literature review postpartum depression

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• Published: 28 December 2022

Interventions to treat and prevent postpartum depression: a protocol for systematic review of the literature and parallel network meta-analyses

• David Thomas Monks   ORCID: orcid.org/0000-0002-1677-5244 1 ,
• Basavaraj Ankalagi   ORCID: orcid.org/0000-0001-9513-755X 2 ,
• Preet Mohinder Singh   ORCID: orcid.org/0000-0001-7642-529X 1 ,
• Ebony Carter   ORCID: orcid.org/0000-0002-7620-4929 3 ,
• Michelle Doering 4 ,
• Meg Guard 5 &
• Shannon Lenze   ORCID: orcid.org/0000-0003-3410-3561 6  

Systematic Reviews volume  11 , Article number:  282 ( 2022 ) Cite this article

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Introduction

Postpartum depression has costly consequences for the mother, baby, and society. Numerous pharmacological and non-pharmacological interventions are available for the prevention and treatment of postpartum depression. To date, no attempt has been made to synthesize the evidence from comparisons of interventions both within and across these categories.

We will perform a systematic review of the literature and perform network meta-analysis of interventions to (a) prevent and (b) treat postpartum depression. This review will include studies of primiparous or multiparous women during pregnancy or within 12 months of delivery of their baby that assess either interventions initiated during pregnancy or within 1 year of childbirth. Comparators will be other eligible interventions or control conditions. The outcome of interests will be related to the antidepressant efficacy of the interventions as well as their acceptability. The published literature will be searched in Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. The search will use a combination of standardized terms and keywords for postpartum depression, a sensitive search filter to limit for randomized controlled trials, and a librarian-created “humans” filter. The search results will be uploaded to the Covidence online systematic review platform (Veritas Health Information Ltd., Victoria, Australia) where two review team members will independently screen articles. We will extract data to include year of publication, language, country, participants (number, demographic data, eligibility criteria, psychiatric symptoms, and co-morbidities), characteristics of the intervention and control conditions, and reported outcomes. Risk of bias for each study will be assessed independently by two review authors using the RoB 2: A revised Cochrane risk of bias tool for randomized trials. Network meta-analysis will be performed using a Bayesian hierarchical model supplemented with a Markov chain Monte Carlo approach.

Postpartum depression is a devastating disease with long-lasting consequences. Given the numerous available interventions to both prevent and treat postpartum depression and the great number of studies comparing them, it is imperative that clinicians and patients are provided with an assessment of their comparative efficacy and acceptability.

Systematic review registration

Prospero registration (CRD42022303247).

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Postpartum depression (PPD) complicates 6–19% of pregnancies, leading to costly consequences for the mother, baby, and society. The effects of PPD are long-lasting, with 25% of women continuing to have symptoms of depression 1 year after diagnosis, and 12.5% continuing to have symptoms for 2 years. Furthermore, of those women whose postpartum depression goes into remission, there is a 40% relapse rate [ 1 , 2 ]. Unfortunately, suicidal thoughts are particularly common, affecting about 20% of women with PPD, and although still rare, suicide accounts for approximately 20% of postpartum deaths [ 3 ]. The societal burden is substantial: one study estimated an equivalent cost of $100,000 per case due to suicide, loss of work, morbidity, and infant malnutrition.

Numerous interventions are available for the prevention and treatment of postpartum depression. These include pharmacological, psychosocial, psychological, educational, and somatic therapies. To date, no attempt has been made to synthesize the evidence from comparisons of interventions both within and across these categories. Various systematic reviews of the literature have been published in the past decade, examining interventions to treat and prevent postpartum depression. These reviews have focused on specific interventions [ 4 ], groups of interventions [ 5 ] and specific patient groups [ 6 ] and have pooled data to perform pairwise meta-analysis or series of pairwise meta-analyses. For example, a 2021 Cochrane review [ 7 ] of antidepressant medications included 11 RCTs (1016 women) that compared antidepressants with placebo, treatment as usual, psychological interventions, psychosocial interventions, any other medicines, or another type of antidepressant; and complementary medicine (food supplements). They reported a series of meta-analyses between each of these and found that women treated with antidepressants might only experience a slightly better antidepressant benefit than women given a placebo. However, to our knowledge, there have been no network meta-analyses performed. Our planned analysis will attempt to compare all these interventions in a common network and utilize direct and indirect evidence to allow clinicians to compare their efficacy and safety. We aim to review the relevant literature and perform network meta-analysis of interventions to (a) prevent and (b) treat postpartum depression within 12 months of delivery. After reviewing our analysis, the reader should be able to assess the effectiveness of varying methods of preventing and treating PPD. Additionally, we will provide the reader with an understanding of the confidence in the evidence to support each intervention examined.

Methods/design

A systematic review of the relevant literature will be performed, employing methods outlined in the Cochrane Handbook, and data extracted to permit network meta-analysis [ 8 ]. Separate networks will be constructed for (a) preventative and (b) treatment interventions. The degree of connection between the networks that predominantly compare pharmacological and non-pharmacological interventions will determine whether separate networks are necessary to calculate network estimates. This protocol has been reported in accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 9 ]. The review will be reported in adherence with the PRISMA extension statement for incorporating network meta-analysis [ 10 ]. A completed PRISMA-P checklist for the current review protocol is provided in Supplementary Fig 1 . This protocol was registered with PROSPERO (CRD42022303247).

Eligibility criteria

Inclusion and exclusion criteria were defined according to the patient, intervention, comparator, outcomes, and study design format (PICOS).

This review will include studies of primiparous or multiparous women during pregnancy or within 12 months of delivery of their baby. As the initial search will include studies for each of the review questions related to (a) prevention and (b) treatment of postpartum depression, participants may or may not be depressed at baseline. We will use the individual study definition of the intervention, as either preventative or therapeutic.

Interventions

Studies of both pharmacological and non-pharmacological interventions initiated during pregnancy or within 1 year of childbirth will be included. Pharmacological interventions will be categorized by class and further sub-categorized by individual drug and dosing regimen as justified by the data. These subcategories will be created to define separate interventions on the condition that there are sufficient comparisons with other interventions to permit a cohesive network. Similarly, non-pharmacological interventions will be broadly categorized based on the nature (psychological, psychosocial, somatic, physical therapy, sensory therapy, etc.) and sub-categorized by clustering of their characteristics. Combinations of interventions will be evaluated according to a similar data-driven strategy. In all instances, the data collected on such characteristics will either inform sub-categorization or be noted as a potential effect modifier and considered a candidate for subsequent meta-regression. A detailed description of the process of node definition and network construction will be reported with the results of this analysis. Table 1 provides an anticipated list of potential categories and subcategories of interventions.

Comparators

In addition to the interventions described above, we anticipate a variety of control conditions which will be differentiated based on their broad categories (usual care, enhanced usual care, waiting-list, non-treatment, and placebo) and individual characteristics. We will, again, use this data and the integrity of potential networks to dictate the sub-division (or not) of these control conditions into separate nodes (interventions).

The outcome of interests will be related to the efficacy and acceptability of the interventions. Efficacy will be assessed, for preventative interventions, by difference in odds of developing PPD and, for therapeutic interventions, by odds of response. Response will be defined as the total number of patients who had a reduction of ≥ 50% of the total depression score, standardized from the validated depression scoring scale. Such rating scales include the Edinburgh Postpartum Depression Scale (EPDS), Hamilton Depression Rating Scale (HAMD), Beck Depression Inventory (BDI), Postpartum Depression Screening Scale, Patient Health Questionnaire (PHQ9), Self-Rating Depression Scale (SDS), Center for Epidemiologic Studies Depression Scale (CESD), Zung Self-Rating Depression Scale, Hospital anxiety and depression scale (HADS), and the Depression anxiety stress scale (DASS). Acceptability will be primarily assessed by modeling the odds of all-cause discontinuation of the interventions (the proportion of patients who withdrew for any reason). Additional outcomes will include related psychiatric symptoms and potential adverse effects of interventions such as anxiety, sedation, suicidal ideation, headache, nausea, dry mouth, insomnia, dizziness, diarrhea, constipation, sexual problems, fatigue, weight gain, tremors, and increased sweating. We will attempt to construct networks for any of these adverse effects that are consistently reported across enough studies and will report the rest in the table of study characteristics. Studies with crossover design will only be included if they give clear outcome data for each group (prior and after the cross over). Study groups evaluating mixed interventions will not be included in the evaluation unless the mixed intervention is considered as a separate node/intervention.

Study design

We will include all peer reviewed randomized and quasi-randomized clinical trials in our initial search. On appraisal of the available studies and the relative contribution of quasi-randomized comparisons, we will decide whether the benefit of including this data is outweighed by the consequent reduction in the confidence in the accumulated evidence.

Search strategy and information sources

The published literature will be searched using strategies created by a medical librarian for clinical trials on postpartum depression. The search will be implemented in Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov. The search will use a combination of standardized terms and keywords for postpartum depression, a sensitive search filter to limit for randomized controlled trials, and a librarian-created “humans” filter. Conference abstracts will be excluded from the Embase and Scopus searches. Results will be imported into Endnote and duplicates will be identified and removed. The search of ClinicalTrials.gov aims to identify emerging studies nearing completion. We will attempt to contact authors of any pertinent unpublished studies to ensure complete data extraction; however, abstracts will be excluded if data remains incomplete. Non-English publications will be included provided an English-language abstract is available. A draft search strategy of Ovid MEDLINE is provided in Table 2 and the strategies for the remaining databases can be found in Supplementary Table 1 .

Study records

The search results will be uploaded to the Covidence online systematic review platform (Veritas Health Information Ltd., Victoria, Australia). Two review team members will screen articles independently using the predefined eligibility criteria. This will be done in two stages, the first by referring to title and abstracts only before confirming the eligibility decision by reference to the full text. In case of any disagreement, a third review team member will mediate consensus. Reasons for excluding full texts will be documented both in Covidence and an Excel spreadsheet. Study authors will be contacted if eligibility criteria remain unclear following article review. Final study inclusion will be presented in a PRISMA flow diagram.

Data extraction

We will use six randomly selected studies of preventative and therapeutic interventions, respectively, to guide the development of a data extraction spreadsheet. In the event of an essential data item being identified beyond the initial six studies, we will reformat the data extraction tool and go back to extract this missing item from all trials. We will extract data to include year of publication, language, country, participants (number, demographic data, eligibility criteria, psychiatric symptoms, and co-morbidities), characteristics of the intervention and control conditions, and reported outcomes. In the prevention network, we will attempt to categorize the population in each trial as “asymptomatic, at risk”, “subclinical symptomatology” or “mixed asymptomatic/subclinical” in accordance with the recommendations of the Institute of Medicine’s report on prevention research [ 11 ]. We will also collect study-level data to inform the definition of interventions, as described above, and other sources of heterogeneity and effect modification.

Assessment of quality of evidence

Risk of bias for each study will be assessed independently by two review authors using the RoB 2: A revised Cochrane risk of bias tool for randomized trials [ 12 ]. The overall risk of bias will be expressed as low risk, some concerns/uncertainty, or high risk. Publication bias will be assessed by visually inspecting a comparison-specific funnel plot (for the primary outcome). A funnel plot will be constructed for pairwise comparison for each of the treatment options included in our analysis. The Confidence in Network Meta-Analysis (CINeMA) approach will be used to evaluate the overall evidence quality. Trials will be individually assessed for the indirectness of evidence. Indirectness refers to the relevance of the included studies to the research question. It helps to establish how well the included studies address the research question for the present network meta-analysis. Included studies will be scored based on uniformity across three parameters: study participants, interventions, and outcome characteristics reported. The more divergence noted in these parameters, the more indirectness assumed. In addition, the GRADE tool will be employed to assess the certainty in the evidence for the pairwise comparison of each agent with a common comparator in the summary of findings table.

Summary of findings table

For the primary outcome, a summary of findings table will be constructed. Summary of findings tables summarize the results of NMA, provide absolute estimates of each interventions’ effect when compared to a common comparator, report probability ranking and an assessment of the certainty in the evidence (using the GRADE tool) in order to facilitate comprehensive interpretation of the results of NMA. Once the network has been constructed, we will identify the intervention that is compared to the most different interventions (i.e., maximally connected) in the largest number of trials (maximal direct evidence) and use this as the common comparator for the purpose of the summary of findings table.

Data synthesis

We will, initially, construct a network of the evidence to determine whether the data from comparisons of pharmacological and non-pharmacological interventions warrants separate analyses or whether one network can maximize the data available to inform network estimates. The resulting network meta-analysis/es will be conducted using Bayesian approach. The odds ratio and 95% CrI will be calculated for dichotomous outcomes. The mean difference (MD) and 95% credible intervals (CI) will be calculated for continuous outcomes. The geometry of each network will be reported in graphical form along with a league table of network estimates for each pairwise network estimates. We will calculate the cumulative probabilities for each intervention being at each possible rank and then use the surface under the cumulative ranking curve (SUCRA) to create a treatment hierarchy. SUCRA is a commonly used method to numerically summarize the cumulative rankings so that SUCRA is 1 when a treatment is certain to be the best and is 0 when a treatment is certain to be the worst [ 13 ]. Attempts will be made to locate and evaluate inconsistencies across the network using node-split modeling.

Statistical analysis

Analysis will be performed using a Bayesian hierarchical model (binomial modeling with logit link function) supplemented with Markov chain Monte Carlo (MCMC) approach. We will initially run 5000 adaptations, 20,000 iterations with a thinning factor of 10. These parameters will be adjusted as necessary to achieve a Potential Scale Reduction Factor (PSRF) of less than 1.05. The convergence diagnostics for the model will be reported in Gelman Rubin diagrams. The indirect estimates will be imputed using common comparators. The outcomes will be reported as credible intervals (CrI). Based on the distribution of credible intervals, rank probabilities (preferred order of therapeutic success) will be calculated for all the included treatment nodes. The statistical analysis will be performed by R assisted by package “gemtc” (Version 0.8-7, Github.com ), Netmeta (Version2.6-0, R-repository), Dmetar [ 14 ], and Bugsnet (bugsnetsoftware.github.io).

Exploration of model fitness, transitivity, and inconsistency

Model fitness will be evaluated using the Deviance Information Criterion (DIC) values and overall deviance for each parameter analyzed. The model with the lowest DIC values (in comparison to the data points) will be used for reporting the results. We intend to use the following network global evaluation metrics to evaluate transitivity: deviance information criterion, net heat plot and direct evidence plot (although not evaluating transitivity, per se, the greater the contribution of direct evidence to each network estimate, the lower the likelihood of inconsistency). For each comparison, we shall also look at the node split model, thus helping us to quantify comparison-specific inconsistency to estimate deficiencies in transitivity. We have identified potential effect modifiers (Table 3 ) from the literature [ 15 , 16 , 17 , 18 ] and will assess the distribution of effect modifiers to judge if the transitivity assumption holds. For those that prove to be a study-level parameter, then we plan to explore the impact of this on our network estimates by employing network meta-regression. We plan to use both Bayesian and Frequentist tools available to localize and quantify the inconsistencies in the network. For this, we will construct a node-spit model and a net-heat plot. We will evaluate the proportion of direct comparisons in the final outcome using the direct evidence plot. Using this approach, we will estimate the minimum number of independent paths in the network contributing to the effect estimate at an aggregated level. “Minimum parallelism” and the “mean path length” will allow estimation of the degree of indirectness in the reported pooled outcome.

Ethics and dissemination

Ethical approval was deemed unnecessary. We report here in a single manuscript, a broad and inclusive search strategy, designed to maximize the contribution of available evidence to answer two separate review questions: (a) what is the comparative effectiveness of available interventions to prevent postpartum depression? (b) what is the comparative effectiveness of available interventions to treat postpartum depression? We anticipate submitting these parallel network meta-analyses in separate manuscripts to recognized psychiatric journals.

Postpartum depression is a devastating disease with long-lasting consequences for patients, their families, and society. Given the numerous available interventions to both prevent and treat postpartum depression and the great number of studies comparing them, it is imperative that clinicians and patients are provided with an assessment of their comparative efficacy and acceptability along with a comprehensive appraisal of the quality of evidence that supports those assessments.

Availability of data and materials

Not applicable.

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Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, USA

David Thomas Monks & Preet Mohinder Singh

Department of Anesthesiology, Toronto Western Hospital, University of Toronto, Toronto, Canada

Basavaraj Ankalagi

Department of Maternal and Fetal Medicine, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, USA

Ebony Carter

Becker Library, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, USA

Michelle Doering

Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, USA

Perinatal Behavioral Health Service, Department of Psychiatry, Washington University School of Medicine, St. Louis, USA

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Supplementary Information

Additional file 1..

PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: recommended items to address in a systematic review protocol*.

Additional file 2: Supplemental Table 1.

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Monks, D.T., Ankalagi, B., Singh, P.M. et al. Interventions to treat and prevent postpartum depression: a protocol for systematic review of the literature and parallel network meta-analyses. Syst Rev 11 , 282 (2022). https://doi.org/10.1186/s13643-022-02157-2

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• Systematic Review
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• Published: 20 October 2021

Mapping global prevalence of depression among postpartum women

• Ziyi Wang 1   na1 ,
• Jiaye Liu 2   na1 ,
• Huan Shuai 3   na1 ,
• Zhongxiang Cai 4   na1 ,
• Yang Liu 6 ,
• Xiong Xiao 7 ,
• Wenhao Zhang 8 ,
• Elise Krabbendam 9 ,
• Shuo Liu 1 ,
• Zhongchun Liu   ORCID: orcid.org/0000-0001-5410-0312 10 ,
• Zhihui Li 2 &
• Bing Xiang Yang   ORCID: orcid.org/0000-0002-0227-4342 1  

Translational Psychiatry volume  11 , Article number:  543 ( 2021 ) Cite this article

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A Correction to this article was published on 20 December 2021

This article has been updated

Postpartum depression (PPD) is the most common psychological condition following childbirth, and may have a detrimental effect on the social and cognitive health of spouses, infants, and children. The aim of this study was to complete a comprehensive overview of the current literature on the global epidemiology of PPD. A total of 565 studies from 80 different countries or regions were included in the final analysis. Postpartum depression was found in 17.22% (95% CI 16.00–18.51) of the world’s population. Meta-regression analysis showed that study size, country or region development, and country or region income were the causes of heterogeneity. Multivariable meta-regression analysis found that study size and country or area development were the most important predictors. Varied prevalence rates were noted in geographic regions with the highest rate found in Southern Africa (39.96%). Of interested was a significantly lower rate of PPD in developed countries or high-income countries or areas. Furthermore, the findings showed that there was a substantial difference in rates of PPD when marital status, educational level, social support, spouse care, violence, gestational age, breast feeding, child mortality, pregnancy plan, financial difficulties, partnership, life stress, smoking, alcohol intake, and living conditions were considered in the pooled estimates. Our results indicated that one out of every five women experiences PPD which is linked to income and geographic development. It is triggered by a variety of causes that necessitate the attention and committed intervention of primary care providers, clinicians, health authorities, and the general population.

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Introduction.

Postpartum depression (PPD), the onset of depressive episodes after childbirth, develops at a critical moment in a woman’s life and can continue for long periods [ 1 , 2 ]. The likelihood of depressive episodes can be twice as high as during other periods of a woman’s life [ 3 ], and they often go undetected and untreated [ 4 ], wreaking havoc on partners as well as the emotional and cognitive growth of infants and adolescents [ 5 , 6 ]. Desperation, sadness, nausea, changes in sleep and eating habits, decreased libido, crying spells, anxiety, irritability, feelings of isolation, mental liability, thoughts of hurting oneself and/or the infant, and even thoughts of suicide are common signs of this form of depression [ 7 ]. Postpartum depression can start at any time within the first year after delivery and continue for several years.

In Western countries, the prevalence of PPD varies from 10 to 15% during the first year after birth [ 8 ]. According to a systematic review of 47 studies from 18 low and lower-middle income countries, the prevalence is 18.6% (95% CI 18.0–19.2). Moreover, another review involving 143 studies from 40 countries found a broader variety of PPD prevalence rates, ranging from 0.5% to around 60% [ 9 ]. Cultural variations, diverse reporting practices, different viewpoints on mental health issues and stigma, socioeconomic class, poverty, poor social services, deficient nutrition, elevated stress, and biological factors can all be related to this broader continuum.

Despite the increasing number of longitudinal studies on postpartum depression around the world, there is a paucity of rigorous systemic data that explores not only the general burden of PPD, but also risk factors associated with it. The current understanding of the epidemiology of PPD is based mostly on a few geographic surveys and very little national evidence. Therefore, the present study aims to close this void by presenting an updated global estimate of postpartum depression epidemiology, synthesizing critical risk factors, and providing evidence-based data for maternal mental health treatment prioritization.

Search strategy and selection criteria

A systematic review and meta-analysis were done in accordance with PRISMA guidelines. Articles from inception to July 2021 were reviewed using the following databases: Medline, Embase, Web of Science, Cochrane, PsycInfo and Google Scholar. Searches were tailored database functionality, but generally used the following terms: “postnatal depression”, “postpartum depression”, “depression” and “depressive symptoms”. For relevant citations, reference lists of retrieved papers, as well as review articles found during the initial search, were screened. In order to uncover additional reports, forward citation checks were performed. Full details of the search strategy are provided in the Supplementary method .

Pre-defined decision rules were used to screen studies. Two reviewers independently screened titles and abstracts, with 10% of studies randomly reviewed by another investigator. Two investigators reviewed the complete texts of theoretically qualifying papers, with any inconsistencies settled through agreement or by another reviewer; consensus was found in all cases and agreement was reached.

Datasets from studies that met the following criteria were deemed eligible: (1) studies identified postpartum depressive disorder or depressive episode; (2) participants were women who completed assessments at least one week after giving birth in order to avoid baby blues being confused with PPD; (3) prevalence or incidence of depression was determined using standardized validated instruments, self-reported questionnaires, or clinically structured interviews; (4) participants were not recruited if they were receiving psychiatric assessment or care, or if they were identified as having possible depression because screening seeks to identify women with otherwise unrecognized major depression; (5) sufficient information was available for authors to calculate the aggregated prevalence of depression in the selected group of participants; and, (6) study undertaken from January, 2000 to July 2021.

Data analysis

Data extracted included the first author of the study, country or region, geographic region, time of publication, study period, income of country or region as assess by the World Bank, the level of country development, study category, study source, diagnostic technique, sample size, study quality and prevalence of disease (Supplementary Table 1 ). In addition, a comparison was made of the prevalence of postpartum depression stratified by marital status (married/cohabiting or single/divorced/widowed), employment (unemployed or paid employment), sex of infant (male or female), parity (primiparous or multiparous), educational level (less than 12 years or more than 12 years), social support from friends/family/parents (YES/NO), support from partner (YES/NO), violence (YES/NO), maternal age (adolescent or adult), residence (urban or rural/suburb), religion (YES/NO), mode of delivery (spontaneous or instrumental/cesarean delivery), ethnicity (indigenous or nonindigenous/immigrant), location of delivery (home or health facility), gestational age (term or pre-/post-term), breast feeding (YES/NO), infant death (YES/NO), sleep (satisfactory or unsatisfactory), pregnancy planned (YES/NO), gender preference (YES/NO), financial problems (YES/NO), partnership (intimate/satisfactory or unsatisfied), life stress (YES/NO), smoker (YES/NO), alcohol use (YES/NO), family type (nuclear or extended), living condition (satisfactory/good or unsatisfactory) and number of children (1 or less/2 or more, Supplementary Table 2 ).

Socio-demographic characteristics of participants were identified and compared with the prevalence of postpartum depression to determine the pool estimates of risk factors for PPD. Data were cross-checked for accuracy against the original source. Researchers reviewed and extracted data from included studies by using a data extraction form specifically designed for the current study. When duplicate data were identified, the duplicate with the smallest sample size or shortest duration of follow-up was excluded.

