Original Research

Fetal Sex, Social Support, and Postpartum Depression

Ri-hua Xie, RN, MSc, PhD1; Guoping He, MD2; Diana Koszycki, PhD, CPsych3;
Mark Walker, MD4; Shi Wu Wen, MB, PhD5

Objective: To examine the impact of prenatal and postnatal social support on the association
between fetal sex and postpartum depression (PPD).
Method: We conducted a prospective cohort study in Changsha, China, between February and
September 2007. We first compared the sociodemographic and obstetric characteristics, and the
prenatal and postnatal social support between women who gave birth to a female infant and
those who gave birth to a male infant. We then examined the association between fetal sex and
PPD by following logistic regression models: fetal sex as the independent variable; with
adjustment for sociodemographic and obstetric factors; with adjustment for sociodemographic,
obstetric factors, and prenatal social support; and with adjustment for sociodemographic,
obstetric factors, and postnatal social support.
Results: Postnatal social support scores were much lower in women who gave birth to a female
infant than in those who gave birth to a male infant. The odds ratio of PPD for women who
gave birth to a female infant, as compared with those who gave birth to a male infant, was 3.67
(95% CI 2.31 to 5.84). The increased risk of PPD for women who gave birth to a female infant
remained after adjustment for sociodemographic and obstetric factors and prenatal social
support, but disappeared after adjustment for postnatal social support score.
Conclusion: We conclude that increased risk of PPD in Chinese women who give birth to a
female infant is caused by lack of social support after childbirth.
Can J Psychiatry. 2009;54(11):750–756.

Clinical Implications
· Lack of social support after childbirth is an important determinant of PPD.
· To maximize cost-effectiveness, interventions aiming at reducing the risk of PPD should focus on
the postpartum period.
· Cultural factors should be taken into consideration in the development of preventive strategies for
PPD.

Limitations
· Our study sample is not sufficiently large, especially for stratified analysis, to assess potential
effect modification.
· Patients at either end of the emotional spectrum might not have been inclined to participate.
· PPD and postnatal Social Support Rating Scale were measured at the same time and they might
have interacted with each other.
· The Edinburgh Postnatal Depression Scale was used to classify women as depressed or not. It
should be noted that this is a screening measure, and it does not constitute a diagnosis of
depression.

