Postpartum depression can occur until up to 4 weeks after birth (Stewart and Vigod, 2016), and is experienced by 10–20% of postpartum women globally (O'Hara and McCabe, 2013; Bolak Boratav et al, 2016; Sharkey et al, 2016), and 13.5% of postpartum women in southeast Asia (Wang et al, 2021). In Indonesia, 13–26% of postpartum mothers experience postpartum depression (Murwati and Suroso, 2017; Nurbaeti et al, 2018; 2019; Kusuma, 2019).
Postpartum depression not only affects mothers, but can also impact their families, societies and the country as a whole. Postpartum depression causes low quality of life for mothers, and increases the risk of schizophrenia, bipolar and depressive disorder and suicide (Sadat et al, 2014; Chen et al, 2021; Lee et al, 2022). For families, postpartum depression is related to paternal depression, sexual dysfunction and relationship dissatisfaction (Goodman, 2004; Khajehei and Doherty, 2017), and can cause emotional problems in children, and impair their development (Walker et al, 2020; Faisal-Cury et al, 2021). Postpartum depression also leads to social and economic burdens, as mothers and their children require more care (van der Zee-van den Berg et al, 2021).
Many interventions to prevent and treat maternal depression have been trialled, including use of medication (O'Hara and Engeldinger, 2018; Wang et al, 2022), psychoeducation (Ugarte et al, 2017), cognitive behaviour therapy (Wang et al, 2022), and incorporating religious perspectives, in particular, listening to recitations from the Holy Quran (Jabbari et al, 2020). Studies have shown that listening to recitations of the Holy Quran has a positive effect on postpartum depression (Jabbari et al, 2020; Saged et al, 2020;Yolanda et al, 2023).
The use of mobile health applications has grown rapidly, including in relation to postpartum depression (Zhang et al, 2017). Studies have been carried out to test the application of mobile apps to early detection (Jiménez-Serrano et al, 2015; Nurbaeti et al, 2021) and intervention (Koçak et al, 2021; Seo et al, 2021) in postpartum depression. Several studies exploring the use of an app in managing postpartum depression have combined the concepts of social support, mindfulness, perceived social support and cognitive behavioural therapy (Cheng et al, 2016; Sun et al, 2019; Jannati et al, 2020; Liu et al, 2022a, b; Seo et al, 2022).
Although studies have investigated the effect of mobile health apps on the symptoms of postpartum depression, to the authors' knowledge, no study has investigated combining a mobile app with the Holy Quran voice, in Indonesia or other countries. Therefore, this study aimed to explore this combination of interventions in order to improve self-esteem and reduce anxiety and other symptoms of postpartum depression.
Methods
A randomised controlled trial using a pre-post-test time series was conducted between June and December 2020 in four working areas of the Banyumas District Public Health Centre, Central Java Province, Indonesia. This trial followed the consolidated standards for reporting trials (CONSORT) guidelines (Figure 1) (Schulz et al, 2010).
Participants
The participants were women in their third trimester of pregnancy (28–40 weeks' gestation) who lived in the working areas of the Banyumas District Public Health Center. Only women who had smartphones and were Muslim were included, to allow them to receive the intervention if selected for the appropriate group. The exclusion criteria were women who drank alcohol or used drugs, and those who were diagnosed with mental disorders, hypertension, anaemia, heart problems, diabetes mellitus, placenta previa, fetal abnormalities, multiple pregnancies, hydramnios and post-term pregnancy.
The sample size was calculated using Cohen (1988), and gave a total of 64 women per group (app and control). To account for drop out, 10% of the sample size was added, yielding a total sample of 140 respondents. A total of 161 pregnant women were eligible for the study.
Development of the mobile application
Development of the DEDE ARUM application aimed to provide information about postpartum depression based on the first six of seven steps of the mobile development lifecycle model: 1. identification, 2. design, 3. development, 4. prototyping, 5. testing, 6. deployment, and 7. maintenance (Vithani and Kumar, 2014). Following a literature search on postpartum depression, application content was compiled that contained the following information on postpartum depression: definitions, causes, risk factors, signs and symptoms, possible impacts, ways to manage the condition and ways to prevent it. Logos and images/photos for illustration were created, and a recitation of Al-Quran Surah Maryam (Jabbari et al, 2020) was recorded. The recitation was performed by a junior high school student who won multiple Al-Quran reading competitions, guided by an expert in reading verses from the Holy Quran, for approximately 20 minutes (Saged et al, 2020). The selected passage for the recitation was the Surah Maryam, chosen by the authors based on a literature search that found that listening to a recitation of this section can reduce stress, anxiety and depression for pregnant and labouring women (El-Sayed et al, 2020; Jabbari et al, 2020; Ulya et al, 2022).
