Relationship of Family Support and Self-Efficacy with Postpartum Depression among Postpartum Mothers

Methods: This study uses a cross-sectional design. The population in this study was postpartum mothers. The sample involved 97 respondents using a consecutive sampling technique. The inclusion criteria in this study were postpartum mothers with 1-4 month periods. The exclusion criteria used were postpartum mothers with severe mental disorders. Data were collected using Sources of Social Support Scale questionnaires, Perceived Maternal Parental Self Efficacy, and Edinburgh Postpartum Depression Scale. The analysis uses the spearman rho test statistical test.


INTRODUCTION
The postpartum period becomes a challenging transition period for postpartum mothers, a big change can make mothers experience mood disorders such as postpartum depression (Mortazavi, Mousavi, Chaman, & Khosravi, 2014). Postpartum mothers who have difficulty caring for babies and are unable to cope with changes can lead to severe stress and experience postpartum depression events (Habel, Feeley, Hayton, Bell, & Zelkowitz, 2015). Feelings such as anger and irritability are characteristic of postpartum depression (Tang, Zhu, & Zhang, 2016). On average mothers who experience postpartum depression suffer from interaction difficulties in the family such as an unsatisfactory relationship with a partner and a lack of support from their mother (Wszołek et al., 2018). Personality factors of mothers who lack confidence and timid can also increase the risk of depressive disorders (Kusuma, 2019).
The Centers for Diseases Control in 2012 recorded an overall prevalence of postpartum depression of 11.5% representing 184.828 women in 27 countries (Ko, Rockhill, Tong, Morrow, & Farr, 2017). Riskesdas 2018 regarding the prevalence of mental-emotional disorders in Indonesia averaged 9.8%, East Java reached 6.8% (Kemenkes RI, 2018). Research conducted at the Morokrembangan Health Center in Surabaya found that of 55 respondents, 53% of mothers had mild depression, 9% had severe depression, and 5% had moderate depression (Indriasari, 2017).
Based on a preliminary study conducted on February 11 th , 2020 by conducting interviews with ten postpartum mothers who made postpartum visits at the Public Health Center in Kenjeran sub-district, Surabaya, Indonesia, it was found that 60% of postpartum mothers experienced symptoms of postpartum depression, 20% of postpartum mothers had less family support. and 30% of postpartum mothers have less confidence. It was found that the information gap between theory and facts was that there were some postpartum mothers who had good family support but experienced symptoms of postpartum depression and there were some postpartum mothers who had less confidence but did not experience symptoms of postpartum depression. This research was conducted by proving the theory of maternal role attainment from mercer by taking variables that are in the scope of the microsystem, namely the variable self-efficacy which is a factor of the mother and variable family support.
Internal and external factors that play a role in postpartum depression are maternal age at birth, maternal occupation, maternal education, maternal age at marriage, pregnancy history, history of childbirth, breastfeeding history, postpartum massage history, and family support (Wahyuni, 2014). The long-term negative effects of postpartum depression can affect maternal emotional health problems, infant development, health and social, emotional, cognitive, and physical development of children and impaired mother-baby interactions (Field, 2010) and (Kokkinaki, 2015).
Mercer in his theory states that women in carrying out the role of the mother are influenced by maternal factors, infant factors, and other factors. Among the many components in the maternal factor are the components of maternal confidence and social support (Alligood, 2014). A mother with good self-confidence will see the difficulty of the task she faces as an obstacle that must be resolved, not as a threat that leads to depression (Leahy-warren, Mccarthy, & Corcoran, 2011). Mercer also stressed the importance of husband and family support since pregnancy and after giving birth (Alligood, 2014). This study aims to analyze the relationship between family support and self-efficacy with the incidence of postpartum depression.

Design
This study is a correlational study that analyzes the relationship between family support and self-efficacy with the incidence of postpartum depression. The approach used is cross-sectional were measuring or observing independent data and dependent data only once at a time (Nursalam, 2016).

Population, Samples, and Sampling
The population in this study were all postpartum mothers who gave birth in the working area of the Public Health Center in Kenjeran sub-district, Surabaya in December 2019 and January-March 2020. This study used a non-probability sampling type of consecutive sampling where researchers took samples of postpartum mothers according to the inclusion and exclusion criteria of the study. The inclusion criteria in this study were postpartum mothers with 1-4 month periods. The exclusion criteria used were postpartum mothers with severe mental disorders. The number of samples obtained in this study were 97 postpartum mothers. The independent variables in this study are family support and self-efficacy while the dependent variable is the incidence of postpartum depression.

