postnatal depression literature review

• Research article
• Open access
• Published: 06 January 2021

Appraisal of systematic reviews on interventions for postpartum depression: systematic review

• Ryan Chow 1 , 2 ,
• Eileen Huang 1 ,
• Allen Li 1 ,
• Sophie Li 3 ,
• Sarah Y. Fu 1 ,
• Jin S. Son 3 &
• Warren G. Foster   ORCID: orcid.org/0000-0001-5762-7371 2 , 3  

BMC Pregnancy and Childbirth volume  21 , Article number:  18 ( 2021 ) Cite this article

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Postpartum depression (PPD) is a highly prevalent mental health problem that affects parental health with implications for child health in infancy, childhood, adolescence and beyond. The primary aim of this study was to critically appraise available systematic reviews describing interventions for PPD. The secondary aim was to evaluate the methodological quality of the included systematic reviews and their conclusions.

An electronic database search of MEDLINE, Embase, and the Cochrane Library from 2000 to 2020 was conducted to identify systematic reviews that examined an intervention for PPD. A Measurement Tool to Assess Systematic Reviews was utilized to independently score each included systematic review which was then critically appraised to better define the most effective therapeutic options for PPD.

Of the 842 studies identified, 83 met the a priori criteria for inclusion. Based on the systematic reviews with the highest methodological quality, we found that use of antidepressants and telemedicine were the most effective treatments for PPD. Symptoms of PPD were also improved by traditional herbal medicine and aromatherapy. Current evidence for physical exercise and cognitive behavioural therapy in treating PPD remains equivocal. A significant, but weak relationship between AMSTAR score and journal impact factor was observed ( p  = 0.03, r = 0.24; 95% CI, 0.02 to 0.43) whilst no relationship was found between the number of total citations ( p  = 0.27, r = 0.12; 95% CI, − 0.09 to 0.34), or source of funding ( p  = 0.19).

Overall the systematic reviews on interventions for PPD are of low-moderate quality and are not improving over time. Antidepressants and telemedicine were the most effective therapeutic interventions for PPD treatment.

Peer Review reports

Childbirth (parturition) can cause significant change in a woman’s priorities, roles, and responsibilities. Though there are many concerns for the mother after parturition, emergence of postpartum depression (PPD) and clinical management strategies remain an important unresolved issue [ 1 ]. PPD is defined by the Diagnostic and Statistical Manual of Mental Disorders IV and is an increasingly prevalent mental health problem that typically begins four to six weeks after parturition [ 2 ]. Common symptoms include sleep and appetite disturbance, diminished concentration, irritability, anxiety, feelings of guilt and worthlessness, loss of interest or pleasure in daily activities, depressed mood and thoughts of suicide [ 3 ].

The prevalence of PPD differs significantly depending on the country and ranges from 1.9 to 82.1% with the highest reported prevalence appearing in the United States and the lowest in Germany [ 4 ]. The consequences of PPD on the child are not restricted to infancy, and can extend into toddlerhood, school age, and even adolescence. PPD can lead to inadequate prenatal care, childhood noncompliance, anger and dysregulated attention, and lower cognitive performance [ 5 ]. As the window to treat PPD is time-sensitive, it is critical to define the efficacy and safety of different therapeutic options. PPD is a complex disorder whose pathophysiology remains poorly defined with sub-optimal therapeutic options and an expanding literature. Numerous systematic reviews describing therapeutic interventions for the management of PPD have emerged in the literature in recent years; however, the most effective therapeutic options remain poorly defined.

Evidence-based medicine is defined as using highest-quality evidence to inform clinical decision-making [ 6 ]. In the hierarchy of evidence, systematic reviews and meta-analyses sit as the very top [ 7 ]. If done correctly, systematic reviews and meta-analyses are able to consolidate and summarize primary evidence for clinicians and policymakers. However, when systematic reviews are poorly conducted, their risk to bias increases and can generate invalid and unreliable results. Guidelines such as the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology have been developed to ensure consistency in the methodological synthesis of systematic reviews [ 8 , 9 ]. In addition to those, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool was developed and is a validated tool [ 10 , 11 ] to assess the methodological quality of systematic reviews.

The aim of this study was to evaluate the quality of systematic reviews on the efficacy and safety of different PPD interventions using the AMSTAR tool and to evaluate different therapeutic strategies stratified by methodological quality. The secondary aim was to investigate whether different publication characteristics (e.g. number of citations, impact factor of the journal, year of publication, funding source) were associated with the methodological rigour of the systematic review. This systematic review was conducted according to PRISMA guidelines [ 8 ].

Search strategy

A comprehensive electronic database search, with a validated search strategy from a medical librarian, of Embase, MEDLINE and the Cochrane Library of Systematic Reviews from inception until March 5th, 2020 was conducted. Search terms include depression, postpartum or post-partum, postnatal or post-natal, and systematic review (Appendix S 1 ). The complete search strategy is available in the online supplement (Table S 1 ).

Study selection

Search results were uploaded into the Covidence software platform (Veritas Health Innovation Ltd). Duplicate articles were removed, and a two-staged independent screening process was used to identify studies for inclusion. Pilots were run for the initial stage of screening until review authors (E.H., S.F., S.L. and J.S.) reached a Cohen’s kappa inter-rater reliability value of 0.8 [ 12 ]. Subsequently, reviewers independently screened titles and abstracts. Eligible articles proceeded to full-text screening. Discrepancies during either stage of screening were resolved by discussion among the authorship team until a consensus was reached. The inclusion criteria involved: (1) the systematic review must investigate the safety and/or effectiveness of any intervention treating post-partum depression; (2) self-identified as a systematic review in the title or abstract; (3) the systematic review must review primary literature. The exclusion criteria involved: (1) outdated reviews where an updated version was accessible; (2) systematic reviews of other systematic reviews; (3) meta-analyses that did not include a systematic review; (4) non-intervention systematic reviews (e.g. preventative or screening tools); (5) reviews aiming to investigate the state of literature, where patient outcomes were not the primary interest; (6) non-English literature, and (7) conference abstracts.

Data extraction

Data was independently extracted by authors (E.H., S.F., S.L. and J.S.). Domains extracted included publication details such as: journal and impact factor (from Clarivate Analytics), year of publication, funding source (e.g. philanthropic, government, industry, etc.), total citations (from Google Scholar), conflict of interest statement (dichotomous), the corresponding author’s country, and the intervention studied (e.g. peer support groups, antidepressants, cognitive behavioural therapy, etc.). Discrepancies were resolved by discussion and consensus among the authorship team. The list of excluded studies is available in the online supplement (Table S 2 ).

Risk of Bias assessment

Authors (E.H., S.F., S.L. and J.S.) independently evaluated the methodological quality of the studies using the AMSTAR quality assessment tool . Scores were tabulated using Microsoft Excel (Redmond, Wash.). Review authors selected either “yes,” “not applicable,” “no,” or “can’t answer” for each of AMSTAR criteria. Discrepancies were resolved by consensus with the authorship team. A point was awarded for each of the AMSTAR criteria that received a “yes.” No points were given for “not applicable,” “no,” or “can’t answer”. Therefore, the highest total score possible was 11.

Strategy for data synthesis

Tables generated using Microsoft Excel (Redmond, Wash.) were used to summarize data. GraphPad Prism (version 7.0, GraphPad Software, Inc., USA) was used to statistically analyze data. Pairwise correlations (AMSTAR Score vs. Total Citations, AMSTAR Score vs. Impact Factor, AMSTAR Score vs. Publication Year) were evaluated using the Pearson correlation coefficient (r). A two-tailed T-Test was used to evaluate potential differences in AMSTAR Score in terms of source of funding (Cochrane article vs. non-Cochrane article, government vs. institution etc.). A P -value less than 0.05 was considered statistically significant.

Included studies were stratified into low, moderate, and high methodological quality, as identified by an AMSTAR score of 1–5, 6–8, and 9–11, respectively (Table S 3 ). Findings from included studies were then narratively synthesized within each stratum. Greater emphasis was placed on extensively researched interventions or reviews with greater methodological rigor.

The electronic searches identified 842 publications, of which 320 (38%) were duplicates (Fig.  1 ). 522 articles proceeded to title/abstract screening with 394 (47%) being deemed ineligible as they did not evaluate an intervention for PPD. 128 (17%) full-text articles were retrieved and subjected to another round of screening from which 41 (5%) studies were excluded as they did not examine interventions for PPD. Three (0.3%) more studies were excluded as they were not systematic reviews. Finally, 84 studies (10%) met the a priori inclusion/exclusion criteria and were included [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 ] for critical appraisal.

Flow Diagram illustrating the management of article titles identified in our literature search, rationale for study exclusion and ultimate inclusion for critical appraisal

Characteristics of included studies

The characteristics of included studies are described in Table S 1 . The greatest number of studies ( n  = 15; 18%) were published in the Cochrane Library with the second most ( n  = 6; 7%) published in The Archives of Women’s Health. Institutional funding involving hospitals and universities were involved with the largest proportion of studies ( n  = 28; 33%). Government sources of funding were involved in a minority of publications ( n  = 17; 20%), no funding was reported for ( n  = 20; 24%) articles, and many articles failed to report a funding source ( n  = 25; 30%) (Table  1 ).

