based on smaller samples. The findings are likely more reflective of the reality given the high PPD screening and referral rates in Shenzhen. However, limitations do exist. First, given that adherence to Intervention referrals was determined by the women\u0026rsquo;s electronic records at psychological/psychiatric departments within maternal and child health institutions or general hospitals, this study may have overlooked women who sought help at private or online mental health institutions. This could lead to an underestimation of the actual rate of intervention uptake. Second, the retrospective study design limits the ability to infer causality or temporal relationships between the variables studied. Third, the study was conducted in Shenzhen, a large and affluent city in China, limiting the generalisability of findings to rural areas or other parts of the country where mental health resources may be less accessible and cultural attitudes towards mental health may differ. Fourth, the study focused solely on the women\u0026rsquo;s adherence to intervention referrals, excluding other crucial aspect of PPD management such as quality of interventions, treatment adherence, and treatment outcomes.\u003c/p\u003e \u003cp\u003eThe findings of this study have important implications for PPD management in China. The large gap between the number of women who screened positive and those who received psychological interventions indicates an urgent need for improvement in the follow-up of PPD screening. This could involve strategies to encourage treatment engagement, such as psychoeducation, on-site counselling, addressing stigma, and providing supportive resources for help-seeking [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The various factors identified to influence the uptake of treatment referrals highlight the necessity of tailoring interventions to the specific needs and circumstances of different groups of women. For instance, more support might be needed for women with high-level depressive symptoms, women with temporary or floating residence, and women with higher education levels. Considering that most women who screened positive for PPD only have temporary or mild symptoms, how to fully utilise limited mental health resources to construct a comprehensive intervention strategy that is personalised, equitable, destigmatised, and capable of effectively increasing the overall psychological intervention rate and sustaining implementation remains a challenging task at the current stage.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study reveals the complex interplay of sociodemographic, psychological, obstetric, and neonatal factors influencing adherence to psychological intervention referrals among women who screened positive for PPD in Shenzhen, China. It highlights the critical gaps in treatment engagement, particularly among women with high level of depressive symptoms, temporary or floating residence, higher education levels, and those who breastfeed. The findings underscore the need for a more personalised, comprehensive, and destigmatised approach to PPD management, which addresses the specific needs and circumstances of different groups of women. While the study advances our understanding of the factors influencing PPD intervention-seeking behaviours, further research is needed to develop and test strategies to increase intervention uptake and improve mental health outcomes among postpartum women in China.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostpartum depression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEPDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEdinburg Postnatal Depression Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCHSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCommunity health service center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChinese yuan\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOddis ratios\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConfidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e This study was approved by the Medical Ethics Committee of Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University [SFYLS[2024]004]. Written consent was obtained from all woman before their enrolment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication.\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials.\u003c/strong\u003e The datasets generated and analysed during the current study are not publicly available due to the data protection policies of Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests.\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u003c/strong\u003e This study was supported by the National Natural Science Foundation of China [72374096], Shenzhen Science and Technology Program [JCYJ20230807120309020], Shenzhen Key Laboratory of Maternal and Child Health and Diseases [ZDSYS20230626091559006], and the Research Fund of Shenzhen Maternity and Child Healthcare Hospital [FYA2022001].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions.\u003c/strong\u003e D.W. conceptualised the study and prepared the manuscript. S. C. carried out the statistical analysis. S. L. and J. Z. undertook the literature review and made contributions to the manuscript. G. Z. was responsible for managing the programme management information system and assisted in data export. L. J. coordinated the PPD screening and intervention programme. J. H. provided valuable comments on the manuscript. All authors have reviewed and given approval for the final version of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements.\u003c/strong\u003e The authors would like to express their gratitude to Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University for the coordination and support of this study. They also acknowledge the dedicated health workers involved in the PPD screening and intervention programme in Shenzhen. Furthermore, they extend their appreciation to all the postpartum women who consented to participate, making this study possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWang, Z.; Liu, J.; Shuai, H.; Cai, Z.; Fu, X.; Liu, Y.; et al. Mapping global prevalence of depression among postpartum women. Transl Psychiatry 2021. 11, 543.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Hara, M.W.McCabe, J.E. Postpartum depression: current status and future directions. Annu Rev Clin Psychol 2013. 9, 379-407.\u003c/li\u003e\n \u003cli\u003eHoward, L.M.; Molyneaux, E.; Dennis, C.L.; Rochat, T.; Stein, A.Milgrom, J. Non-psychotic mental disorders in the perinatal period. 