Key Words: postpartum depression, social support, fetal sex, Chinese

750 W La Revue canadienne de psychiatrie, vol 54, no 11, novembre 2009


ith an onset within 6 months after childbirth, PPD is a
W subtype of major depression.1 The reported rates of
PPD range from 10% to 20%.2–6 PPD is a serious problem that
affects a woman’s health and well-being, marital relationship,
as well as the infant’s health and well-being.7–10 Further,
women affected by PPD were at increased risk for major
depression in their later life.11 The etiology of PPD remains
elusive, although epidemiologic studies have identified
several risk factors such as a personal or family history of
major depression, perinatal stressors, psychosocial stressors,
and sociodemographic, socioeconomic, and sociocultural
factors.4,6,9,12
In our previous study, we found that the relative risk for PPD
in Chinese women who gave birth to a female infant, com-
pared with those who gave birth to a male infant, was 2.89
(95% CI 1.36 to 6.17). This increased risk could not be
explained by differences in maternal demographic factors,
socioeconomic status, and medical care services.6 These find-
ings are consistent with several studies from India13 and
China.14,15 However, studies conducted in Western societies
have not reported an association between infant sex and
PPD.12 The reason for the increased risk of PPD in Chinese
women who give birth to a female infant is unclear. Given the
preference for a male infant in Chinese society, we hypothe-
size that lack of social support after childbirth in women who
give birth to a female infant may contribute to elevated risk for
PPD. Therefore, in this prospective cohort study, we exam-
ined whether lack of support during the postpartum period
mediates the relation between PPD and birth of a female
infant.
Methods
We recruited study participants between February and Sep-
tember 2007 at Hunan Maternal and Infant Hospital, the First
Affiliated and the Third Affiliated Hospitals of the Central
South University in Changsha, Hunan, People’s Republic of
China, during their prenatal visits at 30 to 32 weeks of gesta-
tion. Primiparous married women aged 20 to 45 years present-
ing for prenatal care and planning to stay in Changsha city
during the postpartum period were invited to participate in our
study. The women who agreed to participate gave written
informed consent. Women with a multi-fetal pregnancy or
current or past history of bipolar disorder, psychotic disor-
ders, or with a major chronic disease or obstetric and
Abbreviations used in this article
EPDS Edinburgh Postnatal Depression Scale
PPD postpartum depression
SSRS Social Support Rating Scale
The Canadian Journal of Psychiatry, Vol 54, No 11, November 2009 W
Fetal Sex, Social Support, and Postpartum Depression
pregnancy complication (severe preeclampsia or eclampsia,
placenta previa, placental abruption, major postpartum infec-
tion, still birth, major birth defects, or birth weight of less
than 1500 grams) as recorded in medical charts were
excluded because these conditions may increase the risk of
PPD12 and may introduce bias in our study.
Research nurses conducted face-to-face interviews with par-
ticipating women to collect relevant clinical and demo-
graphic data. A standardized data form was used to record
obstetric and demographic data at 30 to 32 weeks of
gestation.
Social support levels were measured by SSRS at 30 to 32
weeks of gestation and were measured again at 2 weeks
postpartum. The SSRS used in our study was developed by
Xiao,16 based on the unique environmental and cultural con-
ditions in China. This scale consists of 10 items, with 3
dimensions: subjective support (4 items), objective support
(3 items), and support availability (3 items). The SSRS scale
produces a summative score ranging from 8 to 66, with the
higher scores indicating higher levels of social support. This
scale can be used in the general population for people aged 14
years or older. It has been widely used in the Chinese popula-
tion and has demonstrated high reproducibility (0.92) and
internal consistence (0.89 to 0.94). 16
The Chinese version of the EPDS was used at 2 weeks
postpartum to assess PPD, with a score of 13 or higher as the
cut-off for PPD.17 Previous studies have demonstrated the
reliability and validity of the EPDS in identifying depression,
and it has been widely applied both in research and in clinical
settings.18 The sensitivity (0.82) and specificity (0.86) of the
Chinese version of the EPDS were comparable with the origi-
nal scale.17
We first compared the demographic and perinatal character-
istics and the social support levels (total SSRS score and the
scores of the 3 dimensions of social support) that were mea-
sured during pregnancy with those that were measured after
childbirth, and between women who gave birth to a female
infant and those who gave birth to a male infant. We then
examined the association between fetal sex and PPD by
logistic regression with the following strategies: entered only
fetal sex as the independent variable (crude estimation);
adjusted for sociodemographic factors; adjusted for
sociodemographic and obstetric factors; adjusted for
sociodemographic and obstetric factors and prenatal social
support level (total SSRS score); and adjusted for
sociodemographic and obstetric factors and postnatal social
support level (total SSRS score). Sociodemographic and
obstetric factors included in the logistic regression model
were household income, history of abortion, and mode of
delivery. The selection of the confounding variables to be
751
Original Research
entered into the multiple logistic regression model was based
on preliminary analysis of our data as well as biological ratio-
nale. For example, although lack of accompanied delivery and
early contacts was associated with PPD, they were part of the
social support network. To avoid over-adjustment and a
potential collinearity problem, we did not put these 2 variables
into the regression model. Finally, we compared the impact of
the 3 dimensions of social support (that is, subjective support,
objective support, and support availability) on the fetal sex
and PPD association, by entering the SSRS scores for the 3
dimensions into the multiple logistic regression models sepa-
rately. The same set of sociodemographic and obstetric fac-
tors described above were entered into the regression models.
This study has been approved by the Research Ethics Board of
Central South University. All analyses were performed using
SPSS software (SPSS Inc, Chicago IL), version 13.0.
Results
A total of 666 women were invited to participate in the study
and 615 women agreed and completed the prenatal survey. At
2 weeks postpartum, 24 women withdrew, 25 were lost to
follow-up, and 10 had missing information in more than 20%
of the variables. A further 41 women were excluded because
of recorded major psychiatric disorders and obstetric and (or)
pregnancy complications, leaving 534 (86.8% of the con-
sented women at 30 to 32 weeks of gestation) for analysis.
The baseline characteristics of the 2 groups were quite similar,
although women who gave birth to a female infant had a
slightly higher household income, more prenatal care visits,
and higher Cesarean delivery rate (Table 1). One hundred
three women (19.29%) were found to have PPD. The rate of
PPD was significantly higher in women who gave birth to a
female infant than women who gave birth to a male infant
(Table 1).
Table 2 shows that there were no differences in social support
(total SSRS score and the scores of the 3 dimensions of social
support) measured during pregnancy between women who
gave birth to a female infant and those who gave birth to a
male infant. In contrast, postnatal levels of social support
(total SSRS score and the scores of the 3 dimensions of social
support) were significantly lower among women who gave
birth to a female infant.
The odds ratio of PPD for women who gave birth to a female
infant, compared with those who gave birth to a male infant,
was 3.67 (95% CI 2.31 to 5.84). The increased risk of PPD for
women who gave birth to a female infant remained after
adjustment for sociodemographic and obstetric factors and
prenatal social support, but disappeared after adjustment for
postnatal social support score (Table 3).
752
The increased risk of PPD in women who gave birth to a
female infant remained after adjustment for subjective sup-
port, objective support, and support availability scores mea-
sured prenatally. The increased risk of PPD for women who
gave birth to a female infant reduced substantially after
adjustment for subjective and (especially) objective support
scores measured postnatal (Table 4).
Discussion
Our study in a cohort of Chinese women revealed that PPD
occurred in about 19% of the parturient women. This rate is
similar to those reported in previous studies conducted in
China.6,14,15,19–21 The distribution of demographic character-
istics in our study population, such as exceptionally high
marriage and Cesarean delivery rates, is consistent with the
demographic characteristics of Chinese pregnant women
reported in recent Chinese literature.6,22,23 Our study also rep-
licated the findings of earlier studies in China that carrying a
female fetus was significantly associated with greater risk for
developing PPD: there was over a 2-fold increased risk in
these women than in those who carried a male fetus.6,14,15
No major difference in baseline characteristics was found
among women who gave birth to a male or a female infant,
although household income was higher, prenatal care visits
were more frequent, and Cesarean section rates were higher
in women with a female infant, suggesting that prenatal fac-
tors did not play an important role in the increased risk of
PPD in women with a female infant. In our data, parents did
not know the sex of the fetus before delivery. Since 2002,
prenatal sex identification and sex-selective abortion are pro-
hibited in China and physicians who do not comply with
these policies will be charged under the criminal law and risk
suspension of medical licensure. We speculate that the nega-
tive reaction of family members toward the birth of a female
baby, which may subsequently affect their support of the
mother, may be a potential risk factor for PPD within certain
cultural groups.12 Prior to delivery, the levels of social sup-
port, either measured by total SSRS score or scores for the 3
dimensions of SSRS, were similar between women who
carry a female fetus and those who carry a male fetus. This is
not surprising given that fetal sex is unknown at that time.
After delivery, the levels of social support, either measured
by total SSRS score or scores for the 3 dimensions of SSRS,
were substantially lower in women who gave birth to a
female infant. This is not a surprise too, as the fetal sex
became known at this time. The increased risk of PPD for
women who gave birth to a female infant remained after
adjustment for sociodemographic and obstetric factors and
prenatal social support, but disappeared after adjustment for
postnatal social support score, suggesting that lack of social
W La Revue canadienne de psychiatrie, vol 54, no 11, novembre 2009
 Fetal Sex, Social Support, and Postpartum Depression

