Postpartum Depression and Social Support as Predictors for Parenting Self-efficacy among Nepali Postpartum Women

Postpartum Depression and Social Support as Predictors for Parenting Self-efficacy among Nepali Postpartum Women | 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 Research Article Postpartum Depression and Social Support as Predictors for Parenting Self-efficacy among Nepali Postpartum Women Tumla Shrestha, Sangita Pudasainee-Kapri, Kul Kapri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5045830/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Parenting self-efficacy (PSE) is a parent's ability to be responsive and attentive to their child's needs, which may be greatly influenced by perinatal mental health and social factors during postpartum. Limited studies to date have examined how maternal mental health status (i.e., postpartum depression) and Social Support link to PSE among postpartum women during critical stages of infant development in Nepal. Thus, this study aims to examine the postpartum depression (PPD) and perceived Self efficacy as the predictors for PSE among postpartum women within 6 months of childbirth in Nepal. Methods A cross-sectional study was conducted among one to six months postpartum women who attended immunization clinics in two hospitals in Kathmandu. Conveniently selected, 128 women of both low birth weight and normal birth weight infants were recruited for the study. Data were collected using standardized measures of the Edinburgh Postnatal Depression Scale, Karitane parenting self-efficacy scale, postpartum social support scale, and sociodemographic questionnaire via semi-structured interviews with respondents. Data were analyzed in STATA version 17.0 using linear regression analysis. Results Respondents were ethnically and socioeconomically diverse. Results indicated that PPD was significantly but negatively associated with PSE (β= − .29, p < .001). But perceived social support from husband, family, and friends was significantly and positively associated with increased PSE (β = 2.41, p < .001) among women during one to six months of postpartum. The results were statistically significant even after controlling for the effects of multiple control variables in the model. Conclusion PPD and perceived social support are significant predictors of PSE during the first six months postpartum among Nepali women. These findings have important implications for evidence-based interventions for early identification of women with PPD and enhancing postpartum social support after childbirth to enhance the mothers’ confidence in parenting their infants. Postpartum depression women self-efficacy social support infants Background The postpartum period is a time of learning and adaptation for parenting roles among women. Women must learn new parentingbehaviors and skills to care their infants effectively and to achieve satisfaction with parenting ( 1 ). Parenting self-efficacy (PSE) is a significant determinant of parenting quality that contributes to a parent's ability to be responsive and attentive to their child's needs ( 2 ). Self-efficacy is an individual's belief in his or her ability to perform a given task and a core determinant of human behavior ( 1 ). Maternal PSE is specific to the mother’s belief of their capabilities to organize and execute the tasks related to parenting. Parents who are more confident or efficient in their parenting roles and behaviors are more likely to have positive parenting skills in caring their infant. Higher level of maternal PSE is associated with a number of positive outcomes among their children including promotion of overall developmental outcomes (i.e., cognitive, behavioral) and physical and mental health outcomes of children ( 2 , 3 ). In addition, the PSE is a critical foundation for positive mother-infant relationships whichthat indirectly predict positive mother-infant bonding among at-risk infants ( 4 , 5 ) Therefore, improving maternal PSE is critical to promote the well-being of both mother and children. Maternal PSE is one of the significant physical, emotional, and psychological actions of women while caring their infants which is determined by various factors ( 6 ). The systematic review study indicated that maternal PSE is significantly associated with factors including maternal mental health (such as, postpartum depression), parenting stress, and social support ( 7 ). Addiitonal studies also reported that postpartum depression (PPD) is negatively associated with with maternal PSE ( 3 , 4 , 7 – 9 ). A meta-analysis including 35 studies found a bidirectional and inverse association between PPD and PSE in women ( 10 ). Social support is the support available to the postpartum woman, when necessary, through various social ties, including their partner/or husband, family, friends, etc. Social support also includes an individual’s perception of having support from their support figures. Social support in both forms are essential for adjustment and adaptation to the maternal role during the postpartum period ( 11 , 12 ). This is specifically important during the first few months of childbirth since maternal parenting ability in caring for an infant predicts mother-infant outcomes. Specifically, prior research studies and systematic reviews conducted across different countries such as China, Singapore, and Netherlands reported that social supportwas positively associated with a higher level of maternal PSE among postpartum women across diverse backgrounds ( 7 , 8 , 13 , 14 ). Additionally, postpartum women withpreterm (infant born < 37 completed weeks of gestation and/or low birth weight (LBW: birth weight less than 2500 gram at birth) infants are at increased risk for poor PSE due to inadequate parent-child interactions and parenting role alterations during infant hospitalization at birth ( 2 , 5 ). The environmental factors, such as parental separation during the neonatal period due to extensive hospitalization, deprived maternal parenting roles, and special care needs of the LBW preterm infants, are major contributing factors to lower PSE ( 15 , 16 ). In addition to birth weight and infant’s gestational age, systematic review and studies conducted among diverse samples of women across different countries reported that maternal PSE is influenced by other factors such as women’s education, infant health status, socioeconomic status, parity ( 7 , 17 , 18 ). Though prior evidence is available regarding the associations among PPD and social support contributing to PSE in the global context, to our knowledge, no studies have examined the effects of PPD and social support to determine PSE among postpartum women in Nepal. As maternal self-efficacy in parenting is an important variable for infant development and well-being, exploration of mental health and social support factors contributing to PSE during critical period of infant development among Nepali postpartum women is vital. Additionally, identification of factors contributing to maternal self-efficacy will directly link to Goal 3 of the Sustainable Development Goals (SDGs-3) since it contributes to the overall well-being of both mother and infants. The first six months of the postpartum period is a particularly critical age for developing PSE among women as they are transitioning to parenting roles. Additionally, identifying factors that predict maternal PSE are important beyond the first month of postpartum, when mothers are the primary caregivers for infants. Evidence indicated decreased PSE among women at 6–8 weeks ( 18 ), but limited evidence is available in Nepal about factors contributing to maternal ability in caring for infants within 6 months of postpartum period. Thus, the purpose of this study is to examine the association of PPD and social support in predicting PSE among postpartum womenwith infants one to six months of age, controlling for socio-demographic factors and birth weight as they impact PSE. Based on prior evidence, this study hypothesized that PPD will be negatively associated with PSE among women during one to six months postpartum (H1). In addition, the higher levels of perceived social support will be positively associated with increased maternal PSE among women during one to six months postpartum (H2). Materials and Methods Research Design and Study Settings The descriptive cross-sectional study was conducted at the immunization clinics of two tertiary level hospitals in Kathmandu, Nepal. The first site is a tertiary referral center for both women’s health issues and infants' and children’s health issues. It is a pioneer hospital, with general as well as specialized health services in several disciplines. The hospitals provide an array of inpatient and outpatient services for pregnant women, during childbirth, and pediatric services across childhood. The immunization clinic is a part of the pediatric outpatient services. The another research site is a pediatric referral center for the pediatric patient. The immunization clinic is a part of the pediatric outpatient services thatprovides services to neonates to adolescent populations with various health problems through its inpatient and outpatient services. The immunization clinic of this site provides outpatient services to all children and adolescents requiring routine vaccination. Study Population and Sample Size The study population was the women between one to six months postpartum attending in immunization clinics of two hospitals in Kathmandu Nepal. Women having both normal birth weight (NBW) and