Postpartum women experience significant shifts in their social and psychological roles as they adapt to motherhood. This transition may lead to unstable mood changes, including depression and anxiety, and feelings of physical and mental exhaustion, compounded by stress related to parenting responsibilities. The prevalence of depression among Korean and Chinese mothers is reported to be 24.6% [1] and 14.6% [2], respectively, at 6 weeks postpartum. Postpartum depression (PPD) can begin as early as 4 weeks after delivery and may occur at any point during the first year postpartum.

Studies have shown that women with PPD often face challenges when returning to work, including difficulties with concentration, impaired working memory, and other issues that affect their job performance [3]. In daily life, PPD not only disrupts the harmony between couples [4] but also impacts the healthy development of infants. Over time, children exposed to their mothers’ negative emotions are more prone to develop traits such as introversion or a reluctance to express themselves [5]. Mothers may also experience excessive self-blame and resentment due to their perceived failures, which can hinder normal breastfeeding practices [6].

The prevalence of PPD varies significantly around the world. In the United States, it ranges from 8% to 23.5% [7], while in South Korea, the rates are between 22.4% and 32.8% [1]. In India, the prevalence stands at 22% [8]. In China, the figures fluctuate between 6.7% and 27.3% [9-11]. More than half of all births in China involve first-time mothers, a trend influenced by the longstanding one-child policy. Despite the shift to a “two-child policy” in 2016, 75.5% of births were still to primiparous women, compared to 24.5% to multiparous women [12]. The prevalence of PPD in China during 2017 to 2018 was 42.1% at 6 weeks postpartum, with a higher incidence of 43.4% among first-time mothers compared to 37.9% among those having their second child [13]. Therefore, research on postpartum adaptation, including PPD, among first-time mothers continues to be necessary.

Variables associated with PPD include postpartum fatigue [14,15], parenting stress [16,17], and family support [18,19], according to studies from Korea and China. Postpartum fatigue is a prevalent symptom following childbirth [20]. The physical and mental exhaustion resulting from postpartum recovery and infant care adversely affects a mother’s ability to perform daily activities [21]. The incidence of postpartum fatigue varies internationally; for instance, 67% of mothers in Japan reported experiencing postpartum fatigue one month after delivery [22], while in South Korea, the figure rises to 82% at 3 months postpartum [14]. In China, 90% of mothers reported fatigue at 6 weeks postpartum, with 51.9% experiencing moderate to severe levels of fatigue. Mothers suffering from postpartum fatigue are at an increased risk of developing PPD compared to those without such fatigue [15].

Parenting stress is strongly associated with PPD [23]. New mothers often face significant parenting stress due to the extensive time, physical effort, and energy required to raise their children [16]. Specifically, stress related to an infant’s temperament and a mother’s lack of parenting experience is a significant predictor of PPD [1,17].

Family support acts as a protective factor against depression, while postpartum fatigue and parenting stress can contribute to increased depression levels. Spousal support is essential for new mothers as they navigate the life changes associated with welcoming a new family member. When husbands actively support their wives and engage in childcare, they not only enhance the marital relationship but also foster a bond with their infants, alleviate the significant childcare burden typically shouldered by mothers alone, and help reduce PPD [1,23]. Furthermore, when couples share the responsibilities of puerperal maternal care and newborn care, it leads to stronger relationships and better child attachment [24]. In contrast, mothers who receive less support from their spouses tend to struggle more with postpartum emotion regulation and experience higher rates of PPD [25]. To prevent PPD, it is crucial that family members provide both physical support, such as help with childcare and household tasks, and emotional support, which includes empathizing with the mother’s needs and caring for one another [23].

Few studies have considered maternal environmental characteristics, such as living conditions and relationships with family members, as factors influencing PPD in Chinese women. In China, it is expected that not only husbands but also biological parents and in-laws will support new mothers during the postpartum period. This support includes caring for the mother, managing household duties, assisting with baby care, and providing direct material support [19,26]. However, the relationships between mothers and mothers-in-law, which are established through marriage, often suffer from a lack of understanding due to cultural differences [27]. These differences can lead to disagreements over child-rearing philosophies and methods, increasing psychological stress. If spouses do not manage these relationships effectively, it can deteriorate the couple’s relationship and severely impact family life, potentially leading to PPD [28]. Another study indicated that a mother’s relationship with her biological parents could act as a protective factor against PPD [29]. A Japanese study observed that mothers living with their in-laws had a 26.9% incidence of PPD, whereas those living with their spouses, parents, or other children experienced a significantly lower incidence of 10.3% [30]. Additionally, research on Chinese mothers showed that the prevalence of depression was 29.4% among those living with biological parents, compared to 54.4% among those living with in-laws [11,31].

Low family income, low education level, and the husband’s unemployment were significantly associated with PPD among Chinese mothers [32,33]. Additionally, a husband’s uncooperative attitude, reduced time spent with the husband, and poorer relationships with the husband, parents, and in-laws were linked to increased rates of PPD [29,32]. Regarding obstetric characteristics, factors such as unplanned pregnancy [15,34], poor infant and maternal health [35,36], and maternal expectations concerning the baby’s sex [37] were also found to elevate the risk of PPD.

Therefore, this study aimed to explore the levels of postpartum fatigue, parenting stress, family support, and depression experienced by first-time mothers in China and to determine their effects on PPD, along with maternal environmental characteristics.

