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Longitudinal effects of perinatal social support on maternal depression: a marginal structural modelling approach
  1. Ashley Hagaman1,2,
  2. Katherine LeMasters3,4,
  3. Paul N. Zivich3,4,
  4. Siham Sikander5,6,
  5. Lisa M. Bates7,
  6. Sonia Bhalotra8,
  7. Esther O. Chung3,4,
  8. Ahmed Zaidi5,
  9. Joanna Maselko3,4
  1. 1Social Behavioral Sciences, Yale University School of Public Health, New Haven, Connecticut, USA
  2. 2Center for Methods in Implementation and Prevention Science, Yale University, New Haven, Connecticut, USA
  3. 3Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  4. 4Carolina Population Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  5. 5Human Development Research Foundation, Islamabad, Pakistan
  6. 6Global Health Department, Health Services Academy, Islamabad, Pakistan
  7. 7Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
  8. 8Department of Economics, University of Warwick, UK, Coventry, Warwickshire, UK
  1. Correspondence to Professor Ashley Hagaman, Social Behavioral Sciences, Yale University School of Public Health, New Haven, CT 06520-8034, USA; ashley.hagaman{at}


Background Depression in the perinatal period, during pregnancy or within 1 year of childbirth, imposes a high burden on women with rippling effects through her and her child’s life course. Social support may be an important protective factor, but the complex bidirectional relationship with depression, alongside a paucity of longitudinal explorations, leaves much unknown about critical windows of social support exposure across the perinatal period and causal impacts on future depressive episodes.

Methods This study leverages marginal structural models to evaluate associations between longitudinal patterns of perinatal social support and subsequent maternal depression at 6 and 12 months postpartum. In a cohort of women in rural Pakistan (n=780), recruited in the third trimester of pregnancy and followed up at 3, 6 and 12 months postpartum, we assessed social support using two well-validated measures: the Multidimensional Scale of Perceived Social Support (MSPSS) and the Maternal Social Support Index (MSSI). Major depressive disorder was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM IV).

Results High and sustained scores on the MSPSS through the perinatal period were associated with a decreased risk of depression at 12 months postpartum (0.35, 95% CI: 0.19 to 0.63). Evidence suggests the recency of support also matters, but estimates are imprecise. We did not find evidence of a protective effect for support based on the MSSI.

Conclusions This study highlights the protective effect of sustained social support, particularly emotional support, on perinatal depression. Interventions targeting, leveraging and maintaining this type of support may be particularly important for reducing postpartum depression.

  • maternal health
  • depression
  • psychosocial factors
  • developing country

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  • Contributors AH, KL, PZ and JM conceptualised the analysis. AH, KL and PZ designed and conducted the analysis. All authors drafted and revised the manuscript, had access to all data and approved the final submission. SS and JM substantially contributed to the conception and design of the larger study and this analysis. AH had final responsibility for the decision to submit for publication.

  • Funding This work was supported by the National Institute of Mental Health (U19MH95687) and Eunice Kennedy Shriver National Institute of Child Health and Development (NICHD) (R01 HD075875). The research was also supported by institutional grants awarded to the Carolina Population Center at the University of North Carolina at Chapel Hill from the NICHD (T32HD007168 and P2CHD050924 to AH, KL, PZ and JM). PZ was supported by NICHD T32HD091058.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The project received approval from the institutional review boards of the Human Development Research Foundation, Duke University, North Carolina, USA, and University of North Carolina, North Carolina, USA.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request directed to JM, senior author.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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