Low Birth weight (LBW) were included in the study. The inclusion criteria for respondents included postpartum mothers aged 18 to 49 years old with an infant one to six months old, who had a singleton birth with the recent pregnancy, and could report the infant's birth weight verbally or provide the immunization card where birth weight was listed. Respondents were excluded if they were younger than 18 years old, if multiple birth, if their infants had any neonatal complications (such as genetic anomalies, congenital malformations, or other medical problems impacting their mental health or parenting ability), and/or if who are unable to provide written informed consent. Among the women attending the clinics, 128 women were recruited conveniently for the study. We used G Power software with an alpha of 0.05 and a power of 0.80, to calculate a sample size in which a minimum of 128 participants was required for this study. About equal number of respondents from each birth weight group (i.e., n = 63 respondents from the LBW group and n = 65 respondents from normal birth weight group) were enrolled in the study. Using a convenience sample of 128, our study was adequately powered (80% power with alpha = .05) to detect small to moderate total variance explained by our regressions (testing a single coefficient, MDE = .06, for the full model testing 8 coefficients, MDE = .11) ( 19 ). Using other traditional rules of thumb, such as 10 observations per coefficient, was also met by this sample size ( 20 ) Study Variables and Measurement Instruments for this study consisted of respondents’ socio-demographic and infant’s characteristics and perinatal-related variables (such as gestational age, infant’s birth weightdepression/anxiety during pregnancy and three Likert-style questionnaires including Edinburgh Postnatal Depression Scale (EPDS), Karitan Parenting Confidence Scale (KPCS), and Maternity Social Support Scale (MSSS). Sociodemographic Questionnaire It included standard questionnaires related to respondents’ sociodemographic characteristics (socioeconomic status, education, age), perinatal history (depression and anxiety issues during pregnancy), and infant characteristics such as infant’s age, sex, gestational age, and birth weight at the time of data collection. Postpartum Depression The EPDS was used to screen for depressive symptoms among postpartum women ( 21 ). The EPDS scale is a 10-item questionnaire in which respondents rated how they have felt in the past 7 days on a 4-point scale (0–3). The EPDS scores range from 0 to 30. The higher scores on EPDS indicated higher levels of PPD. Individual scores of 10 or greater indicate the need for referral and further evaluation by the mental health provider ( 21 ). This study used the Nepali version of the EDPS, which has been validated as a screening tool for detecting PPD among postpartum women in Nepal ( 22 ). The reliability (Cronbach ’s alpha) scores ranged from 0.74 to 0.87 in prior studies ( 19 , 20 ). Cronbach’s alpha of the 10-item measure was .75 in this study. Social Support The MSSS was used to measure mothers’ perceived social support from family, husband/partner, and friends ( 23 ). The MSSS is a six-item questionnaire for social support on a five-point Likert scale from one (never) to five (always), in which higher scores indicate increased social support ( 23 , 24 ). The total possible score for the MSSS scale is 30, with a recommended cut-off score of 24 ( 21 ). The MSSS has been used in multiple studies that demonstrate high reliability with Cronbach's alpha ranging from 0.82 to 0.90 ( 23 , 25 ). Parenting Self-Efficacy : The KPCS was used to measure perceived self-efficacy or confidence in parenting abilities among postpartum women ( 26 ). The KPCS is a 15-item questionnaire that was initially developed to measure PSE among postpartum women of infants aged birth to 12 months in Australia ( 26 ) and has been validated among postpartum women in Nepal ( 27 ). It is a four-point Likert scale (0: hardly ever, 1: not very often, 2: some of the time, and 3: most of the time) with the scores ranging from 0 to 45, and higher scores represent greater perceived PSE. The Cronbach's alpha for the KPCS ranged from 0.81 to 0.87 ( 26 , 27 ), and test-retest reliability was 0.88 ( 26 ). Data Collection Procedures The eligible respondents attending immunization clinics were approached by research assistants for participation in the study. After obtaining written informed consent, data collection was done through a semi-structured interview method in a private area at the immunization clinic. The Nepali version of the questionnaires was used for the interview. The recommendation for cross-cultural studies was followed ( 28 ). Data collection work, including obtaining informed consent, pretesting questionnaires, and respondents’ interviews, was done by two research assistants from April to June 2022. Respondents’ responses were recorded in the questionnaire form using a paper-and-pencil format by research assistants. Research assistants were provided orientation training regarding instruments for data collection, procedures for obtaining informed consent, and interview techniques before pretesting. The same research assistants were involved in pretesting and data collection. The data collection work of the research assistants was supervised and monitored by the first author in Nepal. Data Analysis To test the proposed hypotheses, we employed an ordinary least square (OLS) model using a following equation: Where self-efficacy i stands for maternal parenting self-efficacy, epds scale i stands for postpartum depression, mssscale i stands for postpartum social support and Z i is a set of control variables. Data were analyzed in STATA version 17.0. Descriptive statistics were calculated for all sociodemographic and control variables. We conducted the normality and multicollinearity tests. The results indicated that the outcome variable and residuals look roughly bell-shaped and symmetric. In addition, the mean and median of self-efficacy variable (36.805 and 37 respectively) are fairly close, which indicates the self-efficacy variable is symmetric. We also tested multicollinearity tests which also shows that there is no multicollinearity problem in the model. Thus, OLS regression analysis is a relevant model to test the proposed hypotheses. Results Demographic Information of Respondents Table 1 representsinformation about the respondents’ socio-demographic characteristics. Table 2 provides descriptive statistics of the main study variables. Total sample consisted of 128 postpartum women during one to six months postpartum period in which 65 of women had normal birth weight infants and 63 of them had low birth weight infants. The mean age of infants was 2.75 months ( SD = 1.29), and the mean age of postpartum women was 27.99 ± 4.28 years. More than half respondents had a cesarean birth (58.59%), followed by normal vaginal delivery (39.84%). Respondents were ethnically diverse, with the majority of them being Brahmin and Chhetri (50%) ethnic group followed by Janajati (34.4%) Madhesi (7.8%), Dalit (7%), and least were Muslim (0.8%). 39% of study respondents had a Bachelor’s degree or higher level of education, with 40% of infants fathers completed a bachelor’s degree or higher. Table 1 Demographic Characteristics of Respondents (n = 128) Variables M ± SD Frequency (% ) Infant age in months Infants' birth weight in grams 2.75 ± 1.28 2458.38 ± 731.45 Infant sex Female 67 (52.3) Male 61 (47.7) Participant's ethnicity Dalit 9 (7.0) Janajati 44 (34.4) Madhesi 10 (7.8) Muslim 1 (0.8) Brahmin and Chhetri 64 (50.0) Type of delivery Vaginal 51 (39.84) Instrumental Vaginal 2 (1.55) Caesarean Section 75 (58.6) Education Unable to read and write Primary Secondary Higher Secondary Bachelor Master’s level/higher 3 (2.3) 3 (2.3) 30 (23.4) 42 (32.8) 25 (19.5) 25 (19.5) Income sufficient for household expenditure 12 months 40 (31.2) Gestational age dummy Less than 37 months 71(55.47) Equal or more than 37 months 57(44.53) Prenatal anxiety/depression dummy Anxious and/or depressive thoughts 43 (33.59) No anxious/depressive thoughts 85(66.41) Table 2 Descriptive Statistics of Key Study Variables (n = 128) Variable Mean SD Min Max Postpartum depression 5.06 3.96 0 21 Social support 2.39 0.39 1.5 3 Parenting self-efficacy 36.8 3.41 26 43 Associations Among Postpartum Depression, Social Support and Parenting Self-EfficacyTable 3 shows the impacts of PPD and self-efficacy on parenting self-efficacy. Columns ( 1 ) and ( 2 ) show the impact of PPD, and columns ( 3 ) and ( 4 ) show the impact of social support. The first column is the direct associations without including the controls, and the second column represents results with control variables. In these columns, the coefficients of both the PPD and social supportare statistically significant at 1% significance level. The coefficients of PPD are negative, and the coefficients of social support are positive. More specifically, on the one hand, the coefficient of PPD in column ( 1 ) is -0.312, and it indicates that a one-point increase in PPD causes a 0.312-point decrease in PSE (Hypothesis 1). On the other hand, the coefficient of social support in column ( 3 ) is 2.781, and it indicates that a one-point increase in social support causes a 2.781-point increase in PSE (Hypothesis 2). Even if we include both PPD and social support variables in the same model as in columns ( 5 ) and ( 6 ), the implication of the coefficients of those variables remains the same. Notice