144 JNK JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk Systematic Review: The Relationship of Spouses’ Support and Postpartum Depression Sinta Effelia Agatra1, Ira Titisari2, Indah Rahmaningtyas3, Finta Isti Kundarti4 1,2,3,4Midwifery Department, Health Polytechnic of the Ministry of Health of Malang, Indonesia Article Information Abstract Postpartum depression is a mental health problem experienced by mothers at 4 weeks after giving birth which is characterized by feelings of sadness, decreased mood, feelings of failure or guilt, and even suicidal ideation, one of which is due to lack of husband support. To analyze the incidence of postpartum depression, the provision of husband support, and the relationship between providing husband support to the incidence of postpartum depression. This study used a systematic review design by tracing journal articles through the database like as Proquest, Garuda Portal, PubMed, and Science Direct with the publication year from January 2012 - January 2022 and discussing husband support and the incidence of postpartum depression, and using Indonesian and English. The keywords used in national journal were "husband's support" and "postpartum depression" or "postpartum depression", for international journal articles used "spousal support" or "partner support" or "husband's support" and "postpartum depression. The results showed that 10 journal articles met the inclusion criteria with all journal articles stating that there was a relationship between husband support and the incidence of postpartum depression. Most postpartum mothers do not experience postpartum depression and receive husband's support. There was a relationship between providing husband's support and the incidence of postpartum depression, where the higher the husband's support, the lower postpartum depression that occurs in postpartum mothers. The results of the study found 10 journal articles that met the inclusion criteria with all journal articles stating that there was a relationship between the provision of husband support and the incidence of postpartum depression. History Article: Received, 07/09/2022 Accepted, 25/04/2023 Published, 30/04/2023 Keywords: postpartum depression, husband's support © 2023 Journal of Ners and Midwifery Correspondence Address: Health Polytechnic of the Ministry of Health of Malang – East Java, Indonesia P-ISSN : 2355-052X Email : iratitisari22@gmail.com E-ISSN : 2548-3811 DOI: https://doi.org/10.26699/jnk.v10i1.ART.p144-153 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) http://jnk.phb.ac.id/index.php/jnk mailto:iratitisari22@gmail.com https://doi.org/10.26699/jnk.v10i1.ART.p144-153 Mitra D.S, Hamid, Firdaus, Nurse Self-Management Experience as a Covid-19 Vaccinator … 145 INTRODUCTION Postpartum depression is a mental health condition that affects women four weeks after giving birth and is marked by erratic emotional changes, loss of interest in daily activities, major weight changes, and memory loss. If the mother is unable to cope, it can also trigger suicide thoughts (Nasri et al., 2018). Postpartum depression can occur due to changes in hormone levels after childbirth, where after the birth of the placenta the levels of the hormones estrogen, progesterone, and hCG decrease drastically in the first 2 weeks. A rapid fall in progesterone levels is hypothesized to be the cause of postpartum depression. One of the consistent biological findings in mood disorders is dysregulation of the hypothalamic-pituitary- adrenocortical (HPA) axis, which undergoes significant changes in the first week following delivery. Events of rapid estrogen decline can cause an increase in receptor sensitivity dopamine, which causes postpartum psychotic episodes in women with bipolar disorder. After delivery, the number of CRH receptors in the hypothalamus declines, which results in a diminished response to adrenocorticotropic hormone (ACTH) and a diminished release of cortisol (Sunarti, 2013). Postpartum depression can be caused by various factors such as economic status, social support, education, occupation, number of births, mode of delivery, hormonal, psychosocial and physical status of the postnatal mother (Arimurti et al., 2020). Research conducted (R. Kusuma, 2019) shows that the prevalence of postpartum depression worldwide is 20%, while the prevalence of postpartum depression in Asia is between 15-20%. The incidence of postpartum depression in Indonesia in 2018 according to (WHO, 2018) shows a percentage of 22.4% and in 2019 the incidence of postpartum depression in Indonesia ranged from 2.5% - 22.3% (Nurbaeti et al., 2019). The incidence of postpartum depression in Asia in 2020 shows a fairly high percentage of around 26% - 85%, while in Indonesia the incidence of postpartum depression ranges from 50% - 70% (Da Silva Tanganhito et al., 2020). The high prevalence of postpartum depression is certainly contrary to the target of SDGs (Sustainable Development Goals) goal 3 which contains the goal of reducing the MMR below 70/100,000 births by 2030 and reducing 1/3 cases of birth deaths due to non-communicable diseases through measures to prevent and treat and promote mental health and well-being. Postpartum depression can have an adverse effect on mother and baby where it can affect interactions between baby and mother. Mothers who pay less attention to their children will not give a positive response to their children, mothers who cannot provide optimal care for children can have an impact on children's health and hygiene that are not optimal, mothers who are not enthusiastic about breastfeeding can also cause impaired child development. Mothers with postpartum depression can also experience sleep disorders, eating disorders, decreased appetite, feelings of depression, and other feelings of sadness that reduce the quality of life of mothers affected by postpartum depression (Gelaye