The Joanna Briggs Institute-Checklist for Prevalence Studies was used to assess the methodological consistency of the qualifying studies (Supplementary Table 1 ). Based on quality score, studies were not omitted in order to improve clarity and to ensure that available data in this field was reported. After checking for consistency, the “Meta” and “Metafor” modules in the R-4.0.0 statistical software package were used for meta-analysis. A 95% confidence interval (95% CI) was estimated using the Wilson score method, and pooled prevalence was calculated with the DerSimonian-Laird random effects model with Logit transformation. Heterogeneity across included studies was assessed using Cochran Q and I 2 statistics. Estimates with a p value lower than 0.05 for the Q-statistic and I² of 50% or greater were considered to have moderate heterogeneity. A random-effects approach was used to pool the prevalence of postpartum depression as global evidence was assumed to be heterogeneous. A series of leave-one out diagnostic tests was performed by sensitivity analysis and findings were further checked using a build-in feature in Metafor. Using a Mixed-Effects Model, meta-regression was then conducted after eliminating the outliers. Covariates considered were geographic regions, development of countries or region, income of countries or regions, diagnostic techniques, publication time, study size and study quality score. Consequently, multivariable meta-regression (multi-model inference) was performed using a “dmetar” package to examine which possible predictor combinations provide the best fit, and which predictors are the most important ones overall. To assess the potential confounding effect of heterogeneity, subgroup analyses were performed. The P value was used to compare the difference between the groups. A P value <0.05 was considered as significant difference. The study protocol was registered at PROSPERO ( https://www.crd.york.ac.uk/prospero ) as CRD42020211478.

Literature search results and study characteristics

The search identified 21,718 records, of which 10,758 records were retained after removing duplicates. Titles and abstracts were screened, resulting in the exclusion of 9,663 ineligible records. Full texts of the remaining 1,095 records were assessed for eligibility, of which 530 were excluded. Overall, 565 eligible studies involving 1,236,365 women were included in the final analysis (Fig. 1 , Supplementary Table 1 ). The quality assessment scores of included studies are displayed in Supplementary Table 1 . The majority of included studies had a cross-sectional design. The mean or median age of participants ranged from 17.76 to 37.70 years.

(Description of the searching methodology).

Participants included 172,342 women from 80 countries, having a diagnosis of postpartum depression. There was a high degree of heterogeneity among documented results with an overall prevalence rate of 17.22% (95% CI 16.00–18.51, I 2  = 99.70%, Table 1 , Fig. 2 ).

(Unbalanced prevalence of postpartum depression was observed between different continents, countries and regions).

In order to further understand the heterogeneity, sensitivity analysis was conducted by performing a set of leave-one out diagnostic tests (Supplementary Table 3 ) and the results were further verified by using a build-in function in Metafor (Supplementary Table 4 and Supplementary Fig. 1 ). As a result, four studies were identified as outliers for estimating pooled prevalence. After removing the outliers, the pooled prevalence of postpartum depression increased to 17.44% (95% CI 16.73–18.17, Fig. 3 ) stratified by countries or regions. To further explore the source of heterogeneity, meta-regression analysis was performed. The univariate meta-regression model indicated that geographical regions ( R 2  = 0, p  = 0.31), diagnostic scales ( R 2  = 0, p  = 0.37), publication year ( R 2  = 0, p  = 0.65), and quality score of the study ( R 2  = 0, p  = 0.55) were not significantly associated with heterogeneity. The source of heterogeneity across the studies, identified by meta-regression analyses, was study size ( R 2  = 0.03, p  < 0.01), development of countries or regions ( R 2  = 0.02, p  < 0.01) and income of countries or regions ( R 2  = 0, p < 0.01, Supplementary Table 4 ). By performing multivariable meta-regression, it was found that the study size and country or region development with the highest predictor importance of 99.99% (Fig. 4 , Supplementary Table 5 ).

(Postpartum depression prevalence varied substantially between different countries and regions, with the lowest prevalence observed in Denmark and highest one in Afghanistan).

(Multi-variable meta-regression was performed in order to find out factors with the highest predictor importance).

To confirm results of the meta-regression, subgroup analysis was performed after removing the outliers. Among geographic regions that had at least five studies, Southern Africa had the highest prevalence rate (39.96%, 95% CI 27.81–53.48), followed by Southern Asia (22.32%, 95% CI 18.48–26.70), South America (21.71%, 95% CI 19.78–23.76), Western Asia (19.83%, 95% CI 17.33–22.58), Northern Africa (18.75%, 95% CI 11.40–29.26), Eastern Asia (17.39%, 95% CI 16.09–18.77), Northern America (17.01%, 95% 15.68–18.44), Eastern Europe (16.62%, 95% CI 10.95–24.43), Southern Europe (16.34%, 95% CI 12.90-20.48), Northern Europe (13.78%, 95% CI 12.47–15.21), Western Africa (13.62%, 95% CI 8.27–21.62), South-Eastern Asia (13.53%, 95% CI 11.00–16.52), and Oceania (11.11%, 95% CI 9.27–13.25, p  < 0.01, Table 1 ). Postpartum depression prevalence varied substantially among countries and regions, from 6.48% (Denmark, 95% CI 5.70-7.36) to 60.93% (Afghanistan, 95% CI 54.25-67.22, Fig. 2 ). Among countries or regions containing at least five relevant studies, South Africa had the highest (38.79%, 95% CI 25.71–53.72) and Spain had the lowest (9.09%, 95% CI 6.97–11.08) postpartum depression prevalence among women (Table 1 ). Considering the income of countries or regions, those with high incomes had a significantly lower prevalence of 15.54% (95% CI 14.90–16.20, p  < 0.01). Besides, developed countries (14.85%, 95% CI 14.22–15.51) shared a significantly lower postpartum depression prevalence than that of developing countries (19.99%, 95% CI 18.76–21.27, p  < 0.01, Table 1 ). With regard to diagnostic scales, use of the Postpartum Depression Screening Scale (PDSS) resulted in the highest postpartum depression prevalence rate (37.23%, 95% CI 21.47–56.27) and the Structured Clinical Interview for DSM Disorders (SCID) with the lowest prevalence rate (10.11%, 95% CI 3.75–24.48). More than 80% of the studies used the Edinburgh Postnatal Depression Scale (EPDS) as their diagnostic tool with a prevalence rate of 16.86% (95% CI 16.04–17.72, Table 1 ). Interestingly, a pattern of increased prevalence rates was found in studies having more than 1,000 participants (12.97%, 95% CI 18.40–20.51) than those with less than 1,000 participants (19.44%, 95% CI 18.40–20.51, p  < 0.01, Table 1 ). To be noted, postpartum depression appears to be universally prevalent in 1–3 months (17.70%, 95% CI 15.95-19.60), 3–6 months (15.31%, 95% CI 14.31–16.36), 6–12 months (18.19%, 95% CI 13.56–23.96) and greater than 12 months (17.95%, 95% CI 13.80–23.01, p  = 0.08, Table 1 ) after birth.

Moreover, results indicated that a significant difference in PPD prevalence was found in the pooled estimate among marital status (married/cohabiting or single/divorced/widowed, 16.37% vs. 28.14%, p  < 0.01), educational level (less than 12 years or more than 12 years, 19.84% vs. 15.66%, p  < 0.01), social support from friends/family/parents (YES/NO, 15.15% vs. 32.03%, p  < 0.01), support from partner (YES/NO, 15.40% vs. 35.99%, p < 0.01), violence (YES/NO, 40.40% vs. 15.65%, p  < 0.01), gestational age (term or pre-/post-term, 15.48% vs. 22.04%, p  = 0.01), breast feeding (YES/NO, 16.51% vs. 25.02%, p  < 0.01), infant death (YES/NO, 43.33% vs. 18.50%, p  < 0.01), planned pregnancy (YES/NO, 17.36% vs. 28.12%, p  < 0.01), financial problems (YES/NO, 31.82% vs. 15.92%, p  < 0.01), partnership (intimate/satisfied or unsatisfied, 17.11% vs. 39.96%, p  < 0.01), life stress (YES/NO, 28.81% vs. 14.53%, p  < 0.01), smoker (YES/NO, 25.17% vs. 15.74%, p  < 0.01), alcohol use (YES/NO, 20.97% vs. 14.49%, p  = 0.02) and living conditions (satisfied/well or unsatisfied, 20.35% vs. 38.82%, p  = 0.02). However, minimal differences were observed among number of children (1 or less/2 or more, 17.74% vs. 19.38%, p  = 0.68), employment (unemployed or paid employment, 21.08% vs. 18.29%, p  = 0.11), sex of infant (male or female, 17.97% vs. 20.77%, p  = 0.13), parity (primiparous or multiparous, 17.39% vs. 17.63%, p  = 0.92), maternal age (adolescent or adult, 23.34% vs. 20.35, p  = 0.52), residence (urban or rural/suburb, 12.10% vs. 14.46%, p  = 0.73), religion (YES/NO, 15.11% vs. 17.47%, p  = 0.77), mode of delivery (spontaneous or instrumental/cesarean delivery, 18.31% vs. 21.01%, p  = 0.40), ethnicity (indigenous or nonindigenous/immigrant, 14.76% vs. 17.06%, p  = 0.27), location of delivery (home or health facility, 14.88% vs. 11.08%, p  = 0.49), sleep (satisfactory or unsatisfactory, 17.20% vs. 30.78%, p  = 0.08), family type (nuclear or extended, 20.66% vs. 21.15%, p  = 0.82) and gender preference (YES/NO, 17.78% vs. 13.82%, p  = 0.40, Table 2 ).

The global prevalence of PPD was found to be approximately 17.22% (95% CI 16.00-18.51) in the largest meta-analysis of PPD to-date. Study findings revealed significant differences between geographic regions, with Southern Africa having the highest prevalence rate (39.96%, 95% CI 27.81–53.48). Furthermore, country development and income inequalities had a major effect on PPD epidemiology. Furthermore, it was discovered that the prevalence of various variables such as marital status, educational level, violence, partnership, life stress, smoking, alcohol use, and living conditions differed significantly. However, no significant difference in PPD was noted in relation to infant gender and gender preference.

There have been recent systematic reviews of PPD worldwide [ 10 , 11 , 12 , 13 ] or in specific regions, including Asia [ 14 , 15 ] and Africa [ 16 ], but to the researchers’ knowledge this is the most comprehensive review with the largest number of studies on PPD globally. Results showed that the estimates are significantly higher than the widely cited prevalence rate of 13% (95% CI: 12.3–13.4%), derived from a meta-analysis of studies from developed countries [ 10 ] and lower than the 19% prevalence rate for PPD derived from studies of relatively low- and middle-income countries [ 12 ]. Interestingly, the current study findings are more similar to pooled estimates of PPD when using the EPDS [ 13 ]. Furthermore, current findings revealed that the prevalence of PPD was closely linked to country development and national or regional income. This is in line with previous research, which has shown that developing countries with low or lower-middle income have a higher prevalence of PPD. Importantly, the PPD prevalence rate varied based on the scale used when comparisons were made between countries with different socioeconomic structures. Previous studies had observed inconsistent PPD prevalence with 1.9% to 82.1% in developed countries, and 5.2% to 74% in developing countries [ 17 ]. Moreover, another study evaluated PPD studies from 40 countries and reported the prevalence of PPD to be 10–15% and found this prevalence to vary between 0% and 60% in developed and developing countries, respectively [ 9 ]. One detailed study found that PPD prevalence in developing countries was greater in developing countries (31.1%) than that of developed countries (21.5%) in rural areas [ 18 ]. It is worth noting that even among nations in similar economic strata, there are differences in national estimates of the prevalence of postpartum depression. For example, the prevalence of PPD in the United Kingdom is 21.5%, while that in New Zealand, another high-income country, is 10.58%; PPD prevalence in Ghana and Egypt were 3% and 22.99% respectively, while in fact they belong to low-income countries and their per capita GDP is similar.

Almost all geographic regions were represented in this review, with the highest coverage in Eastern Asia ( n  = 96) and the lowest coverage in Central America and Caribbean areas ( n  = 1). As a result, the current study’s pooled estimates of Central America and the Caribbean are underrepresented. Furthermore, the current analysis showed substantial variations between graphic areas on the same continent. Southern Asia, for instance, led with the highest prevalence (22.32%, 95% CI 18.48–26.70), followed by Western Asia (19.83%, 95% CI 17.33–22.58), Eastern Asia (17.39%, 95% CI 16.09–18.77), and South-Eastern Asia (13.53%, 95% CI 11.00–16.52). This was mirrored in the vast spectrum of PPD prevalence in Asian countries, which ranged from 9.29 % (Korea) to 60.93% (Afghanistan). These findings matched those of a previous study, which found that Asians made up 3.5% to 63.3% of the population [ 19 ]. To be noted, current study results indicated the prevalence in Southern Asia and Western Asia were significantly higher than that of Northern America, Europe, and Oceania. This is largely in accordance with the results from previous studies [ 20 ]. Differences in cultural traditions may play a role in this disparity. In those areas, girls tended to marry at an early age. But when it comes to age as a risk factor, the literature is conflicting. Some studies discovered that mothers with younger children are more likely to develop PPD [ 21 , 22 ], while other studies discovered that older age is related to PPD [ 23 , 24 ]. No differences were found in a case-control study conducted by Balaha and colleagues [ 25 ]. To be noted, in the current study, the pooled estimates suggest a marginally higher PPD prevalence in adolescent mothers than adult mothers without significant difference. In addition, relationships with mothers-in-law were closely correlated with PPD in those women [ 23 ]. In these research participants, mothers-in-law tend to be essential to the survival of the marriage, as sons remain closely attached to their families of birth, frequently living with and even working within the family company their entire lives. Mothers-in-law often exercise a considerable amount of leverage over their daughters-in-law and grandchildren’s lives. As a result, having a healthy relationship with one’s mother-in-law is crucial in a woman’s life, and having a negative one can lead to depression. Moreover, other risk factors, such as postpartum rituals including the period of 40 days resting, restricted activities, and diets [ 26 ], multiple children [ 27 ] and unemployment [ 21 , 28 ] were also correlated with a high prevalence rate.

Previous studies indicated that the past history of depression significantly enhanced the chance of PPD [ 29 , 30 ]. That explains why studies on new mothers having perinatal depression were not included in pooled estimates. Fifteen factors were found related to an elevated risk of PPD in the current review. In terms of breastfeeding, it is generally thought to be a possible preventive factor, and it was found that starting breastfeeding reduced the likelihood of depression in this current research. Breastfeeding has also been linked to an elevated risk of PPD in several trials. Underlying variables such as the mother’s background traits may be a source of confusion. Moreover, breastfeeding duration and breastfeeding self-efficacy may also be correlated with PPD [ 31 , 32 ]. Besides, according to the findings of the study, postpartum women face a variety of stressful life activities, including relationships, financial problems, social support, and maternal stressors. More than three-quarters of depressed postpartum women (78.2%) reported they had strained ties with their mothers-in-law [ 21 ]. With a strong correlation with their counterparts, almost half of postpartum mothers with depression reported having more than one stressful life events, such as low income (58.1%) and unplanned pregnancy (60.4%) [ 21 ]. Baker et al. found that low socioeconomic status, unwanted pregnancy and stressful life events during pregnancy have been associated with postpartum mental disorders [ 33 ]. Current study results are consistent with previous studies that unplanned pregnancy and a lack of family care were found to be important correlates of PPD. Support should be considered a protective factor based on the literature described previously [ 21 , 34 , 35 ]. Our findings are in line with previous research that support from partners, family members, and friends is shown to be adversely associated with the likelihood of PPD in the current study. The current study also found that women in financial difficulties or experiencing stressful events were at increased risk for PPD. This finding was confirmed in systematic reviews and meta-analyses conducted in low- and middle-income countries [ 36 ]. Due to lack of financial support, women in financial difficulties may be in a state of poverty, which leads to stress [ 36 ]. To be noted, our results indicated that mothers experiencing domestic violence were almost three times more likely than their counterparts to suffer from depression. Other studies found that postpartum depression was linked to mothers having a history of domestic violence and abuse from their husbands or family members [ 14 , 37 , 38 ]. Violence is harmful to one’s mental health. Mothers who are abused experience feelings of helplessness and despair, as well being at high risk to commit suicide. Unexpectedly, in our meta-analysis, an infant’s gender is not related to postpartum depression. Although female infant sex is favorably linked to PPD, according to research conducted in Asia (China, India), Africa (Nigeria), and Turkey, with qualitative research suggesting a role for male gender preference [ 39 , 40 , 41 ]. However, recent studies indicated that several biological mechanisms could underlie our observed findings, including sex-differential shifts in maternal reproductive and other hormones or immune activity [ 42 , 43 , 44 ].

There are strengths and limitations of this study to consider. It is the largest population-based study to-date, and allows for the investigation of factors which have not been previously studied in various regions. This study was a meta-analysis, so the pooled estimates of risk factors resulted in improved accuracy compared with findings from a single study. Limitations were also identified. First, although this was the most comprehensive PPD prevalence study, there remains a significant lack of research studies from developing countries with lower-middle or low incomes. Second, since the current research focused on cross-sectional research studies, recall bias may be present. Third, the diagnostic techniques used were based on participants’ self-reports which can result in reporting bias. Fourth, genes and polymorphisms are reported to be associated with PPD. However, in current study, we cannot further pool estimate those data due to the limited number of study on specific genes.

Postpartum depression affected one out of every five women after they gave birth which was triggered by a variety of causes. This necessitates the attention and committed intervention of primary care providers, clinicians, health authorities, and society as a whole.

Change history

20 december 2021.

A Correction to this paper has been published: https://doi.org/10.1038/s41398-021-01692-1

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Acknowledgements

We thank Pengfei Li and Ling Wang from Erasmus University Rotterdam provided English revision for the manuscript and Prof. Han Luo from Sichuan University for providing us technical assistance for the revision. This research is supported by the National Key R&D Program of China grant (2018YFC1314600) to ZL; Grant of Science and Technology from Sichuan Province (2020YJ0237) to ZL and (2020YFS0259) to XF; The 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University to ZL (ZYJC18025); The National Natural Science Foundation of China to BY (72174152).

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These authors contributed equally: Ziyi Wang, Jiaye Liu, Huan Shuai, Zhongxiang Cai.

Authors and Affiliations

School of Nursing, Wuhan University, Wuhan, Hubei, China

Ziyi Wang, Shuo Liu & Bing Xiang Yang

Department of Thyroid and Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Jiaye Liu & Zhihui Li

Department of Orthopedics, Chengkou People’s Hospital, Chongqing, China

Department of Nursing, Renmin Hospital of Wuhan University, Wuhan, Hubei, China

Zhongxiang Cai

Department of outpatients, West China Hospital, Sichuan University, Chengdu, Sichuan, China

Department of Obstetrics and Gynecology, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China

Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China

Department of Obstetrics and Gynecology, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China

Wenhao Zhang

Department of Medical Library, Erasmus MC-University Medical Center, Rotterdam, The Netherlands

Elise Krabbendam

Department of Psychiatry, Renmin Hospital of Wuhan University, Wuhan, Hubei, China

Zhongchun Liu

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JL, ZW, HS, ZC, and SL completed the study, acquisition, and analysis of data. YL, XX, ZL, ZL, WZ, and BY discussed data; conceptualized the research project, revised the manuscript and provided technical assistance. ZW and JL drafted the manuscript. All authors have read the manuscript and provided feedback. ZW, JL, HS, and ZC shared the co-first author.

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Wang, Z., Liu, J., Shuai, H. et al. Mapping global prevalence of depression among postpartum women. Transl Psychiatry 11 , 543 (2021). https://doi.org/10.1038/s41398-021-01663-6

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Postpartum depression (PPD) affects around 10% of women, or 1 in 7 women, after giving birth. Undiagnosed PPD was observed among 50% of mothers. PPD has an unfavorable relationship with women’s functioning, marital and personal relationships, the quality of the mother-infant connection, and the social, behavioral, and cognitive development of children. We aim to determine the frequency of PPD and explore associated determinants or predictors (demographic, obstetric, infant-related, and psychosocial factors) and coping strategies from June to August 2023 in six countries.

An analytical cross-sectional study included a total of 674 mothers who visited primary health care centers (PHCs) in Egypt, Yemen, Iraq, India, Ghana, and Syria. They were asked to complete self-administered assessments using the Edinburgh Postnatal Depression Scale (EPDS). The data underwent logistic regression analysis using SPSS-IBM 27 to list potential factors that could predict PPD.

The overall frequency of PPD in the total sample was 92(13.6%). It ranged from 2.3% in Syria to 26% in Ghana. Only 42 (6.2%) were diagnosed. Multiple logistic regression analysis revealed there were significant predictors of PPD. These factors included having unhealthy baby adjusted odds ratio (aOR) of 11.685, 95% CI: 1.405–97.139, p  = 0.023), having a precious baby (aOR 7.717, 95% CI: 1.822–32.689, p  = 0.006), who don’t receive support (aOR 9.784, 95% CI: 5.373–17.816, p  = 0.001), and those who are suffering from PPD. However, being married and comfortable discussing mental health with family relatives are significant protective factors (aOR = 0.141 (95% CI: 0.04–0.494; p  = 0.002) and (aOR = 0.369, 95% CI: 0.146–0.933, p  = 0.035), respectively.

The frequency of PPD among the mothers varied significantly across different countries. PPD has many protective and potential factors. We recommend further research and screenings of PPD for all mothers to promote the well-being of the mothers and create a favorable environment for the newborn and all family members.

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Introduction

Postpartum depression (PPD) is among the most prevalent mental health issues [ 1 ]. The onset of depressive episodes after childbirth occurs at a pivotal point in a woman’s life and can last for an extended period of 3 to 6 months; however, this varies based on several factors [ 2 ]. PPD can develop at any time within the first year after childbirth and last for years [ 2 ]. It refers to depressive symptoms that a mother experiences during the postpartum period, which are vastly different from “baby blues,” which many mothers experience within three to five days after the birth of their child [ 3 ].

Depressive episodes are twice as likely to occur during pregnancy compared to other times in a woman’s life, and they frequently go undetected and untreated [ 4 ]. According to estimates, almost 50% of mothers with PPD go undiagnosed [ 4 ]. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PPD include mood instability, loss of interest, feelings of guilt, sleep disturbances, sleep disorders, and changes in appetite [ 5 ], as well as decreased libido, crying spells, anxiety, irritability, feelings of isolation, mental liability, thoughts of hurting oneself and/or the infant, and even suicidal ideation [ 6 ].

Approximately 1 in 10 women will experience PPD after giving birth, with some studies reporting 1 in 7 women [ 7 ]. Globally, the prevalence of PPD is estimated to be 17.22% (95% CI: 16.00–18.05) [ 4 ], with a prevalence of up to 15% in the previous year in eighty different countries or regions [ 1 ]. This estimate is lower than the 19% prevalence rate of PPD found in studies from low- and middle-income countries and higher than the 13% prevalence rate (95% CI: 12.3–13.4%) stated in a different meta-analysis of data from high-income countries [ 8 ].

The occurrence of postpartum depression is influenced by various factors, including social aspects like marital status, education level, lack of social support, violence, and financial difficulties, as well as other factors such as maternal age (particularly among younger women), obstetric stressors, parity, and unplanned pregnancy [ 4 ]. When a mother experiences depression, she may face challenges in forming a satisfying bond with her child, which can negatively affect both her partner and the emotional and cognitive development of infants and adolescents [ 4 ]. As a result, adverse effects may be observed in children during their toddlerhood, preschool years, and beyond [ 9 ].

Around one in seven women can develop PPD [ 7 ]. While women experiencing baby blues tend to recover quickly, PPD tends to last longer and severely affects women’s ability to return to normal function. PPD affects the mother and her relationship with the infant [ 7 ]. The prevalence of postpartum depression varies depending on the assessment method, timing of assessment, and cultural disparities among countries [ 7 ]. To address these aspects, we conducted a cross-sectional study focusing on mothers who gave birth within the previous 18 months. Objectives: to determine the frequency of PPD and explore associated determinants or predictors, including demographic, obstetric, infant-related, and psychosocial factors, and coping strategies from June to August 2023 in six countries.

Study design and participants

This is an analytical cross-sectional design and involved 674 mothers during the childbearing period (CBP) from six countries, based on the authors working settings, namely Egypt, Syria, Yemen, Ghana, India, and Iraq. It was conducted from June to August 2023. It involved all mothers who gave birth within the previous 18 months, citizens of one of the targeted countries, and those older than 18 years and less than 40 years. Women who visited for a routine postpartum follow-up visit and immunization of their newborns were surveyed.

Multiple pregnancies, illiteracy, or anyone deemed unfit to participate in accordance with healthcare authorities, mothers who couldn’t access or use the Internet, mothers who couldn’t read or speak Arabic or English and couldn’t deal with the online platform or smart devices, mothers whose babies were diagnosed with serious health problems, were stillborn, or experienced intrauterine fetal death, and participants with complicated medical, mental, or psychological disorders that interfered with completing the questionnaire were all exclusion criteria. There were no incentives offered to encourage participation.