Of the different therapeutic interventions described, peer support and group therapy were the intervention most frequently examined (n = 20; 24%), whereas cognitive behavioural therapy (CBT) and physical activity were less frequently examined ( n  = 17, 20%; n  = 10 = 12%, respectively) of the studies reviewed. Some interesting interventions such as skin-to-skin infant contact, hypnosis, and specific traditional rituals were only reported in a single systematic review.

Methodological quality of included studies

The overall AMSTAR score for included studies published from 2000 to 2020 had a mean (SD) of 5.6 ± 1.6 (Fig.  2 a). Compliance to each AMSTAR criteria was inconsistent across the studies (Fig. 2 b). The overall methodological quality of the systematic reviews assessed was highly variable, with AMSTAR scores ranging from 1/11 ( n  = 5; 6%) to 10/11 ( n  = 2; 2.4%). The top three AMSTAR criteria that were most satisfied involved inclusion of the characteristics of included studies (criterion 6: n  = 80; 95.2% of studies), the performance of a comprehensive literature search (criterion 3: n  = 78; 92.9% of studies), and the inclusion of a quality assessment (criterion 7: n  = 63; 75% of studies). The three AMSTAR criteria that were the least frequently reported were the reporting of funding sources of included studies (criterion 11: n  = 3; 3.6% of studies), and a tie between an a priori design and the assessment for publication bias (criterion 1 and 10: n  = 25; 29.8% of studies), and the reporting of the included and excluded studies (criterion 5: n  = 27; 32.1% of studies).

The Characteristics of the AMSTAR Assessment of Included Studies. A: The AMSTAR scores from 2000 to 2020, grouped into five-year intervals. Data represented as mean (SD). The mean AMSTAR score throughout the past twenty years was 5.6 (1.6). B: The number (%) of studies adhering to each AMSTAR criteria. Criteria: 1. Was an ‘a priori’ design provided? 2. Was there duplicate study selection and data extraction? 3. Was a comprehensive literature search performed? 4. Was the status of publication (i.e. grey literature) used as an inclusion criterion? 5. Was a list of studies (included and excluded) provided? 6. Were the characteristics of the included studies provided? 7. Was the scientific quality of the included studies assessed and documented? 8. Was the scientific quality of the included studies used appropriately in formulating conclusions? 9. Were the methods used to combine the findings of studies appropriate? 10. Was the likelihood of publication bias assessed? 11. Was the conflict of interest included?

Synthesis of results

Almost half of the included systematic reviews were of low quality ( n  = 37) as identified by an AMSTAR score of 1–5. A significant, but weak relationship between AMSTAR score and journal impact factor was observed (Fig.  3 a; p  = 0.03, r = 0.24; 95% CI, 0.02 to 0.43). No significant relationships between mean AMSTAR score and number of citations (Fig. 3 b; p  = 0.27, r = 0.12; 95% CI, − 0.09 to 0.34) or publication year (Fig. 3 c; p  = 0.14, r = 0.16; 95% CI, − 0.05 to 0.37) were found. No significant differences ( p  = 0.19) were found between the AMSTAR scores of systematic reviews funded by government funding agencies, philanthropists, or institutions (Fig. 3 d). On average, systematic reviews published by the Cochrane Collaboration scored higher than other published systematic reviews we evaluated ( p  = 0.007) (Fig. 3 e).

Association Between Publication Factors and Methodological Quality. A: AMSTAR score vs. journal impact factor ( p  = 0.03, r = 0.24; 95% CI, 0.02 to 0.43). B: AMSTAR score vs. number of citations ( p  = 0.27, r = 0.12; 95% CI, − 0.09 to 0.34). C: AMSTAR score vs. publication year ( p  = 0.14, r = 0.16; 95% CI, − 0.05 to 0.37). D: Differences in AMSTAR score in papers funded by government vs. non-government sources. ( p  = 0.18) E: Differences in AMSTAR score for papers published by the Cochrane Collaboration vs. published in non-Cochrane journals (** p  = 0.007)

For the most highly ranked systematic reviews, the most common interventions studied evaluated involved traditional interventions such as aromatherapy, acupuncture, and rituals [ 27 , 85 , 88 , 89 ], as well as more conventional therapies such as CBT [ 30 , 39 , 95 ], physical activity [ 34 , 65 , 81 ], and pharmacological treatments [ 29 , 42 , 44 , 55 , 57 , 79 ]. Positive benefits of aromatherapy on PPD were reported in two [ 85 , 89 ] systematic reviews, but meta-analysis was not possible due to the heterogeneity of study designs therein. A systematic review on acupuncture reported a pooled mean difference of − 1.27 (95% CI, − 2.55 to 0.01; p  = 0.05, I 2  = 83%) on the Hamilton Depression Scale between 12 randomized controlled trials (RCTs) with 887 participants [ 88 ]. However, they reported that the trials included therein had a high risk of bias and that future trials with higher methodological rigour would be needed to confirm the beneficial effects of acupuncture. Finally, there was no clear evidence on of a beneficial effect of traditional rituals on PPD. [ 27 ]

The efficacy of cognitive behaviour therapy (CBT) as a PPD intervention was examined by multiple reviews. CBT reduced Edinburgh Postnatal Depression Scale (EPDS) depression scores in a meta-analysis of six studies (− 4.48, 95% CI, 1.01 to 7.95) [ 30 ]. Another meta-analysis of seven RCTs showed a significant size-effect of CBT on reducing PPD (d = − 0.54, 95% CI, − 0.716; − 0.423) [ 95 ]. However, a third systematic review found inconsistent and inconclusive results regarding its effectiveness [ 39 ]. Thus, the benefits of CBT as a therapeutic option for the management of PPD remain to be clarified. It is important to note that primary studies and trials with significant limitations were used to reach these conclusions.

In the present review, most of the included systematic reviews were ranked as moderate quality ( n  = 39), characterized by an AMSTAR score of 6–8. About a fourth of the studies in this stratum were published in the Cochrane Database of Systematic Reviews ( n  = 10) and most of the reviews were either funded by institutions ( n  = 15) or did not receive financial support ( n  = 12). The most extensively researched interventions in this stratum were also traditional interventions. Results of a meta-analysis of seven RCTs demonstrated that Chai Hu Shu Gan San had a greater effect on postpartum depression (mean difference = − 4.10, 95% CI, − 7.48 to − 0.72, I 2  = 86%) compared to fluoxetine [ 76 ]. Another systematic review also stated that other forms of Chinese herbal medicine could reduce depression scores, alone or in combination with routine treatments [ 53 , 77 ]. Taken together these data suggest that traditional Chinese herbal medicine could have beneficial effects in the treatment of PPD and provide a useful alternative therapeutic option for women preferring natural therapies over conventional options.

Pharmacological interventions, including antidepressants and hormonal treatments, were also extensively researched [ 1 , 14 , 43 , 46 , 87 ]. Estrogen therapy, progestin-only pills, and levonorgestrel intrauterine devices were reported to be effective, but a limited number of trials were referenced [ 87 ]. On the contrary, another systematic review reported [ 24 ] that in a double-blind randomised placebo-controlled trial, norethisterone enanthate increased the risk of developing PPD (mean EPDS score 10.6 vs 7.5; P  = 0.0022). Three systematic reviews reported that fluoxetine [ 14 , 43 , 46 ] is an effective therapeutic option for PPD. Fluoxetine decreased EPDS depression scores from (9.9 (8.3 to 11.8)] to [7.3 (5.5 to 9.6)) compared to placebo, in a trial with 87 women [ 14 ]. It is reported that most included trials from these systematic reviews were indicated to have a high risk of bias and that results should be interpreted with caution [ 46 ].

The effectiveness of telephone support as a PPD intervention was investigated in three systematic reviews [ 22 , 23 , 37 ]. Findings of one study found that telephone support delivered by health professionals was associated with lower depression scores in the postnatal period [ 37 ]. Telephone peer support was examined in a systematic review that included seven trials with 2492 participants. They found that telephone peer support significantly reduced depressive symptomatology, as rated by the EPDS, at eight weeks postpartum (OR 6.23, 95% CI, 1.40 to 27.84; P  = 0.01) [ 22 ]. However, the methods of administering peer telephone support from the primary studies remain unclear. Additionally, evidence from another systematic review of five primary studies showed an average reduction in EPDS scores of 3.02 (95% CI, 5.34 to 0.70) [ 73 ]. Based on these systematic reviews with a fair rating of methodological rigour, telecommunication strategies show promise as an effective intervention for patients with PPD.

