Relationship between the Noto-Peninsula earthquake and maternal postnatal depression and child-rearing
Environ Health Prev Med
Relationship between the Noto-Peninsula earthquake and maternal postnatal depression and child-rearing
Yuri Hibino 0 1 2
Jiro Takaki 0 1 2
Yasuhiro Kambayashi 0 1 2
Yoshiaki Hitomi 0 1 2
Akemi Sakai 0 1 2
Naomi Sekizuka 0 1 2
Keiki Ogino 0 1 2
Hiroyuki Nakamura 0 1 2
0 A. Sakai N. Sekizuka Department of Health Science, Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
1 J. Takaki K. Ogino Department of Public Health, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences , Okayama , Japan
2 Y. Hibino (&) Y. Kambayashi Y. Hitomi H. Nakamura Department of Environmental and Preventive Medicine, Graduate School of Medical Science, Kanazawa University , 13-1 Takaramachi, Kanazawa , Japan
Objective The aim of our study was to explore the relationship between a medium-scale earthquake and maternal depression and child-rearing in a depopulated community in the Noto Peninsula of Japan. Methods Three months after a major earthquake, selfrating questionnaires were distributed to women who were pregnant at the time of the earthquake or who became pregnant immediately thereafter, and who were receiving care at any of four major hospitals in the most devastated area. A total of 155 women who had given birth returned the completed questionnaire for analysis. Maternal postnatal depression among the participants was assessed using the Edinburgh Postnatal Depression Scale (EPDS). Results The EPDS score was significantly associated with decreased ''satisfaction with delivery'' (b = -0.28, p = 0.01), increased artificial ''lactation'' (b = 0.31, p = 0.002), and increased ''trouble with infant care'' (b = 0.47, p \ 0.001) in multivariate analysis. It was also significantly associated with increased ''anxiety about earthquakes'' (b = 0.30, p = 0.001), and ''anxiety about earthquakes'' was significantly associated with increased ''fear of the earthquake'' (b = 0.20, p = 0.04). Conclusions Earthquake-related factors such as ''anxiety about earthquakes'' and ''fear of the earthquake'' did not have a direct effect on child-rearing factors; however, they did have a significant relationship with increased EPDS. Based on these results, we conclude that screening strategies for maternal depression in peri- and postnatal women under emergency circumstances are necessary.
Child-rearing; Depopulated; Maternal postnatal depression; Earthquake
The Noto Peninsula area is located in northern Japan and
consists of a depopulated community with a large elderly
population. On March 25, 2007, an earthquake measuring
6.9 on the Richter magnitude scale struck the area, severely
damaging the region and completely destroying 684
houses. More than 2500 people had to move to temporary
shelters. A large proportion of the residents in this area are
elderly, reaching slightly more than 50% in one region.
However, 1000 neonates on average are born each year in
the Noto Peninsula, so the effects of disaster-related stress
on perinatal women cannot be ignored.
Numerous studies have addressed the various health
problems caused by devastating earthquakes [
these, few have examined the effects of disaster-related
stress on perinatal women [
]. The findings of these
earlier studies suggest that prenatal stress caused by natural
and man-made disasters may result in minor psychiatric
], low birth weight [
], preterm delivery [
], smaller head circumference [
], skewed sex ratios
], retardation of fetal brain development [
reduction of breast milk supply [
]. It also would seem that
pregnant women are more susceptible to the effects of
stress in the first trimester than in the second and third
6, 10, 12
Stress exposure during the perinatal period may worsen
maternal psychological health, and this in turn may lead to
degradation of the quality of care toward the newborn
infant. There is evidence to suggest that maternal
psychosocial health can have a significant effect on the mother–
infant relationship and that this can have consequences for
both the short and long-term health of the child under
ordinary circumstances [
]. Despite this evidence,
however, studies on the effects of earthquake exposure on
maternal psychological health and the mothering of a new
born baby have been limited.