The educational content and recordings were given to an expert in smartphone application creation with more than 10 years of relevant experience, who produced the final application. Content validity was tested by three experts who were all nurse specialists in maternity nursing with more than 10 years' clinical experience, and the individual-content validity index was 1. The app's content was then tested by three postpartum mothers, to incorporate their input on the suitability of language and terms. After testing was complete and the feedback was addressed, the app was uploaded to the Google Play Store.
Data collection
Tools
The Edinburgh postpartum depression scale is a 10-item scale that uses a 4-point rating (0, 1, 2, and 3) to measure depression in the past 7 days. The total score ranges from 0 to 30, with a higher score indicating greater likelihood of depression. The scale was developed by Cox et al (1987), and the Indonesian version was adapted by Edwards et al (2006), which was shown to be effective in detecting the risk of postpartum depression at 0.01 with Z values of (2.33) and (-2.320) (Latifah and Hartati, 2006).
The state-trait anxiety inventor is a 40-question tool used to measure general anxiety using a Likert scale. The scale uses 20 questions to assess trait anxiety, and 20 to assess state anxiety, yielding a possible range of 20–80 for total score. Higher scores are positively correlated with higher levels of anxiety (Baker et al, 2009). The Indonesian version was tested for reliability with a value of 0.923 using Cronbach's alpha (Latifah et al, 2019).
The Rosenberg self–esteem scale is a 10-item questionnaire that uses a Likert scale (0=strongly disagree to 3=strongly agree) to measure self esteem. The scores range from 0 to 30, with a higher total indicating higher self esteem. This scale has been used globally in 53 nations (Schmitt and Allik, 2005). The Indonesian version was translated by Nurbaeti et al (2019) with an internal consistency of 0.79.
Procedure
Pregnant women who met the inclusion criteria (n=161) were recruited from the public health centre. They were contacted using WhatsApp. After informed consent was obtained, a trained assistant visited the respondent's house to conduct the pre-test. The 140 respondents who had consented were randomly assigned to either the intervention (app) (n=70) or control group (n=70).
Participants in the intervention group were asked to download the DEDE ARUM app, and were taught how to use it. They were asked to read through the information in the app independently and listen to the recordings from the Holy Quran in the app once a day, beginning in their third trimester and continuing until 2 months after birth. The assistant monitored participants via WhatsApp once a week (Danaher et al, 2013) until 2 months after birth. Post-tests were conducted twice, at 1 and 2 months after birth. The control group were allowed to access the application after the second post-test, when monitoring had concluded. At the end of the study, the respondents received a package of herbal essential oils to thank them for their participation. During the study, eight participants chose to discontinue (five in the app group and three in the control group), and data were missing for a further four participants (one in the intervention group and three in the control group), leaving a final sample of 128 women included in the analysis (n=64 per group).
Data analysis
Univariate analysis was used to describe the frequency, mean, median, standard deviation, minimum and maximum of the variables. Bivariate analysis (Chi-squared, Fisher's Exact, Independent t-test, and Mann-Whitney U test) was used to describe the baseline characteristics of the variables. Friedman analysis was used to investigate the difference between each measurement, as the data were not normally distributed.
Ethical considerations
Ethical clearance for this study was obtained from the Faculty of Medicine Universitas Jenderal Soedirman (approval number:109/KEPK/IV/2020). The study's purpose, benefits and time were clearly explained before participants signed an informed consent form. All participants voluntarily participated.
Results
The participants' demographic and clinical characteristics are presented in Table 1. Their ages ranged from 17 to 44 years (mean: 28.63±5.97 years), almost all were married (98.4%), less than half had received senior high education (40.6%), and the majority were unemployed (65.6%). Most reported living with their husbands (85.9%), and more than half lived with their extended families (54.7%). The majority of participants had had one or more prior pregnancies (65.6%), and most current pregnancies were intended (96.9%).