Physical exercise was another extensively researched intervention. A systematic review conducted a robust variance estimation random-effects meta-analysis and found a significant reduction in postpartum depression scores (Overall standard mean difference (SMD) = − 0.22 (95% CI, − 0.42 to − 0.01), p  = 0.04; I 2  = 86.4%) in women physically active during pregnancy relative to those who were not [ 83 ]. Another systematic review found that exercise reduced women’s PPD, as reported by the EPDS, by − 4.00 points (95% CI, − 7.64 to − 0.35) [ 26 ]. These findings were contrary to a systematic review that did not find exercise to reduce postnatal depressive symptoms [ 68 ]. It is evident that studies with greater methodological rigour must be conducted to determine the effectiveness of physical exercise as an intervention for PPD.

The highest AMSTAR score achieved was 10/11 ( n  = 2) and involved a paper published in the Journal of Epidemiology and Community Health, and another in the Cochrane Database of Systematic Reviews. One of these systematic reviews analyzed the use of conventional pharmacological antidepressants [ 46 ], whereas another examined the role of male involvement [ 52 ]. Important conclusions from these studies include that selective serotonin re-uptake inhibitors (SSRIs) such as sertraline, paroxetine and fluoxetine have been shown to have a positive impact in mother’s experiencing PPD (response: RR 1.43, 95% CI, 1.01 to 2.03); remission: RR 1.79, 95% CI, 1.08 to 2.98). Furthermore, a conventional tricyclic antidepressant, nortriptyline, was equally as effective as sertraline. It was concluded that there was no meaningful difference in adverse effects between treatment arms in the studies included in the systematic reviews, although very limited data on effects experienced by breastfed infants were available. Another study [ 52 ] reported that male involvement during antenatal care was associated with a greater utilization of healthcare services and higher quality postnatal care (OR = 1.35, 95% CI not reported; p  = 0.01). Male involvement in the post-partum period significantly decreased the likelihood of PPD by 66% (OR 0.34, 95% CI, 0.19 to 0.62; I 2  = 57%).

Overall, our results revealed a low-moderate level of methodological quality with no statistically significant changes in quality over the past 20 years. Use of antidepressants and telecommunication therapy were the most effective interventions for PPD based on the systematic reviews with the highest methodological quality. In addition, traditional Chinese herbal medicine was also found to be an effective tool for the treatment of PPD and thus may serve as a useful treatment alternative for women who prefer natural therapies over conventional methods. The use of physical exercise, hormonal therapies, and CBT for the treatment of PPD remain equivocal.

There was a weak but significant correlation observed between AMSTAR score and the impact factor of the journal, suggesting that leading journals may evaluate methodological quality a little more rigorously than others. Given the overall low-moderate quality of systematic reviews, it would be beneficial for editorial boards to integrate quality assessment tools in the peer review process. Furthermore, there was no significant correlation between AMSTAR score and total number of citations an article had. This is an observation that is consistently seen in other realms such as hematology [ 96 ].

Systematic reviews published by the Cochrane Library had an average score that was higher compared to non-Cochrane articles ( p  = 0.007). This observation supports the generally accepted position that the Cochrane Collaboration sets a high standard for methodological rigour when undertaking systematic reviews. These results align with the findings from other medical disciplines regarding the methodological quality of Cochrane reviews as well [ 97 ].

A large level of heterogeneity was observed in the quality assessment of peer-reviewed systematic reviews involving the safety and effectiveness of pharmacological and psychosocial interventions to treat PPD. AMSTAR scores ranged from 1/11 ( n  = 5) to 10/11 ( n  = 2). The number of systematic reviews in this field has slowly increased over the past two decades, with the most ( n  = 14) being published in 2019. However, our evaluation of systematic reviews ( n  = 83) did not detect improvements in methodological rigour over the last two decades. This finding diverges from other areas in research, like radiology and critical care, in which methodological rigour of systematic reviews has improved over time [ 98 , 99 ].

A strength of the present study is that a comprehensive literature search according to the AMSTAR criteria was conducted and the PRISMA statement was adhered to. A large scope of evidence was available and retrieved from the Cochrane Library, Medline, and Embase. One limitation of our study is that the quality of the systematic reviews evaluated was carried out by authors aware of the authorship and publication journal of the study. However, the potential for bias was reduced by several authors independently evaluating each systematic review, with final decisions for each quality assessment criteria followed by discussion until consensus was achieved. Furthermore, the analysis between AMSTAR score and the number of citations may be affected by publication date of the systematic review. Recently published systematic reviews may not have garnered as many citations as older publications, even if AMSTAR scores may be higher. However, we utilized this metric as it provides insight on how the methodological quality of given systematic reviews have influenced the field.

Conclusions

The methodological rigor of the systematic reviews of therapeutic options for women with PPD over the past 20 years is of low to moderate quality and has remained unchanged over time. We found that, based on the systematic reviews with the highest methodological quality, the use of antidepressants and telecommunication therapy are the most effective interventions for PPD. Traditional Chinese herbal medicine was effective in the management of PPD and thus could provide a useful therapeutic alternative for women who prefer natural options over conventional therapies. The efficacy of physical exercise, hormonal therapies, and CBT for the treatment of PPD remain equivocal.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

A Measurement Tool to Assess Systematic Reviews

Cognitive behavioural therapy

Edinburgh Postnatal Depression Scale

Post-partum depression

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We appreciate and wish to thank Ms. Denise Smith, Faculty of Health Sciences, McMaster University, for her guidance in preparing the search strategy.

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Additional file 1..

Table S1: Included Studies and Their Characteristics. Table S2: List of Excluded Studies and Their Reasons. Table S3: AMSTAR Scoring of Included Studies. Appendix S1: Search Keywords and Search Strings.

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Chow, R., Huang, E., Li, A. et al. Appraisal of systematic reviews on interventions for postpartum depression: systematic review. BMC Pregnancy Childbirth 21 , 18 (2021). https://doi.org/10.1186/s12884-020-03496-5

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A review of longitudinal studies on antenatal and postnatal depression

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Antenatal depression is a known risk factor for postnatal depression; both are common disorders associated with negative impacts on child development. Few studies have followed up women from pregnancy and through the postnatal period to explore how rates of depression change. This review evaluates recent evidence on depression during pregnancy and after childbirth. A search of Embase, PsychINFO, MEDLINE and Cochrane Reviews was carried out to identify longitudinal studies on antenatal and postnatal depression. Studies that measured depression during pregnancy and up to 1 year after childbirth were evaluated against a set of criteria (e.g. less than 50 % attrition). Of the initial 523 studies identified, 16 studies met the final inclusion criteria with a total of 35,419 women. The average rate of antenatal depression across these studies was 17 and 13 % postnatal depression. The longitudinal nature of the studies revealed that on average 39 % of those who experienced antenatal depression went on to have postnatal depression. Similarly, on average, 47 % of those with postnatal depression had also experienced antenatal depression. On average, almost 7 % of women reported significant depressive symptoms in pregnancy that persisted after childbirth. The review provided evidence that rates of depression tend to be higher during pregnancy than in the first year following childbirth. Furthermore, the longitudinal data show that there is much movement between the groups categorised as depressed or not depressed. There is evidence that postnatal depression is often a continuation of existing antenatal depression.

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Acknowledgments

This review was carried out as part of the Growing Up in New Zealand longitudinal study. Growing Up in New Zealand has been funded by the New Zealand (NZ) Ministries of Social Development, Health, Education, Justice and Pacific Island Affairs; the former Ministry of Science Innovation and the former Department of Labour (now both part of the Ministry of Business, Innovation and Employment); the former Ministry of Women’s Affairs (now the Ministry for Women); the Department of Corrections; the Families Commission (now known as the Social Policy Evaluation and Research Unit); Te Puni Kokiri; NZ Police; Sport NZ; the Housing NZ Corporation and the former Mental Health Commission, The University of Auckland and Auckland UniServices Limited. Other support for the study has been provided by the NZ Health Research Council, Statistics NZ, the Office of the Children’s Commissioner and the Office of Ethnic Affairs. The study has been designed and conducted by the Growing Up in New Zealand study team, led by the University of Auckland. The authors acknowledge the contributions of the original study investigators: Susan M.B. Morton, Polly E. Atatoa Carr, Cameron C. Grant, Arier C. Lee, Dinusha K. Bandara, Jatender Mohal, Jennifer M. Kinloch, Johanna M. Schmidt, Mary R. Hedges, Vivienne C. Ivory, Te Kani R. Kingi, Renee Liang, Lana M. Perese, Elizabeth Peterson, Jan E. Pryor, Elaine Reese, Elizabeth M. Robinson, Karen E. Waldie, Clare R. Wall. The views reported in this paper are those of the authors and do not necessarily represent the views of the Growing Up in New Zealand investigators.