Instruments
The research instruments used were the Sources of Social Support Scale questionnaire, the Perceived Maternal Parental Self Efficacy, and the Edinburgh Postpartum Depression Scale. The Sources of Social Support Scale questionnaire consists of 10 question items with four parameters including emotional, informational, instrumental, and appreciation support (Carver, 2013). The Perceived Maternal Parental Self Efficacy Questionnaire consists of 15 questions with four parameters including baby care procedures, arousing baby behavior, understanding baby behavior, and the relationship of interaction with the baby (Barnes & Adamson-Macedo, 2007). The Edinburgh Postpartum Depression Scale questionnaire consisted of 10 question items with three parameters including feelings, anxiety, and guilty feelings (Cox, Holden, & Sagovsky, 1987). The Sources of Social Support Scale and Edinburgh Postpartum Depression Scale were modified from the Armini (2016) study entitled "Husband's Support is Needed to Prevent Postpartum Depression". The Perceived Maternal Parental Self Efficacy Questionnaire was modified from a study Mariana (2016) entitled "The Relationship between Maternal Self-Efficacy and Postpartum Depression in Primiparaous Mothers". The validity test on this research questionnaire conducted on March 16-18, 2020 was tested on 15 postpartum mothers at the Mulyorejo Health Center who had the same characteristics as the respondents. The validity test is used to measure whether a questionnaire is valid or not. An instrument is said to be valid if the questions on the questionnaire are able to reveal something that is measured by the questionnaire (Ghozali, 2011). The reliability test is carried out to determine the extent to which a measuring instrument has relatively constant consistency if a re-measurement is carried out on the same subject (Nursalam, 2016). the results of the validity test on the three research instruments are declared valid because they have r count ˃ r table (r = 0.514) and are declared reliable because the value of r alpha> r table.

Procedure
Data collection begins with collaboration with the health center and regional midwives to collect data on the telephone numbers of prospective respondents, to be contacted online. Researchers conducted data retrieval using the online questionnaire filling method via google form for respondents who have whatsApp numbers and online interviews by telephone for respondents who do not have a whatsApp number. After obtaining respondent data, the researcher contacts the respondent, introduces himself, explains to the respondent the objectives, benefits, and steps of the study and requests informed consent from the respondent. Researchers provide a google form link to respondents filling out an online questionnaire which takes about 15 minutes.

Analysis
The statistical test in this study uses spearmen correlation with the designed significance level α <0.05. If the test results p <0.05, H1 is accepted, which means there is a significant relationship. This test is used to determine the significance of the relationship between independent and dependent variables with an ordinal scale with a significance level of α = 0.05. This means that if the results of statistical tests show p <0.05 then there is a significant relationship between the independent variable and the dependent variable. Statistical data were analyzed using IBM SPSS 25.

Ethical Clearance
This research was conducted with a protocol approved by the Health Research Ethics Commission of the Faculty of Nursing, Airlangga University No. 1969-KEPK.

RESULT
Characteristics of respondents indicate that the majority of respondents (60.8%) have a history of multipara parity, the majority of respondents (88.7%) aged 21-35 years, the most educational history (48.5%) are high school / vocational high school graduates, most respondents (70.1%) do not work or become Housewives (IRT), the majority of respondents (97.9%) are married, most respondents (62.9%) get married at the age of ≥ 21 years, most ethnic groups (88.7%) are Javanese, and most respondents (88.7%) have a history of normal delivery (88.7%) ( Table 1).
The family support questionnaire shows that the majority of respondents have high family support of 80 respondents (82.5%). The results of the Rho Spearmen statistical test showed p = 0.000 and r = -0.364 which means that there is a relationship between family support and the incidence of postpartum depression with a weak correlation coefficient. The correlation coefficient is negative, which means the relationship of family support to the incidence of postpartum depression is not unidirectional. The results showed that respondents who had high family support did not experience postpartum depression as many as 56 respondents (57.7%) ( Table 2).  The self-efficacy questionnaire showed that most respondents had high self-efficacy as many as 90 respondents (92.8%). The results of the Rho Spearmen statistical test showed p = 0.000 and r = -0.355, which means that there is a relationship between self-efficacy and postpartum depression events with weak correlation coefficient values. The correlation coefficient is negative, meaning that the relationship of self-efficacy with the incidence of postpartum depression is not unidirectional. The results showed that respondents who had high self-efficacy did not experience postpartum depression as many as 60 respondents (61.9%) ( Table 3).