et al., 2016). The incidence of postpartum depression can arise from various things such as the lack of social support from loved ones such as family and partners which is one of the triggering factors for postpartum depression in postpartum mothers (Ramaya, 2021). Husband support can be provided in several forms. First, there is emotional support, which can give the effect of inner calm and feelings of pleasure in the wife so that she is more easily adjusted to caring for her baby. Second, there is appreciation support expressed through respect and appreciation for the wife to increase her self-esteem. Next, there is instrumental support which is material assistance. Finally, there is informative support, which includes positive advice and suggestions. The existence of husband support will contribute significantly to postpartum women in dealing with the stress that arises (Sumantri & Budiyani, 2015). Support itself is an information or response given by others which indicates that the recipient of support is someone who is loved, appreciated, cared for, and always involved in any situation and is dependent on each other (King, 2012). The low level of support for postpartum mothers can affect the occurrence of postpartum depression, when women take on new roles as mothers where they need complex adaptations to adapt physically and emotionally to their new lifestyle and role as mothers. much needed, especially in terms of providing support. The low provision of husband support for postpartum mothers will certainly have a negative impact on both postpartum mothers and babies, due to the fact that if many family members help during pregnancy, childbirth and postpartum it will reduce the burden on the mother to a certain 146 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 144-153 extent (P. D. Kusuma, 2017). The right treatment in reducing the prevalence of postpartum depression is to approach and explain the risk of postpartum depression to postpartum mothers or their families, if not managed properly (Wahyuningsih, 2018). Prevention of postpartum depression symptoms can be prevented to a minimum by early detection of postpartum depression. The management of postpartum depression in postpartum mothers requires special and maximum handling from various parties, both partners, families, and health workers (Sari, 2020). Considering the backdrop described above as well as the existence of numerous research that examine the connection between providing spouse support and the occurrence of postpartum depression. Therefore, conducting research as a systematic review is appealing to researchers. The husband's support is related to the prevalence of postpartum depression, according to a systematic analysis of the literature that was conducted using sources from reputable national and international journals that were published between January 2012 and January 2022. METHOD The researcher employs a research design in this investigation is a systematic review, often referred to as a systematic literature review (SLR), is a process for compiling, analyzing, integrating, and presenting data from multiple research studies on a specific research problem or topic in order to achieve a high degree of understanding. Comparable to typical literature assessments, but more thorough (Delgado-Rodríguez & Sillero-Arenas, 2018). The first step in gathering this literature is identifying the study's topic, which is "The Relationship of Offering Husband's Support to the Incidence of Postpartum Depression," and the second is formulating PEOS, which stands for Population: Postpartum Mothers, Exposure: Postpartum Depression, and Outcome: The Relationship: The Impact of Husband's Support on the Incidence of Postpartum Depression and the Study Design that was determined was cross- sectional, case control, and cohort. The third step is to create keywords to search for national journal articles using the keywords “husband support” and “postpartum depression” or “post-partum depression”. Whereas, the use of keywords in the search for international journal articles in this study in the form of "spousal support" or "partner support" or "husband's support" and "postpartum depression" The fourth step is to search for articles using databases such as Proquest, Portal Garuda, PubMed, and Science Direct with the year of publication from January 2012 - January 2022. The fifth step is to determine the inclusion and exclusion criteria, namely articles discussing postpartum depression and husband's support, having a population of postpartum mothers, speaking Indonesian and English. Then the sixth step is to document the search results in a prism flowchart with the final results as many as 10 journal articles that match the criteria. and Science Direct with the publication year from January 2012 – January 2022. The fifth step is to determine the inclusion and exclusion criteria, namely articles discussing postpartum depression and husband support, having a population of postpartum mothers, speaking Indonesian and English. Then the sixth step is to document the search results in a prism flowchart with the final results as many as 10 journal articles that match the criteria. and Science Direct with the publication year from January 2012 – January 2022. The fifth step is to determine the inclusion and exclusion criteria. The inclusion criteria were the article is about husband’s support and postpartum depression, the article should be available in Indonesian and English, and the population should be postpartum mothers. The exclusion criteria were the articles which cant’t be full texted-accessed, the journal without ISSN or DOI, the article which is not Then the sixth step is to document the search results in a prism flowchart with the final results as many as 10 journal articles that match the criteria. Picture 1. Prism flowchart Mitra D.S, Hamid, Firdaus, Nurse