Table 1 A comparison of sociodemographic and obstetric

characteristics between women who gave birth to a female infant
and those who gave birth to a male infant in Changsha, China, in
2007
Male (n = 295) Female (n = 239)
Characteristic n (%) n (%)

Age, years
20–24 43 (14.6) 27 (11.3)
25–34 234 (79.3) 190 (79.5)
35–45 18 (6.1) 22 (9.2)
Education
University or higher 118 (40.0) 104 (43.5)
College 75 (25.4) 56 (23.4)
High school or lower 102 (34.6) 79 (33.1)
Occupation
Public servant, professional 95 (32.2) 71 (31.1)
Worker, clerk 89 (30.2) 78 (32.6)
Farmer 65 (22.0) 57 (23.8)
Other 46 (15.6) 33 (13.8)
Income (per month per member), ¥
³2000 154 (52.2) 118 (49.4)
1000–1999 73 (24.7) 65 (27.2)
<1000 68 (23.1) 56 (23.4)
Housing condition
Satisfactory 239 (81.0) 193 (80.8)
Unsatisfactory 56 (19.0) 46 (19.2)
Planned pregnancy
Yes 228 (77.3) 168 (70.3)
No 67 (22.7) 71 (29.7)
Gravidity
1 261 (88.5) 198 (82.8)
³2 34 (11.5) 41 (17.2)
Abortion
0 137 (46.4) 94 (39.3)
1 89 (30.2) 69 (28.9)
³2 69 (23.4) 76 (31.8)
Doula delivery
Yes 127 (43.1) 93 (38.9)
No 168 (56.9) 146 (61.1)
Use of pain relief
Yes 250 (84.7) 202 (84.5)
No 45 (15.3) 37 (15.5)
Delivery Model
Vaginal 68 (23.1) 51 (21.3)
Cesarean delivery 227 (76.9) 188 (78.7)
Caesarean type
Emergent 92 57
Elective 135 131
Birth weight, g
2500–3999 253 (85.8) 212 (88.7)
<2499 or ³4000 42 (14.2) 27 (11.3)