DISCUSSION
There is a relationship between family support and the incidence of postpartum depression with the strength of the weak relationship and negative direction. Respondents who have high family support did not experience postpartum depression. The direction of a negative relationship indicates that the higher the family support the lower the chance of experiencing postpartum depression. Wahyuni (2014) explained that the majority of mothers whose family support is not good experienced postpartum depression. In line with the maternal role attainment-becoming a mother theory expressed by Mercer that being a mother means taking a new role and that role is influenced by several factors, one of which is family social support (Alligood, 2014). Mercer stated that the approach influences the process of acting in roles depending on the reactions and interactions they experience with the people around them. Family support has the benefit of managing stress by providing the resources, care, information, and feedback needed to deal with stress and pressure. Mothers who lack family support certainly will more easily feel worthless and are less cared for by their families, so mothers who lack family support in the postpartum period will be easier to experience depression. Tang et al (2016) describe that social support is a major contributor to stress-related to postpartum depression.
Most respondents have high family support. The type of support most often given by families is information support where the majority of respondents feel that their families provide information on how to care for babies. Postpartum mothers who receive information support will have sufficient information resources in carrying out the role of a mother, so individuals can discuss their problems with their families and try to find solutions to solve their problems. Loudon, Buchanan, & Ruthven (2016) states that information support helps mothers feel prepared and confident in their new roles, and eases the transition from their parents. Kadarwati & Susilowati (2013) informative family support can overcome problems faced by a person, including stress, support can include giving advice, direction, ideas or other information needed by the mother. There is a relationship between selfefficacy and the incidence of postpartum depression with the strength of the weak relationship and negative direction. Respondents who have high self-efficacy did not experience postpartum depression. The direction of the negative relationship indicates that the higher the self-efficacy will decrease the chance of experiencing postpartum depression. These results are in line with research Putriarsih, Budihastuti, & Murti (2018), found the results of the analysis with p = 0,000 and r = -0.52 which showed that self-efficacy has a direct relationship with postpartum depression and is statistically significant. Mercer (2006) in the maternal role attainment-becaming a mother theory states that a mother who has good self-confidence will be able to perform her role in nurturing and caring for infants. A mother with good self-confidence will see the difficulty of the task she faces as an obstacle that must be resolved, not as a threat that leads to the emergence of depression (Leahywarren et al., 2011). Mothers with high selfconfidence will try to carry out their duties properly and assume failure and disability become a learning process so that they do not experience negative emotions that ultimately disrupt their daily lives.
This study shows that the majority of respondents have high self-efficacy. Selfefficacy which is most widely owned is the aspect of the interaction between mother and baby. The majority of respondents chose to strongly agree with the statement being able to show affection for their baby. That is because the physical condition of the mother is quite good after giving birth. Demographically, the majority of respondents undergo a normal type of labor rather than the SC, so that the condition causes the mother's emotional well enough and can show affective function in her baby. Astutiningrum, Hapsari, & Purwanta (2016) state that the factors that can influence emotional reactions are the type of labor that is mothers undergoing SC labor. The process of wound healing and the restoration of bodily functions causes physical and psychological discomfort.
Family support and self-efficacy are related to postpartum depression but not all mothers who experience postpartum depression are caused by family support and low maternal self-efficacy, this is because mothers who experience postpartum depression even with family support and high self-efficacy turns out to have other influencing factors such as education level, economic condition, primiparous mother and previous history of depression. (Dira & Wahyuni, 2016) stated that the risk factors that affect postpartum depression are a history of low maternal education, primiparous, a history of child deaths, an unexpected pregnancy. From the results of the study, there were 7 mothers who experienced postpartum depression with high family support and low education. There were also 7 mothers who experienced postpartum depression who had high family support and were primiparous mothers.

CONCLUSION
The higher the family support and selfefficacy, the lower the chance of postpartum depression. Postpartum mothers who get high family support will feel cared for, loved, and can share the burden so they can reduce stress which ultimately reduces postpartum depression. Postpartum mothers who have high self-efficacy tend to regard the task difficulties that she faces as an obstacle rather than as a threat that leads to the emergence of depression. The next researcher is expected to be able to research by adding other independent variables to find out more broadly the factors that influence the incidence of postpartum depression.