that columns ( 1 ), ( 3 ), and ( 5 ) do not include control variables, while columns ( 2 ), ( 4 ), and ( 6 ) include a set of control variables including infant sex dummy, low birth weight dummy, gestational age dummy, educational status of respondents, prenatal anxiety and depression dummy, and household income status. Hence, from the results in Table 3 , we conclude that PPD was negatively associated with PSE during the postpartum period, while perceived postpartum social support was positively associated with PSE. Regarding the coefficients of control variables, all of them are statistically insignificant except the mother's educational status in column ( 6 ). The coefficient of mother's educational status in column ( 6 ) is -0.541 and statistically significant at 5% significance level. It provides a weak and negative association between the mother's educational status and PSE. Table 3 Associations AmongPostpartum Depression and Social Support on Parenting Self-efficacy Variables Model (M) ( 1 ) (M2) (M3) (M4) (M5) (M6) Self-efficacy Self-efficacy Self-efficacy Self-efficacy Self-efficacy Self-efficacy Postpartum depression -0.312*** -0.331*** -0.254*** -0.293*** (0.071) (0.083) (0.073) (0.081) Perceived social support 2.781*** 2.836*** 2.044*** 2.413*** (0.730) (0.805) (0.731) (0.776) Infant sex (male:1) -0.386 -0.178 -0.096 (0.574) (0.589) (0.562) Low birth weight dummy (< 2500g: 1) 0.249 -0.289 0.092 (0.657) (0.658) (0.636) Gestational age dummy (age < 37 months:1) -0.868 -0.540 -0.707 (0.651) (0.660) (0.631) Mother educational status -0.398 -0.400 -0.541** (0.266) (0.271) (0.261) Prenatal anxiety and/ depression dummy -0.124 -0.570 0.348 (0.682) (0.657) (0.676) Household income status -0.112 -0.149 -0.102 (0.393) (0.398) (0.379) Constant 38.385*** 40.701*** 30.165*** 32.515*** 33.207*** 34.859*** (0.458) (1.405) (1.767) (2.335) (1.904) (2.318) Observations 128 128 128 128 128 128 R-squared 0.132 0.165 0.103 0.143 0.183 0.228 Dependent variable: PSE Note: All regressions are estimated by OLS. Robust standard errors are provided in parentheses. * p value significant at < 0.05, ** p value significant at < 0.01, *** p value significant at < 0.001. Discussion The findings of this study indicate that PPD was significantly and negatively associated with PSE among women during one to six months of postpartum. In addition, postpartum social support was the important predictive factor for PSE in which higher levels of perceived social support was positively linked to increased PSE among women during one to six months of postpartum period. We examined these relationships with and without control variables in the model. The most noteworthy finding was that even after controlling for the effects of multiple control variables in the model, both PPD and social support were significantly associated with PSE. To our knowledge, this is the first study that establishes the important links between postpartum mental health and social support for self-efficacy among women during one to six months postpartum among Nepali postpartum women. Our finding was consistent with a cross-sectional study conducted in Ireland among 410 primiparous mothers at 6 weeks after childbirth, in which results showed a statistically significant correlation between social support and maternal PSE (r = 0.21, p < 0.001) ( 1 ). Strengthening social support has been recognized as a potentially effective strategy to enhance PSE ( 13 ). The persons most frequently identified by women as having provided support were their own mothers, husbands/partners, and sisters ( 29 ). In the Nepali context, child rearing is considered the responsibility of the family. Postpartum women are generally supported and guided for childcare by their female family members, like their mother, sisters, and in-laws. Women are completely released from other household and social responsibilities so that they can completely focus on childcare. These social mechanisms are supportive for developing PSE among postpartum women. Similarly, another study of 309 Chinese postpartum women found that postpartum social support was positively associated with maternal PSE (β, 0.39; 95% CI, 0.28–0.49) ( 8 ). Seeing how other parents cope successfully with parenting issues may convince parents they, too, will succeed. Social relationships may provide verbal persuasion and feedback ( 1 ). Multivariable linear regression analysis of data collected among 647 Dutch parents of children aged birth to 8 years was done to examine the association between social support and PSE. Parents who experienced lower levels of social support at the start of the study reported lower PSE at follow-up (β: 0.13; 95% CI: 0.05, 0.21), independent of potential socio-demographic confounders. Parents who were experiencing an increase in perceived social support during the study period were associated with an increase in PSE (β: 0.15; 95% CI: 0.10, 0.21) ( 13 ). On the other side, maternal PSE is negatively correlated with PPD because depressed women hardly view themselves as capable of childcare compared to the women who are not depressed ( 30 ). A study among a racially diverse sample of 142 mother–infant dyads living in low-income households in the United States reported that lower maternal depressive symptoms predicted better PSE ( 9 ). Another Chinese study among 309 parents using the EPDS scale revealed a significant and negative association of PSE with PPD among women (β, − 0.22; 95% CI, − 0.32 to − 0.12)( 8 ). Another study among 410 postpartum women in Ireland using the EPDS scale and PSE scale showed a significant association between PPD and PSE (χ2 = 18.26, df = 2, p < 0.001) ( 29 ). Likewise, a review including eight articles found a negative association of maternal mood states, such as stress, anxiety, and depression, with maternal PSE ( 1 ). A structured clinical interview among 83 women with infants aged birth to–12months admitted to a residential parent–infant program showed inverse correlation of PSE with maternal mental health problems like depression, anxiety ( 4 ). A meta-analytic review of 35 studies found a significant pooled effect of both PPD on PSE and of PSE on PPD, with nearly identical effect sizes (d = − 0.21 and − 0.22, respectively). The association was stronger in samples of women with a younger average age ( 10 ). In addition, maternal PSE is significantly associated with various factors like women’s education, income, family type, employment status, parity, and age of the infants ( 14 , 17 , 18 ). To our knowledge, this is the first study that examined the effects of PPD and postpartum social support in parenting self-efficacy among Nepali postpartum women within the first 6-months of postpartum. Data were obtained from two research sites capturing diverse and broader population. Limitations Although this is the first study in Nepal that examined the impacts of PPD and social support on PSE, there are some notable limitations. Data for this study were taken from self-reports of postpartum women, so there is a possibility of recall bias or social desirability bias due to self-reported data. Another limitation is that the causality of the relationships among study variables cannot be inferred due to the cross-sectional nature of the study. The study was limited only to the immunization clinics of two hospitals in Kathmandu, Nepal, so the research findings cannot be generalized to all postpartum women living in different geographic locations of Nepal or at the national level. Conclusion Despite the limitations, findings of this study contributed to the existing literature that PPD and perceived social support are strong predictors of PSE during one to six months postpartum period among women. Most importantly, higher levels of perceived social support during postpartum was positively related to better PSE whereas maternal psychopathology like PPD during the critical stages of infant development reduces the PSE among women controlling for the spurious effects of multiple variables including LBW, preterm birth, income, education etc. Findings of this study have important implications at multiple levels. First, clinicians and nurses should identify postpartum women at risk for PPD and those who identified positive for depressive symptoms or at-risk should receive timely referral and appropriate treatment andmanagement to prevent its negative effects in their parenting ability. Because self-efficacy or parenting ability is essential for carrying out an effective parenting role for infants and positive bonding relationships, addressing factors contributing to poor parenting self-efficacy are crucial. Additionally, parenting interventions targeting postpartum women to improve postpartum social support, and reduce mental health problems would be crucialto enhance parenting self-efficacy among postpartum women. Future research should include larger and more diverse sampls and expand this research up to 12 months postpartum period, as the first year is critical for both maternal outcomes and infants’ development. Future research should also explore the underlying mechanisms predicting PSE and evaluate the effectiveness of evidence-based interventions aimed at improving maternal mental health and social support Additionnaly, qualitative research is needed to identify barriers and facilitators to enhancing PSE and mental health among postpartum women. Abbreviations PPD Postpartum depression PSE Parenting self-efficacy SS Social Support Declarations Ethical Considerations The research team obtained ethical approval from Rutgers University, New Jersy, USA; Nepal Health Research Council; and two research sites in Nepal to conduct the study. Written informed consent was obtained from the respondents prior to recruiting in the study. Acknowledgment Authors would like to thank the ‘Seed Funding for Data Collection and analysis’ Rutgers University-Camden, Committee on Institutional Equity and Diversity (CIED), Immunization Clinic staff of TUTH and KCH for their support and cooperation during data collection and participants of the study for their participation. Author Contributions TS and SPK wrote the main manuscript, KK prepared Tables. All authors reviewed the manuscript. Funding Declaration This study has no funding support for publication. Fund for data collection and analysis was received from the ‘Seed Funding for Data Collection and analysis’ Rutgers University-Camden, New Jersey. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to privacy or ethical restrictions but are available from the corresponding author on reasonable request. Author Disclosures The authors have no conflict of interest. Ethics approval and consent to participate The research team obtained ethical approval from Rutgers University, New Jersy, USA; the Nepal Health Research Council; and research sites in Nepal to conduct the study. Written informed consent was obtained from the respondents prior to recruiting in the study. Funding Declaration Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Leahy-Warren P, McCarthy G. Maternal parental self-efficacy in the postpartum period. Midwifery [Internet]. 2011;27(6):802–10. 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Midwifery [Internet]. 2011;27(5):745–9. PubMed, ScienceDirect. Mohammad KI, Sabbah H, Aldalaykeh M, ALBashtawy M, Abuobead Z, Creedy K. Informative title: Effects of social support, parenting stress and self-efficacy on postpartum depression among adolescent mothers in Jordan. J Clin Nurs [Internet]. 2021;30(23–24):3456–65. PubMed, WILEY. Črnčec R, Barnett B, Matthey S. Development of an instrument to assess perceived self-efficacy in the parents of infants. Res Nurs Health [Internet]. 2008;31(5):442–53. PubMed, WILEY. Shrestha S, Adachi K, Shrestha S. Translation and validation of the Karitane Parenting Confidence Scale in Nepali language. Midwifery [Internet]. 2016;36:86–91. PubMed, ScienceDirect. Brislin RW. Back-Translation for Cross-Cultural Research. J Cross Cult Psychol [Internet]. 1970;1(3):185–216. Sage Journal. Leahy-Warren P, McCarthy G, Corcoran P. First-time mothers: social support, maternal parental self-efficacy and postnatal depression. J Clin Nurs [Internet]. 2012;21(3–4):388–97. PubMed, WILEY. Azmoude E, Jafarnejade F, Mazloum SR. The Predictors for Maternal Self-efficacy in Early Parenthood. J Midwifery Reprod Heal [Internet]. 2015;3(2):368–76. Available from: https://jmrh.mums.ac.ir/article_4050.html . SEMANTIC SCHOLAR. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 01 Feb, 2026 Reviews received at journal 25 Jan, 2026 Reviewers agreed at journal 08 Dec, 2025 Reviews received at journal 04 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers invited by journal 03 Dec, 2025 Submission checks completed at journal 11 Nov, 2025 First submitted to journal 08 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Shrestha","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYHACxgMMDAdADDYGhgogxczcgFc9DwNYPUgLM1DLGRDNSIoWxjawtfi12EtkJxz48edOPj//+WMPfs6rjeZvB2r5UbENty0SuRsO9rY9s5w5I5ndsHfb8dwZhxkbGHvO3Mar5QBvw2EDgxvMbBK8247lNgC1MDO24ddy8M+fwwb25w+zSf6dcyx3PjFaDvOwAW1hSGaT5m2oAXIJaTnzdsNh2bbDBhI3ks2kZY4dyN0I1HIQn1/Y23M3PnwDdBh//8Fnkm9q6nLnnT988MGPCtxa0MFhMHmAaPVAUEeK4lEwCkbBKBghAAAGlWDV9SkkIQAAAABJRU5ErkJggg==","orcid":"","institution":"Tribhuvan University","correspondingAuthor":true,"prefix":"","firstName":"Tumla","middleName":"","lastName":"Shrestha","suffix":""},{"id":556720278,"identity":"c3639da9-ab85-4d72-9532-75316bbb84a8","order_by":1,"name":"Sangita Pudasainee-Kapri","email":"","orcid":"","institution":"The Rutgers State University of New 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18:36:37","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108109,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-5045830/v1/84ba4ce306464e92a9695631.html"},{"id":100622853,"identity":"f46e8498-4caf-4bb3-9f2b-8e54a786c4c1","added_by":"auto","created_at":"2026-01-19 18:44:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":819338,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5045830/v1/786aeaf8-6c4e-4676-af9f-c45f8fd307c4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Postpartum Depression and Social Support as Predictors for Parenting Self-efficacy among Nepali Postpartum Women","fulltext":[{"header":"Background","content":"\u003cp\u003eThe postpartum period is a time of learning and adaptation for parenting roles among women. Women must learn new parentingbehaviors and skills to care their infants effectively and to achieve satisfaction with parenting (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Parenting self-efficacy (PSE) is a significant determinant of parenting quality that contributes to a parent's ability to be responsive and attentive to their child's needs (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Self-efficacy is an individual's belief in his or her ability to perform a given task and a core determinant of human behavior (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Maternal PSE is specific to the mother\u0026rsquo;s belief of their capabilities to organize and execute the tasks related to parenting.\u003c/p\u003e\u003cp\u003eParents who are more confident or efficient in their parenting roles and behaviors are more likely to have positive parenting skills in caring their infant. Higher level of maternal PSE is associated with a number of positive outcomes among their children including promotion of overall developmental outcomes (i.e., cognitive, behavioral) and physical and mental health outcomes of children (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In addition, the PSE is a critical foundation for positive mother-infant relationships whichthat indirectly predict positive mother-infant bonding among at-risk infants (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Therefore, improving maternal PSE is critical to promote the well-being of both mother and children.\u003c/p\u003e\u003cp\u003eMaternal PSE is one of the significant physical, emotional, and psychological actions of women while caring their infants which is determined by various factors (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The systematic review study indicated that maternal PSE is significantly associated with factors including maternal mental health (such as, postpartum depression), parenting stress, and social support (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Addiitonal studies also reported that postpartum depression (PPD) is negatively associated with with maternal PSE (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A meta-analysis including 35 studies found a bidirectional and inverse association between PPD and PSE in women (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSocial support is the support available to the postpartum woman, when necessary, through various social ties, including their partner/or husband, family, friends, etc. Social support also includes an individual\u0026rsquo;s perception of having support from their support figures. Social support in both forms are essential for adjustment and adaptation to the maternal role during the postpartum period (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This is specifically important during the first few months of childbirth since maternal parenting ability in caring for an infant predicts mother-infant outcomes. Specifically, prior research studies and systematic reviews conducted across different countries such as China, Singapore, and Netherlands reported that social supportwas positively associated with a higher level of maternal PSE among postpartum women across diverse backgrounds (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAdditionally, postpartum women withpreterm (infant born\u0026thinsp;\u0026lt;\u0026thinsp;37 completed weeks of gestation and/or low birth weight (LBW: birth weight less than 2500 gram at birth) infants are at increased risk for poor PSE due to inadequate parent-child interactions and parenting role alterations during infant hospitalization at birth (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The environmental factors, such as parental separation during the neonatal period due to extensive hospitalization, deprived maternal parenting roles, and special care needs of the LBW preterm infants, are major contributing factors to lower PSE (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In addition to birth weight and infant\u0026rsquo;s gestational age, systematic review and studies conducted among diverse samples of women across different countries reported that maternal PSE is influenced by other factors such as women\u0026rsquo;s education, infant health status, socioeconomic status, parity (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThough prior evidence is available regarding the associations among PPD and social support contributing to PSE in the global context, to our knowledge, no studies have examined the effects of PPD and social support to determine PSE among postpartum women in Nepal. As maternal self-efficacy in parenting is an important variable for infant development and well-being, exploration of mental health and social support factors contributing to PSE during critical period of infant development among Nepali postpartum women is vital. Additionally, identification of factors contributing to maternal self-efficacy will directly link to Goal 3 of the Sustainable Development Goals (SDGs-3) since it contributes to the overall well-being of both mother and infants. The first six months of the postpartum period is a particularly critical age for developing PSE among women as they are transitioning to parenting roles.