Table 1. Participants' characteristics
| Characteristic | Frequency (%) | P value | |||
|---|---|---|---|---|---|
| App group (n=64) | Control group (n=64) | Total (n=128) | |||
| Age (years) | Mean ± standard deviation | 26.27 ± 4.42 | 31 ± 6.4 | 28.63 ± 5.97 | 0.094* |
| <20 | 3 (4.7) | 1 (1.6) | 4 (3.1) | ||
| 20–35 | 59 (92.2) | 46 (71.9) | 105 (82.0) | ||
| >35 | 2 (3.1) | 17 (26.6) | 19 (14.8) | ||
| Marital status | Married | 64 (100.0) | 63 (98.4) | 127 (99.2) | 1.000† |
| Not married | 0 (0.0) | 1 (1.6) | 1 (0.8) | ||
| Education | Elementary school | 3 (4.7) | 11 (17.2) | 14 (10.9) | 0.032‡ |
| Junior high school | 15 (23.4) | 22 (34.4) | 37 (28.9) | ||
| Senior high school | 31 (48.4) | 21 (32.8) | 52 (40.6) | ||
| Higher education | 15 (23.4) | 10 (15.6) | 25 (19.5) | ||
| Employment | Employed | 31 (48.4) | 13 (20.3) | 44 (34.4) | 1.000‡ |
| Unemployed | 33(51.6) | 51(79.7) | 84 (65.6) | ||
| Husband in another town for work | Yes | 12 (18.8) | 9 (14.1) | 21 (16.4) | 0.474‡ |
| No | 52 (81.3) | 55 (85.9) | 107 (83.6) | ||
| Living with extended family | Yes | 36 (56.3) | 35 (54.7) | 71 (55.5) | 0.859‡ |
| No | 28 (43.8) | 29 (45.3) | 57 (44.5) | ||
| Parity | 0 | 31 (48.4) | 13 (20.3) | 44 (34.4) | 0.001‡ |
| ≥1 | 33 (51.6) | 51 (79.7) | 84 (65.6) | ||
| Pregnancy intention | Intentional | 63 (98.4) | 61 (95.3) | 124 (96.9) | 0.619† |
| Unintentional | 1(1.6) | 3 (4.7) | 4 (3.1) | ||
| Gestational age at birth | Aterm | 55 (85.9) | 57 (89.1) | 112 (87.5) | 0.593‡ |
| Preterm | 9 (14.1) | 7 (10.9) | 16 (12.5) | ||
| Mode of birth | Vaginal | 51 (79.7) | 50 (78.1) | 101 (78.9) | 0.828‡ |
| Caesarean | 13 (20.3) | 14 (21.9) | 27 (21.1) | ||
| Birth weight (g) | Median (min–max) | 2955 (2000–3890) | 3000 (2450–4900) | 3000 (2000–4900) | 0.04§ |
| Postpartum complications | Yes | 5 (7.8) | 2 (3.1) | 7 (5.5) | 0.44† |
| No | 59 (92.2) | 62 (96.9) | 121 (94.5) | ||
| Content with baby's sex | Yes | 62 (96.9) | 64 (100.0) | 126 (98.4) | 0.496† |
| No | 2 (3.1) | 0 (0.0) | 2 (1.6) | ||
| Postpartum supplementary parenting | Husband | 25 (39.1) | 31 (48.4) | 56 (43.8) | 0.437‡ |
| Parents | 10 (15.6) | 11 (17.2) | 21 (16.4) | ||
| Other family members | 17 (26.6) | 16 (25.0) | 33 (25.8) | ||
| Husband and parents | 12 (18.8) | 6 (9.4) | 18 (14.1) | ||
| History of depression | Yes | 2 (3.1) | 0 (0.0) | 2 (1.6) | 0.496‡ |
| No | 62 (96.9) | 64 (100.0) | 126 (98.4) | ||
| Family history of depression | Yes | 1 (1.6) | 1 (1.6) | 2 (1.6) | 1.000‡ |
| No | 63 (98.4) | 63 (98.4) | 126 (98.4) | ||
Fisher's exact test,
‡Chi-squared test,
§Mann Whitney
Most of the participants' infants were full-term (87.5%), with a median birth weight of 3000 (range: 2000–4900). Most participants reported that they were content with their baby's (98.4%), and had a vaginal birth (78.9%). Most participants did not have postpartum complications (94.5%) and did not have a history (98.4%) or family history of depression (98.4%).