Sample size and techniques

The sample size was estimated according to the following equation: n = Z 2 P (1-P)/d 2 . This calculation was based on the results of a systematic review and meta-analysis in 2020 of 17% as the worldwide prevalence of PPD and 12% as the worldwide incidence of PPD, as well as a 5% precision percentage, 80% power of the study, a 95% confidence level, and an 80% response rate [ 11 ]. The total calculated sample size is 675. The sample was diverse in terms of nationality, with the majority being Egyptian (16.3%), followed by Yemeni (24.3%) and Indian (19.1%), based on many factors discussed in the limitation section.

The sampling process for recruiting mothers utilized a multistage approach. Two governorates were randomly selected from each country. Moreover, we selected one rural and one urban area from each governorate. Through random selection, participants were chosen for the study. Popular and officially recognized online platforms, including websites and social media platforms such as Facebook, Twitter, WhatsApp groups, and registered emails across various health centers, were utilized for reaching out to participants. Furthermore, a community-based sample was obtained from different public locations, including well-baby clinics, PHCs, and family planning units.

Mothers completed the questionnaire using either tablets or cellphones provided by the data collectors or by scanning the QR code. All questions were mandatory to prevent incomplete forms. Once they provided their informed consent, they received the questionnaire, which they completed and submitted. To enhance the response rate, reminder messages and follow-up communications were employed until the desired sample size was achieved or until the end of August. To avoid seasonal affective disorders, the meteorological autumn season began on the 1st day of September, which may be associated with Autum depressive symptoms that may confound or affect our results.

Data collection tool

Questionnaire development and structure.

The questionnaire was developed and adapted based on data obtained from previous studies [ 7 , 8 , 9 , 10 , 11 , 12 ]. Initially, it was created in English and subsequently translated into Arabic. To ensure accuracy, a bilingual panel consisting of two healthcare experts and an externally qualified medical translator translated the English version into Arabic. Additionally, two English-speaking translators performed a back translation, and the original panel was consulted if any concerns arose.

Questionnaire validation

To collect the data, an online, self-administered questionnaire was utilized, designed in Arabic with a well-structured format. We conducted an assessment of the questionnaire’s reliability and validity to ensure a consistent interpretation of the questions. The questionnaire underwent validation by psychiatrists, obstetricians, and gynecologists. Furthermore, in a pilot study involving 20 women of CBA, the questionnaire’s clarity and comprehensibility were evaluated. It is important to note that the findings from the pilot study were not included in our main study.

The participants were asked to rate the questionnaire’s organization, clarity, and length, as well as provide a general opinion. Following that, certain questions were revised in light of their input. To check for reliability and reproducibility, the questionnaire was tested again on the same people one week later. The final data analysis will not include the data collected during the pilot test. We calculated a Cronbach’s alpha of 0.76 for the questionnaire.

The structure of the questionnaire

After giving their permission to take part in the study. The questionnaire consisted of the following sections:

Study information and electronic solicitation of informed consent.

Demographic and health-related factors: age, gender, place of residence, educational level, occupation, marital status, weight, height, and the fees of access to healthcare services.

Obstetric history: number of pregnancies, gravida, history of abortions, number of live children, history of dead children, inter-pregnancy space (y), current pregnancy status, type of the last delivery, weight gain during pregnancy (kg), baby age (months), premature labor, healthy baby, baby admitted to the NICU, Feeding difficulties, pregnancy problems, postnatal problems, and natal problems The nature of baby feeding.

Assessment of postpartum depression (PPD) levels using the Edinburgh 10-question scale: This scale is a simple and effective screening tool for identifying individuals at risk of perinatal depression. The EPDS (Edinburgh Postnatal Depression Scale) is a valuable instrument that helps identify the likelihood of a mother experiencing depressive symptoms of varying severity. A score exceeding 13 indicates an increased probability of a depressive illness. However, clinical discretion should not be disregarded when interpreting the EPDS score. This scale captures the mother’s feelings over the past week, and in cases of uncertainty, it may be beneficial to repeat the assessment after two weeks. It is important to note that this scale is not capable of identifying mothers with anxiety disorders, phobias, or personality disorders.

For Questions 1, 2, and 4 (without asterisks): Scores range from 0 to 3, with the top box assigned a score of 0 and the bottom box assigned a score of 3. For Questions 3 and 5–10 (with asterisks): Scores are reversed, with the top box assigned a score of 3 and the bottom box assigned a score of 0. The maximum score achievable is 30, and a probability of depression is considered when the score is 10 or higher. It is important to always consider item 10, which pertains to suicidal ideation [ 12 ].

Psychological and social characteristics: received support or treatment for PPD, awareness of symptoms and risk factors, experienced cultural stigma or judgment about PPD in the community, suffer from any disease or mental or psychiatric disorder, have you ever been diagnosed with PPD, problems with the husband, and financial problems.

Coping strategies and causes for not receiving the treatment and reactions to PPD, in descending order: social norms, cultural or traditional beliefs, personal barriers, 48.5% geographical or regional disparities in mental health resources, language or communication barriers, and financial constraints.

Statistical analysis

The collected data was computerized and statistically analyzed using the SPSS program (Statistical Package for Social Science), version 27. The data was tested for normal distribution using the Shapiro-Walk test. Qualitative data was represented as frequencies and relative percentages. Quantitative data was expressed as mean ± SD (standard deviation) if it was normally distributed; otherwise, median and interquartile range (IQR) were used. The Mann-Whitney test (MW) was used to calculate the difference between quantitative variables in two groups for non-parametric variables. Correlation analysis (using Spearman’s method) was used to assess the relationship between two nonparametric quantitative variables. All results were considered statistically significant when the significant probability was < 0.05. The chi-square test (χ 2 ) and Fisher exact were used to calculate the difference between qualitative variables.

The frequency of PPD among mothers (Fig.  1 )

The frequency of PPD among the studied mothers

The frequency of PPD in the total sample using the Edinburgh 10-question scale was 13.5% (Table S1) and 92 (13.6%). Which significantly ( p  = 0.001) varied across different countries, being highest among Ghana mothers 13 (26.0%) out of 50 and Indians 28 (21.7%) out of 129. Egyptian 21 (19.1) out of 110, Yemen 14 (8.5%) out of 164, Iraq 13 (7.7%) out of 168, and Syria 1 (2.3%) out of 43 in descending order. Nationality is also significantly associated with PPD ( p  = 0.001).

Demographic, and health-related characteristics and their association with PPD (Table  1 )

The study included 674 participants. The median age was 27 years, with 407 (60.3%) of participants falling in the >25 to 40-year-old age group. The majority of participants were married, 650 (96.4%), had sufficient monthly income, 449 (66.6%), 498 (73.9%), had at least a preparatory or high school level of education, and were urban. Regarding health-related factors, 270 (40.01%) smoked, 645 (95.7%) smoked, 365 (54.2%) got the COVID-19 vaccine, and 297 (44.1%) got COVID-19. Moreover, 557 (82.6%) had no comorbidities, 623 (92.4%) had no psychiatric illness or family history, and they charged for health care services for themselves 494 (73.3%).

PPD is significant ( p  < 0.05). Higher among single or widowed women 9 (56.3%) and mothers who had both medical, mental, or psychological problems 2 (66.7%), with ex-cigarette smoking 5 (35.7%) ( p  = 0.033), alcohol consumption ( p  = 0.022) and mothers were charged for the health care services for themselves 59 (11.9%).

Obstetric, current pregnancy, and infant-related characteristics and their association with PPD (Table  2 )

The majority of the studied mothers were on no hormonal treatment or contraceptive pills 411 (60.9%), the current pregnancy was unplanned and wanted 311 (46.1%), they gained 10 ≥ kg 463 (68.6%), 412 (61.1%) delivered vaginal, a healthy baby 613 (90.9%), and, on breastfeeding, only 325 (48.2%).

There was a significant ( P  < 0.05) association observed between PPD, which was significantly higher among mothers on contraceptive methods, and those who had 1–2 live births (76.1%) and mothers who had interpregnancy space for less than 2 years. 86 (93.5%), and those who had a history of dead children. Moreover, among those who had postnatal problems (27.2%).

The psychosocial characteristics and their association with PPD (Table  3 )

Regarding the psychological and social characteristics of the mothers, the majority of mothers were unaware of the symptoms of PPD (75%), and only 236 (35.3%) experienced cultural stigma or judgment about PPD in the community. About 41 (6.1%) were diagnosed with PPD during the previous pregnancy, and only 42 (6.2%) were diagnosed and on medications.

A p -value of less than 0.001 demonstrates a highly statistically significant association with the presence of PPD. Mothers with PPD were significantly more likely to have a history of or be currently diagnosed with PPD, as well as financial and marital problems. Experienced cultural stigma or judgment about PPD and received more support.

Coping strategies and causes for not receiving the treatment and reaction to PPD (Table  3 ; Fig.  2 )

Causes for not receiving the treatment and reaction to PPD

Around half of the mothers didn’t feel comfortable discussing mental health: 292 (43.3%) with a physician, 307 (45.5%) with a husband, 326 (48.4%) with family, and 472 (70.0%) with the community. Moreover, mothers with PPD felt significantly more comfortable discussing mental health in descending order: 46 (50.0%) with a physician, 41 (44.6%) with a husband, and 39 (42.3%) with a family (Table  3 ).

There were different causes for not receiving the treatment and reactions to PPD, in descending order: 65.7% social norms, 60.5% cultural or traditional beliefs, 56.5% personal barriers, 48.5% geographical or regional disparities in mental health resources, 47.4% language or communication barriers, and 39.7% financial constraints.

Prediction of PPD (significant demographics, obstetric, current pregnancy, and infant-related, and psychosocial), and coping strategies derived from multiple logistic regression analysis (Table  4 ).

Significant demographic predictors of ppd.

Marital Status (Married or Single): The adjusted odds ratio (aOR) among PPD mothers who were married in comparison to their single counterparts was 0.141 (95% CI: 0.04–0.494; p -value = 0.002).

Nationality: For PPD Mothers of Yemeni nationality compared to those with Egyptian nationality, the aOR was 0.318 (95% CI: 0.123–0.821, p  = 0.018). Similarly, for Syrian nationality in comparison to Egyptian nationality, the aOR was 0.111 (95% CI: 0.0139–0.887, p  = 0.038), and for Iraqi nationality compared to Egyptian nationality, the aOR was 0.241 (95% CI: 0.0920–0.633, p  = 0.004).

Significant obstetric, current pregnancy, and infant-related characteristics predictors of PPD

Current Pregnancy Status (Precious Baby—Planned): The aOR for the occurrence of PPD among women with a “precious baby” relative to those with a “planned” pregnancy was 7.717 (95% CI: 1.822–32.689, p  = 0.006).

Healthy Baby (No-Yes): The aOR for the occurrence of PPD among women with unhealthy babies in comparison to those with healthy ones is 11.685 (95% CI: 1.405–97.139, p  = 0.023).

Postnatal Problems (No–Yes): The aOR among PPD mothers reporting postnatal problems relative to those not reporting such problems was 0.234 (95% CI: 0.0785–0.696, p  = 0.009).

Significant psychological and social predictors of PPD

Receiving support or treatment for PPD (No-Yes): The aOR among PPD mothers who were not receiving support or treatment relative to those receiving support or treatment was 9.784 (95% CI: 5.373–17.816, p  = 0.001).

Awareness of symptoms and risk factors (No-Yes): The aOR among PPD mothers who lack awareness of symptoms and risk factors relative to those with awareness was 2.902 (95% CI: 1.633–5.154, p  = 0.001).

Experienced cultural stigma or judgement about PPD in the community (No-Yes): The aOR among PPD mothers who had experienced cultural stigma or judgment in the community relative to those who have not was 4.406 (95% CI: 2.394–8.110, p  < 0.001).

Suffering from any disease or mental or psychiatric disorder: For “Now I am suffering—not at all,” the aOR among PPD mothers was 12.871 (95% CI: 3.063–54.073, p  = 0.001). Similarly, for “Had a past history but was treated—not at all,” the adjusted odds ratio was 16.6 (95% CI: 2.528–108.965, p  = 0.003), and for “Had a family history—not at all,” the adjusted odds ratio was 3.551 (95% CI: 1.012–12.453, p  = 0.048).

Significant coping predictors of PPD comfort: discussing mental health with family (maybe yes)

The aOR among PPD mothers who were maybe more comfortable discussing mental health with family relatives was 0.369 (95% CI: 0.146–0.933, p  = 0.035).

PDD is a debilitating mental disorder that has many potential and protective risk factors that should be considered to promote the mental and psychological well-being of the mothers and to create a favorable environment for the newborn and all family members. This multinational cross-sectional survey was conducted in six different countries to determine the frequency of PDD using EPDS and to explore its predictors. It was found that PPD was a prevalent problem that varied across different nations.

The frequency of PPD across the studied countries

Using the widely used EPDS to determine the current PPD, we found that the overall frequency of PPD in the total sample was 92 (13.6%). Which significantly ( p  = 0.001) varied across different countries, being highest among Ghana mothers 13 (26.0%) out of 50 and Indians 28 (21.7%) out of 129. Egyptian 21 (19.1) out of 110, Yemen 14 (8.5%) out of 164, Iraq 13 (7.7%) out of 169, and Syria 1 (2.3%) out of 43 in descending order. This prevalence was similar to that reported by Hairol et al. (2021) in Malaysia (14.3%) [ 13 ], Yusuff et al. (2010) in Malaysia (14.3%) [ 14 ], and Nakku et al. (2006) in New Delhi (12.75%) [ 15 ].

While the frequency of PPD varied greatly based on the timing, setting, and existence of many psychosocial and post-partum periods, for example, it was higher than that reported in Italy (2012), which was 4.7% [ 16 ], in Turkey (2017) was 9.1%/110 [ 17 ], 9.2% in Sudan [ 18 ], Eritrea (2020) was 7.4% [ 19 ], in the capital Kuala Lumpur (2001) was (3.9%) [ 20 ], in Malaysia (2002) was (9.8%) [ 21 ], and in European countries. (2021) was 13–19% [ 22 ].

Lower frequencies were than those reported; PPD is a predominant problem in Asia, e.g., in Pakistan, the three-month period after childbirth, ranging from 28.8% in 2003 to 36% in 2006 to 94% in 2007, while after 12 months after childbirth, it was 62% in 2021 [ 23 – 24 ]. While in 2022 Afghanistan 45% after their first labour [ 25 ] in Canada (2015) was 40% [ 26 ], in India, the systematic review in 2022 was 22% of Primipara [ 27 ], in Malaysia (2006) was 22.8% [ 28 ], in India (2019) was 21.5% [ 29 ], in the Tigray zone in Ethiopia (2017) was 19% [ 30 ], varied in Iran between 20.3% and 35% [ 31 – 32 ], and in China was 499 (27.37%) out of 1823 [ 33 ]. A possible explanation might be the differences in the study setting and the type of design utilized. Other differences should be considered, like different populations with different socioeconomic characteristics and the variation in the timing of post-partum follow-up. It is vital to consider the role of culture, the impact of patients’ beliefs, and the cultural support for receiving help for PPD.

Demographic and health-related associations, or predictors of PPD (Tables  1 and 4 )

Regarding age, our study found no significant difference between PPD and non-PPD mothers with regard to age. In agreement with our study [ 12 , 34 , 35 ], other studies [ 36 , 37 , 38 ] found an inverse association between women’s age and PPD, with an increased risk of PPD (increases EPDS scores) at a younger age significantly, as teenage mothers, being primiparous, encounter difficulty during the postpartum period due to their inability to cope with financial and emotional difficulties, as well as the challenge of motherhood. Cultural factors and social perspectives of young mothers in different countries could be a reason for this difference. [ 38 – 39 ] and Abdollahi et al. [ 36 ] reported that older mothers were a protective factor for PPD (OR = 0.88, 95% CI: 0.84–0.92].

Regarding marital status, after controlling for other variables, married mothers exhibited a significantly diminished likelihood of experiencing PPD in comparison to single women (0.141; 95% CI: 0.04–0.494; p  = 0.002). Also, Gebregziabher et al. [ 19 ] reported that there were statistically significant differences in proportions between mothers’ PPD and marital status.

Regarding the mother’s education, in agreement with our study, Ahmed et al. [ 34 ] showed that there was no statistically significant difference between PPD and a mother’s education. While Agarwala et al. [ 29 ] showed that a higher level of mother’s education. increases the risk of PPD, Gebregziabher et al. [ 19 ] showed that the housewives were 0.24 times less likely to develop PPD as compared to the employed mothers (aOR = 0.24, 95% CI: 0.06–0.97; p  = 0.046); those mothers who perceived their socioeconomic status (SES) as low were 13 times more likely to develop PPD as compared to the mothers who had good SES (aOR = 13.33, 95% CI: 2.66–66.78; p  = 0.002).

Regarding the SES or monthly income, while other studies [ 18 , 40 ] found that there was a statistically significant association between PPD mothers and different domains of SES, 34% of depressed women were found to live under low SES conditions in comparison to only 15.4% who were found to live in high SES and experienced PPD. In disagreement with our study, Hairol et al. [ 12 ] demonstrated that the incidence of PPD was significantly p  = 0.01 higher for participants from the low-income group (27.27%) who were 2.58 times more likely to have PDD symptoms (OR: 2.58, 95% CI: 1.23–5.19; p  = 0.01 compared to those from the middle- and high-income groups (8.33%), and low household income (OR = 3.57 [95% CI: 1.49–8.5] increased the odds of PPD [ 41 ].

Adeyemo et al. (2020),and Al Nasr et al. (2020) revealed that there was no significant difference between the occurrence of PPD and socio-demographic characteristics. This difference may be due to a different sample size and ethnicity [ 42 , 43 ]. In agreement with our findings, Abdollahi et al. [ 36 ] demonstrated that after multiple logistic regression analyses, there were increased odds of PPD with a lower state of general health (OR = 1.08 [95% CI: 1.06–1.11]), gestational diabetes (OR = 2.93 [95% CI = 1.46–5.88]), and low household income (OR = 3.57 [95% CI: 1.49–8.5]). The odds of PPD decreased.

Regarding access to health care, in agreement with studies conducted at Gondar University Hospital, Ethiopia [ 18 ], North Carolina, Colorado [ 21 ], Khartoum, Sudan [ 44 ], Asaye et al. [ 45 ], the current study found that participants who did not have free access to the healthcare system were riskier for the development of PPD. the study results may be affected by the care given during the antenatal care (ANC) visits. This can be explained by the fact that PPD was four times higher than that of mothers who did not have ANC, where counseling and anticipatory guidance care are given that build maternal self-esteem and resiliency, along with knowledge about normal and problematic complications to discuss at care visits and their right to mental and physical wellness, including access to care. The increased access to care (including postpartum visits) will increase the diagnosis of PPD and provide guidance, reassurance, and appropriate referrals. Healthcare professionals have the ability to both educate and empower mothers as they care for their babies, their families, and themselves [ 46 ].

Regarding nationality, for PPD mothers of Yemeni nationality compared to those of Egyptian nationality, the aOR is 0.318 (95% CI: 0.123–0.821, p  = 0.018). Similarly, for Syrian nationality in comparison to Egyptian nationality, the aOR is 0.111 (95% CI: 0.0139–0.887, p  = 0.038), and for Iraqi nationality compared to Egyptian nationality, the aOR is 0.241 (95% CI: 0.0920–0.633, p  = 0.004). These findings indicated that, while accounting for other covariates, individuals from the aforementioned nationalities were less predisposed to experiencing PPD than their Egyptian counterparts. These findings can be explained by the fact that, in Egypt, the younger age of marriage, especially in rural areas, poor mental health services, being illiterate, dropping out of school early, unemployment, and the stigma of psychiatric illnesses are cultural factors that hinder the diagnosis and treatment of PPD [ 40 ].

Obstetric, current pregnancy, and infant-related characteristics and their association or predictors of PPD (Tables  2 and 4 )

In the present study, the number of dead children was significantly associated with PPD. This report was supported by studies conducted with Gujarati postpartum women [ 41 ] and rural southern Ethiopia [ 43 ]. This might be because mothers who have dead children pose different psychosocial problems and might regret it for fear of complications developing during their pregnancy. Agarwala et al. [ 29 ] found that a history of previous abortions and having more than two children increased the risk of developing PPD due to a greater psychological burden. The inconsistencies in the findings of these studies indicate that the occurrence of postpartum depression is not solely determined by the number of childbirths.

In obstetric and current pregnancy , there was no significant difference regarding the baby’s age, number of miscarriages, type of last delivery, premature labour, healthy baby, baby admitted to the neonatal intensive care unit (NICU), or feeding difficulties. In agreement with Al Nasr et al. [ 42 ], inconsistent with Asaye et al. [ 45 ], they showed that concerning multivariable logistic regression analysis, abortion history, birth weight, and gestational age were significant associated factors of postpartum depression at a value of p <  0.05.

However, a close association was noted between the mode of delivery and the presence of PPD in mothers, with p  = 0.107. There is a high tendency towards depression seen in mothers who have delivered more than three times (44%). In disagreement with what was reported by Adeyemo et al. [ 41 ], having more than five children ( p  = 0.027), cesarean section delivery ( p  = 0.002), and mothers’ poor state of health since delivery ( p  < 0.001) are associated with an increase in the risk of PPD [ 47 ]. An increased risk of cesarean section as a mode of delivery was observed (OR = 1.958, p  = 0.049) in a study by Al Nasr et al. [ 42 ].

We reported breastfeeding mothers had a lower, non-significant frequency of PPD compared to non-breast-feeding mothers (36.6% vs. 45%). In agreement with Ahmed et al. [ 34 ], they showed that with respect to breastfeeding and possible PPD, about 67.3% of women who depend on breastfeeding reported no PPD, while 32.7% only had PP. Inconsistency with Adeyemo et al. [ 41 ], who reported that unexclusive breastfeeding ( p  = 0.003) was associated with PPD, while Shao et al. [ 40 ] reported that mothers who were exclusively formula feeding had a higher prevalence of PPD.

Regarding postnatal problems, our results revealed that postnatal problems display a significant association with PPD. In line with our results, Agarwala et al. [ 29 ] and Gebregziabher et al. [ 19 ] showed that mothers who experienced complications during childbirth, those who became ill after delivery, and those whose babies were unhealthy had a statistically significant higher proportion of PPD.

Hormone-related contraception methods were found to have a statistically significant association with PPD, consistent with the literature [ 46 ]; this can be explained by the hormones and neurotransmitters as biological factors that play significant roles in the onset of PPD. Estrogen hormones act as regulators of transcription from brain neurotransmitters and modulate the action of serotonin receptors. This hormone stimulates neurogenesis, the process of generating new neurons in the brain, and promotes the synthesis of neurotransmitters. In the hypothalamus, estrogen modulates neurotransmitters and governs sleep and temperature regulation. Variations in the levels of this hormone or its absence are linked to depression [ 19 ].

Participants whose last pregnancy was unplanned were 3.39 times more likely to have postpartum depression (aOR = 3.39, 95% CI: 1.24–9.28; p  = 0.017). Mothers who experienced illness after delivery were more likely to develop PPD as compared to their counterparts (aOR = 7.42, 95% CI: 1.44–34.2; p  = 0.016) [ 40 ]. In agreement with Asaye et al. [ 45 ] and Abdollahi et al. [ 36 ], unplanned pregnancy has been associated with the development of PPD (aOR = 2.02, 95% CI: 1.24, 3.31) and OR = 2.5 [95% CI: 1.69–3.7] than those of those who had planned, respectively.

The psychosocial characteristics and their association with PPD

Mothers with a family history of mental illness were significantly associated with PPD. This finding was in accordance with studies conducted in Istanbul, Turkey [ 47 ], and Bahrain [ 48 ]. Other studies also showed that women with PPD were most likely to have psychological symptoms during pregnancy [ 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. A meta-analysis of 24,000 mothers concluded that having depression and anxiety during pregnancy and a previous history of psychiatric illness or a history of depression are strong risk factors for developing PPD [ 50 , 51 , 52 ]. Asaye et al. [ 45 ], mothers whose relatives had mental illness history were (aOR = 1.20, 95% CI: 1.09, 3.05 0) be depressed than those whose relatives did not have mental illness history.