Several of the earlier studies have indicated that natural
disaster stress affects parental psychological health and
family function and that this correlates with the children’s
mental health [
]. One study found that child abuse
reports were disproportionately higher after the occurrence
of a natural disaster . Mental health status can therefore
be transmitted from generation to generation. However,
this perspective has only rarely been examined in the
earlier earthquake studies. Natural disasters, such as
earthquakes, should be considered a public health issue affecting
maternal and neonatal health in the community.
The aims of the study reported here was to explore the
relationship between earthquake and maternal depression
and child-rearing in a depopulated community in Japan. An
empirically based understanding of the possible influence
of the Noto Peninsula earthquake on maternal and neonatal
health is important for future policy decisions.
Subjects and methods
We chose to collect data using a self-rating questionnaire.
Three months after the earthquake, a questionnaire was
distributed to pregnant women who were receiving routine
perinatal care, either by a physician or a midwife, at any of
four major hospitals in the most devastated area. The study
design was cross-sectional. All of the study participants
were pregnant at the time of the earthquake or became
pregnant immediately thereafter and were living in the
disaster area. Between 25 June 2007 to 31 January 2008,
311 of the 399 questionnaires distributed were returned.
Some participants in this panel study completed
questionnaires both before and after their deliveries. Among a total
of 199 participants, 93 women completed two
questionnaires and 19 completed three. Among these, the 155
women who returned one questionnaire after childbirth
were analyzed in our study. This study was approved by the
Ethics Committee of the Kanazawa Graduate School of
Socio-demographic data included the participant’s age,
marital status, and birth history (primipara/multipara).
Perinatal data included gestational age at the time of the
earthquake and the number of days since childbirth. These
variables were considered to be potential confounding
Earthquake-related factors included whether or not an
‘‘evacuation’’ shelter or temporary housing was used (yes/
no), ‘‘fear of the earthquake’’ (not very fearful/very
fearful), ‘‘anxiety about earthquakes’’ during pregnancy (yes/
no), and whether or not there was ‘‘house damage’’ (yes/
no) when the earthquake occurred. All of these
earthquakerelated variables were dichotomous.
Maternal psychological status was assessed with the
Edinburgh Postnatal Depression Scale (EPDS) developed
by Cox in 1987 [
]. Its validity and reliability have been
confirmed in the Japanese population [
]. The EPDS scale
consists of ten items, each of which is a four-point Likert
scale. The total score ranges from 0 to 30. The cutoff point
of the EPDS among Japanese population is a score of 9 [
]. Respondents with scores [9 are considered to be at a
significantly increased risk of maternal depression.
Cronbach’s a in this study was 0.83, indicating adequate internal
Maternal satisfaction with the delivery was assessed
with the Self-Evaluation Scale for Experience of Delivery
]. This scale consists of 18 items, including ‘‘I was
relaxed in the face of childbirth’’, ‘‘I accepted childbirth
pain open-mindedly’’, and ‘‘My childbirth experience was
like what I had wanted’’, each of which is a five-point
Likert scale. These items were constructed referencing
some Western studies [
] and were adjusted to reflect
the Japanese context. Respondents with higher scores are
likely to be more satisfied with their childbirth experience.
The total score ranges from 5 to 90. Cronbach’s a in this
study was 0.89, indicating adequate internal reliability.
As child-rearing-related variables, ‘‘lactation’’ (maternal
milk/artificial milk or mix) and ‘‘trouble with infant care’’
(yes/no) were also assessed. These two variables were
To evaluate the relationship between variables, Pearson’s
correlation coefficient (r) or correlation ratio (g) was
calculated. To explore the significant predictive factors for
EPDS or ‘‘satisfaction with delivery’’, ‘‘lactation’’,
‘‘trouble with infant care’’, and ‘‘fear of the earthquake’’,
stepwise multivariate regression analysis using a forward,
stepwise method was performed. The entry and exit criteria
were set at p = 0.05 and p = 0.10, respectively. For
missing data, listwise deletion was used. In all multivariate
analyses, adjustment was conducted for age and birth
history. As a result, a path diagram representing the
relationships between these variables was constructed.