\u003c/p\u003e\u003cp\u003eAdditionally, identifying factors that predict maternal PSE are important beyond the first month of postpartum, when mothers are the primary caregivers for infants. Evidence indicated decreased PSE among women at 6\u0026ndash;8 weeks (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), but limited evidence is available in Nepal about factors contributing to maternal ability in caring for infants within 6 months of postpartum period. Thus, the purpose of this study is to examine the association of PPD and social support in predicting PSE among postpartum womenwith infants one to six months of age, controlling for socio-demographic factors and birth weight as they impact PSE. Based on prior evidence, this study hypothesized that PPD will be negatively associated with PSE among women during one to six months postpartum (H1). In addition, the higher levels of perceived social support will be positively associated with increased maternal PSE among women during one to six months postpartum (H2).\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch Design and Study Settings\u003c/h2\u003e\u003cp\u003eThe descriptive cross-sectional study was conducted at the immunization clinics of two tertiary level hospitals in Kathmandu, Nepal. The first site is a tertiary referral center for both women\u0026rsquo;s health issues and infants' and children\u0026rsquo;s health issues. It is a pioneer hospital, with general as well as specialized health services in several disciplines. The hospitals provide an array of inpatient and outpatient services for pregnant women, during childbirth, and pediatric services across childhood. The immunization clinic is a part of the pediatric outpatient services. The another research site is a pediatric referral center for the pediatric patient. The immunization clinic is a part of the pediatric outpatient services thatprovides services to neonates to adolescent populations with various health problems through its inpatient and outpatient services. The immunization clinic of this site provides outpatient services to all children and adolescents requiring routine vaccination.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Population and Sample Size\u003c/h3\u003e\n\u003cp\u003eThe study population was the women between one to six months postpartum attending in immunization clinics of two hospitals in Kathmandu Nepal. Women having both normal birth weight (NBW) and Low Birth weight (LBW) were included in the study.\u003c/p\u003e\u003cp\u003eThe inclusion criteria for respondents included postpartum mothers aged 18 to 49 years old with an infant one to six months old, who had a singleton birth with the recent pregnancy, and could report the infant's birth weight verbally or provide the immunization card where birth weight was listed. Respondents were excluded if they were younger than 18 years old, if multiple birth, if their infants had any neonatal complications (such as genetic anomalies, congenital malformations, or other medical problems impacting their mental health or parenting ability), and/or if who are unable to provide written informed consent.\u003c/p\u003e\u003cp\u003eAmong the women attending the clinics, 128 women were recruited conveniently for the study. We used G Power software with an alpha of 0.05 and a power of 0.80, to calculate a sample size in which a minimum of 128 participants was required for this study. About equal number of respondents from each birth weight group (i.e., n\u0026thinsp;=\u0026thinsp;63 respondents from the LBW group and n\u0026thinsp;=\u0026thinsp;65 respondents from normal birth weight group) were enrolled in the study. Using a convenience sample of 128, our study was adequately powered (80% power with alpha\u0026thinsp;=\u0026thinsp;.05) to detect small to moderate total variance explained by our regressions (testing a single coefficient, MDE\u0026thinsp;=\u0026thinsp;.06, for the full model testing 8 coefficients, MDE\u0026thinsp;=\u0026thinsp;.11) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Using other traditional rules of thumb, such as 10 observations per coefficient, was also met by this sample size (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eStudy Variables and Measurement\u003c/h3\u003e\n\u003cp\u003eInstruments for this study consisted of respondents\u0026rsquo; socio-demographic and infant\u0026rsquo;s characteristics and perinatal-related variables (such as gestational age, infant\u0026rsquo;s birth weightdepression/anxiety during pregnancy and three Likert-style questionnaires including Edinburgh Postnatal Depression Scale (EPDS), Karitan Parenting Confidence Scale (KPCS), and Maternity Social Support Scale (MSSS).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSociodemographic Questionnaire\u003c/strong\u003e\u003cp\u003eIt included standard questionnaires related to respondents\u0026rsquo; sociodemographic characteristics (socioeconomic status, education, age), perinatal history (depression and anxiety issues during pregnancy), and infant characteristics such as infant\u0026rsquo;s age, sex, gestational age, and birth weight at the time of data collection.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePostpartum Depression\u003c/strong\u003e\u003cp\u003eThe EPDS was used to screen for depressive symptoms among postpartum women (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The EPDS scale is a 10-item questionnaire in which respondents rated how they have felt in the past 7 days on a 4-point scale (0\u0026ndash;3). The EPDS scores range from 0 to 30. The higher scores on EPDS indicated higher levels of PPD. Individual scores of 10 or greater indicate the need for referral and further evaluation by the mental health provider (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). This study used the Nepali version of the EDPS, which has been validated as a screening tool for detecting PPD among postpartum women in Nepal (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The reliability (Cronbach \u0026rsquo;s alpha) scores ranged from 0.74 to 0.87 in prior studies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Cronbach\u0026rsquo;s alpha of the 10-item measure was .75 in this study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSocial Support\u003c/strong\u003e\u003cp\u003eThe MSSS was used to measure mothers\u0026rsquo; perceived social support from family, husband/partner, and friends (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The MSSS is a six-item questionnaire for social support on a five-point Likert scale from one (never) to five (always), in which higher scores indicate increased social support (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The total possible score for the MSSS scale is 30, with a recommended cut-off score of 24 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The MSSS has been used in multiple studies that demonstrate high reliability with Cronbach's alpha ranging from 0.82 to 0.90 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eParenting Self-Efficacy\u003c/b\u003e: The KPCS was used to measure perceived self-efficacy or confidence in parenting abilities among postpartum women (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The KPCS is a 15-item questionnaire that was initially developed to measure PSE among postpartum women of infants aged birth to 12 months in Australia (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) and has been validated among postpartum women in Nepal (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). It is a four-point Likert scale (0: hardly ever, 1: not very often, 2: some of the time, and 3: most of the time) with the scores ranging from 0 to 45, and higher scores represent greater perceived PSE. The Cronbach's alpha for the KPCS ranged from 0.81 to 0.87 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), and test-retest reliability was 0.88 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003eThe eligible respondents attending immunization clinics were approached by research assistants for participation in the study. After obtaining written informed consent, data collection was done through a semi-structured interview method in a private area at the immunization clinic. The Nepali version of the questionnaires was used for the interview. The recommendation for cross-cultural studies was followed (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Data collection work, including obtaining informed consent, pretesting questionnaires, and respondents\u0026rsquo; interviews, was done by two research assistants from April to June 2022. Respondents\u0026rsquo; responses were recorded in the questionnaire form using a paper-and-pencil format by research assistants. Research assistants were provided orientation training regarding instruments for data collection, procedures for obtaining informed consent, and interview techniques before pretesting. The same research assistants were involved in pretesting and data collection. The data collection work of the research assistants was supervised and monitored by the first author in Nepal.