This can be attributed to the links between genetic predisposition and mood disorders, considering both nature and nurture are important to address PDD. PPD may be seen as a “normal” condition for those who are acquainted with relatives with mood disorders, especially during the CBP. A family history of mental illness can be easily elicited in the ANC first visit history and requires special attention during the postnatal period. There are various risk factors for PPD, including stressful life events, low social support, the infant’s gender preference, and low income [ 53 ].

Concerning familial support and possible PPD, a statistically significant association was found between them. We reported that mothers who did not have social support (a partner or the father of the baby) had higher odds (aOR = 5.8, 95% CI: 1.33–25.29; p  = 0.019) of experiencing PPD. Furthermore, Al Nasr et al. [ 42 ] revealed a significant association between the PPD and an unsupportive spouse ( P value = 0.023). while it was noted that 66.5% of women who received good familial support after giving birth had no depression, compared to 33.5% who only suffered from possible PPD [ 40 ]]. Also, Adeyemo et al. [ 41 ] showed that some psychosocial factors were significantly associated with having PPD: having an unsupportive partner ( p  < 0.001), experiencing intimate partner violence ( p  < 0.001), and not getting help in taking care of their baby ( p  < 0.001). Al Nasr et al. (2020) revealed that the predictor of PPD was an unsupportive spouse (OR = 4.53, P  = 0.049) [ 48 ].

Regarding the perceived stigma, in agreement with our study, Bina (2020) found that shame, stigma, the fear of being labeled mentally ill, and language and communication barriers were significant factors in women’s decisions to seek treatment or accept help [ 53 ]. Other mothers were hesitant about mental health services [ 54 ]. It is noteworthy that some PPD mothers refused to seek treatment due to perceived insufficient time and the inconvenience of attending appointments [ 55 ].

PPD was significantly higher among mothers with financial problems or problems with their husbands. This came in agreement with Ahmed et al. [ 34 ], who showed that, regarding stressful conditions and PPD, there was a statistically significant association with a higher percentage of PPD among mothers who had a history of stressful conditions (59.3%), compared to those with no history of stressful conditions (40.7%). Furthermore, Al Nasr et al. (2020) revealed that stressful life events contributed significantly ( P value = 0.003) to the development of PPD in the sample population. Al Nasr et al. stressful life events (OR = 2.677, p  = 0.005) [ 42 ].

Coping strategies: causes of fearing and not seeking

Feeling at ease discussing mental health topics with one’s husband, family, community, and physician and experiencing cultural stigma or judgment regarding PPD within the community was significantly associated with the presence of PPD. In the current study, there were different reasons for not receiving the treatment, including cultural or traditional beliefs, language or communication barriers, social norms, and geographical or regional disparities in mental health resources. Haque and Malebranche [ 56 ] portrayed culture and the various conceptualizations of the maternal role as barriers to women seeking help and treatment.

In the present study, marital status, nationality, current pregnancy status, healthy baby, postnatal problems, receiving support or treatment for PPD, having awareness of symptoms and risk factors of PPD, suffering from any disease or mental or psychiatric disorder, comfort discussing mental health with family, and experiencing cultural stigma or judgment about PPD in the community were the significant predictors of PPD. In agreement with Ahmed et al. [ 34 ], the final logistic regression model contained seven predictors for PPD symptoms: SES, history of depression, history of PPD, history of stressful conditions, familial support, unwanted pregnancy, and male preference.

PPD has been recognized as a public health problem and may cause negative consequences for infants. It is estimated that 20 to 40% of women living in low-income countries experience depression during pregnancy or the postpartum period. The prevalence of PPD shows a wide variation, affecting 8–50% of postnatal mothers across countries [ 19 ].

Strengths and limitations

Strengths of our study include its multinational scope, which involved participants from six different countries, enhancing the generalizability of the findings. The study also boasted a large sample size of 674 participants, increasing the statistical power and reliability of the results. Standardized measures, such as the Edinburgh Postnatal Depression Scale (EPDS), were used for assessing postpartum depression, ensuring consistency and comparability across diverse settings. Additionally, the study explored a comprehensive range of predictors and associated factors of postpartum depression, including demographic, obstetric, health-related, and psychosocial characteristics. Rigorous analysis techniques, including multiple logistic regression analyses, were employed to identify significant predictors of postpartum depression, controlling for potential confounders and providing robust statistical evidence.

However, the study has several limitations that should be considered. Firstly, its cross-sectional design limits causal inference, as it does not allow for the determination of temporal relationships between variables. Secondly, the reliance on self-reported data, including information on postpartum depression symptoms and associated factors, may be subject to recall bias and social desirability bias. Thirdly, the use of convenience sampling methods may introduce selection bias and limit the generalizability of the findings to a broader population. Lastly, cultural differences in the perception and reporting of postpartum depression symptoms among participants from different countries could influence the results.

Moreover, the variation in sample size and response rates among countries can be attributed to two main variables. (1) The methodology showed that the sample size was determined by considering several parameters, such as allocating proportionately to the mothers who gave birth and fulfilling the selection criteria during the data collection period served by each health center. (2) The political turmoil in Syria affects how often and how well people can use the Internet, especially because the data was gathered using an online survey link, leading to a relatively low number of responses from those areas. (3) Language barrier in Ghana: as we used the Arabic and English-validated versions of the EPDS, Ghana is a multilingual country with approximately eighty languages spoken. Although English is considered an official language, the primarily spoken languages in the southern region are Akan, specifically the Akuapem Twi, Asante Twi, and Fante dialects. In the northern region, primarily spoken are the Mole-Dagbani ethnic languages, Dagaare and Dagbanli. Moreover, there are around seventy ethnic groups, each with its own unique language [ 57 ]. (4) At the end of the data collection period, to avoid seasonal affective disorders, the meteorological autumn season began on the 1st day of September, which may be associated with autumm depressive symptoms that may confound or affect our results. Furthermore, the sampling methods were not universal across all Arabic countries, potentially constraining the generalizability of our findings.

Recommendations

The antenatal programme should incorporate health education programmes about the symptoms of PPD. Health education programs about the symptoms of PPD should be included in the antenatal program.

Mass media awareness campaigns have a vital role in raising public awareness about PPD-related issues. Mass media.

The ANC first visit history should elicit a family history of mental illness, enabling early detection of risky mothers. Family history of mental illness can be easily elicited in the ANC first visit history.

For effective management of PPD, effective support (from husband, friends, and family) is an essential component. For effective management of PPD effectiveness of support.

The maternal (antenatal, natal, and postnatal) services should be provided for free and of high quality The maternal (antenatal, natal, postnatal) services should be provided free and of high quality.

It should be stressed that although numerous studies have been carried out on PPD, further investigation needs to be conducted on the global prevalence and incidence of depressive symptoms in pregnant women and related risk factors, especially in other populations.

Around 14% of the studied mothers had PPD, and the frequency varies across different countries and half of them do not know. Our study identified significant associations and predictors of postpartum depression (PPD) among mothers. Marital status was significantly associated with PPD, with married mothers having lower odds of experiencing PPD compared to single mothers. Nationality also emerged as a significant predictor, with Yemeni, Syrian, and Iraqi mothers showing lower odds of PPD compared to Egyptian mothers. Significant obstetric, current pregnancy, and infant-related predictors included the pregnancy status, the health status of the baby, and the presence of postnatal problems. Among psychological and social predictors, receiving support or treatment for PPD, awareness of symptoms and risk factors, experiencing cultural stigma or judgment about PPD, and suffering from any disease or mental disorder were significantly associated with PPD. Additionally, mothers who were maybe more comfortable discussing mental health with family relatives had lower odds of experiencing PPD.

These findings underscore the importance of considering various demographic, obstetric, psychosocial, and coping factors in the identification and management of PPD among mothers. Targeted interventions addressing these predictors could potentially mitigate the risk of PPD and improve maternal mental health outcomes.

Data availability

Yes, I have research data to declare.The data is available when requested from the corresponding author [email protected].

Abbreviations

Adjusted Odds Ratio

• Postpartum depression

Primary Health Care centers

Socioeconomic Status

program (Statistical Package for Social Science

The Edinburgh Postnatal Depression Scale

The Neonatal Intensive Care Unit

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Acknowledgements

We would like to express our deep thanks to Rovan Hossam Abdulnabi Ali for her role in completing this study and her unlimited support. Special thanks to Dr. Mohamed Liaquat Raza for his role in reviewing the questionnaire. Moreover, we would like to thank all the mothers who participated in this study.

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Department of Public Health and Community Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Samar A. Amer

Department of Family Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Nahla A. Zaitoun

Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Heba A. Abdelsalam

Faculty of Medicine, Al-Azhar University, Damietta, Egypt

Abdallah Abbas

Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Mohamed Sh Ramadan

Hammurabi Medical College, University of Babylon, Al-Diwaniyah, Iraq

Hassan M. Ayal

Hardamout University College of Medicine, Almukalla, Yemen

Samaher Edhah Ahmed Ba-Gais

Department of General Medicine, Shadan Institute of Medical Science, Hyderabad, India

Nawal Mahboob Basha

College of Medicine, Sulaiman Alrajhi University, Albukayriah, Al-Qassim, Saudi Arabia

Abdulrahman Allahham

Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana Legon, Accra, Ghana

Emmanuael Boateng Agyenim

Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt

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Contributions

Conceptualization: Samar A. Amer (SA); Methodology: SA, Nahal A. Zaitoun (NZ); Validation: Mohamed Ramadan Ali Shaaban (MR), Hassan Majid Abdulameer Aya (HM), Samaher Edhah Ahmed Ba-Gais (SG), Nawal Mahboob Basha (NB), Abdulrahman Allahham (AbAl), Emmanuael Boateng Agyenim (EB); Formal analysis: Abdallah Abbas (AA); Data curation: MR, HM, SG, NB, AbAl, NZ, and EB; Writing original draft preparation: SA, Heba Ahmed Abdelsalam (HAA), and NZ; Writing review and editing: MR, AA, Walid Amin Elshrowby (WE); Visualization: SA, AA; Supervision: SA; Project administration: AA. All authors have read and agreed to the published version of the manuscript.

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All participants were provided with electronic informed consent after receiving clear explanations regarding the study’s objectives, data confidentiality, voluntary participation, and the right to withdraw. The questionnaire did not contain any sensitive questions, and data collection was performed anonymously. We affirm that all relevant ethical guidelines have been adhered to, and any necessary approvals from the ethics committee have been obtained. Approval was received from the ethical committee of the family medicine department, the faculty of medicine at Zagazig University, and from the patients included in the study. IRP#ZU-IRP#11079-8/10-2023.

Practicing ethical decision-making is crucial for providing clinical treatment. Such decisions are frequently made challenging due to a lack of knowledge and the mother’s ability to handle the associated complexities and uncertainties that affect the patient’s current level of functioning and ability to take care of her child. At the end of the survey, we raised concerns regarding the red flags, such as suicidal thoughts, and called for a revisit for the psychiatrist’s evaluation of the discussion of the risks, benefits, and alternatives to using medication.

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Amer, S.A., Zaitoun, N.A., Abdelsalam, H.A. et al. Exploring predictors and prevalence of postpartum depression among mothers: Multinational study. BMC Public Health 24 , 1308 (2024). https://doi.org/10.1186/s12889-024-18502-0

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DOI : https://doi.org/10.1186/s12889-024-18502-0

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• The Edinburgh postnatal depression scale (EPDS)
• Determinants
• Psychosocial

BMC Public Health

ISSN: 1471-2458

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Timing of Postpartum Depressive Symptoms

ORIGINAL RESEARCH — Volume 20 — November 9, 2023

Cheryl L. Robbins, PhD 1 ; Jean Y. Ko, PhD 1 ,2 ; Denise V. D’Angelo, MPH 1 ; Beatriz Salvesen von Essen, MPH 1 ; Connie L. Bish, PhD 1 ; Charlan D. Kroelinger, PhD 1 ; Heather D. Tevendale, PhD 1 ; Lee Warner, PhD, MPH 1 ; Wanda Barfield, MD, MPH 1 ( View author affiliations )

Suggested citation for this article: Robbins CL, Ko JY, D’Angelo DV, Salvesen von Essen B, Bish CL, Kroelinger CD, et al. Timing of Postpartum Depressive Symptoms. Prev Chronic Dis 2023;20:230107. DOI: http://dx.doi.org/10.5888/pcd20.230107 .

PEER REVIEWED

Introduction

Acknowledgments, author information.

What is already known on this topic?

Postpartum depression is common and can last long-term. Few studies have examined depressive symptoms late (9–10 months) in the postpartum period.

What is added by this report?

We found 7.2% of postpartum women had depressive symptoms at 9 to 10 months after giving birth, 57.4% of whom did not have postpartum depressive symptoms at 2 to 6 months after giving birth. About 3.1% had symptoms of depression at both times.

What are the implications for public health practice?

Screening for depression throughout the first postpartum year can identify women who are not symptomatic early postpartum but later develop symptoms.

Postpartum depression is a serious public health problem that can adversely impact mother–child interactions. Few studies have examined depressive symptoms in the later (9–10 months) postpartum period.

We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods.

Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression.

Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Postpartum depression is a serious public health problem that can have long-lasting and multigenerational consequences (1). A systematic review of published literature (2005–2016) provides evidence of the negative effects of postpartum depression on maternal health, including relationships, risky behaviors, and quality of sleep; infant cognitive and language development; and mother–child interactions, including bonding and breastfeeding (2). In its most severe form, postpartum depression can result in obtrusive thoughts of and attempts at suicide or infanticide (2). Although suicide has many contributing factors, pregnancy-related mental health deaths (including deaths from suicide, overdose/poisoning related to substance use disorder, and other deaths determined to be related to a mental health condition) account for more than 20% of all pregnancy-related deaths in the US and are the leading cause of preventable pregnancy-related deaths (3).

Postpartum depression is self-reported in approximately 12% to 16% of US women (4). Co-occurring anxiety (5) and substance use (6) are common and can complicate diagnosis and treatment. Population-based studies examining correlates of postpartum depressive symptoms (PDS) have mostly focused on the first 2 to 6 months postpartum (7,8). Professional guidelines on depression during and after pregnancy also focus on screening for depressive symptomology during that period (9,10).

Epidemiologic studies have examined correlates of depressive symptoms later in the postpartum period (11–13), but most studies were based on data from a single state (12,13); one study was based on a nationally representative sample of individuals who gave birth in 2005 (11). Examination of characteristics associated with depression or depressive symptoms in the later postpartum period is important because more than 60% of pregnancy-related deaths due to mental health conditions occur 43 to 365 days postpartum (14). The objectives of this study were to estimate the prevalence and identify the correlates of PDS at 9 to 10 months and estimate the prevalence of PDS at both 2 to 6 months and 9 to 10 months, by using population-based data from 7 states in 2019.

We analyzed population-based data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing survey (hereinafter referred to as the PRAMS Core Survey) that routinely collects jurisdiction-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. In 2019, forty-seven states, the District of Columbia, New York City, and Puerto Rico participated in PRAMS. Each month, a random sample of women with a recent live birth is selected from birth certificate records and is contacted 2 to 6 months after delivery. Participants respond to the PRAMS Core Survey via mail (self-administered) or, among those who do not respond by mail, by telephone (interviewer-administered); the median time from initial outreach to participation was 4 months. The PRAMS Core Survey is implemented through a standardized protocol and questionnaire, described elsewhere (15). Additional details are available from the PRAMS website (www.cdc.gov/prams).

In 2019, PRAMS implemented 2 surveys related to illicit use of opioids and prescription opioid use and misuse, which included a 13-question supplemental module on prescription opioid use and misuse during pregnancy (hereinafter referred to as the Opioid Supplement) and a 58-question telephone follow-up survey 9 to 10 months postpartum (hereinafter referred to as the Call-Back Survey) (16). Thirty-two PRAMS sites and 2 non-PRAMS sites (California and Ohio) implemented the Opioid Supplement (16). The Call-Back Survey was a telephone-only survey that used standardized PRAMS telephone interview procedures for data collection (15) and was fielded in 7 PRAMS sites with high rates of opioid-involved overdose deaths (Kentucky, Louisiana, Massachusetts, Missouri, Pennsylvania, Utah, and West Virginia). Respondents to the PRAMS Core Survey in the 7 jurisdictions were recontacted by telephone to participate in the Call-Back Survey 9 months after the infant’s birth. Respondents had a 31-day window for completing the questionnaire (until 10 months postpartum). All PRAMS respondents in the 7 states were eligible for the Call-Back Survey unless they opted out of being recontacted. Data collection for the Call-Back Survey occurred October 2019 through April 2020.

For this analysis, we linked data from the Call-Back Survey for the 7 sites with the sites’ PRAMS Core Survey data, which includes birth certificate data. The weighted response rates for the 7 participating states ranged from 49% to 73% (median = 58%) for the 2019 PRAMS Core Survey and 45% to 70% (median = 59%) for the Call-Back Survey. The analytic sample included women with data on PDS at 9 to 10 months ( Figure 1 ). The Centers for Disease Control and Prevention (CDC) and each site’s institutional review board reviewed and approved the PRAMS study protocol.

We assessed self-reported PDS at 9 to 10 months (yes/no) by using a modified version of the 2-item Patient Health Questionnaire (PHQ-2), which aligns with definitions of PDS used in previous surveillance reports (7,8). Two questions assessed frequency of depressive symptoms (always, often, sometimes, rarely, and never) in the past 30 days: 1) “how often have you felt down, depressed, or hopeless?” and 2) “how often have you had little interest or little pleasure in doing things?” We defined PDS at 9 to 10 months as responses of always or often to either question. We also examined PDS at both time points, at 2 to 6 months and at 9 to 10 months, hereinafter referred to as PDS at both time periods.

Sociodemographic characteristics

We obtained information on sociodemographic characteristics from the linked birth certificate data, including maternal age (≤24, 25–34, ≥35 y), race and ethnicity (Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, and non-Hispanic Other race [included American Indian, multiple races, and other non-White race; no respondents self-identified as Native Hawaiian or Alaska Native]), number of years of education (<12, 12, >12 y), and marital status (married, not married). Information on postpartum health insurance (none, Medicaid, private, other) was self-reported on the Call-Back Survey.

Perinatal mental health characteristics

Respondents retrospectively self-reported depression 3 months before pregnancy (yes/no) and depression during pregnancy (yes/no) at the time of the PRAMS Core Survey. On the basis of those responses, we created a binary variable to reflect depression before or during the most recent pregnancy (hereinafter referred to as prior depression). Self-reported PDS at 2 to 6 months (yes/no) was assessed at the time of the PRAMS Core Survey by using the same modified version of the PHQ-2 and definition of PDS that were used to define PDS at 9 to 10 months. However, the questions for PDS at 2 to 6 months asked about depressive symptoms since the baby was born (not in the past 30 days). Current anxiety at 9 to 10 months (yes/no) was self-reported at the time of the Call-Back Survey and was assessed by using the prompt “Do you currently have any of the following health conditions [5 items, including anxiety, were listed]?” Respondents who answered yes to the question on anxiety were considered to have anxiety.

Postpartum substance use

Postpartum substance use was assessed by self-report at the time of the Call-Back Survey (9–10 months). Postpartum smoking (yes/no) was assessed by using the following prompt: “Since your baby was born, have you used cigarettes, e-cigarettes, or any other tobacco products?” We evaluated postpartum alcohol consumption by using responses to the following questions: “Since your baby was born, how many alcoholic drinks did you have in an average week?” and “Since your baby was born, how many times did you drink 4 alcoholic drinks or more in a 2-hour time span?” Heavy drinking or binge drinking (yes/no) was defined as consuming 8 or more alcoholic drinks (ie, wine, wine cooler, beer, liquor, or mixed drinks) per week or 4 or more alcoholic drinks in a 2-hour time span. Postpartum marijuana or cannabidiol use (yes/no) was assessed by using the prompt “Since your baby was born, have you used any of the following medications or drugs for any reason?” The list included 15 types of medications and drugs, including marijuana or hash, cannabidiol, or cannabidiol products.

We calculated the prevalence and 95% CIs of PDS at 9 to 10 months overall and by maternal characteristics (ie, sociodemographic, perinatal mental health, and postpartum substance use). We examined prior depression among those with and without PDS at both time periods. We used unadjusted prevalence ratios (PRs) to examine associations between maternal characteristics and PDS at 9 to 10 months; we considered a P value <.05 to be significant. Sample size constraints did not permit multivariate regression modeling. Missing data on maternal characteristics ranged from 0% (age) to 2.0% (self-reported depression during pregnancy) and were excluded from analyses. We conducted all analyses in Stata version 17.0 (StataCorp LLC) and used weighted data to calculate percentages, adjusting for the complex survey design, sampling design, nonresponse, and noncoverage specific to the births within the sampling period of the Call-Back Survey.

Of 1,954 participants in the analytic sample, approximately one-quarter (24.8%; n = 464) reported prior depression (before or during pregnancy) ( Table 1 ). The prevalence of PDS at 2 to 6 months was 11.9% (n = 269); at 9 to 10 months, 7.2% (n = 161); and at both time periods, 3.1% (n = 75). The prevalence of PDS at 9 to 10 months ranged by PRAMS site from 3.8% (Massachusetts) to 12.4% (West Virginia). Most of the sample was aged 25 years or older (81.2%) and had 12 or more years of education (91.2%) ( Table 1 ). PDS at 9 to 10 months was positively associated with being younger than 24 years (PR = 2.30; 95% CI, 1.42–3.72), non-Hispanic Black (PR = 1.82; 95% CI, 1.10–3.00), and not married (PR = 1.77; 95% CI, 1.13–2.80); having postpartum Medicaid insurance (PR = 2.34; 95% CI, 1.44–3.81); and reporting prior depression (PR = 4.03; 95% CI, 2.53–6.42), current postpartum anxiety (PR = 3.58; 95% CI, 2.20–5.83), postpartum smoking (PR = 2.67; 95% CI, 1.62–4.39), and postpartum marijuana or cannabidiol use (PR = 3.35; 95% CI, 1.81–6.22) ( Table 2 ). PDS at 9 to 10 months was negatively associated with having more than 12 years of education (PR = 0.51; 95% CI, 0.28–0.91).

Of the 161 respondents with PDS at 9 to 10 months, 86 (57.4%; 95% CI, 45.7%–68.4%) did not report PDS at 2 to 6 months ( Figure 2 ). Of the 75 respondents who reported having PDS at both time periods, 54 (68.5%; 95% CI, 51.2%–81.9%) had prior depression (before or during pregnancy), whereas of the respondents who did not have PDS at both time periods, 403 (23.4%; 95% CI, 20.4%–26.6%) reported prior depression.

In this population-based study of women with live births in 7 US states with high rates of opioid-involved overdose deaths, we found that approximately 1 in 15 women with a recent live birth reported PDS at 9 to 10 months (7.2%) and 11.9% reported PDS at 2 to 6 months. More than half of women with PDS at 9 to 10 months (57.0%) reported having prior depression (before or during pregnancy). Notably, more than half (57.4%) of women with PDS at 9 to 10 months did not report depressive symptoms earlier in the postpartum period (ie, at 2–6 months). We also found that overall, 3.1% of women had PDS at both time periods, and more than two-thirds (68.5%) of those women reported having prior depression.

Our findings on the prevalence of PDS and PDS at both time periods are generally consistent with previously published literature. We used a modified version of the PHQ-2 to assess PDS, and our prevalence estimate of PDS at 9 to 10 months (7.2%) is within the range of other US cohort studies that examined depressive symptoms at 12 months postpartum (range 5%–8%) (12,13). Our finding that 3.1% of women had PDS at both time periods is slightly lower than estimates of persistent perinatal depression from other US studies that followed women for 2 to 3 years postpartum (range 5%–8%) (13,17). Compared with our study, all 3 prior studies were conducted in different locales, during different time periods, and used different depression assessment instruments (12,13,17). For example, Mora and colleagues followed inner-city women living in Pennsylvania from their pregnancy (in 2000–2002) through 2004 and assessed depressive symptomology by using the Center for Epidemiologic Studies Depression Scale (CES-D) (18), with a score of 16 or more suggestive of clinical depression risk (17). Another study, also based in Pennsylvania (12), used data from The First Baby Study (2009–2011) and defined depression as a score of 12 or more on the Edinburgh Postnatal Depression Scale (EPDS) (19). The third study used data from the population-based birth cohort in the Upstate KIDS study in New York State (13), collected data during 2008–2010, and reported mean scores from the EPDS-5 instrument (20). That study reported the prevalence of moderate depressive symptoms by using a cut-off score of 7 or more (13).