Most of the participants' demographic and obstetric characteristics showed no significant differences between the two groups. However, there were significant differences in education, parity and infant birth weight. When tested for correlation with depression, anxiety and self-esteem, the only significant correlation was between self esteem and education (Table 2).
Table 2. Correlation between education, parity and birth weight with depression, anxiety and self-esteem
| Variable | P value | ||
|---|---|---|---|
| Depression | Anxiety | Self-esteem | |
| Education | 0.604 | 0.154 | <0.001 |
| Parity | 0.648 | 0.185 | 0.095 |
| Birth weight | 0.094 | 0.058 | 0.766 |
In the Friedman analysis, the differences between the pre-test, post-test 1 (1 month postpartum) and post-test 2 (2 months postpartum) were assessed (Table 3). There was a significant difference in the app group for depression scores (P<0.001); however, there were no differences in anxiety or self esteem scores. In the control group, there were no differences in scores across all three dimensions.
Table 3. Friedman test comparison of total scores for each group
| Group | Pre-test | Post-test (1 month) | Post-test (2 months) | P value | ||||
|---|---|---|---|---|---|---|---|---|
| Mean (standard deviation) | Min–Max | Mean (standard deviation) | Min–Max | Mean (standard deviation) | Min–Max | |||
| App (n=64) | Depression | 12.06 (1.94) | 8–16 | 11.31 (2.39) | 6–18 | 10.92 (2.76) | 2–18 | <0.001 |
| Anxiety | 48.63 (5.01) | 37–64 | 48.16 (6.01) | 33–62 | 48.23 (6.05) | 33–67 | 0.718 | |
| Self esteem | 21.27 (3.51) | 13–30 | 21.45 (4.41) | 9–30 | 21.67 (4.22) | 11–30 | 0.437 | |
| Control (n=64) | Depression | 11.89 (2.32) | 7–18 | 11.64 (2.19) | 6–17 | 11.70 (2.27) | 7–19 | 0.576 |
| Anxiety | 49.34 (5.60) | 34–66 | 48.45 (6.91) | 33–68 | 47.83 (6.24) | 36–63 | 0.229 | |
| Self esteem | 20.83 (3.06) | 8–28 | 20.25 (2.67) | 14–27 | 20.50 (2.74) | 13–29 | 0.673 | |
The mean depression score in the app group was significantly reduced between the pre-test and second post-test. For anxiety, the mean score was reduced by 0.4 points in the app group, which was a smaller reduction than in the control group (1.51 points). The self esteem scores were higher in the app group than the control group both before and after the intervention. In the intervention group, self esteem increased at each time point, whereas in the control group, the score decreased between the pre-test and 1 month postpartum and then rose at 2 months postpartum (Figure 2).
The number of participants who had depression scores ≥10 are shown in Table 4. Both the app and control groups experienced a decrease in score over time; however, the decrease in the intervention group was much greater (25.0%) than the control group (7.8%).
Table 4. Changes in depression scores of ≥10 pre- and post-intervention
| Test | Frequence, n=128 (%) | ||
|---|---|---|---|
| Total | App group | Control group | |
| Pre-test | 112 (87.5) | 58 (90.6) | 54 (84.4) |
| Post-test (1 month) | 98 (76.6) | 49 (76.6) | 49 (76.6) |
| Post-test (2 months) | 91 (71.1) | 42 (65.6) | 49 (76.6) |
Discussion
This study was conducted to investigate the effect of using a mobile application with readings from the Holy Quran on anxiety, self-esteem, and depressive symptoms among postpartum women. The study found that the app reduced depression symptoms, although it had no apparent effect on anxiety or self esteem.
The mobile app contained information about postpartum depression, and was designed to ensure mothers understood when and how to take action to prevent or manage symptoms of depression. There is a proven relationship between knowledge and postpartum depression (Branquinho et al, 2019). A study in Nigeria reported that only 6% of participants had good knowledge of postpartum depression, while the prevalence of postpartum depression was as high as 52.3% (Obioha and Okafor, 2022). Knowledge about postpartum depression is also related to a greater likelihood of seeking professional help (Branquinho et al, 2020).