A p value \0.05 was thought to be statistically significant.
Statistical analysis was performed using SPSS (Statistical
Package for Social Sciences, Chicago, IL) version 14.0 for
The basic characteristics of study participants who
experienced the Noto Peninsula earthquake during pregnancy
are outlined in Table 1. The mean age (± standard
deviation, SD) of the 155 participants was 29.7 ± 4.7 years. The
mean number of weeks after earthquake exposure was
15.8 ± 9.06. The mean number of days after childbirth was
29.7 ± 11.2. The mean EPDS score (±SD) was 4.2 ± 4.2,
and the percentage of scores C9 was 11.6%.
Correlations between variables are presented in Table 2.
The EPDS scores were significantly correlated with increased
‘‘trouble with infant care’’ (g = 0.42, p \ 0.01), increased
artificial ‘‘lactation’’ (g = 0.31, p \ 0.01), decreased
‘‘satisfaction with delivery’’ (r = -0.27, p \ 0.01), increased
‘‘anxiety about earthquakes’’ (g = 0.26, p \ 0.01). ‘‘Birth
history’’ significantly correlated with increased ‘‘satisfaction
with delivery’’ (g = 0.27, p \ 0.01), decreased ‘‘trouble
with infant care’’ (r = -0.26, p \ 0.01), and decreased
EPDS (g = -0.29, p \ 0.01). ‘‘Anxiety about earthquakes’’
significantly correlated with increased ‘‘fear of the
earthquake’’ (r = 0.20, p \ 0.05).
Stepwise multivariate analysis was performed, and the
results are presented in Table 3. ‘‘Anxiety about
earthquakes’’ was associated with ‘‘fear of the earthquake’’
(b = 0.20, p = 0.004). The EPDS score was significantly
associated with ‘‘anxiety about earthquakes’’ (b = 0.30,
p \ 0.001) and ‘‘birth history’’ (b = -0.23, p = 0.01). In
this model, women who were anxious about experiencing
an earthquake during pregnancy and were primipara had an
increased prevalence of postnatal depression. The EPDS
score was significantly associated with ‘‘satisfaction with
delivery’’ (b = -0.28, p = 0.01), ‘‘trouble with infant
care’’ (b = 0.47, p \ 0.001), and ‘‘lactation’’ (b = 0.31,
p = 0.002), respectively. All other explanatory variables
were excluded from the model (see footnote to Table 3).
Based on these results, a path diagram was depicted
29.7 ± 4.7 (16–40)
The mean EPDS score for women who experienced a
moderate-scale earthquake during pregnancy was 4.2, and the
percentage of women falling into the high risk category for
postnatal depression was 11.6%. A large population study on
Japanese women with postnatal depression reported that the
percentage who fell into the high risk category was 13.9%
], suggesting that our study participants had almost the
same prevalence of postnatal depression as that of the
general Japanese population. However, this result does not
a Age, birth history, evacuation, and house damage were excluded from the model
b Age, evacuation, house damage, and fear of the earthquake were excluded from the model
c Age, evacuation, anxiety about earthquakes, house damage, and fear of the earthquake were excluded from the model
d Age, birth history, evacuation, anxiety about earthquakes, house damage, and fear of the earthquake were excluded from the model
e Age, birth history, evacuation, anxiety about earthquakes, house damage, and fear of the earthquake were excluded from the model
necessarily mean that pregnant women who experienced the
Noto Peninsula earthquake did not experience
disasterrelated stress. Rather, it may be a reflection of the fact that
depression levels are relatively lower in rural areas. Another
interpretation of this result is selection bias: women with
severe psychiatric symptoms may have been excluded from
our study, thereby resulting in an underestimation of the
prevalence of depression.
The results of our study indicate that ‘‘anxiety about
earthquakes’’ during pregnancy were significantly
associated with postnatal depression among the study participants.
Previous studies have demonstrated that the correlation
between anxiety and depression is generally high [
one study reported a calculated correlation coefficient of 0.5
]. This association was also seen in the our study.