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Underwood, L., Waldie, K., D’Souza, S. et al. A review of longitudinal studies on antenatal and postnatal depression. Arch Womens Ment Health 19 , 711–720 (2016). https://doi.org/10.1007/s00737-016-0629-1

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The effects of pre- and post-partum depression on child behavior and psychological development from birth to pre-school age: a protocol for a systematic review and meta-analysis

• Lea Takács   ORCID: orcid.org/0000-0002-8137-026X 1 ,
• Vít Kandrnal 2 ,
• Šárka Kaňková 3 ,
• František Bartoš 1 &
• Jiří Mudrák 1  

Systematic Reviews volume  9 , Article number:  146 ( 2020 ) Cite this article

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Pre- and post-partum depression is a common mood disorder with detrimental effects on both mother and child. The aim of the proposed review is to summarize evidence related to the effects of both pre- and post-partum depression on child behavior and development from birth to preschool age. In particular, our review will address mutual relations between pre- and post-partum depression in order to determine whether pre- and post-partum depression predict child psychological outcomes independently, whether there is an effect of timing of depression on child outcomes, whether pre- and post-partum depression interact to affect child outcomes, and whether the effect of pre-partum depression is mediated by depression after child’s birth.

We will include prospective longitudinal studies that report data about the effects of both pre- and post-partum depression on child psychological outcomes as published in peer-reviewed academic journals since January 1998. We will search EMBASE, MEDLINE, PsycARTICLES, PsycINFO, ISI Web of Science, Scopus, and Wiley Online databases to identify original research articles written in English. Two independent reviewers will screen search results in two stages: (i) titles and abstracts and (ii) full text. The first one will extract data into tables, while the latter will verify whether the data extracted are correct. We will assess the risk of bias in the selected studies using the Critical Appraisal Skills Programme (CASP), Cohort Study Checklist. The results of the review will be reported in a narrative form. If there are sufficient data available, a meta-analysis will be conducted using metaSEM package in R.

The proposed review will be the first systematic review summarizing the effects of both pre- and post-partum depression on child psychological development and behavior from birth to preschool age. The results of such a review may contribute to a better understanding of mutual relations between pre- and post-partum depression in their effects on child outcomes. They may also shed light on what periods in early human development are most vulnerable to the effects of maternal depression.

Trial registration

PROSPERO CRD42018106269

Peer Review reports

Perinatal depression is a relatively frequent condition that affects between 5.2 and 13.0% of mothers in developed countries [ 1 ] and possibly up to 20% of mothers in low- and middle-income countries [ 2 ]. A recent meta-analysis estimates that the global prevalence of perinatal depression stands at 17.7% [ 3 ]. According to some authors, the figure would be even higher if screening was routinely applied in maternity health services [ 4 ].

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [ 5 ] defines depression in perinatal period as a major depressive disorder with onset in the peripartum period up to 4 weeks after delivery, but according to some authors evidence supports also an expanded concept of childbirth-related depression which includes the entire first postpartum year [ 6 , 7 , 8 ]. Given the similarities between depressive symptoms and general symptoms accompanying pregnancy or postpartum period, detection of perinatal depression is a challenging task. Moreover, many women may feel reluctant to report negative emotions after the birth of their child and are more likely to report physical rather than psychological issues to their obstetricians [ 9 ]. These factors help account for the fact that postpartum depression is often unnoticed by healthcare professionals and remains, for the most part, underdiagnosed and untreated.

The factors commonly associated with perinatal depression include family history of depression, personal history of depressive and/or anxiety symptoms, overall poor health, low socioeconomic status, negative birth experience [ 10 ], and low partner support [ 11 , 12 , 13 ]. One of the strongest predictors of postpartum depression is antenatal depression [ 14 , 15 ]. It is, however, unclear whether postpartum depression is a continuation of antenatal depression or rather an independent condition. In a recent review, antenatal depression has been reported as more prevalent than its postpartum counterpart [ 15 ], but the prevalence rates differ across the studies according to trimester, sampling, type of assessment used, and cut-off points applied [ 16 ]. Another review found similar prevalence rates for pre- and post-partum depression, with a somewhat higher upper limit for postpartum depression [ 6 ].

There is convincing evidence that maternal depression may have detrimental effects on child neurodevelopment and behavior [ 17 , 18 , 19 , 20 ]. Infants of depressed mothers show increased motor and cry response to unknown stimuli [ 21 , 22 ] and lower social engagement [ 23 ] than children of non-depressed mothers. They also score higher on negative affectivity [ 24 , 25 ] and more frequently develop insecure attachment with the mother [ 26 ]. The effect of maternal depression on the offspring seems to be long-lasting. For instance, Pawlby et al. [ 27 ] linked antenatal depression with increased risk of depression in adolescents.

The pathways through which depression may affect child development seem to be different for depression during pregnancy and depression in the postpartum period [ 20 ]. During pregnancy, maternal depression may affect placental function and via this route influence the programming of fetal neurodevelopment [ 28 ]. After birth, depression might affect child outcomes via changes in maternal bonding, parenting sensitivity and behaviors, and maternal self-esteem [ 23 , 25 , 29 ]. It is especially in the first years of their life that children are particularly vulnerable to the effects of maternal depression since these early years represent a period of rapid brain development and maturation of key physiological systems, such as HPA axis [ 30 ], leaving the developmental trajectories more open to external influences [ 31 ]. Apart from the mediating factors underlying the association between maternal depression and child developmental outcomes, existing studies identified several factors functioning as moderators, affecting the strength or direction of such association: children of mothers with higher socioeconomic status, education, or more optimal parenting behaviors have been found less likely to suffer from the adverse effects of maternal postpartum depression [ 20 ].

Despite a relatively high prevalence of pre-partum depression, multiple studies examined the effects of postpartum depression without paying attention to the potential effects of depression in the prenatal period while the studies on the effects of antenatal depression often failed to follow-up mother-child pairs in the postpartum period. Clearly enough, studies spanning both antenatal and postpartum period are needed to examine whether the effect of antenatal depression is mediated by postpartum depression and whether antenatal and postpartum depression have additive effects or interact to affect child behavior and development. Such studies are also needed to disentangle the effects of depression at different time periods and to determine the vulnerable phases or sensitive periods in child development, since exposure to maternal depression at different time periods may lead to different outcomes. Summarizing the current knowledge on the effects of perinatal mental disorders on child outcomes, Stein et al. [ 20 ] pointed out that there was some evidence indicating independent effects of pre- and post-partum depression on child outcomes and that the timing of depression might have different effects on different developmental domains. Yet, it is a matter of further research to know whether pre- and post-partum depression have additive, interactive, or cumulative effects.

Existing reviews accounting for both pre- and post-partum depression focused on infant health status [ 32 ] or infant growth [ 33 ]. Kingston and Tough [ 34 ] reviewed the articles that reported on the effects of maternal mental health problems in pregnancy or postpartum period on development in school-aged children. Although an increasing number of studies covers both antenatal and postpartum period to investigate the effects of maternal depression on child development, to the best of our knowledge, no systematic review has as yet examined the effects of both pre- and post-partum depression (with postpartum depression defined as spanning the first postpartum year) to determine their relative contribution to child developmental problems from birth to preschool age.

Our aim will be to review what is known about the effects of pre- and post-partum depression on child psychological development and behavior from birth to pre-school age (i.e., 5 years of age). We will only include studies reporting the effects of both pre- and post-partum depression. In particular, we will focus on the following questions:

Do pre- and post-partum depression predict child psychological outcomes independently?

Is there a sensitive period during which maternal depression is likely to have a higher impact on child psychological outcomes, i.e., is the effect of maternal depressive symptoms stronger in the prenatal or in the postnatal period?

Is the effect of pre-partum depression mediated by the effect of postpartum depression?

Is there an interaction between pre- and post-partum depression with respect to their impact on child psychological outcomes?

Methods/design

Our intention is to conduct a systematic review of studies that investigate the effects of both pre- and post-partum depression on child behavior and psychological development from birth to the age of five. The review has been registered with PROSPERO (International prospective register of systematic reviews) at the National Institute for Health Research and the Centre for Reviews and Dissemination (CRD) at the University of York (registration no.: CRD42018106269). This protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) [ 35 ] (see Additional file 1 ).

Inclusion criteria

Studies will be included in the systematic review and meta-analysis based on the following criteria.

Study design

We will include empirical observational studies with a prospective longitudinal design. We will exclude studies with retrospective or cross-sectional designs, qualitative analyses, reviews, meta-analyses, and case studies. By restricting the review to prospective longitudinal studies, we intend to include studies reporting on maternal depression at given time points during pregnancy and postpartum period and not only retrospectively. Since our aim is to compare the effects of maternal depression at different time points, the studies with a longitudinal design should provide us with stronger indicators of causal relations than the studies with a cross-sectional design. Nevertheless, we are aware that causality cannot be proven based on solely observational data.

Participants

We will include mother-child pairs with children aged 0 to 5 years (pre-school age). This age restriction is necessitated by the large number of studies on the subject: we have decided to restrict the age range to make the review manageable. In addition, the first years of life represent a particularly vulnerable phase for brain development and maturation of the key physiologic systems. Maternal influence on child is highest in the first postpartum years; once the child starts attending primary school, there become many other factors involved that might affect child outcomes.