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eTo test the proposed hypotheses, we employed an ordinary least square (OLS) model using a following equation: \u003c/p\u003e\u003cp\u003eWhere \u003cem\u003eself-efficacy\u003c/em\u003e\u003csub\u003e\u003cem\u003ei\u003c/em\u003e\u003c/sub\u003e stands for maternal parenting self-efficacy, \u003cem\u003eepds scale\u003c/em\u003e\u003csub\u003e\u003cem\u003ei\u003c/em\u003e\u003c/sub\u003e stands for postpartum depression, \u003cem\u003emssscale\u003c/em\u003e\u003csub\u003e\u003cem\u003ei\u003c/em\u003e\u003c/sub\u003e stands for postpartum social support and \u003cem\u003eZ\u003c/em\u003e\u003csub\u003e\u003cem\u003ei\u003c/em\u003e\u003c/sub\u003e is a set of control variables.\u003c/p\u003e\u003cp\u003eData were analyzed in STATA version 17.0. Descriptive statistics were calculated for all sociodemographic and control variables. We conducted the normality and multicollinearity tests. The results indicated that the outcome variable and residuals look roughly bell-shaped and symmetric. In addition, the mean and median of self-efficacy variable (36.805 and 37 respectively) are fairly close, which indicates the self-efficacy variable is symmetric. We also tested multicollinearity tests which also shows that there is no multicollinearity problem in the model. Thus, OLS regression analysis is a relevant model to test the proposed hypotheses.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eDemographic Information of Respondents\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e representsinformation about the respondents\u0026rsquo; socio-demographic characteristics. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides descriptive statistics of the main study variables. Total sample consisted of 128 postpartum women during one to six months postpartum period in which 65 of women had normal birth weight infants and 63 of them had low birth weight infants. The mean age of infants was 2.75 months (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.29), and the mean age of postpartum women was 27.99\u0026thinsp;\u0026plusmn;\u0026thinsp;4.28 years. More than half respondents had a cesarean birth (58.59%), followed by normal vaginal delivery (39.84%). Respondents were ethnically diverse, with the majority of them being Brahmin and Chhetri (50%) ethnic group followed by Janajati (34.4%) Madhesi (7.8%), Dalit (7%), and least were Muslim (0.8%). 39% of study respondents had a Bachelor\u0026rsquo;s degree or higher level of education, with 40% of infants fathers completed a bachelor\u0026rsquo;s degree or higher.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic Characteristics of Respondents (n\u0026thinsp;=\u0026thinsp;128)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (% )\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfant age in months\u003c/p\u003e\u003cp\u003eInfants' birth weight in grams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e\u003cp\u003e2458.38\u0026thinsp;\u0026plusmn;\u0026thinsp;731.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfant sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67 (52.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61 (47.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant's ethnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDalit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (7.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJanajati\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44 (34.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMadhesi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10 (7.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBrahmin and Chhetri\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64 (50.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVaginal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e51 (39.84)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstrumental Vaginal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (1.55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaesarean Section\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75 (58.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003cp\u003eUnable to read and write\u003c/p\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003cp\u003eHigher Secondary\u003c/p\u003e\u003cp\u003eBachelor\u003c/p\u003e\u003cp\u003eMaster\u0026rsquo;s level/higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (2.3)\u003c/p\u003e\u003cp\u003e3 (2.3)\u003c/p\u003e\u003cp\u003e30 (23.4)\u003c/p\u003e\u003cp\u003e42 (32.8)\u003c/p\u003e\u003cp\u003e25 (19.5)\u003c/p\u003e\u003cp\u003e25 (19.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncome sufficient for household expenditure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (5.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u0026ndash;11 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15 (11.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66 (51.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40 (31.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestational age dummy\u003c/p\u003e\u003cp\u003eLess than 37 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71(55.47)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEqual or more than 37 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57(44.53)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrenatal anxiety/depression dummy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxious and/or depressive thoughts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43 (33.59)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo anxious/depressive thoughts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e85(66.41)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive Statistics of Key Study Variables (n\u0026thinsp;=\u0026thinsp;128)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eMin\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eMax\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostpartum depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParenting self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAssociations Among Postpartum Depression, Social Support and Parenting Self-EfficacyTable 3 shows the impacts of PPD and self-efficacy on parenting self-efficacy. Columns (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) show the impact of PPD, and columns (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) show the impact of social support. The first column is the direct associations without including the controls, and the second column represents results with control variables. In these columns, the coefficients of both the PPD and social supportare statistically significant at 1% significance level. The coefficients of PPD are negative, and the coefficients of social support are positive.\u003c/p\u003e\u003cp\u003eMore specifically, on the one hand, the coefficient of PPD in column (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) is -0.312, and it indicates that a one-point increase in PPD causes a 0.312-point decrease in PSE (Hypothesis 1). On the other hand, the coefficient of social support in column (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) is 2.781, and it indicates that a one-point increase in social support causes a 2.781-point increase in PSE (Hypothesis 2). Even if we include both PPD and social support variables in the same model as in columns (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), the implication of the coefficients of those variables remains the same.\u003c/p\u003e\u003cp\u003eNotice that columns (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) do not include control variables, while columns (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) include a set of control variables including infant sex dummy, low birth weight dummy, gestational age dummy, educational status of respondents, prenatal anxiety and depression dummy, and household income status.\u003c/p\u003e\u003cp\u003eHence, from the results in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, we conclude that PPD was negatively associated with PSE during the postpartum period, while perceived postpartum social support was positively associated with PSE.\u003c/p\u003e\u003cp\u003eRegarding the coefficients of control variables, all of them are statistically insignificant except the mother's educational status in column (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The coefficient of mother's educational status in column (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) is -0.541 and statistically significant at 5% significance level. It provides a weak and negative association between the mother's educational status and PSE.