Additionally, our results show that women who experience
anxiety about earthquakes also tend to be very fearful about
the possible occurrence of earthquakes. Taken together,
these results suggest that the earthquake may have aroused
negative psychological symptoms, such as fear and anxiety,
in the pregnant women participating in our study, which in
turn may have led to postnatal depression. Therefore,
women who have fears or anxiety about earthquakes may be
more at risk of postnatal depressive symptoms, or vice
versa, as we were unable to determine the direction of the
causal relationship within the framework of our study.
It should be noted, however, that objective indicators of
earthquake damage such as ‘‘evacuation’’ and ‘‘house
damage’’ did not reach the level of statistical significance
against the outcome variables. One possible interpretation
Fig. 1 Path diagram regarding
earthquake factors that relate
childbirth and child-rearing
is that the participants who responded to the questionnaire
experienced minimal physical and material damage. The
fact that no injuries were reported among these participants
may contribute to the lack of association between
depression and physical and material damage. Selection bias in
this study may also be one reason why study participants
had minimal physical and material damage. Consequently,
any interpretation of the associations found in this study
must take into account bias due to missing data in the
A large number of studies on postnatal depression have
been conducted on populations other than earthquake
survivors. The findings of these revealed that a number of
sociodemographic and personal factors, such as single motherhood
], teenage pregnancy [
], lack of support from a spouse
], presence of extended family [
], and social isolation
], are significant risk factors for the development of
postnatal depression. Our study may be the first to assess
earthquake-affected perinatal women with the EPDS scale.
We found that primiparous women living in the disaster area
were at significant risk of postnatal depression. Primiparous
women, due to their lack of experience with pregnancy,
childbirth, and child-rearing, may be more vulnerable to
earthquake-induced stress. Thus, support for women with risk
factors for postnatal depression identified in previous studies
and our study is of critical importance following an event
such as a medium-scale earthquake.
The results from previous studies also indicated that
postnatal depression in populations other than earthquake
survivors may be significantly related to cessation of
], degradation of mother–infant
attachment , more concerns about the baby [
unfavorable patterns of seeking healthcare services [
These outcomes may also be applicable for women with
high EPDS scores living in the disaster area. Our study
found that EPDS score was significantly associated with a
lower ‘‘satisfaction with delivery’’, lower prevalence of
breast-feeding, and increased ‘‘trouble with infant care’’.
These results are basically consistent with those of earlier
studies in terms of a number of outcomes related to
maternal postnatal depression.
In summary, based on the results of our study, we were
unable to determine a direct relationship between
earthquake-related factors and child-rearing variables.
However, earthquake-related factors are associated with
postnatal depression, and postnatal depression may then
have lead to degradation of maternal child-rearing (see
Fig. 1). Thus, earthquake survivors with a high EPDS
score may be at increased risk of experiencing negative
effects on their child-rearing abilities, and a screening
system using the EPDS may be of significant value in
non-catastrophic disaster areas. Therefore, when
formulating an appropriate support system for perinatal women
with high EPDS, we should strengthen and expand
support not only in ordinary situations but also under less
extraordinary circumstances, especially in the aftermath
of a non-catastrophic disaster.
There are a number of limitations to our study. This was
a cross-sectional study and as such it was not possible to
determine causal relationships. There was a potential bias
due to convenience sampling and self-report bias, and the
results may not be applicable to all perinatal women
inhabiting depopulated or disaster-affected communities.
Additionally, missing values may increase the bias.
However, literature on this subject is sparse, and the findings of
our study make an important contribution to the prediction
of the long-term impact of non-catastrophic natural
disasters on child-rearing in depopulated communities.
Acknowledgments The authors would like to thank the participants
of this study. We would also like to thank those who made this study
possible: Dr. Kouya Aoyama at Wajima Hospital, Dr. Yukio
Nakahama at Anamizu General Hospital, Dr. Tomoko Fujita at Noto
General Hospital, and Dr. Takafumi Kohama at Keiju General
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