We will assess the effects of maternal depression both during pregnancy (in one or more trimesters of pregnancy) and postpartum period. To achieve our objectives, we will only include studies that report data about both pre- and post-partum depression. As noted above, depressive disorder related to pregnancy and childbirth is defined in the DSM-5 as depression with peripartum onset up to 4 weeks after delivery. Nevertheless, we decided to include studies reporting on maternal depression up to 12 months after the child’s birth. Such decision seems justified as many authors recommend extending the concept of peripartum depression to the entire first postpartum year [ 6 , 7 , 8 ] given the high prevalence of depressive episodes occurring after the first postpartum month.

Moreover, we will include only those studies that assessed depression using cut-off scores on self-report validated scales (such as Edinburgh Postnatal Depression Scale (EPDS), Center for Epidemiologic Studies Depression Scale (CES-D), or Beck Depression Inventory (BDI)) indicating positive screening for pre- and post-partum depression, diagnostic interview, or hospital records. We will not include studies that assessed the effects of antidepressant medication on child behavior or development but only studies focusing on the effect of maternal depression.

Since various existing research shows that maternal depression may affect not only the child’s socioemotional but also cognitive and overall psychomotor development, we will not limit our investigation of child outcomes to the emotional domain. Our aim is to assess the impact of maternal depression on all of the following domains of child development: psychomotor, cognitive, socioemotional, and behavioral development, including temperament and behavioral difficulties. We will include only studies that examine psychological, not biological or biochemical outcomes in children (such as health condition, hormone levels, brain development). Our intention is to include not only studies that used objective measures (such as direct psychological assessment of child’s development) but also those which relied on maternal reports on child behavior and development, provided they were collected using validated tools. As noted above, we will include only studies which assess child behavior and development at a given time point and not retrospectively. Moreover, we will only include studies that focus on child-related and not maternal outcomes, so that for instance studies on child attachment patterns will be included, but studies on maternal bonding will not.

Search methods

We will search the following electronic bibliographic databases: EMBASE, MEDLINE, Psycarticles, PsycINFO, ISI Web of Science, Scopus, and Wiley Online Library. Titles and abstracts only will be searched. We will restrict our search to studies written in English and published from 1 January 1998 in peer-reviewed academic journals. Moreover, apart from studies selected by systematic search of the databases listed above, we will also screen references listed in the selected studies to identify other sources that might be relevant to our review and add studies identified by a manual search. Prior to the final analysis, we will re-run our searches to make sure that recent studies meeting our selection criteria are also included.

The search strategy has been developed in cooperation with an experienced university librarian. The university librarian will run the search including deduplication of the results. A final search strategy is presented in Additional file 2 .

Selection of studies

A two-step selection process will be adopted. In the first step, titles and abstracts of studies identified by the search will be screened for eligibility independently by two team members using the following criteria:

Does the study report on maternal depression both during pregnancy and the postpartum period (up to 1 year postpartum)? Yes/No/Not clear

Does the study report on child psychological outcome/s (psychomotor development, cognitive development, social-emotional development, temperament, behavior)? Yes/No/Not clear

Is the age of children 0 to 5 years? Yes/No/Not clear

Does the study have a prospective longitudinal design? Yes/No/Not clear

All studies rated “Yes” or “Not clear” will be screened against the same criteria in the second step, where their full texts will be examined to determine whether they meet our criteria or not. Articles will be reviewed for suitability by two independent researchers. In case of disagreement, a third reviewer will make the final decision.

The eligibility criteria for the second stage of the selection process:

Does the study report on maternal depression both during pregnancy and the postpartum period (up to 1 year postpartum)? Yes/No

Does the study use a validated tool with a set cut-off to indicate positive screening for depression or a psychiatric interview to assess depression? Yes/No

Does the study report on child psychological outcome/s (psychomotor development, cognitive development, social-emotional development, temperament, behavior)? Yes/No

Does the study apply a validated tool/method to assess child outcomes? Yes/No

Is the age of children 0 to 5 years? Yes/No

Does the study have a prospective longitudinal design? Yes/No

Possible disagreement between reviewers at this stage of the selection process will be addressed in a team discussion, i.e., in a group including at least one other team member aside from the two reviewers who assessed the article in question.

Risk of bias (quality assessment)

Methodological quality of the selected studies will be assessed using the Critical Appraisal Skills Programme [ 36 ]. This checklist consists of 12 questions covering cohort recruitment, exposure and outcome measurement, adjustment for confounding factors, follow-up measurement, reliability, and validity of study results. Quality assessment will be conducted by two research team members independently, and a third reviewer will be consulted in case of discrepancy.

Data extraction

Data extracted from the selected studies should include title of the paper, authors’ names, year of publication, country where the study was conducted, year/s when the sample was recruited, method/s of participant recruitment, sample size, attrition rate, exclusion criteria, sample characteristics (maternal age, parity, marital status, socioeconomic status, ethnicity, delivery mode, birth weight, gestational age, newborn health status, child’s sex, breastfeeding, maternal health status in both pregnancy and postpartum period, smoking and alcohol consumption during pregnancy and postpartum period, a history of depression), depression assessment in pregnancy and postpartum (timing, measure used for assessing depression, cut-off used for identifying women with a positive screening for depression, depression prevalence, type of informant: self-reported/objective assessment), offspring assessment/s (timing, measure/s, type of informant), confounding variables included, quantitative results on association between pre-/post-partum depression and child outcomes (correlation coefficients, odds ratios, beta coefficients, SE, confidence intervals, p values), and information about possible moderators/mediators. The data will be extracted by two research team members. The first one will extract data into tables, while the latter will verify whether the data extracted are correct.

Strategy for data synthesis

Our intention is to present the findings in the form of a narrative synthesis. We will summarize the results of the selected studies relevant for our four main review questions: the independent effects of pre- and post-partum depression on child outcomes, the vulnerable phase for the effects of depression on the child (whether the effect is more detrimental when child is exposed to depression in the prenatal or in the postpartum period), possible mediation of the effect of pre-partum depression by postpartum depression, and possible interaction between pre- and post-partum depression in their effects on child outcomes. In addition, we aim to summarize the results of the selected studies as regards the potential covariates, moderators, and mediators of the association between pre- and post-partum depression and child outcomes.

The following information will be presented in tables accompanying the narrative synthesis: author, year of publication, country where the study was conducted, sample size, specific sample characteristics (primiparous/multiparous women, medically low-/high-risk women, low-/high-income families etc.), timing of depression measurement in pregnancy (gestational week), timing of depression measurement in the postpartum period (weeks/months), instrument used to measure pre- and post-partum depression and a cut-off set to identify women with a positive screening for depression, prevalence of pre- and post-partum depression (positive screening for depression or psychiatric diagnosis), child outcomes, an instrument used to measure child outcomes and type of informant, timing of measurement of child outcomes, confounders included, association between pre- and post-partum depression and child outcomes, moderating/mediating role of postpartum depression, and other moderators/mediators. The individual tables will be divided into several parts by child outcome (we plan to develop separate tables for particular areas of child development).

The selected studies will be examined for their potential to be included in a meta-analysis. If possible, we will examine the review objectives 1, 2, and 3 by means of the meta-analysis: we will examine the independent contribution of pre- and post-partum depression to child outcomes, compare their effects size to assess the effect of timing of depression, and analyze whether the effect of prenatal depression on child outcomes is mediated by postpartum depression. We also intend to investigate the differences in child outcomes according to various types of measurement of maternal depression (various questionnaires to assess depression; maternal report/objective assessment) and the effects of maternal depression on various child outcomes (e.g., different domains of development) and on the same child outcomes measured at different developmental stages (infants, toddlers, preschoolers). If there are sufficient data available, we will also report the results for specific subgroups (primiparae vs. multiparae, groups with different socioeconomic status, medically low-risk vs. medically high-risk women etc.).

Where appropriate, we will conduct a separate meta-analysis for each type of outcome using a meta-analytic structural equation modeling (MASEM) framework [ 37 ]. We will follow the recommendation outlined by Sheng et al. [ 38 ] and utilize a two-stage MASEM, which estimates a pooled meta-analytic correlation matrix in the first stage that is subsequently used to fit a structural equation model in the second stage [ 39 ]. The independence of pre- and post-partum depression will be assessed as a direct effect while the mediation of the pre-partum depression effect by post-partum depression will be assessed as an indirect effect in the mediation MASEM framework, with the combined effect of pre- and post-partum depression assessed as a total effect.

For the analysis, we will extract bivariate correlation coefficients between the pre- and post-partum depression and the dependent variable. In order to ensure that the elements in the correlation matrices are generated in the similar way, we will only include studies identified on the base of our inclusion criteria. We will use the random-effect version of the two-stage MASEM which allows to account for the missing correlations between the variables of interest. Following the first stage, the heterogeneity of the estimated meta-analytic correlation matrix will be tested using a Q-test and evaluated by I 2 statistics. In case of heterogeneity, we will assess its impact by re-estimating the MASEM for different subgroups of possible moderators mentioned above (e.g., different methods for measuring depression) and by comparing the resulting models [ 40 , 41 , 42 ]. The results will be interpreted with a focus on effect sizes. The meta-analysis will be conducted in R [ 43 ] using the metaSEM package [ 44 ].