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociations AmongPostpartum Depression and Social Support on Parenting Self-efficacy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModel (M) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(M2)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(M3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(M4)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(M5)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(M6)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostpartum depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.312***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.331***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.254***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.293***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(0.071)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.083)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.073)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.081)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived social support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.781***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.836***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.044***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.413***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(0.730)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.805)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(0.731)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.776)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfant sex (male:1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.386\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.178\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.096\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.574)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.589)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.562)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow birth weight dummy (\u0026lt;\u0026thinsp;2500g: 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.249\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.092\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.657)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.658)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.636)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestational age dummy (age\u0026thinsp;\u0026lt;\u0026thinsp;37 months:1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.868\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.540\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.707\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.651)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.660)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.631)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMother educational status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.398\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.400\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.541**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.266)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.271)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.261)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrenatal anxiety and/ depression dummy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.570\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.348\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.682)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.657)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.676)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousehold income status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-0.102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(0.393)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.398)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(0.379)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.385***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.701***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30.165***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32.515***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e33.207***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e34.859***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(0.458)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(1.405)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(1.767)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(2.335)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(1.904)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(2.318)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObservations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR-squared\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.143\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.228\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eDependent variable: PSE\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: All regressions are estimated by OLS. Robust standard errors are provided in parentheses. * p value significant at \u0026lt;\u0026thinsp;0.05, ** p value significant at \u0026lt;\u0026thinsp;0.01, *** p value significant at \u0026lt;\u0026thinsp;0.001.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study indicate that PPD was significantly and negatively associated with PSE among women during one to six months of postpartum. In addition, postpartum social support was the important predictive factor for PSE in which higher levels of perceived social support was positively linked to increased PSE among women during one to six months of postpartum period. We examined these relationships with and without control variables in the model. The most noteworthy finding was that even after controlling for the effects of multiple control variables in the model, both PPD and social support were significantly associated with PSE. To our knowledge, this is the first study that establishes the important links between postpartum mental health and social support for self-efficacy among women during one to six months postpartum among Nepali postpartum women.\u003c/p\u003e\u003cp\u003eOur finding was consistent with a cross-sectional study conducted in Ireland among 410 primiparous mothers at 6 weeks after childbirth, in which results showed a statistically significant correlation between social support and maternal PSE (r\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Strengthening social support has been recognized as a potentially effective strategy to enhance PSE (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The persons most frequently identified by women as having provided support were their own mothers, husbands/partners, and sisters (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In the Nepali context, child rearing is considered the responsibility of the family. Postpartum women are generally supported and guided for childcare by their female family members, like their mother, sisters, and in-laws. Women are completely released from other household and social responsibilities so that they can completely focus on childcare. These social mechanisms are supportive for developing PSE among postpartum women. Similarly, another study of 309 Chinese postpartum women found that postpartum social support was positively associated with maternal PSE (β, 0.39; 95% CI, 0.28\u0026ndash;0.49) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Seeing how other parents cope successfully with parenting issues may convince parents they, too, will succeed. Social relationships may provide verbal persuasion and feedback (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Multivariable linear regression analysis of data collected among 647 Dutch parents of children aged birth to 8 years was done to examine the association between social support and PSE. Parents who experienced lower levels of social support at the start of the study reported lower PSE at follow-up (β: 0.13; 95% CI: 0.05, 0.21), independent of potential socio-demographic confounders. Parents who were experiencing an increase in perceived social support during the study period were associated with an increase in PSE (β: 0.15; 95% CI: 0.10, 0.21) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOn the other side, maternal PSE is negatively correlated with PPD because depressed women hardly view themselves as capable of childcare compared to the women who are not depressed (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A study among a racially diverse sample of 142 mother\u0026ndash;infant dyads living in low-income households in the United States reported that lower maternal depressive symptoms predicted better PSE (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Another Chinese study among 309 parents using the EPDS scale revealed a significant and negative association of PSE with PPD among women (β, \u0026minus;\u0026thinsp;0.22; 95% CI, \u0026minus;\u0026thinsp;0.32 to \u0026minus;\u0026thinsp;0.12)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Another study among 410 postpartum women in Ireland using the EPDS scale and PSE scale showed a significant association between PPD and PSE (χ2\u0026thinsp;=\u0026thinsp;18.26, df\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLikewise, a review including eight articles found a negative association of maternal mood states, such as stress, anxiety, and depression, with maternal PSE (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A structured clinical interview among 83 women with infants aged birth to\u0026ndash;12months admitted to a residential parent\u0026ndash;infant program showed inverse correlation of PSE with maternal mental health problems like depression, anxiety (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A meta-analytic review of 35 studies found a significant pooled effect of both PPD on PSE and of PSE on PPD, with nearly identical effect sizes (d\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.21 and \u0026minus;\u0026thinsp;0.22, respectively). The association was stronger in samples of women with a younger average age (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In addition, maternal PSE is significantly associated with various factors like women\u0026rsquo;s education, income, family type, employment status, parity, and age of the infants (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo our knowledge, this is the first study that examined the effects of PPD and postpartum social support in parenting self-efficacy among Nepali postpartum women within the first 6-months of postpartum. Data were obtained from two research sites capturing diverse and broader population. \u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAlthough this is the first study in Nepal that examined the impacts of PPD and social support on PSE, there are some notable limitations. Data for this study were taken from self-reports of postpartum women, so there is a possibility of recall bias or social desirability bias due to self-reported data. Another limitation is that the causality of the relationships among study variables cannot be inferred due to the cross-sectional nature of the study. The study was limited only to the immunization clinics of two hospitals in Kathmandu, Nepal, so the research findings cannot be generalized to all postpartum women living in different geographic locations of Nepal or at the national level.