The Canadian Journal of Psychiatry, Vol 54, No 11, November 2009 W 753
Original Research

Table 1 continued
Male (n = 295) Female (n = 239)
Characteristic n (%) n (%)

Early contact
Yes 261 (88.5) 202 (84.5)
No 34 (11.5) 37 (15.5)
Rooming-in
Yes 263 (89.2) 204 (85.4)
No 32 (10.8) 35 (14.6)
Breastfeeding (any)
Yes 284 (96.3) 222 (92.9)
No 11 (3.7) 17 (7.1)
PPD
Yes 31 (10.5) 72 (30.1)
No 264 (89.5) 167 (69.9)

Table 2 A comparison of social support levels (SSRS score in mean [SD]) measured during
pregnancy and after childbirth between women who gave birth to female and male infants in
Changsha, China, in 2007
SSRS Male Female ta P

Prenatal
Total score 43.70 (6.08) 43.34 (6.43) 0.660 0.510
Subjective support 23.71 (3.76) 24.03 (4.10) 0.944 0.346
Objective support 11.46 (2.92) 11.05 (3.14) 1.577 0.115
Support availability 8.53 (1.84) 8.26 (1.78) 1.681 0.093
Postnatal
Total score 46.30 (4.74) 39.25 (5.66) 15.667 <0.001
Subjective support 25.03 (2.77) 21.70 (3.78) 11.731 <0.001
Objective support 12.99 (2.15) 10.28 (2.46) 13.558 <0.001
Support availability 8.28 (1.65) 7.27 (1.46) 7.438 <0.001
a
df = 1

support after childbirth may mediate the relation between risk
for PPD and giving birth to a female infant.
Social support has been widely found to be a determinant of
PPD, although the magnitude of the effect of social support on
PPD varied among different studies.4,9,12,24–26 Deteriorating
marital or partner relationship after the birth of a baby girl may
be another explanation.5 Preference for boys to girls is a
widely recognized phenomenon in China, especially in rural
China. There are several potential explanations for this phe-
nomenon. Because of the lack of social security system in
China, parents rely on their sons for economic support when
they become old. Women usually live in their husband’s home
after marriage and cannot provide the same level of support to
their own parents as men can. Moreover, family names are
considered an important symbol of the family and these
names usually follow the husband’s family name. The effect
of male preference may be one of the most important risk fac-
tors in a mother being depressed in a society that values boys
more highly.
Limitations of our study should be acknowledged. The EPDS
was used to classify women as depressed or not. It should be
noted that this is a screening measure, and does not constitute
a diagnosis of depression. The study sample is not suffi-
ciently large, especially when there is a need for stratified
analysis to assess potential effect modification. Selection
bias might be possible during the recruitment process (that is,
patients at either end of the emotional spectrum may not be
inclined to participate). We do not know how representative

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 Fetal Sex, Social Support, and Postpartum Depression