Dissemination

A manuscript containing the review results will be submitted to an international peer-reviewed journal. The findings will also be presented at a scientific conference. If it turns out that our findings could be of interest to the public, we will disseminate them through the mass media.

The aim of this systematic review is to provide a summary of existing knowledge regarding the effects of pre- and post-partum depression on child behavior and development during a period spanning from birth to the age of five. To the best of our knowledge, this review will be the first to use only studies that report on both pre- and post-partum depression to compare the effects of both conditions on child behavior and development.

Maternal depression is one of the most frequent complications related to childbirth, but little is known about which are the most sensitive stages in the early development, i.e., at what stage of fetal/infant development is exposure to maternal depression most likely to affect developmental outcomes. Moreover, the relation between pre- and post-partum depression and their distinct or combined effects on child remain unclear. The results of this review may help determine the phases of early development that are most vulnerable to maternal depression. This may be helpful for clinicians to identify children who are at high risk of adverse outcomes and could benefit from timely intervention.

Availability of data and materials

Not applicable.

Abbreviations

Beck Depression Inventory

Edinburgh Postnatal Depression Scale

Center for Epidemiologic Studies Depression Scale

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Acknowledgements

This study protocol was funded by the Czech Science Foundation, project GAČR 17-10464S “Perinatal risk factors, maternal competences and child development – A prospective study from prenatal period to pre-school age.”

This work was supported by the European Regional Development Fund-Project “Creativity and Adaptability as Conditions of the Success of Europe in an Interrelated World” (No. CZ.02.1.01/0.0/0.0/16_019/0000734).

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Takács, L., Kandrnal, V., Kaňková, Š. et al. The effects of pre- and post-partum depression on child behavior and psychological development from birth to pre-school age: a protocol for a systematic review and meta-analysis. Syst Rev 9 , 146 (2020). https://doi.org/10.1186/s13643-019-1267-2

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• Antenatal Depression, Postpartum Depression, Perinatal Depression
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• Child Health

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Postnatal depression: a review of recent literature

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Depression affects 5-22% of women after childbirth. Some women with postnatal depression will experience a prolonged or relapsing illness that may last until their children enter school. It has adverse effects upon the coping abilities of women, their relationships with their infants, partners and social networks and may adversely affect the educational attainment and behaviour of their children. Since many more women are now active in the workforce, the effects of postnatal depression have obvious economic consequences both for their families and their employers. This article discusses the association between depression and the puerperium and reviews the evidence for vulnerability factors that may make a woman prone to depression. It is suggested that women with, or vulnerable to, postnatal depression can be identified and helped.

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• Depressive Disorder* / epidemiology
• Depressive Disorder* / therapy
• Puerperal Disorders* / epidemiology
• Puerperal Disorders* / therapy

• Open access
• Published: 07 May 2024

Prenatal depression among pregnant women attending public health facilities in Babile district, Eastern Ethiopia: a cross-sectional study

• Sherif Jibrael Ahmed 1 ,
• Melkamu Merid 2 ,
• Dumessa Edessa 3 ,
• Ahmedin Aliyi Usso   ORCID: orcid.org/0000-0001-6507-202X 4 ,
• Hassen Abdi Adem 2 ,
• Mandaras Tariku 5 ,
• Abdulbasit Seid 4 , 6 ,
• Addisu Alemu 2 ,
• Addis Eyeberu 4 &
• Mohammed Yuya 2  

BMC Psychiatry volume  24 , Article number:  339 ( 2024 ) Cite this article

Metrics details

Depression during pregnancy is a significant health concern that can lead to a variety of short and long-term complications for mothers. Unfortunately, there is a lack of information available on the prevalence and predictors of prenatal depression in rural eastern Ethiopia. This study assessed prenatal depression and associated factors among pregnant women attending public health facilities in the Babile district, Eastern Ethiopia.

An institution-based cross-sectional study was conducted among 329 pregnant women attending Babile District Public Health Facilities from November 1 to December 30, 2021. Bivariable and multivariable logistic regression were used to identify factors associated with prenatal depression. The adjusted odds ratio (AOR) with a 95% confidence interval was used to report the association, and the significance was declared at a p-value < 0.05.

The prevalence of prenatal depression was 33.1% (95% CI = 28.0%, 38.2%). A lower income (AOR = 3.85, 95% CI = 2.08, 7.13), contraceptive use (AOR = 0.53, 95% CI = 0.28, 0.98), unintended pregnancy (AOR = 2.24, 95% CI = 1.27, 3.98), history of depression (AOR = 5.09, 95% CI = 2.77, 9.35), poor social support (AOR = 5.08, 95% CI = 2.15, 11.99), and dissatisfied marriage (AOR = 2.37, 95% CI = 1.30, 4.33) were the factors associated with increased prenatal depression among pregnant women.

Conclusions

One in every three pregnant women in rural eastern Ethiopia had prenatal depression. Monthly income, contraceptive use, pregnancy intention, history of depression, social support, and marriage satisfaction status were the determinants of prenatal depression. Preventing unintended pregnancies by encouraging women to utilize modern contraceptive methods is essential for mitigating and controlling the risks and burdens of prenatal depression and its negative consequences.

Peer Review reports

Introduction

Depression is a mood disorder characterized by persistent feelings of low self-worth, loss of interest, feelings of regret, restlessness, loss of appetite, fatigue, and poor concentration [ 1 , 2 , 3 ]. Prenatal depression is a depression that occurs during the time from conception to delivery and is a precursor of postpartum depression if it remains untreated or mismanaged [ 4 ]. It is the most prevalent psychiatric disorder experienced during pregnancy, and almost 25% of women experience depression at some point in their life, most commonly during childbearing age [ 5 , 6 ].

Prenatal depression is a global burden of disease and affects approximately 10% of pregnant women each year [ 5 ]. The burden of prenatal depression is 25.5% in lower- and middle-income countries (LMICs) [ 7 ]. The burden is also higher than that in sub-Saharan Africa (SSA), which ranges from 10 to 47% [ 8 , 9 , 10 ], and the prevalence of prenatal depression ranges from 12 to 35% in Ethiopia [ 10 , 11 , 12 , 13 , 14 ].

Prenatal depressive disorders can lead to various short and long-term fetal and maternal negative consequences, including low birth weight, intrauterine growth restriction, preterm birth, and stillbirth, and can also contribute to maternal and neonatal disability, morbidity, and mortality [ 15 , 16 , 17 ]. In addition, it negatively influences social adjustment and marital relationships [ 18 , 19 ] and affects maternal-infant interactions through its influence on the occurrence of postnatal depression [ 20 , 21 ].

Prenatal depression has a significant potential effect on the economy, and it is more susceptible to adverse effects through its impact on healthcare costs and work absenteeism, which accounts for one-third of the work days missed and one-fifth of all primary healthcare appointments missed [ 22 ]. Although reports on prevalence rates lack consistency, substantially higher rates were reported in developing countries [ 5 ].

There are various factors affecting prenatal depression, but little is known about these factors in developing countries, including Ethiopia. The studies indicated that factors such as low economic status, previous history of psychiatric illness, abortion history, and previous stillbirth history were determinants of prenatal depression [ 23 , 24 , 25 , 26 ]. The government of Ethiopia launched and enforced a mental health strategy that aimed at providing mental health services in all health systems of the country [ 27 ]. However, there is a gap in providing mental health services in routine maternal health services. Even though investigating prenatal depression and its risk factors is essential for designing and monitoring the implementation of preventive and rehabilitative interventions designed to reduce the impacts of depression, the evidence regarding prenatal depression is inconsistent in Ethiopia.

Hence, addressing the gaps in burdens and risk factors for prenatal depression among pregnant women is a top priority in reducing and preventing prenatal depression and its negative short- and long-term consequences. Previous studies have shown that the burden of prenatal depression is inconsistent in Ethiopia [ 11 , 23 ], and there is limited information available concerning this topic in rural eastern Ethiopia. In addition, previous studies conducted in the country were performed in a one-site region of Ethiopia, and almost all the studies failed to evaluate the association between prenatal depression and the use of contraceptive methods. Overall, there is limited information on the prevalence and factors associated with prenatal depression among pregnant women in rural Eastern Ethiopia. Thus, this study aimed to assess the level of prenatal depression and associated factors among pregnant women attending public health facilities in the Babile district, eastern Ethiopia.

Materials and methods

Study design and setting.