The clinical course of perinatal depressive symptom severity and duration varies from person to person, and persistent depressive symptoms can last well beyond the perinatal period (21). One study reported that up to one-quarter of women have elevated depressive symptoms at some point during the 3 years postpartum (13), and another study estimated that one-fifth of mothers continued having depressive symptoms up to 21 years after giving birth (22). Differences in the prevalence and trajectories of PDS have been attributed to the absence of a standardized approach to screening instruments, cutoff scores used for defining depression, and time points of assessment (21).

In line with previous findings, we showed that prior depression (21), comorbid anxiety (5), and substance use (ie, tobacco, marijuana, or cannabidiol use) (6) were associated with PDS. Our estimate of prior depression before or during pregnancy (57.0%) among women with PDS at 9 to 10 months was similar to the estimate from a large screening study at an urban obstetric hospital; the study reported that 60% of women with postpartum depression at 4 to 6 weeks postpartum entered pregnancy with depression or first developed it during pregnancy (23). Consistent with previous findings, we found that rates of postpartum anxiety, smoking, and marijuana or cannabidiol use at 9 to 10 months were higher among women who reported PDS than among those without PDS (5,24).

Our findings highlight the importance of ongoing care and care coordination in the later postpartum period (10,25). Pregnancy-related mental health deaths account for more than 20% of all pregnancy-related deaths in the US and are a leading cause of preventable, pregnancy-related deaths (3). Moreover, from 2008 to 2017, more than 60% of pregnancy-related mental health deaths occurred 43 to 365 days postpartum (14), which speaks to the opportunity for health care providers to ask patients if they have been pregnant in the past year, as promoted in CDC’s Hear Her campaign, to identify urgent maternal warning signs (26).

Clinical guidance for mental health and substance use screening exists for adults in general and specifically for the perinatal period (9,10,27,28). The American College of Obstetricians and Gynecologists’ (ACOG’s) clinical guidelines currently recommend depression, anxiety, and substance use screening at least once during the postpartum period (before 12 weeks postpartum) and transition to follow-up and ongoing care in a primary medical home (10,25). The American Academy of Pediatrics (9) recommends routine screening for maternal postpartum depression during pediatric visits throughout the first 6 months postpartum. The Health Resources and Services Administration’s Screening and Treatment for Maternal Depression and Related Behavioral Disorders program aims to heighten awareness of the importance of screening for maternal mental health conditions, including postpartum anxiety, substance use, and postpartum depression (29). Yet, barriers to postpartum depression screening and treatment remain.

Lack of insurance coverage is a barrier to care for physical and mental health conditions that require ongoing monitoring and care after giving birth (30). Medicaid expansion can increase health insurance coverage to support these important screenings beyond the initial postpartum checkup (25,31). Continuous health insurance coverage through 12 months postpartum can support management of chronic conditions, including depression, after the initial postpartum checkup through coverage of ongoing care (25,31). State Medicaid expansion is associated with improvements in perinatal mental health (32,33). Federal law requires that states extend pregnancy-related Medicaid eligibility from conception through 60 days postpartum for women with household incomes up to the federal minimum standard of 133% of the federal poverty level (34). To address gaps in health insurance coverage during the postpartum period, states also may extend pregnancy-related Medicaid coverage to 12 months postpartum under the American Rescue Plan (35).

Our study contributes to the growing literature that establishes perinatal depressive symptoms can last or even develop well beyond the early postpartum period. It also adds to the evidence of characteristics associated with PDS in the later postpartum period (11–13). By linking data from a one-time call-back survey with routine surveillance data, we demonstrated how existing surveillance systems can be augmented to monitor chronic conditions such as PDS in the later postpartum period and related comorbidities. Similarly, data linkages could capture longitudinal data to examine other predictors of developing depression later in the postpartum period. Future research can examine associations with delivery complications, severe maternal morbidity, and the social determinants of health that underlie structural causes of inequalities in postpartum depression. For example, studies can improve our understanding about how access to educational and employment opportunities and quality health care can affect postpartum depression, particularly PDS, that lasts into the later postpartum period. Other social determinants of health that can be examined in the context of postpartum depression include housing insecurity, food insecurity, neighborhood safety, racial and ethnic discrimination, and other experiences of racism.

Strengths and limitations

Our study has several strengths. It adds to the limited literature of epidemiologic studies that have examined depressive symptoms later in the postpartum period (11–13) and demonstrates that innovations to augment surveillance systems can be helpful for monitoring chronic conditions such as persistent postpartum depression and related comorbidities. Additionally, the study used data from PRAMS, which had high response rates and small percentages of missing data. However, our findings are subject to limitations. First, depressive symptoms were self-reported on the PHQ-2 and do not necessarily reflect a diagnosis of depression. However, the PHQ-2 has been shown to have high sensitivity (84%) and specificity (79%) for identifying postpartum depression (36). Second, social desirability bias may have resulted in underreporting of stigmatized maternal behaviors and experiences, such as depression and substance use. Third, because of small sample sizes and the relatively small percentage of participants with PDS at both time periods, the data did not permit multivariate regression modeling or comprehensive examination of correlates with that outcome. Small sample sizes also did not permit further examination of PDS by race and ethnicity. Large longitudinal studies with nationally representative data are needed to facilitate multivariable regression analyses that can disentangle the complex relationships between PDS and the correlates examined in this study as well as others, such as social determinants of health. Finally, our results may not be generalizable beyond the study sites. The data represent only women with a recent live birth in the 7 PRAMS sites that implemented the Opioid Supplement and the Call-Back Survey, which used methods during 2019 to oversample counties with high rates of opioid-involved overdose deaths. The findings do not reflect the prevalence of depressive symptoms among women in other parts of the US or women who had other pregnancy outcomes. Additionally, the PRAMS Core Survey and the Call-Back Survey occurred during the early phases of the COVID-19 pandemic, which was associated with increases in psychological distress and depression among the general population (37). Given that timing, estimates of depressive symptoms may be inflated.

Conclusions

Our findings, that more than half of women with PDS at 9 to 10 months did not report symptoms earlier in the postpartum period and that 3 in 5 women with PDS at 9 to 10 months had comorbid anxiety symptoms, underscore the importance of screening for depression, anxiety, and substance use throughout the perinatal period (10,28,29).

The authors gratefully acknowledge the analytic contributions of Madison Levecke, MPH, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), CDC, and the Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee; and the Pregnancy Risk Assessment Monitoring System (PRAMS) Working Group members: Tracey D. Jewell, Kentucky; Rosaria Trichilo, Louisiana; Hafsatou Diop, Massachusetts; Venkata Garikapaty, Missouri; Sara E. Thuma, Pennsylvania; Nicole Stone, Utah; Melissa Baker, West Virginia. We also thank the PRAMS Team, Women’s Health and Fertility Branch, Division of Reproductive Health, NCCDPHP, CDC.

The authors have no conflicts of interest to report. No financial support was received for this work. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of CDC. No copyrighted materials were used in this research or article.

Corresponding Author: Beatriz Salvesen von Essen, MPH, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, MS S107-2, Atlanta, GA 30341-3717 ( [email protected] ).

Author Affiliations: 1 Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. 2 US Public Health Service Commissioned Corps, Atlanta, Georgia.

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a Postpartum depressive symptoms at 9 to 10 months defined as feeling down, depressed, hopeless, or having little interest or pleasure in doing things usually enjoyed (always or often) in the past 30 days as self-reported at time of Call-Back Survey 9 to 10 months. b Pregnancy Risk Assessment Monitoring System (PRAMS) Core Survey and Call-Back Survey data from Kentucky, Louisiana, Massachusetts, Montana, Pennsylvania, Utah, and West Virginia; prevalence ratios weighted to adjust for the complex survey design, sampling design, nonresponse, and noncoverage specific to the births within the sampling period of the Call-Back survey. c Percentages are based on number of respondents for whom we had data; percentages may not sum to 100.0 because of rounding. d Information obtained from birth certificates. e Includes American Indian, Other race, and multiple race. f Based on self-report at time of the Call-Back Survey 9 to 10 months. g Defined as depression 3 months before pregnancy or during pregnancy; based on self-report at time of PRAMS Core Survey (2 to 6 months postpartum). h Defined as drinking ≥8 drinks/week or having ≥4 drinks in a 2-hour span since baby was born. i Defined as using marijuana or hash, cannabidiol, or cannabidiol products since baby was born.

a Postpartum depressive symptoms at 9 to 10 months defined as feeling down, depressed, hopeless, or having little interest or pleasure in doing things usually enjoyed (always or often) in the past 30 days as self-reported at time of Call-Back Survey 9 to 10 months. b Pregnancy Risk Assessment Monitoring System (PRAMS) Core Survey and Call-Back Survey data from Kentucky, Louisiana, Massachusetts, Montana, Pennsylvania, Utah, and West Virginia; prevalence ratios weighted to adjust for the complex survey design, sampling design, nonresponse, and noncoverage specific to the births within the sampling period of the Call-Back Survey. c Information obtained from birth certificates. d Includes American Indian, Other race, and multiple race. e Based on self-report at time of the Call-Back Survey 9 to 10 months. f Defined as depression 3 months before pregnancy or during pregnancy; based on self-report at time of PRAMS Core Survey (2 to 6 months postpartum). g Defined as drinking ≥8 drinks/week or having ≥4 drinks in a 2-hour span since baby was born. h Defined as using marijuana or hash, cannabidiol, or cannabidiol products since baby was born.

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Multidimensional influencing factors of postpartum depression based on the perspective of the entire reproductive cycle: evidence from western province of China

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• Published: 24 May 2024

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• Yiyun Zhang 1 ,
• Xinwei Liu 2 ,
• Mengmei Liu 3 ,
• Ping Chen 3 ,
• Guanghong Yan 3 ,
• Qingyan Ma 3 ,
• Ye Li 4 &
• Dingyun You 5  

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China has a serious burden of Postpartum depression (PPD). In order to improve the current situation of high burden of PPD, this study explores the factors affecting PPD from the multidimensional perspectives with physiology, family support and social support covering the full-time chain of pre-pregnancy–pregnancy–postpartum.

A follow-up survey was conducted in the Qujing First People’s Hospital of Yunnan Province from 2020 to 2022, and a total of 4838 pregnant women who underwent antenatal checkups in the hospital were enrolled as study subjects. Mothers were assessed for PPD using the Edinburgh Postnatal Depression Scale (EPDS), and logistic regression was used to analyse the level of mothers’ postnatal depression and identify vulnerability characteristics.

The prevalence of mothers’ PPD was 46.05%, with a higher prevalence among those who had poor pre-pregnancy health, had sleep problems during pregnancy, and only had a single female fetus. In the family support dimension, only family care (OR = 0.52, 95% CI 0.42–0.64) and only other people care(OR = 0.78, 95% CI 0.64–0.96) were the protective factors of PPD. The experience risk of PPD was higher among mothers who did not work or use internet.

The PPD level in Yunnan Province was significantly higher than the global and Chinese average levels. Factors affecting mothers’ PPD exist in all time stages throughout pregnancy, and the influence of family support and social support on PPD shouldn’t be ignored. There is an urgent need to extend the time chain of PPD, move its prevention and treatment forward and broaden the dimensions of its intervention.

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Introduction

Postpartum depression (PPD) is caused by a combination of factors in the pre-pregnancy, pregnancy, and postpartum periods. It is one of the most prevalent and disabling but most underappreciated complications in women of childbearing age [ 1 ]. PPD not only leads to mothers’ morbidity in forms of guilt, fatigue, loss of appetite and sleep disorder. It also adversely affects the health and well-being of the newborn, partners and other family members, disrupting infant care and family dynamics [ 2 ]. PPD is experienced by women around the world, making it an important public health issue [ 3 ]. Globally, about 10–15% of the mothers suffered PPD in the postpartum period, while the prevalence of PPD was about 9.4% to 27.4% in China [ 4 ]. PPD is not only affected by physiological factors such as changes in hormone and immune levels but also affected by traditional Chinese fertility culture [ 5 ]. Chinese mothers are subject to higher levels of family and social intervention. Moreover, 40% of women who have experienced PPD will experience depression again in their lifetime; nearly 50% will experience PPD again in subsequent pregnancies [ 6 ].

Mothers are vulnerable to depression due to a combination of psychological and social attributes [ 7 , 8 ]. In the case of depression, mothers’ treatment options are limited by the potential adverse effects of medications on the baby [ 9 ]. Therefore, early preconception identification, intervention and elimination of risk factors for PPD are particularly important for both mothers and newborns. However, previous studies have mostly focused on capturing risk factors for mothers’ depression during pregnancy and postpartum [ 10 , 11 , 12 , 13 ], without fully considering the time-cumulative characteristics of PPD, lacking analyses of factors such as pre-pregnancy health and pre-pregnancy preparation, and the nodes of concern have not covered the full chain of the pregnancy cycle. It was also found that previous studies have explicitly explored the mechanism of physiological factors influencing PPD [ 14 , 15 ], and although some studies have also paid attention to the impact of multidimensional factors such as family support and social risk on PPD [ 16 , 17 ], the mechanisms of influence remain unclear.

Generally, this study takes pre-pregnancy, pregnancy and post-pregnancy as analysis nodes to identify the vulnerability gap of PPD in the whole-time chain, comprehensively considers the multi-attribute characteristics of the disease, and explores the influencing mechanism of PPD based on multiple dimensions of socio-demographic, family support and social support.

Study sample

The study subjects were pregnant women undergoing prenatal care at Qujing First People’s Hospital Inclusion Criteria: have reading comprehension and communication skills, voluntarily participate in the survey and complete the questionnaire. Exclusion criteria: stillbirth, birth defects, miscarriage, lack of information, etc. The total of 4838 participants were included in this study after deleting missing values and abnormal values.

Questionnaire and content

A self-designed questionnaire was used to collect demographic data on pregnant women and information on depression during postpartum. The demographic data of pregnant women include: residence, marital status, pre-pregnancy health status, whether trained in pregnancy knowledge, whether the pregnancy reaction is intense, single or double fetus, sleep, gestational weeks of childbirth, depression score, infant gender, infant birth weight, type of care, work, and Internet use.

Screening tools for PPD

Depressive symptoms are assessed using the EPDS, which is widely used to screen for PPD. The scale assesses the intensity of depressive symptoms in the past 7 days, and contains a total of 10 items, each of which is divided into “never”, “occasionally”, “often”, and “always” according to the intensity of depressive symptoms, corresponding to “0 points”, “1 point”, “2 points”, and “3 points”. The total score ranges from 0 to 30 points, and the higher the score, the more severe the depressive symptoms. In this study, participants were divided into depressive (≥ 12) and non-depressive (< 12) groups using 12 points as cut-off values.

Model variable

The dependent variable in this study was PPD.

The covariates included in this study were socio-demographic factors (residence and marital status), pre-pregnancy factors (pre-pregnancy health status and whether trained in pregnancy knowledge), pregnancy factors (whether the pregnancy reaction is intense, single or double fetus, sleep, and gestational weeks of childbirth), postpartum factors (gender of the infant, birth weight of the infant), family support factors (type of care), and social support factors (work and internet use).

Statistical analysis

The study used SPSS 22.0 for descriptive statistics analysis. Firstly, each risk factor was individually tested for variability. Secondly, using logistic regression model, all significant risk factors were subjected to multivariate logistic regression, in order to assess the risk factors for PPD. The results of the study were expressed as odds ratio (OR) and 95% confidence interval (CI). A p-value of less than 5% was considered statistically significant in all tests.

Sample characteristics

Table 1 presents the basic information of all participants. More than half of the participants lived in the city (67.16%); participants’ marital status was mostly married (88.90%). 92.35% of the participants reported having good pre-pregnancy health conditions; the percentage of attending pregnancy knowledge training was relatively balanced, with 58.60% of participants attending and 41.40% not attending. In the pregnancy period, about one-third of the participants reported that they had severe pregnancy reactions (34.15%); only a small percentage of the mothers gave birth to double fetuses (1.84%); the percentage of the participants who had normal sleep was 59.1%, while 18.44% often insomnia or sleep poorly and 22.53% somnolence; and the majority of the mothers gave birth at full term (93.12%). In the postpartum period, the prevalence of PPD was 46.05%, single fetus only with the gender of the infant was female or male was more prevalent in the variable of the infant gender, their values respectively were 47.15% and 52.07%, and the majority of the newborns weighed from 2.5 to 4.5 kg (90.51%). In the family support and social support dimensions, the types of care were more prevalent in the type only by family members and only by other people, at 32.68% and 32.74% respectively; about half of the participants went to work (56.24%); and 98.51% of the participants reported going online.

Postpartum depression profiles

In the total sample (n = 4838), 2610 (53.95%) mothers had an EPDS score of < 12 and 2228 (46.05%) had an EPDS score ≥ 12. Therefore, the prevalence of PPD was 46.05%.

Table 2 presents the association of sociodemographic, family support and social support dimensions factors with PPD. Grouped by marital status, the prevalence of PPD was 51.40% in the unmarried group and 45.38% in the married group. The prevalence of PPD was higher in women with excessively low and excessively high family support, women cared by only family members and only others were relatively less affected by PPD. Women with low social support experienced higher levels of PPD and those who had social support experienced less depression, this is related to the shift from family to society of women’s attention.

Table 3 presents the relationship between factors and PPD throughout pregnancy. The PPD prevalence of the women with good pre-pregnancy health was 44.49% and it was 64.86% of those with poor pre-pregnancy health; the prevalence of PPD was higher in women with pregnancy knowledge training (48.71%), compared with that in those without training. The experience risk of PPD was lower in women with severe pregnancy reactions (43.04%) than in women with normal pregnancy reactions (47.61%); and it was lower in women with normal sleep, relative to those with frequent insomnia or poor sleep (61.32%), and somnolence (51.74%). In infant gender, the prevalence of PPD was particularly high among women with double fetuses that both infant gender were female (80.00%).

Binary logistic regression analysis of influencing factors of PPD

Figure  1 shows the results of binary logistic regression analysis of socio-demographic, whole pregnancy, family support, and social support dimensions with PPD. In the sociodemographic dimension, the marital status of married and unmarried did not show a significant difference. In the pre-pregnancy period, women with poor pre-pregnancy health were 2.12 times more likely to experience PPD than the reference category (good pre-pregnancy health); women who received pregnancy knowledge training (OR = 1.18, 95% CI 1.04–1.35) had a higher experience risk of PPD compared to the reference group. In the pregnancy period, intense pregnancy reactions were a protective factor against PPD for women; having normal sleep was important in protecting women from depression. Compared to the experience risk of PPD in women with normal sleep, those who had often insomnia or sleep poorly were 2.36 times more likely to occur, and those who had somnolence were 1.51 times more likely to occur. In the postpartum period, the variable of infant gender showed a significant difference between only single female fetus and double fetuses with one male and one female infant, double fetuses with one male and one female infant (OR = 0.15, 95% CI 0.03–0.69) was a protective factor against mothers’ PPD compared to single fetus with female infant. In the family support dimension, being cared only by family members (OR = 0.52, 95% CI 0.42–0.64) and being cared only by other people (OR = 0.78, 95% CI 0.64–0.96) were protective factors for PPD compared to being cared by no one, and women cared by no one were more susceptible to the effects of PPD. The variables in the social support dimension were all significantly different, the women who lack social support were more likely to be affected by PPD, and going to work (OR = 0.87, 95% CI 0.77–0.99), going online (OR = 0.48, 95% CI 0.29–0.81) were protective factors for women’s PPD.

Risk factor analysis for PPD in sociodemography–whole pregnancy–family support–social support dimension

We assessed the prevalence of PPD in Yunnan Province, China, and explored the associations between the full-time chain of pre-pregnancy–pregnancy–postpartum, sociodemographic–family support–social support, and PPD. We also expanded the time chain of PPD research, breaking through the causal mechanism of PPD occurrence beyond just physiological or social dimension. We realised the dynamic capture of PPD under the full-time chain, and mapped the vulnerability characteristics atlas of PPD from a multidimensional perspective. The study revealed a high prevalence of 46.1% for PPD in Yunnan Province, which is significantly higher than global (17.22%) and Chinese regional (21.4%) averages [ 18 , 19 ]. Similar trends were observed when side-by-side comparing with cities such as Shanghai (23.2%) and Guangzhou (27.37%) [ 20 , 21 ]. Traditional Chinese cultural beliefs regarding unique family dynamics and gender roles may lead to increased family conflicts and closed social networks [ 22 ], while China’s rapid economic growth has escalated life stress and elongated work hours [ 23 ]. Yunnan Province’s economy is relatively underdeveloped and the scarcity of healthcare resources led to mental health issues being easily neglected. In this study, the average age of childbearing for women was 34 years old. Considering the higher age of childbearing, concerns over medical risks contribute to an increased psychological burden [ 24 ]. These factors all contributed to the severe situation of PPD in Yunnan Province. Based on the full-time chain perspective, the PPD prevalence was higher among mothers with poor pre-pregnancy health (64.86%) and sleep problems during pregnancy (often insomnia, sleep poorly: 61.32%; somnolence: 51.74%); and mothers with double fetuses of one male and one female infant had better mental health status after giving birth. In the multidimensional analysis, only family care and only other people care were positive factors for PPD in the family support dimension; going to work or going online had a protective effect on mothers’ health.

Prevention and treatment of PPD should focus on the whole pre-pregnancy–pregnancy–postpartum period and extend the intervention chain.

The PPD experience risk of women with poor pre-pregnancy health was (2.12 times) higher than women with good. This result is consistent with the findings of Michael W. O'Hara et al. [ 25 ]. In the pre-pregnancy period, mothers had a previous depression history or possible comorbidities such as hypertension, diabetes, gynecological disorders, with a low physical health level [ 26 , 27 ]; and in the postpartum period, they suffered from fatigue, pain in wounds, and weakness [ 28 , 29 ]. The multiple discomforts superimposition makes mothers more prone to postpartum psychiatric problems, such as anxiety, depression, and despondency. Notably, mothers with pregnancy knowledge training were more likely to experience PPD. The possible reason is the mothers with pregnancy knowledge training were more aware of the psychological and physiological changes, that occur during pregnancy and the postpartum period, and they were more likely to think what may cause unnecessary tension, anxiety, and uneasiness [ 30 , 31 ]. And this increased the PPD experience risk. During the pregnancy period, often insomnia or sleep poorly/somnolence hurt mothers; Some studies have indicated that mothers who sleep 6 h or less were more likely to experience PPD, and sleeping more than 8 h did not significantly decrease the PPD prevalence [ 32 ]. The major neurotransmitter systems in the brain involved in regulating sleep have been linked to the development of psychiatric disorders [ 33 ]. Therefore, neurotransmitter imbalances can lead to PPD increase. In the postpartum period, twin births of a male and a female infant were a protective factor compared to having only single female infant. In the context of traditional Chinese fertility culture, family members may show some negative reactions to female infants’ birth, that may result in less support for mothers giving birth to a female fetus; whereas a preference for male fetus may be communicated to mothers, and ease their postpartum stress [ 34 ]. Additionally, lower marital satisfaction following the birth of female fetus may explain for the increased risk of PPD among the mothers with female fetus. Family members should be well-informed about pregnancy-related matters and offer psychological support to pregnant women. mothers need to maintain a healthy lifestyle and engage in activities that alleviate stress. After childbirth, the focus should shift from solely preventing PPD to prevention and treatment. Nursing interventions are provided to mothers without PPD. Receiving prompt follow-up visits and developing personalized treatment plans is crucial for individuals who have suffered from PPD.

The prevention and treatment of PPD are inseparable from the dual support of family and society, with social support playing an increasingly prominent role.

In terms of family support, only family care and only other care were protective factors of PPD. Family care is the main resource of family support [ 35 ]. Family not only provides tangible support such as material and financial support, but also offer mental support from family members, especially husbands, which greatly enhances mothers’ self-esteem and self-confidence, alleviating tension and stress during various pregnancy stages. In addition to family members, medical personnel, friends and colleagues also influence mothers by providing information support, emotional accompaniment and value recognition [ 36 , 37 ]. In terms of social support, going to work or going online can reduce the risk of PPD, it not only increases mothers’ self-efficacy, but also provides the understanding and appreciation they need as they transition to motherhood [ 38 ]. The social climate in social networks reflects a stigma associated with mental health problems, which acts as a barrier to seeking professional help for mothers. However, positive social behaviours can enhance cognitive abilities of mental health problems, overcome perceptual barriers and help-seeking intentions, and reduce the stigma of mental illness [ 39 ]. Family support for mothers should encompass emotional, informational, material, and interactive aspects, focusing on recognizing emotional shifts, providing comfort, sharing childcare knowledge, and ensuring effective communication. Communities ought to deliver holistic primary health care, including early detection, education, and postpartum support. The government should consider establishing childcare allowances and creating job opportunities to facilitate mothers’ societal reintegration post-birth.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

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Acknowledgements

Each author contributed to the concept, design, research, data analysis, drafting of the article. I have obtained written permission from all authors.