The application designed for the present study also allowed users to play recordings from the Holy Quran. For Muslims, listening to readings of the Quran can promote spiritual comfort and faith, which can positively impact anxiety and depression. Al-Quran therapy is being developed for postpartum women to aid relaxation and manage postpartum depression (Yolanda et al, 2023). It has been reported to be an effective treatment for spiritual and psychological issues (Saged et al, 2020) and has the potential to improve mental disorders and psychological wellbeing (Owens et al, 2023). Quran therapy can also reduce stress hormones, activate natural endorphins, increase relaxation, divert attention from fear, anxiety and tension, reduce blood pressure and slow breathing, heart rate, pulse and brain wave activity (Kurniyawan et al, 2018; Anwar et al, 2019).
The excerpt of the Holy Quran used in the application for the present study was Surah Maryam. Listening to the recitation for 20 minutes each day for 3 weeks has been shown to reduce stress, anxiety and depression during pregnancy (Jabbari et al, 2020). Listening for 25 minutes a day for 14–17 days reportedly reduced anxiety in third-trimester pregnant women (Ulya et al, 2022). In labouring women, listening to the recitation has been shown to reduce pain, anxiety and hemodynamic parameters (El-Sayed et al, 2020).
Previous research has shown that listening to the Al Quran can reduce anxiety (Owens et al, 2023). However, the results of the present study showed that there were no differences in anxiety before and after the intervention. The COVID-19 pandemic was ongoing at the time of the study, which may have led to heightened anxiety related to the social restrictions in place to prevent transmission of the virus (Puspita and Mardliyana, 2021). Sabrin et al (2021) found that during the COVID-19 pandemic, 53.3% of pregnant women in Indonesia experienced anxiety. Additionally, studies from Indonesia reported that during the pandemic, 20.2–44.3% of pregnant women reported moderate to severe anxiety (Zainiyah and Susanti, 2020; Margawati et al, 2022), while before the pandemic, only 3.7–6.9% of pregnant women in Indonesia reported the same level of anxiety (Astuti and Afsah, 2019; Azizah and Rohimah, 2019).
The present study's results showed that the self esteem score in the intervention group was higher than in the control group for all time points. Although there was no statistically significant difference between the intervention and control groups before and after the intervention, there was a small increase in scores in the intervention group between the pre-test and second post-test, whereas the control group's score remained at a similar level throughout the study. There is a relationship between self esteem and depression; mothers with low self esteem are more at risk of experiencing postpartum depression than those with high self esteem (Onyemaechi et al, 2017). Similarly, the present study's results showed that the average depression score decreased significantly in the intervention group, while their self esteem scores increased. Meanwhile, in the control group, there was a small increase in self esteem and decrease in depression scores between the pre-test and first post-test, but an overall insignificant decrease to both scores by the final post-test.
Strengths and limitations
This is the first investigation to combine a mobile application with recitations of the Holy Quran. This combination is suitable to the situation in Indonesia, where most of the population is Muslim and can access the internet using smartphones. By modifying the language, this application may also be suitable for use in other countries with a Muslim population.
However, this study had several limitations. First, the participants' compliance to daily use of the application and listening to the recitations was not assessed. Second, participants' knowledge of postpartum depression was not assessed and so it is not possible to assess whether reduced depression scores were solely the result of listening to the Holy Quran, or greater understanding of postpartum depression and preventive or treatment measures. Third, respondent characteristics such as parity and education, which are risk factors for postpartum depression, were not considered.
Conclusions
The results of this study show that use of a mobile application combined with recitations from the Holy Quran was effective in reducing postpartum depression symptoms, and is therefore likely to be a useful tool for postpartum mothers who are Muslims. Further research should be conducted to explore mothers' experiences of using mobile applications. Adapting the mobile application to other languages for use in different populations of Muslim women would be beneficial.
Key points
- Postpartum depression has a negative effect on mothers, families, society and countries.
- Maternity nurses and midwives can provide non-pharmacological interventions to prevent postpartum depression.
- The combination of a mobile application and listening to recitations of the Holy Quran Voice can reduce postpartum depression symptoms among Muslim women in the postpartum period.
CPD reflective questions
- Could the intervention outlined in this study be applied to your own practice?
- What facilities do you have to support implementation of postpartum depression interventions?
- Does the education provided during antenatal education on preventing and managing postpartum depression incorporate cultural or religious elements? Do you feel that women in your area would benefit from inclusion of this aspect in antenatal education?