Table 3 Association between fetal sex and PPD in Table 4 Impact of the 3 dimensions of social support
Changsha, China, in 2007 on the association between fetal sex and PPD in
Changsha, China, in 2007
Model OR (95% CI)
Model OR (95% CI)
Crude 3.67 (2.31–5.84)
Adjusted for sociodemographic factors 3.81 (2.37–6.12) Adjusted for sociodemographic 3.64 (2.241–5.915)
factors, obstetric factors, and
Adjusted for sociodemographic factors 3.72 (2.30–6.01) subjective support measured
and obstetric factors during pregnancy
Adjusted for sociodemographic factors, 3.76 (2.31–6.10) Adjusted for sociodemographic 3.78 (2.338–6.127)
obstetric factors, and total SSRS score factors, obstetric factors, and
measured during pregnancy objective support measured
Adjusted for sociodemographic factors, 1.47 (0.82 –2.62) during pregnancy
obstetric factors, and total SSRS score Adjusted for sociodemographic 3.66 (2.261–5.929)
measured after childbirth factors, obstetric factors, and
support availability measured
during pregnancy
Adjusted for sociodemographic 2.08 (1.200–3.619)
of the general population the women in our study were. This factors, obstetric factors, and
subjective support measured
may affect the generalizability of our study. The measurement
after childbirth
of postnatal social support was conducted at the same time
Adjusted for sociodemographic 1.92 (1.116–3.301)
with PPD, and the measurements of these 2 may interact with factors, obstetric factors, and
each other and therefore bias the results. In particular, women objective support measured
who were depressed might also have had low postnatal SSRS after childbirth
score, because both EPDS and SSRS scores were calculated Adjusted for sociodemographic 3.33 (2.034–5.456)
factors, obstetric factors, and
by questions answered by the study subjects. However, in the
support availability measured
assessment of the impact of the 3 dimensions of SSRS scores after childbirth
on the association between fetal sex and PPD, we found that
objective support had a greater impact than subjective sup-
port. If there is a potential information bias, the influence of
subjective support on the association between fetal sex and Foundation of China (06JJ4055), Scientific Research Fund of
Hunan Provincial Education Department (06C072), and Hunan
PPD should be stronger than that of objective support. But we Ministry of Science and Technology (06FJ4103).
observed the opposite, which makes it less likely that our
study findings were confounded by information bias during
Acknowledgements
the assessment of social support and PPD. We thank the pregnant women and the staff of the participating
hospitals in Changsha, China, for their support.
In summary, our prospective cohort study of 534 Chinese
women found that the lack of social support after childbirth is
the most likely reason for the increased risk of PPD in Chinese References
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This paper was presented at the Annual American College of
Epidemiology Meeting, Tucson AZ, 2008 Sep 13–17.
1
Research Fellow, Obstetrics, Maternal, and Neonatal Investigations
(OMNI) Research Group, Department of Obstetrics and Gynecology,
University of Ottawa, Faculty of Medicine, Ottawa, Ontario; Research
Fellow, Ottawa Health Research Institute, Clinical Epidemiology
Program, Ottawa, Ontario; Associate Professor and Chair, Department of
Nursing Huaihua Medical College, Huaihua, China.
2
Professor and Dean, School of Nursing, Central South University,
Changsha, China.
3
Associate Professor, Stress and Anxiety Clinical Research Unit,
University of Ottawa Institute of Mental Health Research, Ottawa,
Ontario.
4
Associate Professor, OMNI Research Group, Department of Obstetrics
and Gynecology, University of Ottawa, Faculty of Medicine, Ottawa,
Ontario; Senior Scientist, Ottawa Health Research Institute, Clinical
Epidemiology Program, Ottawa, Ontario.
5
Professor, OMNI Research Group, Department of Obstetrics and
Gynecology, University of Ottawa, Faculty of Medicine, Ottawa, Ontario;
Senior Scientist, Ottawa Health Research Institute, Clinical Epidemiology
Program, Ottawa, Ontario; Visiting Professor, School of Public Health,
Central South University, Changsha, China.
Address for correspondence: Dr S Wu Wen, OMNI Research Group,
Department of Obstetrics and Gynecology, University of Ottawa, Faculty
of Medicine, 501 Smyth Rd, Box 241, Ottawa, ON K1H 8L6;
swwen@ohri.ca

Résumé : Sexe fœtal, soutien social, et dépression du postpartum

Objectif : Examiner l’effet du soutien social prénatal et postnatal sur l’association entre le sexe
fœtal et la dépression du postpartum (DPP).
Méthode : Nous avons mené une étude de cohorte prospective à Changsha, en Chine, entre février
et septembre 2007. En premier lieu, nous avons comparé les caractéristiques sociodémographiques
et obstétricales, le soutien social prénatal et postnatal entre les femmes qui ont donné naissance à un
bébé de sexe féminin, et les femmes qui ont eu un bébé de sexe masculin. Nous avons ensuite
examiné l’association entre le sexe fœtal et la DPP en suivant des modèles de régression logistique :
le sexe fœtal comme variable indépendante; avec ajustement pour les facteurs sociodémographiques
et obstétricaux; avec ajustement pour les facteurs sociodémographiques, obstétricaux, et le soutien
social prénatal; et avec ajustement pour les facteurs sociodémographiques, obstétricaux, et le
soutien social postnatal.
Résultats : Les scores de soutien social postnatal étaient beaucoup plus faibles chez les femmes qui
ont donné naissance à un bébé de sexe féminin que chez celles ayant eu un bébé de sexe masculin.
Le rapport de cotes de DPP pour les femmes qui ont donné naissance à un bébé de sexe féminin,
comparativement à celles ayant eu un bébé de sexe masculin, était 3,67 (IC 95 % 2,31 à 5,84). Le
risque accru de DPP pour les femmes qui ont donné naissance à un bébé de sexe féminin demeurait
après ajustement pour les facteurs sociodémographiques, obstétricaux, et le soutien social prénatal,
mais il disparaissait après ajustement pour les scores de soutien social postnatal.
Conclusion : Nous concluons que le risque accru de DPP chez les femmes chinoises qui ont donné
naissance à un bébé de sexe féminin est causé par le manque de soutien social après la naissance.

756 W La Revue canadienne de psychiatrie, vol 54, no 11, novembre 2009