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World Psychiatry 2007. 6, 177-85.\u003c/li\u003e\n \u003cli\u003eDennis, C.L.; Falah-Hassani, K.Shiri, R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry 2017. 210, 315-323.\u003c/li\u003e\n \u003cli\u003eCooklin, A.R.; Amir, L.H.; Nguyen, C.D.; Buck, M.L.; Cullinane, M.; Fisher, J.R.W.; et al. Physical health, breastfeeding problems and maternal mood in the early postpartum: a prospective cohort study. Arch Womens Ment Health 2018. 21, 365-374.\u003c/li\u003e\n \u003cli\u003eBarney, L.J.; Griffiths, K.M.; Jorm, A.F.Christensen, H. Stigma about depression and its impact on help-seeking intentions. Aust N Z J Psychiatry 2006. 40, 51-4.\u003c/li\u003e\n \u003cli\u003eBurgard, S.A.; Seefeldt, K.S.Zelner, S. Housing instability and health: findings from the Michigan Recession and Recovery Study. Soc Sci Med 2012. 75, 2215-24.\u003c/li\u003e\n \u003cli\u003eKawachi, I.Berkman, L.F. Social ties and mental health. 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Stud Health Technol Inform 2019. 258, 1.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postpartum depression, Psychological intervention, Referral uptake, Influencing factor, Perinatal care, China","lastPublishedDoi":"10.21203/rs.3.rs-6502238/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6502238/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostpartum Depression (PPD) is a significant public health issue in China. Despite the launch of a universal PPD screening and intervention programme in Shenzhen, Southern China, there remains a substantial gap between the number of women who screened positive and were referred for psychological interventions and those who actually presented at mental health institutions for further evaluation and treatment. To inform enhancements of the programme, this study sought to understand the factors influencing adherence to intervention referrals among women with positive PPD screening results.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing a retrospective study design, data from the programme management information system was analysed. The sample comprised 35,390 women who gave births in Shenzhen and screened positive for PPD between January 2016 and December 2020. Chi-square test and stepwise logistic regression were employed to determine factors affecting intervention uptake, with a \u003cem\u003ep\u003c/em\u003e-value of less than 0.05 indicating statistical significance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study found that although referral messages were given to 85.9% of women with positive PPD screening results, only 16.1% of them received psychological interventions. High school education (OR\u0026thinsp;=\u0026thinsp;1.266, 95% CI: 1.1602\u0026thinsp;~\u0026thinsp;1.38), anxiety (OR\u0026thinsp;=\u0026thinsp;1.126, 95% CI: 1.048\u0026thinsp;~\u0026thinsp;1.210) and depressive symptoms (OR\u0026thinsp;=\u0026thinsp;1.054, 95% CI: 0.968\u0026thinsp;~\u0026thinsp;1.145) during pregnancy, as well as bottle (OR\u0026thinsp;=\u0026thinsp;1.368, 95% CI: 1.218\u0026thinsp;~\u0026thinsp;1.535) and mixed feeding (OR\u0026thinsp;=\u0026thinsp;1.110, 95% CI: 1.043\u0026thinsp;~\u0026thinsp;1.181) were positively associated with treatment engagement. Conversely, women with high level of depressive symptoms after childbirth (OR\u0026thinsp;=\u0026thinsp;0.892, 95% CI: 0.836\u0026thinsp;~\u0026thinsp;0.953), and temporary (OR\u0026thinsp;=\u0026thinsp;0.860, 95% CI: 0.800\u0026thinsp;~\u0026thinsp;0.924) or floating residence (OR\u0026thinsp;=\u0026thinsp;0.628, 95% CI: 0.550\u0026thinsp;~\u0026thinsp;0.713) were less likely to seek mental health support.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study is, to date, the largest quantitative investigation of its kind in China. It contributes to a better understanding of the factors influencing intervention-seeking behaviours among women who screened positive for PPD. The main findings underline the necessity for tailored interventions that cater to the specific needs and circumstances of different groups of women. It is crucial to encourage treatment engagement through strategies such as psychoeducation, addressing stigma, and providing supportive resources.\u003c/p\u003e","manuscriptTitle":"Factors influencing adherence to psychological intervention referrals: a study of 35,390 women who screened positive for postpartum depression between 2016 and 2020 in Shenzhen, Southern China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 13:25:09","doi":"10.21203/rs.3.rs-6502238/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-18T04:09:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-10T10:44:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221923711623839262238235764916168016585","date":"2025-06-30T03:37:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-24T15:10:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T07:11:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229803348888652555962438511037417395141","date":"2025-06-15T02:04:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"158931095198871333282420493155408357886","date":"2025-06-14T17:14:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220684996575810868633945633818002851912","date":"2025-06-14T15:17:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25282665368989337446784993451069806035","date":"2025-06-13T01:32:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-12T17:09:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-12T17:04:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-06T02:54:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T11:17:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-22T08:42:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"435a2645-75ce-44d2-b0a5-c682927df8fc","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":50059725,"name":"Health sciences/Diseases/Psychiatric disorders/Depression"},{"id":50059726,"name":"Health sciences/Health care/Public health/Population screening"}],"tags":[],"updatedAt":"2025-09-01T16:09:58+00:00","versionOfRecord":{"articleIdentity":"rs-6502238","link":"https://doi.org/10.1038/s41598-025-17281-x","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-08-25 15:58:12","publishedOnDateReadable":"August 25th, 2025"},"versionCreatedAt":"2025-06-16 13:25:09","video":"","vorDoi":"10.1038/s41598-025-17281-x","vorDoiUrl":"https://doi.org/10.1038/s41598-025-17281-x","workflowStages":[]},"version":"v1","identity":"rs-6502238","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6502238","identity":"rs-6502238","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}