This study was supported by National Natural Science Foundation of China (Grant Nos. 82073569, 81960592), Outstanding Youth Science Foundation of Yunnan Basic Research Project (Grant No. 202001AW070021), Reserve Talent Project for Young and Middle-aged Academic and Technical Leaders (Grant No. 2012005AC160023), Key Science Foundation of Yunnan Basic Research (Grant No. 202101AS070040).

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Yiyun Zhang

Research Center of Health Policy and Management, School of Health Management, Harbin Medical University, Harbin, 150086, Heilongjiang, China

School of Public Health, Kunming Medical University, Kunming, 650500, Yunnan, China

Mengmei Liu, Min Li, Ping Chen, Guanghong Yan & Qingyan Ma

School of Public Health, Hangzhou Normal University, Hangzhou, 311121, Zhejiang, China

Yunnan Provincial Key Laboratory of Public Health and Biosafety & School of Public Health, Kunming Medical University, Kunming, 650500, Yunnan, China

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Conceptualization: Dingyun You and Ye Li; Analysis and interpretation of data: Mengmei Liu and Min Li; Statistical analysis: Ping Chen and Xinwei Liu; Writing - Original Draft: Yiyun Zhang; Critical revision of the manuscript for important intellectual content: Dingyun You; Funding acquisition: Dingyun You; Visualization and Acquisition of data: Guanghong Yan and Qingyan Ma.All authors reviewed the manuscript.

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Zhang, Y., Liu, X., Liu, M. et al. Multidimensional influencing factors of postpartum depression based on the perspective of the entire reproductive cycle: evidence from western province of China. Soc Psychiatry Psychiatr Epidemiol (2024). https://doi.org/10.1007/s00127-024-02686-2

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Basic Research Powers the First Medication for Postpartum Depression

May 14, 2024 • Feature Story • 75th Anniversary

At a Glance

• Postpartum depression (PPD) is a common mental disorder that many women experience after giving birth.
• Onset of PPD coincides with a dramatic drop in levels of a brain-derived steroid (neurosteroid) known as allopregnanolone.
• Decades of research supported by NIMH illuminated the role of neurosteroids like allopregnanolone in mental illnesses.
• In 2019, brexanolone—a medication that acts by mimicking allopregnanolone—became the first approved drug to treat PPD.
• Able to significantly and rapidly reduce PPD symptoms, brexanolone was a major leap forward in depression treatment.

Joshua A. Gordon, M.D., Ph.D., a practicing psychiatrist at the time, would never forget the call he received one night from a distraught mother.

“She was plagued with a deep, inescapable hopelessness—so depressed she was afraid she was going to hurt her month-old daughter. I helped her get to the hospital, where she spent the next 2 months in an in-patient program trying every available treatment to recover,” said Dr. Gordon, now the Director of the National Institute of Mental Health (NIMH).

Unfortunately, this experience is not uncommon among women and other postpartum people who may feel intense sadness, anxiety, and loss of interest after giving birth. These symptoms can be signs of a clinical disorder known as postpartum depression (PPD) . Unlike the "baby blues" or feelings of sadness many new mothers experience in the days after delivery, PPD is more intense and long-lasting, with damaging impacts on health and well-being.

More than the blues: Impacts of PPD on women's mental health

Depression is a common but serious mood disorder. According to the Centers for Disease Control and Prevention (CDC), rates of depression are high—and rising—among postpartum women. Using data from the 2018 Pregnancy Risk Assessment Monitoring System  , the CDC found that about 1 in 8 postpartum women had symptoms of depression, while another CDC study  showed rates of PPD that were seven times higher in 2015 compared to 2000.

Depression can happen to anyone, and it's especially tough for new moms dealing with the physical challenges of childbirth and the stresses of caring for a young child. When women experience PPD, they often have strong feelings of sadness, anxiety, worthlessness, and guilt. Their sleep, eating, thoughts, and actions can all change noticeably. These mood and behavior changes can be highly distressing and even life-threatening, making it difficult for a woman to do everyday things and take care of herself or her child. In extreme cases, women with PPD may be at risk of hurting themselves or their child or attempting suicide.

Fast-acting, effective treatment for PPD can be life-changing and potentially lifesaving. However, for too long, such care was hard to reach, leaving many women to struggle with depression at a pivotal point in life. Despite some similarities, PPD is not the same as major depression at other times in life. Because of this, usual depression treatments are much less effective in managing the symptoms of PPD.

“PPD is very difficult to treat,” said Mi Hillefors, M.D., Ph.D., Deputy Director of the NIMH Division of Translational Research. “It is usually treated with medications originally approved for major depression—despite limited evidence that they are effective in treating PPD. Standard depression treatments, including antidepressants, psychotherapy, and brain stimulation therapy, can also take weeks or longer to work.”

PPD’s unique risk factors reflect the physical changes of pregnancy and the postpartum period, which include dramatic changes in levels of many hormones and other molecules.

These biological changes had long been seen as a possible source of postpartum mood disorders like depression. But could they also be a solution?

Unlocking the power of allopregnanolone through basic research

Some psychiatric medications owe their discovery to chance. Not so with brexanolone, the first-ever medication to specifically treat PPD. Brexanolone culminated a long series of research studies, much of it funded by NIMH as part of its commitment to understand and support women’s mental health .

Thanks to NIMH-supported basic research, brexanolone was developed by design—a design centered around a molecule called allopregnanolone  .

Allopregnanolone is a steroid naturally produced in the brain and with important actions there, such as regulating neurotransmitter activity and protecting neurons from damage. Its impact extends to mental health, with higher levels linked to better mood, lower anxiety, and reduced depression  .

Allopregnanolone is also important to pregnancy  , during which its levels are extremely high. This happens because of the enhanced production of a hormone called progesterone, which prepares the body for pregnancy and childbirth.

In the last few months of pregnancy, the ovaries and placenta make more progesterone, causing a huge rise in allopregnanolone levels. These levels then drop rapidly after birth. Because allopregnanolone plays a crucial role in mood, these ups and downs can impact a woman’s mental health during and after pregnancy.

Researchers had been aware of brain-derived steroids like allopregnanolone as far back as the 1940s. But the journey to a new PPD treatment began within NIMH's Intramural Research Program (IRP) . At the helm was the NIMH Scientific Director at that time, Steven Paul, M.D., who collaborated with researchers in the NIMH Clinical Neuroscience Branch and at other NIH institutes, including the National Institute of Neurological Disorders and Stroke (NINDS). The researchers sought to understand how the steroids work, change over time, respond to stress, and ultimately relate to health and disease.

Early discoveries came in the 1980s. Paul, working with Maria Majewska, Ph.D., Jacqueline Crawley, Ph.D., A. Leslie Morrow, Ph.D., and other researchers showed that hormones such as progesterone and molecules derived from them have calming and anxiety-reducing effects  . Extensive research by Paul’s lab showed that these anxiolytic effects come from enhancing the activity of GABA  by binding to specific sites on its receptor. As the main inhibitory neurotransmitter (chemical messenger), GABA reduces the activity of neurons, making them less likely to fire. When molecules bind to its receptor, GABA becomes more potent at inhibiting electrical activity  in the brain, with calming effects on behavior.

Paul and IRP colleague Robert Purdy, Ph.D., used the term “ neuroactive steroids  ,” or neurosteroids, to describe these molecules able to bind to receptors in the brain to rapidly alter neuronal excitability. Their work in animals confirmed that allopregnanolone is synthesized in the brain  . They also showed the effects of allopregnanolone on GABA receptors in humans. Moreover, they found that allopregnanolone affects the response to stress  , with acute stress leading the neurosteroid to increase to levels that alter GABA activity. These findings suggested that neurosteroids play an important role in helping animals “reset” and adaptively respond to stressful life events.

Together, this IRP-conducted research established the importance of neurosteroids via their presence in the brain, ability to reduce neuronal activity, and release during stress. Although much of this work was conducted in animals, it would spotlight neurosteroids—and allopregnanolone in particular—as promising targets for treating mental disorders, eventually opening the door to their therapeutic use in humans.

Bridging the gap to advance clinical intervention

While NIMH intramural researchers were making remarkable strides, researchers at other institutions were also conducting work bolstered by funding from NIMH. Among them were Alessandro Guidotti, M.D., at the University of Illinois at Chicago; Istvan Mody, Ph.D., at the University of California, Los Angeles; and Charles Zorumski, M.D., at Washington University in St. Louis. Their NIMH-funded research propelled understanding of inhibitory neurosteroids and their importance in reducing the adverse effects of stress. This work would be the impetus for homing in on allopregnanolone as a treatment for PPD.

Guidotti and colleagues conducted several NIMH-funded studies. Their research in rodents confirmed that allopregnanolone is produced in the brain  and helps regulate neuronal excitability  by acting on GABA receptors. They also built on the knowledge that neurosteroids are affected by stress. However, unlike acute stress, a stressor lasting multiple weeks led to a decrease in allopregnanolone  in brain areas involved in anxiety- and depression-like behaviors.

Importantly, their NIMH-funded work offered some of the earliest evidence that allopregnanolone contributes to depression by showing significantly lower levels  in people with depression compared to people without the disorder, a rise in levels (but not that of other neurosteroids) after treatment with antidepressant medication  , and a link between increased levels and reduced depression symptoms  .

NIMH and NINDS funded multiple studies by Mody and colleagues on interactions of neurosteroids, stress, and GABA receptors. This research was integral to understanding a mechanism in the brains of mice  that might explain why some people become depressed after childbirth. Their NIMH-supported research  showed changes in GABA receptors in the brain, where neurosteroids are active, that impaired the body’s ability to adapt to hormonal fluctuations. Animals with an irregular GABA receptor component lacking sensitivity to neurosteroids showed depression-like behaviors and reduced maternal care; treating them with a drug that restored the receptor’s function reversed those changes.

Another study by Mody and colleagues  revealed changes in GABA expression during pregnancy that led to greater neuronal activity in the brain—but could be brought down by allopregnanolone. This finding opened the door to future studies exploring whether a postpartum drop in the neurosteroid contributed to the risk for mood disorders after birth.

Zorumski led a team in extensively studying neurosteroids as well. Among their seminal findings was identifying the mechanisms by which inhibitory neurosteroids like allopregnanolone affect GABA receptor activity  . Their NIMH-funded work dramatically augmented knowledge of how neurosteroids alter GABA receptors to contribute to the risk for mental disorders like PPD.

“The accumulated evidence from these studies established the necessary bridges to justify examining a potential therapeutic role for allopregnanolone in women with PPD,” said Peter Schmidt, M.D., Chief of the NIMH Behavioral Endocrinology Branch.

By the 2010s, researchers had a much better understanding of how allopregnanolone is linked to PPD. Studies showed decreased allopregnanolone in pregnant  and postpartum  women with symptoms of depression and higher allopregnanolone associated with a lower risk of PPD  . The possibility that PPD might be caused by the downregulation of GABA receptors in response to low levels of allopregnanolone after birth inspired researchers to put that theory to the test in clinical studies with human participants.

Taking allopregnanolone from bench to bedside

Extensive research, supported by NIMH and other NIH institutes, found that neurosteroids play a key role in how people deal with stress. They also contribute to the development of mood disorders like anxiety and depression. For allopregnanolone, evidence that it sharply decreases after pregnancy and regulates GABA activity gave rise to the notion that it contributes to PPD—and inspired hope it could be used to treat the disorder.

The biopharmaceutical company Sage Therapeutics utilized this basic research to develop brexanolone. Administered intravenously by a health care professional in a doctor’s office or clinic, brexanolone mimics the effects of allopregnanolone, increasing the inhibitory actions of GABA receptors.

Stephen Kanes, M.D., Ph.D., at Sage Therapeutics and Samantha Meltzer-Brody, M.D., MPH, at the University of North Carolina led several randomized clinical trials to measure the effectiveness of the medication in treating PPD and evaluate its safety and tolerability. The studies, which recruited adult women with PPD from hospitals, research centers, and psychiatric clinics across the United States, measured the effects of brexanolone compared to a placebo over 4 weeks.

The trials were a success. Brexanolone significantly and meaningfully reduced PPD symptoms  , and it had only mild side effects. Compared to usual depression treatments, brexanolone brought about a faster response and greater improvement  . Whereas most antidepressants take weeks to work, brexanolone improved symptoms and functioning in women with PPD within a few hours to days. And the effects lasted up to a month after the treatment stopped. Not only was brexanolone more effective, but it also worked faster than other depression medications.

“The dramatic impact of basic research on real-world health outcomes has been inspiring. The fact that NIMH-supported studies contributed to successful drug development in a matter of decades is a remarkable feat and a powerful demonstration of the potential of this foundational research,” said Dr. Gordon.

Based on this promising evidence, the U.S. Food and Drug Administration (FDA) gave brexanolone priority review and breakthrough therapy designation in September 2016. Then, in March 2019, the FDA approved brexanolone  , making it the first drug to treat PPD.

Brightening the future for women with PPD

For women with PPD, brexanolone was a long-awaited reason to celebrate. For NIMH, it was a testament to discoveries made through the decades of research it supported. Although some barriers to treatment persisted, women now had greater hope for treating depression symptoms after pregnancy.

“The approval of brexanolone was an important milestone. Finally, an effective, fast-acting medication specifically to treat PPD,” said Dr. Hillefors. “It was also a victory for psychiatric neuroscience because basic and translational research—by design, not chance—led to a truly novel and effective treatment for a psychiatric disorder.”

Without NIMH-supported studies providing the foundational knowledge of neurosteroids, researchers may have never made the connection between allopregnanolone and treating PPD. “That’s why the approval of brexanolone is such a cause for celebration for mental health research: It represents a true bench-to-bedside success,” said Dr. Gordon.

The success of brexanolone has continued to open the door to exciting advancements in mental health care. For instance, researchers and clinicians are investigating ways to make brexanolone work better for all postpartum people. Researchers are also testing how neurosteroids can be used to treat other forms of depression and other mental health conditions.

Just the beginning of treatment advances for PPD

Brexanolone is only the start of what will hopefully be a new future for PPD treatment. In August 2023, the FDA approved zuranolone  as the first oral medication for PPD. Zuranolone acts via similar biological mechanisms as brexanolone. Its approval reflects the next step in NIMH-supported basic research being translated into clinical practice with real-world benefits.

The success of the drug, which is taken in pill form, was shown in two randomized multicenter clinical trials  . Women with severe PPD who received zuranolone showed statistically significant and clinically meaningful improvements in depression symptoms compared to women who received a placebo. These effects were rapid, sustained through 45 days, and seen across a range of clinical measures. The benefits were mirrored in patients’ self-assessment of their depression symptoms.

According to Dr. Schmidt, “The approval of zuranolone to treat PPD provides women with a rapid and effective treatment that avoids some of the limitations of the original intravenous medication.”

And the journey is far from over. Researchers, clinicians, and industry are continuing to innovate new treatments for PPD to increase access and availability to ensure all people can receive help for their postpartum symptoms.

“While I will never forget that phone call from my patient, the development of these effective medications brings us hope for helping people with PPD and for the overall impact of basic research to truly make a difference in people’s lives,” concluded Dr. Gordon.

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• Perinatal Depression (NIMH brochure)
• Depression in Women: 4 Things You Should Know (NIMH health topic page)
• Depression (NIMH health topic page)
• Major Depression (NIMH statistics page)
• Women and Mental Health (NIMH health topic page)
• A Bench-to-Bedside Story: The Development of a Treatment for Postpartum Depression (NIMH Director’s Message)
• Bench-to-Bedside: NIMH Research Leading to Brexanolone, First-Ever Drug Specifically for Postpartum Depression (NIIMH press release)
• Population Study Finds Depression Is Different Before, During, and After Pregnancy (NIMH research highlight)
• FDA Approves First Treatment for Post-Partum Depression  (FDA news release)
• FDA Approves First Oral Treatment for Postpartum Depression  (FDA news release)

• Open access
• Published: 25 May 2024

Perinatal posttraumatic stress disorder as a predictor of mother-child bonding quality 8 months after childbirth: a longitudinal study

• Maria Vega-Sanz   ORCID: orcid.org/0000-0002-0852-6264 1 ,
• Ana Berastegui   ORCID: orcid.org/0000-0002-8554-1791 1 &
• Alvaro Sanchez-Lopez   ORCID: orcid.org/0000-0003-2815-7803 2  

BMC Pregnancy and Childbirth volume  24 , Article number:  389 ( 2024 ) Cite this article

Metrics details

Negative childbirth experiences can be related to the onset of perinatal post-traumatic stress symptomatology (P-PTSS), which significantly impacts the mother and the infant. As a response in the face of the discomfort caused by P-PTSS, maladaptive emotion regulation strategies such as brooding can emerge, contributing to the consolidation of post-partum depressive symptoms. Ultimately, both types of symptomatology, P-PTSS and post-partum depression, can act as risk factors for developing mother-child bonding difficulties. Still, this full set of temporal paths has to date remained untested. The present longitudinal study aimed to analyze the risk factors associated with the appearance of P-PTSS after post-partum and to test a path model considering the role of P-PTSS as an indirect predictor of bonding difficulties at eight months of postpartum.

An initial sample of pregnant women in the third trimester of gestation ( N  = 594) participated in a longitudinal study comprising two follow-ups at two and eight months of postpartum. The mothers completed online evaluations that included socio-demographic data and measures of psychological variables. A two-step linear regression model was performed to assess the predictive role of the variables proposed as risk factors for P-PTSS, and a path model was formulated to test the pathways of influence of P-PTSS on bonding difficulties.

A history of psychopathology of the mother, the presence of depression during pregnancy, the presence of medical complications in the mother, and the occurrence of traumatic birth experiences all acted as significant predictors of P-PTSS, explaining 29.5% of its variance. Furthermore, the path model tested further confirmed an indirect effect of P-PTSS, triggered by a negative childbirth experience, on subsequent bonding difficulties eight months after labor through its association with higher levels of brooding and, ultimately, postpartum depression levels. A further path showed that bonding difficulties at two months postpartum can persist at eight months postpartum due to the onset of brooding and postpartum depression symptoms.

We identified a set of robust predictors of P-PTSS: the mother’s previous history of depression, perinatal depression during pregnancy, the presence of medical complications in the mother and the occurrence of traumatic birth experiences, which has important implications for prevention. This is particularly relevant, as P-PTSS, when triggered by a negative childbirth experience, further indirectly predicted the development of mother-child bonding difficulties through the mediation of higher use of brooding and symptoms of postpartum depression. These findings can serve as a basis for developing new longitudinal studies to further advance the understanding of perinatal mechanisms of mental health.

Peer Review reports

The childbirth experience may sometimes be associated with different uncertainties and complications, making childbirth a potentially threatening situation for some women, especially first-time mothers [ 1 ]. This can sometimes lead to experiencing childbirth as a traumatic event, being even associated with the subsequent development of perinatal post-traumatic stress symptomatology in the mother after childbirth (P-PTSS) [ 2 ]. In this study we aimed to provide an integrative analysis of the risk factors that contribute to the onset of P-PTSS and its subsequent contribution to the emergence of further crucial problems such as the emergence of mother-child bonding difficulties at post-partum.

Traumatic childbirth and its relation to perinatal post-traumatic stress symptoms

The stress of the intervention, the perceived threat to the mother’s or baby’s life, and early separation from the baby [ 3 ] can all make childbirth a traumatic experience, impacting the mother, her baby, and the whole family [ 4 , 5 , 6 , 7 , 8 ]. The experience of childbirth as a traumatic event has been consistently linked to P-PTSS due to the negative psychological impact of the childbirth experience for some women [ 9 , 10 , 11 ]. It is estimated that around 4–16% of women may present symptoms clinically compatible with a P-PTSS after giving birth and that 30% would even meet diagnostic criteria for this disorder [ 12 ]. P-PTSS is primarily characterized by nightmares, flashbacks, irritability, guilt, and attempts to avoid thinking or talking about the birth experience [ 4 , 8 ]. Some of the most prominent risk factors for the onset of P-PTSS are the presence of a previous history of depression, as well as the occurrence of depression [ 13 ], medical complications [ 12 ] and the experience of stressful life events [ 14 ] during pregnancy. The quality of medical care received during childbirth [ 12 , 14 , 15 , 16 ], negative subjective experiences of childbirth [ 11 , 12 , 13 , 15 , 17 – 18 ] and medical complications in the mother [ 12 ] as in the newborn [ 14 ], such as preterm birth [ 11 , 19 ], also stand out from the moment of birth itself as contributors to P-PTSS.

As it can be seen, although studies on risk factors for P-PTSS are numerous and identify multiple associated factors, these studies lack the inclusion of an integrative analysis considering this series of factors as a whole and do not take into consideration the occurrence of different risk factors that can emerge at different times (i.e., previous history, pregnancy period, time of childbirth) through longitudinal designs. Therefore, this was our first aim in this study. As a second aim, once we established the specific contribution of each of this series of known risk factors for the occurrence of P-PTSS, we aimed to establish its own contribution to further central problems of post-partum, such as the emergence of mother-child bonding difficulties, considering its influence in other individual processes of emotional management, such as maternal ruminative response styles (specifically brooding) that may facilitate the emergence of these problems.

Ruminative response style as a strategy to regulate discomfort related to perinatal post-traumatic stress symptomatology

The cognitive model of PTSD proposed by Ehlers et al. [ 20 ] states that rumination is used as a strategy to regulate the distress generated by intrusive memories of the traumatic experience. Ruminations may comprise focusing on the traumatic event (i.e., its meaning, consequences, including intrusions, and what life would be like if the event had not occurred), with the aim of understanding it and working through it [ 21 ]. However, this form of response style would not be helpful for the person to make a coherent narrative of the trauma, rather making it challenging to integrate it [ 20 ], and thus increasing and maintaining the presence of PTSD and its severity [ 22 ].

Moreover, maintaining a rumination-focused emotion regulation style exacerbates negative emotions in the long term [ 20 ]. Specifically, depressive rumination or “brooding”, namely repetitively thinking in response to a sad mood, focusing on past problems [ 23 ], is associated with an increased vulnerability to a depressive episode [ 24 ], as well as with increases in the duration of depressive episodes [ 25 ], which makes its study particularly relevant as a possible mechanism for the maintenance of PTSD [ 22 ], but also as an origin of depressive symptomatology in the postpartum period [ 26 ].

Appropriate screening for P-PTSS risk markers may therefore have the added value of identifying mothers at increased risk for developing mood problems. However, the specific mechanisms by which the onset of P-PTSS may lead to depression and related problems in the postpartum period remain unclear, making the study of associated brooding response styles as an intervening mechanism particularly relevant.

P-PTSS, response style, and postpartum depression

Some studies indicate that 48–55% of people diagnosed with PTSD would also meet criteria for depressive symptomatology [ 27 ]. The relationship between both pathologies could be explained by a causal relationship in which people with PTSD symptoms have a negative view of themselves, others, and the world, corresponding to the cognitive triad usually present in depression [ 28 ], which would facilitate the appearance of depressive symptomatology [ 29 ]. Specifically, P-PTSS can also act as a risk factor related to the occurrence of depressive symptomatology during the pos-partum [ 30 ]. Some studies indicate that the risk for developing postpartum depression when a woman has a single symptom of P-PTSD is 11.1 times higher than in women who do not have P-PTSS and 9.7 times higher if all PTSD criteria are met [ 12 ].

Looking at individual psychological processes, the relationship and high comorbidity between both symptomologies could be explained through the presence of common factors such as negative thoughts, which are symptoms in both clinical conditions [ 11 ]. In that way, brooding has been identified as a further predictor of postpartum depressive symptomatology during the puerperium [ 26 ]. It could therefore be argued that P-PTSS may facilitate postpartum depressive symptomatology through a higher use of ruminative brooding as a maladaptive emotion regulation strategy to cope with distress (see Fig.  1 ).