Self-Management Experience as a Covid-19 Vaccinator … 147 In this study, researchers will analyze the results of systematic reviews of journals from various sources that have been gathered beginning with the study's findings in order to develop conclusions that are consistent with the established research objectives. The identification process of Systematic Review is used to identify journal articles, which include finding similarities (compare), finding differences (contrast), presenting perspectives (criticizing), comparison (synthesize), and summarizing (summarize). The most important aspect of conducting a systematic review in this research is comparing concepts, theories, and hypotheses with literature sources and reading as much literature as possible RESULTS Literature Review Results Data and conclusions from various journal articles are collected and presented in the form of tables and narratives that describe the presentation in tabular form. Study Characteristics Table 1: Study Characteristics Category N % Publication Year 2021 3 30 2020 2 20 2019 1 10 2018 0 0 2017 2 20 2016 0 0 2015 1 10 2014 0 0 2013 1 10 2012 0 0 Total 10 100% Postpartum Depression Instrument Edinburgh Postnatal Depression Scale (EPDS) 9 90 Beck Depression Inventory (BDI) 1 10 Total 10 100% Husband Support Instrument Questionnaire 9 93.3 Interview 1 6.7 Total 10 100% Research design Case Control 1 10 Cohort 1 10 Cross Sectional 8 80 Total 10 100% Based on the results of the search for journal articles, it was found 10 journal articles that met the inclusion criteria and showed a relationship between husband's support and the incidence of postpartum depression based on the search results of journal articles using keywords. Of the 10 journal articles found, there was 1 journal article published in 2013; 1 journal article published in 2015; 2 journal articles published in 2017; 1 journal article published in 2019; 2 journal articles published in 2020; and 3 research journal articles published in 2021. Based on the use of the instrument in the research on the incidence of postpartum depression, of the 10 journal articles analyzed, it was found that as many as 9 journal articles used the Edinburgh Postnatal Depression Scale (EPDS) instrument, while for 1 research article used the Back Depression Inventory research instrument as an instrument in measuring postpartum depression. 148 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 144-153 Measuring the level of husband's support from 10 journal articles that have been analyzed as many as 9 journal articles using a questionnaire instrument, then there is 1 research journal article that uses an interview instrument to collect husband's support data. Of the 10 journal articles analyzed, the majority of the research conducted using a cross-sectional design, namely 8 journal articles, then 1 journal article using a Case-study research design and 1 journal article using a Cohort research design. Research with cross-sectional design is widely used because it has several advantages, such as the ability to study many factors at once, low cost, and the ability to be completed in a short time. Characteristics of Respondents Table 2: Characteristics of Respondents Based on Number of Respondents, Age of Respondents, Education, Occupation, and Level of Parity Category F % Number of Respondents <100 2 20 101 – 200 2 20 >200 6 60 Amount 10 100% Respondent Age <20 1 0 20-35 9 90 >35 0 0 Not mentioned 0 0 Amount 10 100% Education Base 3 30 Intermediate 3 30 Tall 1 10 Not mentioned 3 30 Amount 10 100% Work Housewife 6 60 Private employees 2 20 civil servant 0 0 Not mentioned 2 20 Amount 10 100% Parity Rate 2 4 40 2 4 40 Not mentioned 2 20 Amount 10 100% Based on 10 journal articles that have been analyzed, the average number of respondents who participated in the study ranged from >200 respondents (60%) with an average age of 20-35 years (90%), the average journal article stated that respondents had a basic education level and medium, in addition there are journal articles that do not mention the level of respondents (30%), the average respondent's occupation is as a housewife (IRT) (60%), while for the parity level the average respondent is primiparous and multiparous mothers ( 40%). DISCUSSION Incidence of Postpartum Depression According to (Janiwarty B, 2013) postpartum depression is a feeling disorder experienced by mothers after giving birth where mothers feel sadness, loss of energy, difficulty concentrating, feelings of guilt and worthlessness. In addition, mothers cry easily, easily despair, are useless in their Mitra D.S, Hamid, Firdaus, Nurse Self-Management Experience as a Covid-19 Vaccinator … 149 lives, always feel sad, have suicidal ideation, anxiety, and excessive worry about the health of themselves and their babies. Based on the results of the analysis of 10 journal articles, there were 9 journal articles which showed that postpartum mothers did not experience postpartum depression with a percentage of 46.4% - 91.3% and the remaining 1 journal article showed that postpartum mothers who experienced postpartum depression had the percentage of 53.6%. Postpartum mothers who do not experience postpartum depression according to the results of the study (Tolongan et al., 2019) because the mother is able to adjust after giving birth, understand the situation after giving birth and not allow herself to be in a bad situation, and often share stories both with other people and her husband so as to make the coping mechanism in postpartum mothers work well. This is in line with research conducted by (Rahmandani, 2010) where mothers who have good coping strategies can be caused by mothers always looking for calm, joking, laughing, and diverting attention to other forms of behavior or activities that minimize depression, so that it is very helpful for mothers to undergo physiological