This study was conducted among Chinese primiparous mothers to identify the factors influencing PPD. The mean PPD score was 13.94, with 78.7% of participants falling into the depression risk group (scores ≥10). This is significantly higher than the previously reported 34.0% in Chinese first-time mothers at 6 weeks postpartum [32]. This increase may be attributed to the challenges of postpartum adjustment for first-time mothers, compounded by the data collection period coinciding with the COVID-19 pandemic in China and globally. In response to the pandemic, the Chinese government enforced home quarantine and strict control over high- and medium-risk areas [48]. Therefore, mothers were unable to meet with their families and lacked adequate family support compared to pre-pandemic times, potentially contributing to the higher PPD levels observed in this study.

The proportion of mothers reporting moderate to severe postpartum fatigue in this study (88.6%) exceeds the 51.9% prevalence of moderate to severe postpartum fatigue among mothers at 6 weeks postpartum in Shanghai, China [15]. This higher rate is likely attributable to a combination of factors including the mothers’ physical recovery needs during the postpartum period, inexperience with newborn care, round-the-clock caregiving, mental stress and exhaustion, and the lack of family support during the pandemic.

The parenting stress score (88.93±21.11), with 45.3% of participants experiencing high levels of stress, is slightly higher than previous studies: 80.24 from Chinese primiparous women at 6 weeks postpartum [42] and 82.29 from Korean mothers at 6 months postpartum [16]. This elevated stress among primiparous women may reflect lower satisfaction and self-efficacy in parenting. The high level of parenting stress could be attributed to insufficient knowledge about and experience with parenting. Additionally, cultural differences in postpartum care practices between South Korea and China should be considered. According to the Korean Ministry of Health and Welfare’s 2021 Postpartum Care Survey, the utilization rate of postpartum caregivers in Korea was 78.1%; however, even in first-tier developed cities in China, this rate was only 7% to 8%, and it was even lower in smaller cities [49]. Moreover, most Chinese families are extended, with the parents of both spouses living together, likely providing a greater degree of family support than is available to Korean mothers, who are predominantly part of nuclear families. Therefore, compared to the postpartum parenting pressure experienced by primiparous women in South Korea, the pressure faced by their counterparts in China is relatively low.

The family support score was 26.64, higher than the 13.29 recorded in 2016 [47], and comparable to the score of 25.30 observed in 2021 [19]. Higher expectations placed by mothers on their families, spouses, and other close relatives due to their lack of parenting experience are associated with a larger discrepancy between these expectations and the low support they perceive. This discrepancy leads to lower maternal satisfaction with the support received. A gap in expectations of social support can result in negative emotions for mothers, such as frustration and helplessness. Therefore, family members should improve communication with mothers, listen patiently to their needs, show tolerance and understanding, and strive to meet their needs for parenting knowledge, skills, and emotional support. This approach will help narrow the expectation gap, empower mothers to care for their babies independently, facilitate their adjustment to the maternal role, and reduce the incidence of PPD [19].

Among mothers’ characteristics, poor relationships with husbands, in-laws, and biological parents were found to be influential, aligning with findings from previous studies [17,32,35]. For Chinese new mothers, maintaining a favorable relationship with family members, particularly in-laws, appears to reduce the risk of maternal PPD. Therefore, it is crucial to acknowledge that indicators reflecting the sociocultural context and environmental characteristics surrounding the mother can also impact PPD.

The factors making the strongest contribution to PPD in first-time mothers were identified as postpartum fatigue, followed by parenting stress and family support, after accounting for environmental factors such as living conditions and relationships with family members. This aligns with previous research indicating that higher levels of maternal depression are associated with increased postpartum fatigue [38], greater parenting stress [16,17], and lower satisfaction with family support [17,26]. Additionally, this study revealed that poor relationships with biological parents, husbands, and in-laws were significant contributors to higher PPD. Specifically, strained relationships with in-laws, increased postpartum fatigue, elevated parenting stress, and dissatisfaction with the level of family support received were significant factors influencing PPD, even after controlling for environmental factors. The variable concerning the relationship with in-laws remained a significant predictor of PPD in Chinese first-time mothers. Therefore, assessments and interventions targeting PPD should consider the significance of in-law relationships in Chinese culture.

During the data collection period for this study, the Chinese government implemented stringent infection control policies, which included enforcing home quarantine and strictly controlling access to high- and medium-risk areas [48]. As a result, mothers were prevented from meeting with their families and could not receive the same level of family support as they would have during a non-coronavirus period. This lack of support may have contributed to higher levels of PPD. Therefore, it may have been challenging for first-time mothers to adapt to motherhood, exacerbated by this unexpected situational factor that potentially worsened PPD. Given that the level of PPD could have been influenced by the situational crisis of COVID-19, caution is advised when interpreting the results of the study.

Another limitation of this study is that it was conducted among healthy, married, first-time mothers residing in urban areas; therefore, caution should be exercised when generalizing the results. Future research should include comparative studies of PPD among urban and rural mothers, as well as follow-up studies to explore PPD levels after mothers return to work.

Implications for nursing practice include the following strategies. Nurses should perform depression screenings during regular checkups for mothers to identify those at risk for PPD. They should also offer education and counseling to help prevent and alleviate depression. To combat maternal postpartum fatigue and parenting stress, nurses should provide education on newborn care and breastfeeding techniques either at discharge or during postpartum visits to strengthen parenting skills. Additionally, nurses should direct mothers to informational support resources available through social media to bolster postpartum support networks. They should encourage mothers to share household and childcare responsibilities with their partners.