An institution-based cross-sectional study was conducted in the Babile district, eastern Ethiopia, from November 1 to December 30, 2021. The Babile district is one of 24 districts in the East Hararghe Zone, located 560 km, east of Addis Ababa (the capital city of Ethiopia). Administratively, the district had one urban and 23 rural kebeles, and based on the 2007 Central Statistical Agency population census, the district has a projected total population of 103,575, with 22,921 reproductive-age women and 3594 pregnant women. According to the Babile District Health Office annual report of 2020, there is one general hospital, four health centers, and 24 health posts, with two private drug shops providing routine healthcare services for the general public in the district. The annual antenatal care (ANC) attendance in the facilities of the district was 6780 in the Babile Health Center, 1020 in the Abdibuch Health Center, 1320 in the Erer Health Center, and 1500 in the Bisidimo General Hospital.

Population and sampling

All pregnant women attending public health facilities in the Babile district in Eastern Ethiopia were the source population. The study population included pregnant women attending selected public health facilities in the Babile district in Eastern Ethiopia during the study period. Married pregnant women aged 18 years and older who were permanent residents of the district and who attended public health facilities for antenatal care service were included in the study. Women who were unable to understand the local language (Afan Oromo), who were critically sick pregnant women, or who were urgently or immediately referred to a higher-level facility upon arrival at the interview were excluded from the study.

The sample size ( n  = 330) was calculated by Epi Info version 7.1 using the single population proportion formula. Considering the following assumptions, the average monthly ANC attendance in the district was 565, the confidence interval was 95%, the margin of error was 5%, the prevalence of prenatal depression was 26.6% in southern Ethiopia [ 28 ], and the nonresponse rate was 10%.

We selected purposefully all public health facilities (four health centers and one hospital) in the district. The projected sample size was proportionally allocated to each facility based on the average ANC attendance flows over the previous three months. The sample sizes were proportionally allocated to the Babile Health Center ( n  = 90), Abdibuch Health Center ( n  = 50), Erer Health Center ( n  = 64), Awsherif Health Center ( n  = 53), and Bisidimo General Hospital ( n  = 73). Then, a systematic random sampling technique was used to select the study participants, and every three eligible women who visited ANC facilities were selected from among the health facilities. After providing written informed consent, a face-to-face interview was conducted in a separate and quiet area.

Data collection procedures and tools

The data were collected through face-to-face interviews using a structured questionnaire adapted from validated scales and published literature [ 23 , 25 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. The questionnaire included information on sociodemographic characteristics, obstetric-related characteristics, behavioral characteristics, mental health and psychosocial characteristics, and prenatal depression. Before data collection began, the questionnaire was pretested on 5% of the sample (17 pregnant women) in a separate health facility in the neighboring district to ensure its validity. The questionnaire was first prepared in English, subsequently translated to the local language (Afan Oromo), and returned to English by two experts who were in good command of both languages. Five trained diploma nurses collected the data through face-to-face interviews in a quiet private room. The overall data collection process was supervised by trained BSc nurses at each facility.

Measurements

• Prenatal depression

The Edinburgh Postnatal Depression Scale (EPDS) was used to detect prenatal depression [ 32 ]. The EPDS is a validated scale with 10 Likert scale items, each rated from 0 (mild depression) to 3 (high depression), for detecting depression in antepartum and postpartum samples across the world; this scale includes information from Ethiopia (postpartum depression assessment in Addis Ababa with a sensitivity of 80.6% and a specificity of 77%) [ 29 ]. Similar to other studies conducted abroad and in Ethiopia, the cutoff point of the EPDS was 13 and above to identify pregnant women with depressive symptoms. The internal consistency of the index score was confirmed with a Cronbach’s α of 0.92. Pregnant women who scored 13 or above were categorized as depressed women, while those who scored less than 13 were categorized as not depressed women [ 25 ].

Level of social support

Social Support was measured using the Oslo Social Support Scale-3 item (OSSS-3). The OSSS-3 contains three items: the number of close intimates, the perceived level of concern from others, and the perceived ease of getting help from neighbors. The composite index score was computed from three items ranging from 3 to 14, and OSSS-3 scores were categorized into three categories of social support. The internal consistency of the index score was confirmed with a Cronbach’s α of 0.76. The scores were subsequently assigned as 3–8 for ‘poor social support’, 9–11 for ‘moderate social support’, and 12–14 for ‘strong social support’ [ 30 ].

Marital satisfaction

This was measured using the Kansas Marital Satisfaction Scale (KMSS), which contains three Likert scale items. The marriage satisfaction scale included three items, each of which had a 7-point scale ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied ); the composite index score was computed from three items ranging from 3 to 21. The internal consistency of the index score was confirmed with a Cronbach’s α of 0.83. A cutoff point of 17 and above was used to indicate that women were satisfied with their current marital relations, while a cutoff point less than 17 was used to indicate that women were dissatisfied with their current marital relations [ 31 , 33 ].

Substance use was assessed using a self-report of exposure to at least one of the three substances (alcohol, khat, or tobacco) during the current pregnancy. A pregnant woman was considered to use a substance when she used at least one type of substance during her current pregnancy, regardless of the dose and frequency [ 36 ].

Data quality control

The data quality was maintained using standard questionnaires adapted from validated scales and relevant published literature. The questionnaires were first written in English and subsequently translated into the local language (Afan Oromo) and returned to English by two experts with good mastery of both languages. The data collectors and supervisors trained for one day on the objective of the study and the data collection technique. Before starting the statistical analysis, several composite index scores were computed and used accordingly, which improved the validity of the measurements and respective computed indices and estimates used in the study.

Data processing and analysis

After checking for completeness and consistency, the data were entered into EpiData version 3.1 and analyzed using SPSS version 24. Descriptive statistics such as frequency, a measure of central tendency, and dispersion were used to characterize pregnant women accordingly. Before analysis, the internal consistency of the items was checked for each composite index score using reliability analysis (Cronbach’s α). We observed high internal consistency across all the composite indices of the EPDS use items (Cronbach’s α = 0.92), the KMSS use items (Cronbach’s α = 0.83), and the OSSS use items (Cronbach’s α = 0.76). Bivariable and multivariable logistic regression analyses were also conducted to identify factors associated with prenatal depression among pregnant women. Variables with a p-value < 0.25 in the bivariable analysis were selected as candidate predictors for multivariable logistic regression analysis. A multivariable logistic regression analysis was conducted to identify the significant risk factors for prenatal depression using the backward stepwise likelihood ratio method for model building. The Hosmer and Lemeshow goodness-of-fit test was employed to determine the overall adequacy of the model, with a p-value of 0.65 indicating an adequate fit. The adjusted odds ratio (AOR) with its 95% confidence interval (CI) was used to report the strength of an association, and a p-value < 0.05 indicated statistical significance.

Participants sociodemographic characteristics

A total of 330 eligible pregnant women were invited to participate in the study, and 329 (99.7%) participated in the study. The mean age of the participants was 29.2 (± 5.6) years, and the majority (65.5%) of them were in 25–34 years age group, followed by 27.4% in the 18–24 years age group and 26.1% in the ≥ 35 years age group. More than half (55.0%) of the participants were from rural residences. Approximately half (49.5%) of the participants had an education level of primary school, followed by being unable to read and write (36.8%), secondary school (9.7%), and college and above (4.0%). Among occupational status, the majority (63.5%) of the participants were housewives, followed by merchants (18.2%) and government employees (13.1%). Regarding average monthly income, a majority (54.1%) of the participants had a monthly income less than or equal to 2000 Ethiopian Birr (ETB), and their median average monthly income was 2000 ETB (quartile 1 = 1200 ETB, quartile 3 = 3200 ETB) (Table  1 ).

Obstetrics and psychosocial-related characteristics

The means (± SD) gravidity and parity were 4.8 (± 2.4) and 3.9 (± 2.1), respectively. Almost one in every five (21.1%) women had at least one abortion history, and one in every four (25.3%) participants had at least one stillbirth history. The majority (59.6%) of the women had never used modern contraceptive methods before their current pregnancies, and approximately 38.9% of the current pregnancies were unintended pregnancies. The majority (58.7%) of women were in the second trimester, followed by the third trimester (33.1%) and the first trimester (8.2%). Approximately 15.5% of pregnant women used at least one type of substance during their current pregnancy. About 31.6% of the pregnant women were violated by their partners, and approximately 32.8% of the pregnant women had a history of depression. Regarding social support, 41.6%, 41.0%, and 17.3% of the pregnant women had poor, moderate, and strong social support, respectively. Almost seven out of ten pregnant women (69.3%) were satisfied with their marriage relationship (Table  2 ).

Prevalence of prenatal depression

In this study, the internal consistency of the prenatal depression (EPDS) tool was acceptable, with Cronbach’s α = 0.92. The overall prevalence of prenatal depression (EPDS score ≥ 13) among pregnant women was 33.1% (95% CI = 28.0%, 38.2%) in the Babile district, eastern Ethiopia.

Factors associated with prenatal depression

The bivariable logistic regression analysis showed that average monthly income, gravidity, current pregnancy intentions, trimester, substance use, parental violence, history of depression, level of social support, and marriage satisfaction status were factors significantly associated with prenatal depression. However, in the multivariable logistic regression analysis, average monthly income, use of contraceptives, pregnancy intention, history of depression, level of social support, and marriage satisfaction status were the main predictors of prenatal depression among pregnant women.