Proposed relationship between the variables P-PTSS, brooding and postpartum depression symptomatology

Importantly, several authors point out how the presence of these two types of symptomatology in the mother during the postpartum period can significantly influence the quality of mother-child bonding, which is a fundamental aspect for the correct development of the baby [ 31 , 32 , 33 ]. In this study, we thus finally aimed to consider how P-PTSS and post-partum depression, and through which paths, contribute to mother-child bonding difficulties across the post-partum period.

Mother-child bonding difficulties

Mother-child bonding comprises the mother’s mental representation of her child and her caring behaviors towards her child [ 34 ]. The consequences of difficulties in mother-child bonding are problems in emotional self-regulation, problems in stress regulation and social adaptation, alterations in the infant temperament, and difficulties in cognitive and social development from the age of three months [ 31 ].

Symptomatology of P-PTSS, brooding [ 33 ], as well as postpartum depression [ 31 ], have all been found to be related to a poorer quality of mother-child bonding across separate studies. In the case of P-PTSS, mothers who experience P-PTSS tend to have less experiences of positive emotions toward the infant [ 35 ], difficulties in caregiving tasks, and problems establishing quality bonding [ 36 – 37 ]. In addition, mothers with P-PTSS also frequently experience emotions of anger towards the infant [ 36 ] and a decrease in their perceived self-efficacy [ 3 ]. It has also been reported in the literature that, in these cases, the newborn may act as a reminder of the traumatic event, producing feelings of rejection of the mother towards her child in the initial moment [ 13 , 38 – 39 ] Moreover, the experience of P-PTSS by the mother acts as a risk factor for her child to exhibit poorer emotion regulation at 6 months [ 39 ], lower cognitive development at 17 months [ 40 ], and worse socio-emotional development at 2 years [ 41 ].

Some previous research on P-PTSS and its relationship with bonding quality suggests that this relationship might be mediated by the presence of postpartum depression symptoms [ 40 , 41 ]. verall PTSD symptomatology directly impacted bonding quality but also indirectly through depressive symptomatology [ 11 ]. The relationship and high comorbidity between both symptomologies could be explained through the presence of common factors such as negative thoughts, which are symptoms in both clinical conditions [ 11 ]. Additionally, the relationship between P-PTSS and the presence of depressive symptoms in the postpartum period could be mediated using brooding as a maladaptive emotion regulation strategy to cope with distress [ 26 ]. Moreover, brooding has been related to a poorer quality of mother-child bonding in the postpartum period [ 33 ] because depletes the mother’s cognitive resources, making it difficult for her to manage the new cohabitation with a newborn, and limiting her ability to respond to the baby’s needs in a responsive, rapid, and congruent manner [ 33 ]. It that way, a higher use of brooding may facilitate postpartum depressive symptomatology. When the mother presents depressive symptomatology during the postpartum period, she tends not to bond adequately with her child, which may cause her to emotionally distance herself from her child, experiencing fewer positive feelings towards her baby, isolating herself from the baby’s emotional demands and attending only to his/her basic needs [ 32 ]. Furthermore, it has been found that children of mothers with postpartum depression exhibit poorer cognitive and socioemotional functioning in preschool and middle childhood [ 42 – 43 ].

Overall, it is crucial to continue expanding research in this area [ 44 ] Specifically, it is necessary to clarify the possible influence of P-PTSS on lower-quality bonding during the postpartum period through its indirect impact on the use of brooding and associated depressive symptomatology. Hence, the second aim of this study was to formulate and test an empirically informed and integrative path model, with this being particularly relevant to know the processes through which P-PTSS, after childbirth, may ultimately lead to the appearance of bonding problems at eight months of postpartum, by the hypothetical mediation of brooding and postpartum depression symptoms (see Fig.  2 below).

Proposed path model

Finally, the experience of childbirth, the birth itself, should be seen as an event that takes place in each socio-cultural and health care environment, which influences the experience itself. In terms of the socio-cultural context, in Spain there are different healthcare services: public health service, private medical insurance and entirely private healthcare. The latter two options offer greater flexibility in choosing the hospital and doctor. Most deliveries take place in public or private hospitals, with the option of using birthing centers being very uncommon, and home births being extremely rare. The delivery can be either vaginal or by cesarean section, depending on the circumstances and the preferences of the healthcare professionals. During labor, women are attended to by midwives and obstetricians, but the figure of the doula is not yet established. The presence of a companion is usually allowed, except for cesarean deliveries, which varies by hospital. Options for pain control are offered, with pharmacological methods being the most prevalent nowadays, especially the use of epidurals.

In terms of the health context, the health crisis caused by the COVID-19 pandemic was still occurring at the time of the present study. Women in this study gave birth between November 2020 and May 2021. During these months, the COVID-19 pandemic in Spain was at its peak, triggering the implementation of many new protocols in the hospital context. Despite the challenges posed by the pandemic, a combination of childbirth options was maintained, and the presence of a companion continued to be valued, although temporary restrictions could vary depending on hospital policies and health conditions. Similarly, despite the limited number of community services for parents during the postpartum period in Spain, efforts were made to provide telephone and online follow-ups to address potential difficulties in the early stages.

In this study, we considered women’s negative childbirth experiences and how they may sometimes lead to the development of Perinatal Post Traumatic Stress symptoms (P-PTSS), as well as the specific paths of contribution of this problem to subsequent mother-child bonding difficulties across the postpartum. Therefore, two main aims were defined, and were addressed through an extensive longitudinal study with multiple time assessments across the pregnancy and post-partum period. First, we conducted a detailed analysis of the risk factors occurring before and during pregnancy, and at childbirth, identified by previous empirical research [ 12 , 13 , 14 , 15 , 16 , 17 , 18 ], that can predict a higher presence of P-PTSS after childbirth. Specifically, to address this first aim, we conducted an integrative study of predictors for P-PTSS that have been separately identified as risk factor in the previous literature, including pre-pregnancy (previous history of depression; 13), during pregnancy (presence of perinatal depression symptoms, generalized anxiety symptoms, the experience of stressful life events and medical complications; 12–14), as well as childbirth factors (quality of medical care received, birth experience and infant complications during childbirth; 12–18). To study the relationship between all these factors and P-PTSS, a first section of the longitudinal design was formulated to integrate them and consider their occurrence at different times (pre-pregnancy, during-pregnancy, and childbirth-related predictors of P-PTSS at eight months of postpartum).

As for the second aim, we formulated a path model to test the hypothesis that P-PTSS has an indirect predictive role in bonding difficulties at eight months of postpartum through its direct influence on brooding and associated post-partum depressive symptomatology (see Fig.  2 for more details). Thus, based on the reviewed literature, it was expected that a higher presence of P-PTSS after childbirth would predict subsequent higher levels of brooding [ 20 , 21 , 22 ], which would be associated with higher postpartum depressive symptomatology levels [ 3 , 12 ], and that in turn, these problems would be associated with higher increases of mother-child bonding difficulties across the postpartum period [ 31 , 33 ].

Design and participants

A longitudinal study with three data collection phases was designed. A non-discriminatory exponential chain demonstration (i.e., snowball sampling technique) was performed to recruit the sample. The inclusion criteria for the study were being a woman over 18 years of age and in the third trimester of pregnancy. The first evaluation (T1) comprised recruiting an initial sample of women of N  = 594 in their third trimester of pregnancy. This phase was conducted from November 2020 to February 2021. The mean week of gestation in women recruited at T1 was 33.37 (SD = 3.77). The second evaluation (T2) consisted of reassessing all T1 participants two months after childbirth. A sub-sample of N  = 326 was obtained from T1. This phase was conducted between January and July 2021. The average week of gestation at which participants went into labour was 39.33 (SD = 1.57). Finally, in the third evaluation (T3), the longitudinal follow-up of T2 participants continued. This T3 evaluation was completed eight months after giving birth and six months after the previous assessment at T2. This final sample was the one used in this study as all T3 participants had completed the longitudinal follow-up of all three phases. This phase was conducted between July 2021 and January 2022.

The mean age of the final sample was 32.16 (SD = 4.18), 74% of the participants had completed university studies, 95% had a couple or were married at the time of the first evaluation. The average number of children of the participants was 0.33 (SD = 0.55), and 68% followed up on their pregnancy by the public health system.

The 26% of the women reported psychotherapy during the first eight months postpartum and 6.8% reported using anxiolytics during that time. Descriptive socio-demographic data are shown in Table  1 . All participating women signed informed consent. The Ethics Committees of Universidad Pontificia Comillas approved the study protocol .

Instruments

Data were collected through online evaluation surveys using Google Forms. First, the surveys included questions on socio-demographic data: age, type of medical care, marital status, educational level, and type of delivery. The surveys also included questions testing the psychological impact of variables such as medical complications for the mother during pregnancy (i.e., ‘Did you have any medical complications during your pregnancy?‘) and during childbirth (i.e., ‘Did you have any medical complications during childbirth?‘), and the baby afterward during delivery (i.e., ‘Did your baby have any medical complications during childbirth?‘) all based on a yes/no answer option. If mothers answered ‘yes’ to any of these questions, they were asked another question about the type of complication they experienced (e.g., ‘Could you indicate what type of complication/s it was/were?‘). The quality of medical care received and the type of birth experience (i.e., whether distressing or even traumatic) was assessed through single questions formulated by the researchers (i.e., “In relation to the medical care received during the birth, please indicate how you experienced it: satisfactory, adequate, negative or threatening”; “In relation to your birth experience, please indicate whether you experienced it as a satisfactory birth, a difficult but satisfactory birth or a traumatic birth”).

Secondly, the following standardized questionnaires were used to assess risk factors for P-PTSS, as well as the variables used to test the relationship between P-PTSS and subsequent brooding, depression and mother-child bonding.

Perinatal posttraumatic stress symptoms . PCL-5, PTSD Checklist for DMS-5. The Post-traumatic Stress Disorder Symptom Checklist [ 45 ] comprises 20 items and a Likert-type response scale (5 response options). It was specified that mothers should complete this questionnaire based on their birth experience. The internal consistency in this study at eight months postpartum was excellent α = 0.93. This questionnaire was administered at T3.

Previous history of depression . The Centre for Epidemiological Studies Depression Scale, CESD-8 [ 46 ], is an 8-item scale that can be used to detect the occurrence of depressive episodes at different periods. This study assessed the degree of depression levels experienced in the worst period of the previous life identified by the participants before the third semester of pregnancy. The items are rated on a 4-point Likert scale. The scale shows a Cronbach’s alpha of 0.82 in Spanish validation [ 47 ]. The internal consistency in this study was good α = 0.89. A cut-off score ≥ 9 was used to indicate the existence of a previous history of depression. Participants were divided into two groups according to the above cut-off for the total score obtained on this questionnaire. Those who scored below the cut-off point were assigned to group 0 (i.e., no previous history of depression), and those who scored at or above the cut-off point were assigned to group 1 (i.e., presence of a prior history of depression). This questionnaire was administered at T1.

Stressful life events. Participants were asked to indicate whether they had experienced any stressful life events from the following pre-specified list of life stressors [ 48 ] during their pregnancy: separation or divorce, death in the family, job loss, domestic violence, or unwanted pregnancy. Participants who did not select any stressful life events were assigned to group 0 (i.e., no significant stressors occurred), and those who did were assigned to group 1 (i.e., significant stressors occurred). This questionnaire was administered at T1.

General anxiety. The Generalised Anxiety Scale, GAD-7 [ 49 ], is a 7-item scale rated on a 4-point Likert scale. A cut-off score ≥ 10 was used to identify clinical levels of anxious symptomatology at the time of assessment [ 49 ]. This scale shows a Cronbach’s alpha of 0.93 in its Spanish validation [ 50 ]. The internal consistency in this study, in the third trimester of pregnancy, was good α = 0.87. This questionnaire was administered at T1.

Perinatal and post-natal depression : The Edinburgh Postnatal Depression Scale, EDPS [ 51 ], has been validated in the perinatal and postnatal stages. It is a 10-item scale, and items are rated on a 4-point Likert scale. The cut-off score ≥ 13 indicates a high risk of depression during pregnancy and ≥ ten postpartum. The internal consistency of the Spanish adaptation of the instrument was 0.91 [ 52 ]. Internal consistency in this study, in the third trimester of pregnancy, was good, α = 0.86 and α = 0.88 at eight months postpartum. This questionnaire was administered at T1, T2, and T3.

Ruminative Response. The Ruminative Response Scale, RRS [ 53 ], was used to assess individual styles of ruminative response, differentiating between the use of reflection (reflective rumination) and brooding (depressive rumination). It is a 22-item scale. The items are rated on a 4-point Likert scale. The Spanish adaptation shows a Cronbach’s alpha of 0.93 for the full scale [ 54 ]. At eight months postpartum, the internal consistency in this study was excellent α = 0.94 for the total scale, and good α = 0.82 for the brooding subscale. This questionnaire was administered at T3.

Postpartum bonding difficulties. The Postpartum Bonding Questionnaire [ 55 ] was used to detect the presence of bonding difficulties. It provides a total score of the quality of bonding. It comprises 25 items with a Likert-type response scale (5 response options). The adaptation to Spanish shows a Cronbach’s alpha of 0.90 on the full scale. The internal consistency in this study, at the two postpartum assessment periods was good, α = 0.83, at two postpartum months and α = 0.86 at eight postpartum months. This questionnaire was administered at T2 and T3.

Complementarily, further measures of other variables not relevant to the aims of this study were also collected in the study. The full set of measures relevant to this study, collected at each assessment time, are summarized in Table  2 .

Statistical analyses

Statistical analyses were performed using IBM SPSS Statistics version 22 software. Initially, descriptive analyses of socio-demographic data and psychological measures of the participants were performed. In addition, a preliminary analysis with t-tests for independent samples was carried out on the sample’s representativeness.

Subsequently, Pearson bivariate correlation analyses were carried out on the association between the risk factors proposed and P-PTSS (i.e., aim 1) and the principal variables of the subsequent path model (i.e., aim 2: perinatal post-traumatic stress symptom score → brooding → depressive symptomatology → bonding difficulties). Moreover, t-tests for independent samples were carried out for differences in the dimensional variables by other risk dichotomous variables. Following Cohen’s [ 56 ] criteria, the following magnitudes will be followed to interpret the results: between +/- 0.10 and +/- 0.29 low; between +/- 0.30 and +/- 0.49 medium or moderate; between +/- 0.50 and +/- 1.0 high correlation.

As for the first aim, to determine the percentage of explained variance of the dependent variable (P-PTSS at T3) by the variables considered as predictors, a linear regression analysis was performed in three steps, considering the contribution of antenatal variables (T1; step 1) pregnancy variables (T1; step 2) and partum variables (T2; step 3).

As for the second aim, we tested the initial hypothesized path model (see Fig.  2 ) using a structural equation that included the complete set of significantly correlated variables. In that model, P-PTSS (T3) acted as an exogenous variable, predicting bonding difficulties directly (T3) and indirectly through the influence of brooding (T3) (i.e., mediator 1) and postpartum depressive symptomatology (T3) (i.e., mediator 3). For this purpose, bonding difficulties at two months postpartum (T2) were controlled (i.e., regressed on bonding difficulties at eight months postpartum, T2), which allowed to establish the change in bonding that was solely due to the proposed predictor variables in the model. The estimation of standardized parameters of the path model followed the full information maximum likelihood (FIML) estimation method. Adjustment of our model we tested using standard criteria [ 57 ]: (a) χ2: non-significant value; (b) χ2 / gl: values lower than 2;c) comparative fit index and Tucker-Lewis index, a value ≥ 0.95 indicates a good fit ; d) root mean square error of approximation, a value ≤ 0.05 indicates a good fit; e) standardized root mean square, a smaller value indicates a better fit between the observed data and the tested model; and f) Akaike information criterion, a lower value indicates the preference for selecting a model when compared to another model [ 58 – 59 ]. Moreover, we used the Mardia coefficient for assessing multivariate normality (a value ≤ 70 indicates the possibility to assume multivariate normality) [ 60 ]. Hypothesized mediation pathways (i.e., P-PTSS → brooding → depressive symptomatology → bonding difficulties) with the variable of previous levels of bonding difficulties (T2) being a controlled, providing a measure of temporal change of bonding difficulties (Fig.  3 ), were tested via the estimation of indirect effects within the full path model. The model was then reformulated following modification indices and considering the predictive role of childbirth complications at T2 in P-PPTSS levels as T3 as the predictor (see the Results section for full details on this final model). The final model’s adjustment and its mediational pathways on T2-T3 changes in bonding difficulties were tested following the same criteria and steps as detailed above. These structural equation models and the analyses of the resulting path analyses were conducted using AMOS v18.0 (SPSS).

Initial proposed path model

Note. T2 = two months of postpartum; T3 = eight months of postpartum

Descriptive data of socio-demographic data and psychological impact variables of the participants in the study are shown in Table  1 above. Descriptive data of dichotomous psychological measures, and further mean and standard deviations of dimensional psychological measurements are depicted in Table  2 below.

Representativeness of the sample

For psychological measures that were collected multiple times, no significant differences were found in the variables collected in T1 between completers and non-completers at T2 (perinatal depression t= -0.998; bonding difficulties t= -0.495; brooding t = 0.650; all p’s > 0.05) and completers and non-completers at T3 (perinatal depression t= -0.335; bonding difficulties t= -0.501; brooding t = 1.407; all p’s > 0.05). No differences were neither found in variables collected in T2 between completers and non-completers at T3 (postpartum depression t= -0.402; bonding difficulties t= -0.870; brooding t= -0.845; all p’s > 0.05).

Risk factors of post-traumatic stress symptoms at eight months of postpartum

Bivariate correlations and t-tests for independent samples.

Bivariate correlation analyses showed significant correlations between post-traumatic stress symptoms and risk factors assessed to test the first aim. Specifically, P-PTSS (T3) were significantly moderate and positively related to perinatal depression (T1; r  = 0.448; p  = 0.001), moderate and positively related to general anxiety (T1; r  = 0.388; p  = 0.001), low and positively related to quality of care received (T2; r  = 0.196; p  = 0.018) and low and positively related to childbirth experience (T2; r  = 0.277; p  = 0.001).

The t-tests for independent samples indicated that women with a history of depression (T1) had, in comparison to those without a previous depression episode, higher P-PTSS (T3), t(148) = − 4.897; p  = 0.001. There were no statistically significant differences in P-PTSS (T3) as a function of differences in the experience of a stressful life event during pregnancy (T1), t(36.815) = 0.748; p  = 0.459, the presence of complications in the mother during the pregnancy (T1), t (148) = 1.678; p  = 0.095, and during the childbirth (T2), t (148) = 0.460; p  = 0.646,or the presence of complications in the baby during childbirth(T2), t (77.300) = − 0.532; p  = 0.596.

Main analyses (Aim 1): Linear regression model considering three-step predictors of P-PSTD

The linear regression model was composed of three steps. In the first step [ 1 ] pre-pregnancy predictor variables were entered: previous history of depression (assessed retrospectively at T1). In the second step [ 2 ], psychological predictor variables present during the third trimester of pregnancy: perinatal depressive symptomatology, generalized anxiety symptomatology, the experience of stressful life events, and complications during pregnancy (T1) were entered (assessed at T1). In the third step [ 3 ], predictor variables specific to the childbirth were entered in the equation: quality of medical care received, birth experience, and complications in the baby after delivery (assessed retrospectively at T2, two months after labor). The outcome variable of the model was P-PTSS, assessed eight months after childbirth (T3). The results of the linear regression model are shown in Table  3 .

As can be seen in the table, 29.5% of the variance in P-PTSS (T3) at eight months postpartum was explained by the model. The significant positive predictive power of the a previous history of depression (Step 1) explained 13.7% of the variance in P-PTSS in the eighth month of postpartum. A further 11.1% of variance in P-PTSS was accounted by predictors referred to the pregnancy period (Step 2), from which perinatal depression was the only significant rpedictor. Finally, a further 4.7% of the variance in P-PTSS was predicted by predictors referred to the childbirth (Step 3), among which medical complications in the mother during childbirth and the birth experience as traumatic acted as the significant predictors. Thus, more threatening, and traumatic women’s appraisal of their birth experience accounted for greater levels of P-PTSS at eight months of postpartum.

Predictive role of post-traumatic stress symptoms at eight months of postpartum on bonding difficulties

Bivariate correlations.

Preliminary bivariate correlation analyses supported significant correlations between the main variables under study (aim 2). All variables were significantly related. Postpartum depression (T3) was significantly moderate and positively related to brooding (T3), r  = 0.670; p  = 0.001, bonding difficulties (T3), r  = 0.517; p  = 0.001, and P-PTSS (T3), r  = 0.641; p  = 0.001. Brooding was significantly moderate and positively related to bonding difficulties at T3, r  = 0.526; p  = 0.001, and P-PTSS at T3, r  = 0.613; p  = 0.001. Finally, P-PTSS was significantly moderate and positively related to bonding difficulties at T3, r  = 0.482; p  = 0.001.

Main analyses (Aim 2): path model of P-PTSS as an indirect predictor of mother-child bonding

Based on the previous bivariate correlation analysis we tested an equation model where bonding difficulties at eight months of postpartum (T3) variables were predicted by P-PTSS (at eight months of postpartum; T3) directly and/or indirectly through the use of brooding (T3) as emotional regulation strategy and the development of postpartum depressive symptoms (T3), with the variable of previous levels of bonding difficulties (T2) being a controlled, providing a measure of temporal change of bonding difficulties. All the goodness-of-fit indices are shown in Table  4 .

As shown in Table  4 , the goodness-of-fit indices for the initial hypothesized path model were not good. Moreover, the Mardia coefficient yielded a value of 15.94 which is far for the critical value (± 5). Since the fit of our initial model (Model 1) was poor, re-specification was carried out following Wald and Lagrange multiplier tests [ 61 ]. All paths with nonsignificant P  values were removed consecutively. Only the path P-PTSS to bonding difficulties, both at 8 months of postpartum was removed. The variable ‘birth experience,’ assessed at 2 months postpartum (T2), was further introduced as a predictor of the onset of P-PTSS at 8 months postpartum (T3), and an additional path was included in the model, through which bonding difficulties at 2 months of postpartum predicted brooding at 8 months of postpartum (Fig.  4 ). The final respecified model (Model 1R) showed a very good fit in all the indices (Table  4 ). Despite the Mardia coefficient remaining slightly elevated at 13.67, it improved compared to Model 1, and it would be appropriate to use maximum likelihood estimation as it did not exceed the value of 70 [ 60 ].

The respecified model (Model 1R) with standardized regression weights

Note. T2: 2 months postpartum. T3: 8 months postpartum

Indirect effects were tested using bias-corrected bootstrap estimations (2000 bootstrap samples with 95% CI). First, the hypothesized path was significant, with an indirect effect of P-PTSS triggered by a negative birth experience at T2 on bonding difficulties’ changes from T2 to T3, through individual differences in P-PTSS in ruminative brooding, subsequently leading to higher postpartum depression symptom levels and ultimately resulting in lower bonding ( p  = 0.001; SE = 1.375; 95% CI 3.759 to 8.281), supporting the hypothesized path. Additionally, a further indirect effect of P-PTSS after a negative birth experience on bonding difficulties, exclusively through individual differences in brooding after controlling for depression levels was also statistically significant ( p  = 0.001; SE = 1.388; 95% CI 3.053 to 7.606). There was also a significant indirect effect of P-PTSS after a negative birth experience on bonding difficulties, exclusively through postpartum depression symptoms after controlling for brooding levels ( p  = 0.001; SE = 1.370; 95% CI 3.062 to 7.575). Furthermore, the indirect effect of bonding difficulties at two months (T2) on bonding difficulties at eight months postpartum (T3) through individual differences in ruminative brooding, subsequently leading to higher postpartum depression symptom levels and ultimately resulting in lower bonding, was significant ( p  = 0.001; SE = 0.161; 95% CI 0.917 to 1.449). Additionally, the significant indirect effect of low-quality bonding (T2) on bonding difficulties (T3) through individual differences in brooding, after controlling for depression levels, was also statistically significant ( p  = 0.015; SE = 0.192; 95% CI 0.182 to 0.821).

