Introduction
The birth of a new child and adapting to the postpartum period are stressful for mothers and they face many challenges. The challenges faced by mothers in the postpartum period can cause mental disorders, such as, anxiety, depression, or blouse after childbirth. The maternal blouse is the mildest form of mood disorder in the postpartum period. The prevalence rate of this disorder is between 13.7% and 76%. Symptoms of postpartum blouse include insomnia, mood swings, the tendency to cry, exhaustion, irritability, and emotional instability. Although the exact cause of maternal blouse is not known, several factors, such as hormonal changes, socio-cultural and socioeconomic status, relationship conflicts, domestic violence, male gender preference, fatigue due to insomnia, anxiety about not being able to take care of the baby, fear of decreasing the attractiveness after childbirth, etc., are related to this disorder. In recent years, measures in the social determinants of health based on the World Health Organization (WHO) model, have been considered a priority for preventing mental disorders. In this model, there are two groups of structural and intermediate determinants. Structural factors include education, employment, income, gender, and ethnicity, and intermediate factors include material conditions, psychosocial, behavioral, and biological factors, and health systems. This study was conducted to determine the predictors of maternal blouse in the postpartum period based on social determinants of health of (WHO).

Methods
This study is a prospective quantitative study on pregnant women referred to selected hospitals in Tehran to determine the structural and intermediate factors affecting maternal blouse. The sampling method was multi-stage. Participants were followed up until delivery, and information about delivery and pregnancy outcomes was collected to determine the incidence of maternal blouse. In this study, in order to determine the factors related to maternal grief, a conceptual model was first determined through a review of comprehensive texts, and then the final model was confirmed by holding meetings with a group of experts and researchers in the field of reproductive health and social determinants affecting health or mental health (Figure 1).

Path analysis is an analytical and extensive method of regression analysis that is used to test causal models and requires setting a model in the form of a diagram. The number of samples was considered to be 449 people. Questionnaires were used for data collection, including Demographic and Midwifery Characteristics Questionnaire, Socio-Economic Status Questionnaire (SES), Depression Anxiety and Stress Scale (DASS-21), Multidimensional Scale of Perceived Social Support (MSPSS), Social Readjustment Rating Scale (SRRS), Domestic Violence Questionnaire (DVQ), Unhealthy Behavior Questionnaire, and Stein Maternal Blouse Questionnaire. Collected data were analyzed using SPSS (version 26, SPSS Inc., Chicago, IL, USA) and LISREL (version 8.8, Scientific Software International, IL, USA) software. A significant level of less than 0.05 was considered. Path analysis was used to determine the most important determinants of the maternal blouse and the direct and indirect effects of various variables and test the proposed conceptual model.
Results
The information of 449 pregnant women participating in the study was examined. According to the findings, the average age of women was 26.96±4.46 years and that of their husbands was 32.17±5.6 years, their stress score was 4.2±5.9, anxiety was 3.1±5.3, and depression was 3.1±5.6. Based on the results of the path analysis, among the variables that were related to sadness, socio-economic status had the most negative effect on sadness in the indirect path (one-path test), and DASS21 had the most negative effect in the direct path (B=-0.19) and Incidents had the most positive effect (B=0.18) with sadness. Among the variables that were related to sadness (two-path test), violence had the most positive effect (B=0.36), and a woman’s age, gestational age, and the number of family members (B=-0.2) had the most negative effect on sadness (Table 1 and Figure 2).

 

 Discussion
The path analysis results demonstrated that among the variables related to maternal blouse(one-path test), in the indirect path analysis, socio-economic status had the most negative effect on the maternal blouse and also in the direct path analysis, DASS21 showed the most negative effect on the maternal blouse (B=-0.19) and the unfortunate event had the most positive effect (B=0.18). Violence had the most positive effect on maternal blouse in the two-path test (B=0). Evidence shows that risk factors for postpartum depression include poor social support, marital discord, domestic violence, economic insecurity, and poor maternal care during childhood. Socioeconomic status (occupation, education, and income) is a structural social factor determining health. This factor has a known effect on the occurrence of postpartum mood disorders. Okunola et al. [30] showed that women with higher education get lower scores on the Edinburgh Questionnaire. Stress, anxiety, and depression only directly affect the occurrence of postpartum blouse, although as intermediary determinants, some factors can affect them. Neurophysiological changes in the postpartum period increase vulnerability to depression in stressful situations. This study found that social support can, directly and indirectly, affect the occurrence of postpartum blouse. Badr et al. [44] found that women who received more social support during the prenatal and postpartum stages did not have postpartum depression. Social support can affect the stressful phenomena and stress and anxiety and depression of women and increase the incidence of postpartum blouse. In the postpartum period, when women’s stressful situations increase, adequate support can positively affect a person’s mental and physical health. Violence directly affects the occurrence of blouse; it can also increase stress, anxiety, depression, and the amount of blouse after childbirth. Women of reproductive age, especially during pregnancy and after childbirth, are vulnerable to mental health problems due to domestic violence. According to the results, the proposed model can be recommended for the planning of policymakers and healthcare workers to improve women’s mental health in the postpartum period and provide a solution to eliminating risk factors.

Ethical Considerations
Compliance with ethical guidelines
All ethical considerations were considered in this study. All participants were allowed to leave the study at any time and were assured of the confidentiality of their information. This study received ethical approval from Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.RETECH.REC.1400.595).

Funding
This study was funded by the Midwifery and Reproductive Health Research Center and the Vice-Chancellor for Research and Technology of Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Authors contributions
The authors contributed equally to preparing this paper.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank all participants cooperated in this study and the Shahid Beheshti University of Medical Sciences and the Midwifery and Reproductive Health Research Center.

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