Female agency and probable depression in the perinatal period and beyond: Longitudinal findings from rural Pakistan

In Pakistan, a setting with high gender inequality, the relationship between female agency and mental health has not been studied longitudinally or beyond a defined life stage like pregnancy. Using data from the Bachpan cohort of mother-infant dyads in Pakistan, we investigated female agency and depression at two life stages: perinatal (third trimester to 6-months postpartum; n = 1154) and beyond (3- to 4-years postpartum). Modified Poisson models estimated adjusted prevalence ratios (PR) for probable depression (PHQ-9) associated with female agency (freedom of movement and participation in household decision-making) at the two life stages. Among 1154 mothers (average age 26.6 years), female agency was substantially lower during pregnancy than it was at 3-years and depression was more common during postpartum than at 4-years. Low freedom of movement during pregnancy nominally increased the likelihood of postpartum depression (PR: 1.33; 95% CI: 0.98, 1.80). The risk of depression was higher for low- (PR: 1.01; 95% CI: 0.72-1.41) and high- (PR: 1.24; 95% CI: 0.65-2.36) participation in household decision-making compared to moderate, but estimates were imprecise. Results from beyond the perinatal period indicated a stronger relationship between low freedom of movement and subsequent depression (PR: 1.89; 95% CI: 1.12, 3.20; Table 3). Low- (PR: 1.19; 95% CI: 0.67-2.12) and high- (PR: 1.21; 95% CI: 0.67-2.17) decision-making continued to demonstrate a nominal U-shaped relationship with depression, but estimates were imprecise. Overall, restricted freedom of movement beyond the perinatal period, may increase the likelihood of depression. Future research should explore the nuances of participation in decision-making and how it impacts women's mental health.