and psychological adjustments during the postpartum period. useful in minimizing the occurrence of postpartum depression. Meanwhile, the incidence of postpartum depression in postpartum mothers according to the results of the study (Eslahi et al., 2021) this is due to the absence of life satisfaction such as environmental conditions that have a negative influence and the existence of stressful life events that make the mother unhappy and burdened. Life satisfaction in postpartum mothers according to (Moreno Maldonado et al., 2020) can be used as a measure of the possibility of postpartum psychological disorders, where life satisfaction can be a protective factor against the negative effects of stressful life events. Study (Tolongan et al., 2019), also mentioned that postpartum mothers who experience postpartum depression due to pressure problems that make mothers think they are not capable, mothers often believe they cannot take care of their babies and mothers often injure themselves, problems after giving birth make mothers unable to care for babies. Postpartum depression causes the mother to lose interest and skills in her baby, cannot identify the baby's needs, refuses to breastfeed her baby, even wants to hurt herself and her baby (Nasri et al., 2018) The incidence of postpartum depression is not caused by one factor alone, but can occur from various factors such as a history of previous psychological problems which can be in the form of postpartum blues that occur for a long time and are not immediately resolved so that it can have an impact on the occurrence of postpartum depression. In addition, the change in the role of a mother where the mother cannot adjust herself to baby-rearing activities can make the mother unable to rest enough to recover after giving birth. Lack of rest can lead to fatigue, both physically and emotionally, and ultimately trigger postpartum depression. Husband's Support Husband's support is a form of verbal and nonverbal communication in the form of guidance, assistance, or appropriate behavior in the mother's environment after giving birth (Friedman & Bowden, 2010). Based on the results of the analysis of 10 journal articles, there were 6 journal articles which showed that postpartum mothers received husband's support with a percentage of 60% - 97.1% and the remaining 4 journal articles showed that postpartum mothers who did not receive husband's support had a percentage of 2.9% - 80.8%. The form of husband's support that can be given to postpartum mothers according to (Tolongan et al., 2019) it can be a husband who takes care of his wife after giving birth, provides good postpartum care, is always there for the mother after giving birth, and motivates the mother to be a good mother for her baby. In line with (Fitriani, 2011) which states that the support that husbands can give to postpartum mothers can be in the form of providing protection and tranquility, providing empathy, trust and attention to their husbands, all of which can affect the emotional calm of postpartum mothers, thus making them feel more valued, comfortable, safe, and loved. Meanwhile, the lack of husband's support for postpartum mothers in the study (Tolongan et al., 2019) can be described by the act of not paying special attention, the husband let the mother do the work and take care of the baby alone, and the husband did not provide motivation and support, thus making the mother worried about her ability to care for the baby or carry out her role as a mother. In research conducted by (Yuliawan, 2014) stated that the lack of husband's support will affect the mother's 150 Journal of Ners and Midwifery, Volume 10, Issue 1, April 2023, page 144-153 health, because the husband is the closest person to the mother and must be aware of changes in her partner, this can cause pressure on the mother so that it leads to unfavorable behavior such as not wanting to eat and not paying attention to her health. Low husband support in research (Alit Armini et al., 2017), due to the rules in the Ile Boleng culture where the position of men and women are not the same, the husband is only in charge of earning a living, not allowed to do housework such as cooking, washing, from these cultural rules cause the husband's lack of attention in devoting affection to his wife. In research (Febriana, 2017) explained that culture affects the level of husband support for postpartum mothers, where the culture still influences the customs, rules, and norms in people's lives that regulate husband and wife relationships such as the position between men and women, and includes what obligations must be borne in that culture. The husband is the closest person to the mother who has the responsibility to ensure the health of the mother and is obliged to provide optimal support continuously during pregnancy until delivery. Husband's support is very important for a wife, with husband's support it can affect the mother's health both physiologically and psychologically. Lack of husband's support can cause pressure on the mother, resulting in unfavorable behavior such as not wanting to eat and not paying attention to her health. The support provided by the husband can be in the form of spending time together, providing motivation and praise, thinking about physical and mental health by creating a comfortable and relaxed atmosphere, and paying attention to changes in the mother during pregnancy and childbirth. Relationship of Husband's Support to Postpartum Depression The analysis of the 10 journal articles revealed that there is a significant correlation between the incidence of postpartum depression and the availability of husband support. Accordingly, the higher the level of husband support, the lower the risk of postpartum depression in postpartum mothers, and the opposite is true if the husband does not provide support. In postpartum mothers, it