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite the limitations, findings of this study contributed to the existing literature that PPD and perceived social support are strong predictors of PSE during one to six months postpartum period among women. Most importantly, higher levels of perceived social support during postpartum was positively related to better PSE whereas maternal psychopathology like PPD during the critical stages of infant development reduces the PSE among women controlling for the spurious effects of multiple variables including LBW, preterm birth, income, education etc.\u003c/p\u003e\u003cp\u003eFindings of this study have important implications at multiple levels. First, clinicians and nurses should identify postpartum women at risk for PPD and those who identified positive for depressive symptoms or at-risk should receive timely referral and appropriate treatment andmanagement to prevent its negative effects in their parenting ability. Because self-efficacy or parenting ability is essential for carrying out an effective parenting role for infants and positive bonding relationships, addressing factors contributing to poor parenting self-efficacy are crucial. Additionally, parenting interventions targeting postpartum women to improve postpartum social support, and reduce mental health problems would be crucialto enhance parenting self-efficacy among postpartum women.\u003c/p\u003e\u003cp\u003eFuture research should include larger and more diverse sampls and expand this research up to 12 months postpartum period, as the first year is critical for both maternal outcomes and infants\u0026rsquo; development. Future research should also explore the underlying mechanisms predicting PSE and evaluate the effectiveness of evidence-based interventions aimed at improving maternal mental health and social support Additionnaly, qualitative research is needed to identify barriers and facilitators to enhancing PSE and mental health among postpartum women.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePostpartum depression\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePSE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eParenting self-efficacy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSocial Support\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team obtained ethical approval from Rutgers University, New Jersy, USA; Nepal Health Research Council; and two research sites in Nepal to conduct the study. \u0026nbsp;Written informed consent was obtained from the respondents prior to recruiting in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors would like to thank the ‘Seed Funding for Data Collection and analysis’ Rutgers University-Camden, Committee on Institutional Equity and Diversity (CIED), Immunization Clinic staff of TUTH and KCH for their support and cooperation during data collection and participants of the study for their participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTS and SPK wrote the main manuscript, KK prepared Tables. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has no funding support for publication. Fund for data collection and analysis was received from the ‘Seed Funding for Data Collection and analysis’ Rutgers University-Camden, New Jersey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to privacy or ethical restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Disclosures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team obtained ethical approval from Rutgers University, New Jersy, USA; the Nepal Health Research Council; and research sites in Nepal to conduct the study. \u0026nbsp;Written informed consent was obtained from the respondents prior to recruiting in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLeahy-Warren P, McCarthy G. 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PubMed, WILEY.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAzmoude E, Jafarnejade F, Mazloum SR. The Predictors for Maternal Self-efficacy in Early Parenthood. J Midwifery Reprod Heal [Internet]. 2015;3(2):368\u0026ndash;76. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://jmrh.mums.ac.ir/article_4050.html\u003c/span\u003e\u003cspan address=\"https://jmrh.mums.ac.ir/article_4050.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. SEMANTIC SCHOLAR.\u003c/span\u003e\u003c/li\u003e\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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postpartum depression, women, self-efficacy, social support, infants","lastPublishedDoi":"10.21203/rs.3.rs-5045830/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5045830/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eParenting self-efficacy (PSE) is a parent's ability to be responsive and attentive to their child's needs, which may be greatly influenced by perinatal mental health and social factors during postpartum. Limited studies to date have examined how maternal mental health status (i.e., postpartum depression) and Social Support link to PSE among postpartum women during critical stages of infant development in Nepal. Thus, this study aims to examine the postpartum depression (PPD) and perceived Self efficacy as the predictors for PSE among postpartum women within 6 months of childbirth in Nepal.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted among one to six months postpartum women who attended immunization clinics in two hospitals in Kathmandu. Conveniently selected, 128 women of both low birth weight and normal birth weight infants were recruited for the study. Data were collected using standardized measures of the Edinburgh Postnatal Depression Scale, Karitane parenting self-efficacy scale, postpartum social support scale, and sociodemographic questionnaire via semi-structured interviews with respondents. Data were analyzed in STATA version 17.0 using linear regression analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eRespondents were ethnically and socioeconomically diverse. Results indicated that PPD was significantly but negatively associated with PSE (β= \u0026minus;\u0026thinsp;.29, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). But perceived social support from husband, family, and friends was significantly and positively associated with increased PSE (β\u0026thinsp;=\u0026thinsp;2.41, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) among women during one to six months of postpartum. The results were statistically significant even after controlling for the effects of multiple control variables in the model.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePPD and perceived social support are significant predictors of PSE during the first six months postpartum among Nepali women. These findings have important implications for evidence-based interventions for early identification of women with PPD and enhancing postpartum social support after childbirth to enhance the mothers\u0026rsquo; confidence in parenting their infants.\u003c/p\u003e","manuscriptTitle":"Postpartum Depression and Social Support as Predictors for Parenting Self-efficacy among Nepali Postpartum Women","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 18:02:27","doi":"10.21203/rs.3.rs-5045830/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-01T14:49:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T05:45:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191515088046644417909671673933064007301","date":"2025-12-08T05:31:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T01:28:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18852973591851913725473243816508970299","date":"2025-12-03T06:52:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-03T05:27:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-11T10:47:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-11-08T17:22:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"508fedde-7b28-4736-a9c0-4971d23ff5f0","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-10T18:54:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 18:02:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5045830","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5045830","identity":"rs-5045830","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}