Women who had an average monthly income less than or equal to 2000 ETB were almost four times more likely to be depressed during pregnancy (AOR = 3.85, 95% CI: 2.08, 7.13) than those who had an average monthly income greater than 2000 ETB. The women who used contraceptive methods before their current pregnancy were almost 50% less likely to develop prenatal depression during pregnancy (AOR = 0.53; 95% CI = 0.28, 0.98). The odds of prenatal depression were approximately two times greater among women with unintended pregnancies than among those with planned pregnancies (AOR = 2.24, 95% CI = 1.27, 3.98). Women who had a history of previous depression were five times more likely (AOR = 5.09, 95% CI = 2.77, 9.35) to develop prenatal depression than those who had no previous history of depression. Pregnant women who had poor social support were five times more likely to develop prenatal depression than those who had strong social support (AOR = 5.08, 95% CI = 2.15, 11.99). The odds of prenatal depression were approximately two times greater (AOR = 2.37, 95% CI: 1.30, 4.33) among women dissatisfied with their marriage than among women who were satisfied with their marriage (Table  3 ).

This study assessed the prevalence and associated factors of prenatal depression among pregnant women attending public health facilities in the Babile district, eastern Ethiopia. We found that the prevalence of prenatal depression was 33.1% among pregnant women attending public health facilities in Babile district, eastern Ethiopia.

This finding is consistent with previous studies conducted in Arba Minch, southern Ethiopia (35.4%) [ 14 ], west Showa, central Ethiopia (32.3%) [ 37 ], Bale, southeast Ethiopia (31.5%) [ 17 ], Adama, central Ethiopia (31.2%) [ 11 ], and northern Tanzania (33.8%) [ 38 ]. However, this finding is higher than those of studies conducted in east Gojam, northwest Ethiopia (17.8%) [ 39 ], Addis Ababa, central Ethiopia (24.9%) [ 25 ], Hawasa, southern Ethiopia (21.5%) [ 26 ], Gondar, northwest Ethiopia (23.0%) [ 13 ], Nigeria (24.5%) [ 35 ], and Bangladesh (18.0%) [ 40 ]. This variation might be due to sociodemographic differences: almost all the study subjects in comparable studies were urban residents [ 25 ], while more than half of our study subjects were rural residents. This difference might also be due to differences in the reproductive characteristics of the study subjects. For instance, the rate of contraceptive use was higher in Addis Ababa but lower in our study, which may have resulted in a higher burden of unintended pregnancy associated with prenatal depression. In addition, geographical, cultural, and economic variations may contribute to the higher prevalence of this disease.

On the other hand, the prevalence of depression in this study is lower than that in studies conducted in South Africa (47.0%) [ 9 ], Pakistan (81.0%) [ 41 ], and Koria (40.5–61.4%) [ 41 ]. These variations in prenatal depression could be attributable to differences in the study setting and verification tools used to screen for symptoms of depression and cutoff points for prenatal depression. For instance, the study in Koria used the EPDS with a cutoff point greater than or equal to a score of 9 to diagnose prenatal depression, while our study used a cutoff point greater than or equal to a score of 13.

This study indicated that women with an average monthly income of less than or equal to 2000 ETB were almost four times more likely to develop prenatal depression than women with an income greater than 2000 ETB. These findings imply that lower household income increases the risk of incidental mental disorders. These findings are supported by those of a previous study, which indicated that pregnant women with lower incomes were more likely to develop depression and anxiety [ 42 , 43 ]. Given that thriving during a healthy pregnancy requires access to adequate nutrition, a safe and reliable place to rest, and other sources of social support.

Women who used contraceptive methods before their current pregnancy were almost 50% less likely to develop prenatal depression during pregnancy than women who did not use contraceptive methods. This finding implies that the use of contraceptives indirectly reduces prenatal depression by reducing the burden of unintended pregnancies. On the other hand, the odds of prenatal depression were greater among women with unintended pregnancies. This could be due to the presence of women who missed opportunities to use modern contraceptive methods for preventing and reducing unintended pregnancy; only a few women may have intended to become pregnant. These women may develop prenatal depression as a result of stress, which is associated with perceiving unintended motherhood with poor social support [ 44 , 45 ]. It is worrisome that unintended pregnancy could increase the risk of prenatal depression during pregnancy. Reducing the burden of unintended pregnancy through improving the utilization of modern contraceptive methods at the community level is essential for reducing and preventing prenatal depression and its negative consequences.

The odds of prenatal depression were higher among women who had a previous history of depression. This finding is supported by studies conducted in northwestern and central Ethiopia [ 25 , 39 ]. The risk of depression recurrence is high during pregnancy due to physiological changes. In addition, physical and hormonal changes that occur during pregnancy may precipitate earlier depression, increasing susceptibility to recurrence [ 23 , 25 , 46 ].

Pregnant women who had poor social support were five times more likely to develop prenatal depression than those who had strong social support. This finding is supported by the findings of a study conducted in Hawassa, southern Ethiopia. A poor social life may reduce women’s interaction with others, and it can lead to stress and cause mood changes. This finding is also supported by the findings of previous studies indicating that depression and anxiety are less common among pregnant women who perceive a greater degree of social support [ 47 , 48 ].

Marriage satisfaction status was significantly associated with prenatal depression. The odds of prenatal depression were about two times higher among women who were dissatisfied with their marriage than among women who were satisfied with their marriage. Marital dissatisfaction leads to marital instability, which may aggravate psychosocial stress and precipitate depression disorder. During pregnancy, women need their husbands’ psychological, physical, and financial support; however, if their marital status is dissatisfied during critical times, they may miss mandatory support and may develop mood instability [ 49 ].

As a strength, the study used standard validated instruments for data collection; these instruments can be generalized to pregnant women attending public health facilities in urban and rural settings. However, because of the cross-sectional study design, the study may not have shown a temporal relationship between prenatal depression and the predictors. In addition, because this study was conducted among pregnant women who received antenatal care at health facilities, the findings may not apply to women who did not receive antenatal care.

This study concluded that one in every three pregnant women attending ANC visits at public health facilities in the Babile district had prenatal depression. Having a lower income, not using contraceptives, unintended pregnancy, a history of previous depression, poor social support, and dissatisfied marriage relations were found to be independent predictors of prenatal depression. Prevention of unintended pregnancies by encouraging women to utilize modern contraceptive methods is essential for mitigating and controlling the risks and burdens of prenatal depression and its negative consequences. In addition, strengthening and building strong social support and healthy marital relationships are paramount for reducing the burden of prenatal depression and its adverse effects.

Data availability

Data that support the findings are available and will be provided by the correspondence author on a reasonable request.

Abbreviations

Adjusted odds ratio

Antenatal care

Edinburgh Postnatal Depression Scale

Low middle-income country

Sub-Saharan Africa

World Health Organization

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Acknowledgements

We thank all the study participants, data collectors and supervisors. We also want to thank the Babile Health Office and the respective facilities for facilitating the study.

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East Hararghe Zone Health Office, Oromia Regional Health Bureau, Federal Ministry of Health, Harar, Ethiopia

Sherif Jibrael Ahmed

School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia

Melkamu Merid, Hassen Abdi Adem, Addisu Alemu & Mohammed Yuya

School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia

Dumessa Edessa

School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia

Ahmedin Aliyi Usso, Abdulbasit Seid & Addis Eyeberu

Department of Psychiatry, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia

Mandaras Tariku

School of Public Health and Preventive Medicine, Monash University, Melbourne VIC 3004 , Australia

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SJA, MM, DE, AAU, HAA, MT, AS, AA, AE and MY participated in the conception of the idea, development, and amendment of the proposal, data collection, and analysis, and write up the results. SJA, MM, DE, AAU and HAA analyzed the data. AAU drafted the manuscript with continuous input from SJA, MM, DE, AAU, HAA, MT, AS, AA, AE and MY reviewed the manuscript for intellectual content. All authors read and approved the final manuscript.

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Correspondence to Ahmedin Aliyi Usso .

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The study was conducted in accordance with the Helsinki Declaration of Studies involving Human Subjects [ 50 ]. The study was also approved by the Institutional Health Research Ethical Review Committee of the College of Health and Medical Sciences, Haramaya University, Ethiopia (Ref.no: IHRERC/172/2021). Written informed consent was obtained from all participants after the purpose and benefits of the study were explained.

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Ahmed, S.J., Merid, M., Edessa, D. et al. Prenatal depression among pregnant women attending public health facilities in Babile district, Eastern Ethiopia: a cross-sectional study. BMC Psychiatry 24 , 339 (2024). https://doi.org/10.1186/s12888-024-05732-0

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Received : 22 November 2023

Accepted : 29 March 2024

Published : 07 May 2024

DOI : https://doi.org/10.1186/s12888-024-05732-0

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