may raise the risk of postpartum depression. The main source of support for women in the postpartum period is their partners, according to a study result (Kızılırmak et al., 2021), and the correlation between perceived husband support and postpartum depression has shown that providing more husband support results in a lower risk of postpartum depression. This is consistent with study (Alasoom & Koura, 2014), which found that 42.9% of women who did not receive partner support had a high risk for postpartum depression whereas 14.7% of women who did were at low risk. Husband's support has a significant influence on the occurrence of depression in postpartum mothers. This is because after the postpartum mother goes through labor, the mother will experience hormonal changes such as a drastic decrease in the hormones estrogen, progesterone, hCG and also endorphins where these hormonal changes can affect the emotional stability of postpartum mothers. The husband is the first person who is crucial in preserving the mother's physical and mental health by offering support to the mother after giving birth. The support given by the husband during the postpartum period can make the mother feel happy and happy with her new role as a mother. The feeling of happiness and pleasure that postpartum mothers get with the provision of husband support can certainly increase the production of endorphins in the mother's body (Asmayanti, 2017). Study (Urbayatun, 2012), stated that women who did not get adequate support from their husbands were more likely to feel worthless and uncared for by their husbands and families, thus making women who did not receive support from their husbands during the postpartum period more likely to experience feelings of depression. So that it can be interpreted that the provision of husband's support can affect the mother's daily life and play an important role in the occurrence of postpartum depression in postpartum mothers. Management of mothers with postpartum depression can be done with pharmacological and non-pharmacological therapy based on the severity and symptoms experienced by the patient. Mother, including the mother's ability to care for and interact with the baby. If only mild symptoms occur, then intervention can be done social services in the form of increased support for mothers such as support from family, peers, and counseling from health practitioners. Support that can be given is in the form of emotional support such as providing protection, calm, and a sense of security to the mother (Sari, 2020). When it comes to postpartum depression, formal psychotherapy with a psychiatrist is an option for those with moderate to severe symptoms or for those with mild symptoms who are not responding to psychosocial intervention. Examples of these Mitra D.S, Hamid, Firdaus, Nurse Self-Management Experience as a Covid-19 Vaccinator … 151 therapies include cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Currently, the husband can help the mother with instrumental support in the form of meeting her financial needs, informational support in the form of assisting her in finding treatment information, and reward support in the form of praising and encouraging the mother (Sari, 2020). Changes in postpartum women both physiologically and psychologically can make postpartum women feel depressed and cannot live it well, if this happens for a long time it can result in postpartum depression. The husband's support can help postpartum mothers to undergo these changes well. The support provided can give strength to postpartum mothers so that postpartum mothers are more prepared, happy, and have high confidence to be able to complete the changes during the postpartum period so that postpartum mothers can avoid postpartum depression. Research Limitations The limitation of this study is that there are several journal articles studied that do not explain the incidence of postpartum depression based on its severity, such as non-depression, mild depression, moderate depression, and major depression, making it difficult for researchers to analyze the incidence of depression in postpartum mothers. CONCLUSION It is possible to draw the following conclusions from the identification, analysis, and discussion outcomes of the 10 journal articles discussed in the preceding chapter such as according to the findings of researchers' examination of scientific articles, the majority of postpartum women do not experience postpartum depression.The majority of spouses assist their postpartum partners, and there is a connection between providing husband support and the likelihood of postpartum depression; the more support a husband provides, the less likely it is that a woman would experience postpartum depression after giving birth, and the reverse is also true. SUGGESTION Further researchers are expected to enable other academics field of study to carry out study on the numerous factors that influence the occurrence of postpartum depression. It is hoped that relevant agencies and health workers can provide health information to prevent and overcome postpartum depression, as well as provide health services, especially postpartum maternal care, and carry out health promotion efforts in the form of public education about postpartum depression, emphasizing the importance of husband's support. Moreover, it is hoped that the general public can gain knowledge and insight about postpartum depression, so that it can help reduce the prevalence of postpartum depression. ACKNOWLEDGEMENT We thank Health Polytechnic Ministry of Malang for giving permission to this research and gave full support until it was done. FUNDING This research was funded by the first author and the publication fee was funded by second author. CONFLICTS OF INTEREST There’s no conflict of interest in this research. 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