The present study considers the type of birth experience for the mother as a bridging event between pregnancy and postpartum psychological experiences, whose relevance is of great importance in the postpartum period, not only for the psychological well-being of the mother but also for the bond with her child [ 4 , 5 , 6 , 7 , 8 ]. Sometimes childbirth is not experienced as a positive but as a negative or even traumatic event [ 12 ], which can lead to P-PTSS [ 9 – 10 ]. Previous research has been focused on comprehensively studying the risk factors that may influence P-PTSS development after childbirth. Yet, these previous studies did not typically consider all possible predictors in an integrative manner, neither used different temporal assessments of relevant risk factors at different relevant periods (before and during pregnancy, and at childbirth). The first aim of the present study was thus to assess the risk factors identified in previous literature for the development of P-PTSS, but integrating all the factors identified in different studies into the model, while also taking into account their occurrence at different times (i.e., prior to pregnancy, pregnancy period, time of childbirth), through a rigorous and extensive longitudinal design.

Results indicated that the presence of an history of depression before pregnancy as well as the higher presence of depressive symptoms during the third trimester of gestation both stood out as significant predictors of P-PTSS eight months after childbirth. These results align with evidence from previous studies [ 13 ] and show the impact of the mother’s life history and current psychological well-being during pregnancy on her childbirth experience. Moreover, experiencing medical complications during childbirth by the mother, as well as perceiving the childbirth experience as threatening or traumatic, were both identified as additional significant risk factors for the subsequent development of P-PTSS. Thus, the more complex and traumatic the mothers’ childbirth experience, the greater the probability of developing P-PTSS. These results align with evidence from previous research on this issue [ 12 , 14 – 15 , 17 ], while being obtained in an integrative model that consider all these variables at different temporal stages of pregnancy and childbirth.

In contrast, generalized anxiety symptomatology during pregnancy, the experience of stressful life events and complications during pregnancy, the quality of medical care received, and the complications in the baby during birth were not found to be significant predictors of P-PTSS above and beyond the mentioned main risk factors. These results apparently contrast to the ones from other studies [ 12 , 13 , 14 , 15 ]. Nonetheless, the absence of predictive power of these other variables could be due to the lack of representativeness and variability of these variables in the present sample. The participants’ mean anxiety level in this study was below the cut-off point on the generalized anxiety symptomatology questionnaire during pregnancy, 84% did not report to have experienced stressful life events, and 81% did not report to have experienced medical complications during pregnancy. Similarly, 72% did no have medical complications after delivery. Finally, the medical quality variable could not be a predictor due to limitations in the assessment method, as it was only assessed through a single question that did not show sufficient sensitivity.

Overall, using an integrative and extensive longitudinal design, the present study allowed to determine the main risk factors contributing to higher levels of P-PTSS. This seems essential, as this problematic has been identified as a core source of dysfunction for some mothers itself but also a further predictor of additional central problems at postpartum, such as the appearance of difficulties in mother-child bonding. Yet, the specific paths for this influence remained to date unclear.

Thus, the second aim of the study was establishing the indirect impact of P-PTSS symptomatology on mothers’ bonding with the newborn through other identified regulatory and mental health issues emerging during postpartum (i.e., brooding, postpartum depression). The initial path model formulated (see Fig.  3 for more details) did not show good fit indices, so we followed modification indices and introduced the variable ‘birth experience’ into the model as the initial predictor, creating a new revised model (Model 1R, see Fig.  4 for more detail). This new path model would allow us to see two pathways of influence towards the presence of bonding difficulties at 8 months postpartum. Results showed that, on the one hand, the birth experience would act as a risk factor predicting the subsequent appearance of P-PTSS, in response to which the mother would use emotional regulation strategies based on the use of brooding, which in turn would trigger depressive symptomatology, ultimately impacting on the quality of bonding. For P-PTSS to impact the quality of bonding, brooding (a maladaptive emotion regulation strategy associated with P-PTSS) and postpartum depression symptomatology (comorbid to P-PTSS and usually caused by this type of brooding ruminative response style) must be considered as potential intervening meditators. Our analyses empirically confirmed these paths and are discussed into detail below. Moreover, in the final model, no direct effect of a negative birth experience on bonding difficulties was found, and it only indirectly influenced it through the above-mentioned path. This suggests that women may have a more difficult or potentially traumatic birth, but this would not necessarily affect her ability to bond with her baby. A negative birth experience would only impact the bond only if postpartum PTSD symptoms is subsequently developed. Thus, it would not be the experience itself but the traumatic interpretation and processing of that experience what would influence the appearance of bonding difficulties.

As suggested by other authors, ruminative response styles would be habitually used by women with P-PTSS as a maladaptive regulation strategy of their experienced distress [ 20 , 62 ]. A higher use of brooding would not promote trauma integration [ 20 ] but instead increase the severity of P-PTSS [ 20 , 22 ], generating long-term negative emotions [ 20 ], among others, being associated to postpartum depressive symptoms. For this reason, in line with our results, P-PTSS should be considered a risk factor for developing postpartum depressive symptomatology, as is the case with general PTSS and depressive symptoms [ 29 – 30 ]. The literature indicates that the causal relationship between PTSD and depressive symptomatology would be due to that people with PTSD have a negative view of themselves, others, and the world, which corresponds to the cognitive triad usually promoting risk for the onset and maintenance of depressive symptomatology [ 28 ].

Considering the postpartum stage, the presence of P-PTSS is also related to symptoms of postpartum depression, with the prevalence of this symptomatology at two months of postpartum being between 10 and 20% of women and increasing to 12–25% in new mothers [ 31 ]. In addition, postpartum depression tends to be preceded by brooding [ 26 ] which comprises a higher attention to negative cognitions referred to the cognitive triad (63. In the final supported model in this study, P-PTSS would predict a ruminative style as a maladaptive regulation strategy of distress, mainly shaped by brooding, being then related to higher postpartum depressive symptom levels.

The results also indicate that postpartum depressive symptomatology impacts the quality of mother-child interactions, favoring higher levels of bonding difficulties [ 32 ]. In addition, a higher use of brooding itself, which is responsible for facilitating depressive symptomatology, would also partly directly impact the development of poorer quality mother-child bonding [ 33 ]. This may be because brooding drains the mother’s cognitive resources, preventing her from having her baby in mind and thus limiting her ability to respond to her newborn’s needs in a responsive, rapid, and congruent manner [ 33 ]. Therefore, the occurrence of P-PTSS would play a further specific indirect role in the generation of bonding difficulties through both ruminative mechanisms as well as through higher associated levels of depressive symptomatology in the postpartum period.

Moreover, the presence of bonding difficulties at two months postpartum would predict, by itself, the continuation of these difficulties at eight months postpartum, both directly and through the emergence of brooding and postpartum depression symptoms. As mentioned earlier, the use of brooding, in this case as rumination in response to difficulties a mother may be experiencing in feeling connected to her baby, would generate long-term negative emotions in the mother [ 20 ], implicating a higher attention to negative cognitions referred to the cognitive triad [ 63 ], which is associated with postpartum depressive symptoms. This, in turn, impacts the quality of mother-child interactions, leading to higher levels of bonding difficulties [ 32 ].

Taken together, these results have several implications that should be considered. The results suggest the importance of developing preventive strategies in the postpartum, including identifying mothers with a previous history of depression and reducing avoidable stress during childbirth to reduce the risk of onset of P-PTSS.

In this line, it is essential to develop training programs for health personnel so that they can learn what aspects can turn childbirth into a traumatic event. By doing so, they can identify those mothers with whom they should work to prevent the development of a traumatic interpretation of childbirth and, consequently, avoid the onset of P-PTSS. In addition, programs focusing on screening and intervening to redirect mothers’ ruminative patterns and depressive symptoms in the early postpartum period would be very helpful in reducing their influence in the appearance of bonding disorders [ 64 ].

Limitations and strengths

Although, as commented above, the present results have several interesting implications for promoting mothers’ mental health and reducing bonding difficulties during the postpartum, a series of limitations must be considered. First, regarding the risk factors for P-PTSS development that were studied, it was only possible to collect pre-birth aspects such as the presence of psychopathology, as well as a broader view of the medical quality received by the health personnel and the birth experience, being based on a general self-report of the mother, assessed with a single question designed for the study that did not show sufficient sensitivity. Future studies should use more precise assessments of these variables and consider other potential risk factors informed by previous literature [ 12 , 13 , 18 ].

Furthermore, the diagnostic criteria established for detecting P-PTSS or postpartum depression state that the assessment should be carried out six months after presenting symptoms [ 65 ], but in the present study, it was assessed at eight months postpartum. Similarly, the assessment of P-PTSS was carried out using a PTSD scale designed for its use in the general population due to the lack of validated and standardized questionnaires specifically designed for the perinatal population. Moreover, as for the path model testing longitudinal changes in bonding difficulties, although our model considered theoretical sound paths among variables, by design, most variables needed to be assessed within the same time period, as sociodemographic variables. Thus, further intensive longitudinal research might add value by modelling how each of our supported variables predict such longitudinal changes when modelled across different time points. Similarly, these results refer to a specific socio-cultural (Spain) and health (COVID-19 pandemic) context, which, despite their relevance to the study, have not been controlled for, so it is necessary to be able to replicate this research in other contexts.

Despite these limitations, a series of strengths of the study must be highlighted. First, online recruitment, as the one used in this study, provided an opportunity to obtain larger samples of participants than most of previous studies, and to recruit more women who experience postpartum PTSD or depression, which is useful when studying patho-mechanisms of bonding problems. In this study we were able to conduct a longitudinal study at multiple phases of 150 mothers, which is not typically common, and helped to provide reliable and consistent tests of the hypotheses of our study. Further, the study of factors involved in the onset and maintenance of P-PTSS, as well as its comorbidities and subsequent influences, is a very novel adding of this research, as there are numerous studies about PTSD in the general population [ 20 , 21 , 22 ], but not in the perinatal population. Specifically, this study has aimed to provide more extensive evidence about individual cognitive processes, such as a ruminative response style, in studying P-PTSS and its relationship with postpartum depression, that are not typically integrated within this line of research. A limited number of studies have previously explored the relationship between these variables [ 20 ] and always in the general population. Furthermore, despite what has been stated about the comorbidity between P-PTSS and depressive symptomatology and the difficulties that this comprises to separate the statistical influence of one on each other [ 66 ], the specific nature of the instruments used to assess P-PTSS symptomatology and postpartum depression, made it possible to reduce the covariance of both variables at the statistical level and to isolate the effects of one on each other. Finally, this research highlights the importance of studying the presence of psychopathology during the perinatal stage, specifically in moments of great relevance but less studied, such as the childbirth stage. To this end, the longitudinal approach used in this study highlights the importance of the mother’s life and the pregnancy experience for the understanding the development of problems of mother-child bonding.

Conclusions

The present study investigated risk factors for P-PTSS in the eighth month of postpartum and the possible mechanisms for its contribution on further bonding problems. The results allow to conclude that previous history of depression, depressive symptomatology during pregnancy, presence of medical complications in the mother, and a negative childbirth experience may be risk factors predicting P-PTSS in the postpartum period. This symptomatology, triggered by a negative childbirth experience, could, in turn, lead to difficulties in mother-child bonding. This relationship would be mediated by the presence of brooding and the development of postpartum depression. P-PTSS would predict a brooding coping style in the mother, increasing the likelihood of depressive symptoms. Moreover, mothers who already had bonding issues at two months postpartum, these could persist at eight months postpartum due to the onset of brooding and postpartum depression symptoms.

These findings are highly informative and may serve as a basis for the development of new future longitudinal studies that continue advancing the understanding of these mechanisms of perinatal mental health. Studies aimed at replicating and extending the relationships between these variables will improve knowledge about the risk factors that are present during the mothers’ life history, her pregnancy, and their influence on their childbirth experience, as well as on their subsequent postpartum mental health, and the quality of mother-child bonding.

Data availability

the dataset analysed during the current study is available from the corresponding author on reasonable request.

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this research is part of the research project “Psychological well-being in the perinatal stage and quality of the mother-baby bond"of the call for funding of own research projects 2022 financed by Universidad Pontificia Comillas.

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Maria Vega-Sanz: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Writing-original draft. Ana Berástegui: Conceptualization, Methodology, Writing-review, and editing. Álvaro Sánchez-López: Conceptualization, Methodology, Writing-review, and editing.

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Vega-Sanz, M., Berastegui, A. & Sanchez-Lopez, A. Perinatal posttraumatic stress disorder as a predictor of mother-child bonding quality 8 months after childbirth: a longitudinal study. BMC Pregnancy Childbirth 24 , 389 (2024). https://doi.org/10.1186/s12884-024-06570-4

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Perspective of Postpartum Depression Theories: A Narrative Literature Review

Fatemeh abdollahi.

Department of Public Health, Faculty of Health, Mazandaran University of Medical Sciences, Sari, Iran

Munn-Sann Lye

1 Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia

Mehran Zarghami

2 Department of Psychiatry, Faculty of Medicine and Health Sciences, Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran

Postpartum depression is the most prevalent emotional problem during a women's lifespan. Untreated postpartum depression may lead to several consequences such as child, infant, fetal, and maternal effects. The main purpose of this article is to briefly describe different theoretical perspectives of postpartum depression. A literature search was conducted in Psych Info, PubMed, and Science Direct between 1950 and 2015. Additional articles and book chapters were referenced from these sources. Different theories were suggested for developing postpartum depression. Three theories, namely, biological, psychosocial, and evolutionary were discussed. One theory or combinations of psychosocial, biological, and evolutionary theories were considered for postpartum depression. The most important factor that makes clinicians’ choice of intervention is their theoretical perspectives. Healthcare providers and physicians should help women to make informed choices regarding their treatment based on related theories.

Introduction

The postpartum period is recognized as the time when many women are vulnerable to a variety of emotional symptoms.[ 1 ] The most prevalent mental or emotional problem associated with childbirth is postpartum depression (PPD).[ 2 , 3 ] A latest review reported its prevalence to be 1.9 to 82.1% and 5.2 to 74.0% in developing and developed countries, respectively, using a self-reported questionnaire. Its prevalence has also been reported to vary from 0.1 to 26.3% using a structured clinical interview.[ 4 ]

Given that PPD is one of the psychiatric conditions that is amenable to treatment, early recognition is a significant task for all physicians who are working with women during prenatal and postnatal period and can help them in providing treatment plans to reduce their distress.[ 5 , 6 ]

Despite scholars’ efforts, the etiology of depression after birth is inconsistent and unknown.[ 7 , 8 ] Numerous etiologies have been suggested; however, no single hypothesis can elucidate this phenomenon.[ 7 , 9 ]

Because there is no single etiology for developing PPD, a single modality could not be effective for treatment of all women. Some scholars affirm that theoretical perspectives should be evaluated before taking a decision regarding treatment options. This article is a review of the possible theories proposed for PPD.

Biological Theories

Beck (2002) stressed that one of the theoretical bases of PPD is the medical model which is considered as an illness as well as a medical condition. It is also a personal pathological mood disorder which is not considered to be a result of social or environmental conditions. From this point of view, women are passive individuals in the medical model who are under influence of biological factors.[ 10 ] They suffer more from depression episodes around particular periods during their lifespan.[ 11 ]

Different theories exist regarding pathophysiological hormonal effects on PPD including the withdrawal theory,[ 12 ] interaction among the hypothalamic–pituitary–gonadal system and the hypothalamic–pituitary–adrenal system (HPA),[ 13 , 14 ] and change in the levels of gonadal hormones.[ 15 ]

In the prenatal period, HPA axis and women's reproductive system changes with strong interaction between them. It is possible that the HPA axis functions differently in women who are susceptible to depression through the suppression of corticotrophin-releasing hormone (CRH) during postpartum period in the hormonal pathway for affective disorders.[ 16 , 17 ] On the other hand, other studies have demonstrated that CRH suppression does not correlate with mood fluctuation, and therefore the HPA axis in the physiology of PPD is possibly not well-founded.[ 18 ]

Hormones such as estrogen, progesterone, beta-endorphin, human chorionic gonadotrophin, and cortisol increase during pregnancy and significantly drop after birth.[ 12 , 19 ] Quick shifts in hormones, such as estrogen in the puerperium, changes the levels of these hormones either too high or too low leading to PPD.[ 6 ] Moreover, a sharp decline in reproductive hormone levels that occurs after delivery is assumed to be the main cause of PPD in women by some researchers.[ 6 , 13 ] This modification is said to be a trigger for changes in the peripheral and central monoamine centers.[ 12 , 20 ] Sudden withdrawal of these hormones could be a trigger of depression and women with a history of PPD may respond differently and more sensitively to sudden decrease of plasma levels of gonadal steroids.[ 12 ]

Reduced estradiol plasma levels with depressed group in contrast with the control group was reported.[ 13 ] Estrogen and progesterone have an effect on neurotransmitters which are involved in the emotional and cognitive processes.[ 12 ] The function of estrogen is to keep serotonin stable in order to keep more transmitters in the brain. Furthermore, estrogen has an influence on adrenaline, norepinephrine, and serotonin receptors. The latter interaction could be due to antidepressant function and depression.[ 21 ] Moreover, neuropeptides have various roles in physiological and behavioral parts of the cerebral nervous system (CNS).[ 22 ] Levels of estrogen decrease prior to menstruation, after delivery, and during menopause. In addition, gonadal hormones keep the rate of depression down during pregnancy.[ 23 ] This effect manifests itself during the last trimester of pregnancy. Within a few days after childbirth, gonadal hormones decrease markedly, which demonstrates a probable correlation with an unexpected increase in the development of nonpsychotic and psychotic mental illness.[ 23 , 24 ] However, other research findings did not find hypogonadal levels of estrogen and progesterone to be a risk factor for PPD.[ 25 ]

It has been also suggested that the serotonin (5HT) system has a significant role in prenatal and postnatal depression because depressed mothers respond well to serotonergic antidepressants.[ 26 ] According to this study results, 5HT1A serotonin receptor binding decreased from 20 to 28% in the depressed group in comparison with the control group.[ 26 ]

Even though, many scholars have concluded that physiological fluctuations are the causes of PPD, hormonal cause for the PPD is not supported consistently by the literature.[ 6 ] While the genetic basis of varying sensitiveness to gonadal steroids remains unclear, genetic polymorphisms in genes that regulate reproductive hormones may make some women susceptible to mood disorders.[ 24 ]

A correlation between personality and genetic factors such as Cytochrome P4502D6 (CYP2D6) has been demonstrated.[ 27 , 28 ] The presentation of CYP2D6 is prevalent under the genetic control.[ 29 ] The rate of CYP2D6 metabolism in pregnant and postpartum depressed mothers was more than anticipated in a general population.[ 29 ]

To sum up, the previous studies did not reach a unified conclusion. It appears that an internal abnormal reaction to hormonal changes contributes to PPD.[ 20 ]

Psychosocial Theory

Specific neurophysiological and neurochemical changes in the brain are triggered by psychosocial stressors and interpersonal events that significantly change the neurotransmitter balance. It is considered that depression is related with psychosocial stressors, as described below.[ 30 ]

Psychodynamic theory

The psychodynamic point of view supports the idea that some unfinished business in women's childhood or family may cause more psychological troubles after birth.[ 31 ] Women have a tendency to imitate their own mother's role as soon as they become mother after birth, however, if there is a rejection in accepting their own mother's role, they have trouble coping or adapting to their new role of motherhood.[ 30 ] The outcome of the mother's role conflict can lead to rejecting the female identity as well as threaten her feminism.[ 30 ] Some experts have also noted that childbirth results in loss of their identity and leads to withdrawal of love, affection, and loss of independence.[ 31 , 32 ] Moreover, family's negative attitude affects women's well-being and results in the maladjustment of coping mechanisms.[ 31 ]

Cognitive psychology theory

The cognitive approach instead of postulating internal conflicts in psychodynamic theory emphasizes certain characteristics of personality which predispose new mothers to PPD. It is the unrealistic expectation of childbirth and motherhood which may cause mothers to be anxious, controlling, perfectionist, and exhibit compulsive tendencies.[ 33 ] Beck (1967) postulated that depressed mood is the result of thought disturbances.[ 34 ] Pessimism toward oneself, the world, and the future contributes to a depressive mood.[ 31 , 33 , 35 ] In addition, in the absence of suitable role models, the woman feels loss of control and anxiety resulting in a lack of a capability to cope with infant's demands and care.[ 31 ]

Social and interpersonal theory

Egeline (2008) contends that environment plays a significant role in an individual's life.[ 36 ] Attachment theory says that interpersonal struggles in an individual's life have significant influences on mental health. It is obvious that an individual requires affection which needs to be fulfilled in the initial stage of a relationship. Uncertainties concerning a relationship may result to disappointment and bring about depression and anxiety.[ 37 ] A number of interpersonal factors play a role in women's distress and sensitivity makes them prone to develop postpartum disorders. These include insufficient social support and marital conflicts.[ 38 ] Childbirth is a significant transitional event in life and support at this stage can potentially affect women's mental status after delivery.[ 39 ] Sudden psychosocial fluctuations within motherhood and its challenges coupled with stresses could be other factors that may trigger PPD.[ 20 ]

Behavioral theory

According to the behavioral theory, depressive episode can result from major life events that disrupt an individual's normal support pattern.[ 40 ] Life stressors and psychological problems such as parent's divorce, low parental emotional support, mother-daughter conflict, and self-esteem are predictors of PPD.[ 38 ]

The theory of operant condition paradigm claims that depression is a consequence of a decrease in the positive efficient reinforced behavior and could be a sign of obvious punishment for nonconformant behavior. It is also the result of a decrease in the accessibility of reinforcement events, personal ability to maneuver the environment, the impact of variety of events, or a combination of the above. Moreover, a negative feedback of social reinforcement behaviors may result from unavailability of support from family and other social networks such as social withdrawal. However, a low rate of positive reinforcement for mood-enhancing behavior and high rate of positive reinforcement for depressive behavior may be experienced by people who experience major stress originating from unexpected events.[ 40 ]

Evolutionary theory

Scholars have suggested relevant adaptive functions for PPD which are consistent with ideas of evolutionary theorists. Usually the women experiences negative effects such as gloomy and depressed mood due to problems concerning the infant, marital problems, and lack of social support associated with the social and family environment. Some women, who suffer from major PPD and with symptoms such as psychomotor retardation, weight loss, loss of interest in activities, lack of concentration, and constant suicidal thoughts may sometimes not seek social support. Moreover, actions that women take to reduce these psychological problems predispose her to PPD.[ 41 ]

From an evolutionary perspective, there are situations when it would be in the women's best interest to decrease her investment for a baby, for instance when there is a lack of sufficient social support to raise the newborn or when the child has a problem.[ 31 , 41 ]

According to evolutionary theorists, PPD results from an adaptive function that signals a potential fitness cost to the mother. Thus, PPD is not a dysfunction but rather an adaptive mechanism. It signals a mother who has suffered a social cost motivating her to evaluate whether to continue to or cease to provide care to her offspring. From this viewpoint, PPD is a universal phenomenon that appears in women around the world. As a result, in societies that give rise to the circumstances, its prevalence is reduced.[ 42 ]

There is no common consensus among theorists regarding the nature of PPD. Three theoretical perspectives on PPD have been reviewed in this paper. One theory or combination of theories may be suspected for a postpartum depressed woman. Biological theory, such as physiological fluctuations of hormones, psychosocial theory, such as interpersonal struggles in an individual's life, and finally evolutionary theory that suggests adaptive functions as a model for PPD were discussed.

The most important factor that affects health care providers and clinicians’ choice of intervention (prevention or treatment) is their theoretical perspectives on PPD.[ 10 ] In some cases, combination of these theories may be applied. For example, antidepressant therapy (medical model) along with psychotherapy (psychosocial model) may be employed for treatment. Healthcare providers should inform depressed women about the range of treatment approaches available that are set based on appropriate theories and help them to make informed choices regarding their treatment.

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Mazandaran University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

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Peer-reviewed

Research Article

Childhood abuse and perinatal outcomes for mother and child: A systematic review of the literature

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Psychology, Charles Sturt University, Bathurst Campus, Bathurst, NSW, Australia

• Robyn Brunton

• Published: May 24, 2024
• https://doi.org/10.1371/journal.pone.0302354
• Peer Review
• Reader Comments

Childhood abuse can have long-term adverse outcomes in adulthood. These outcomes may pose a particular threat to the health and well-being of perinatal women; however, to date, this body of knowledge has not been systematically collated and synthesized. This systematic review examined the child abuse literature and a broad range of perinatal outcomes using a comprehensive search strategy. The aim of this review was to provide a clearer understanding of the distinct effect of different abuse types and areas where there may be gaps in our knowledge. Following PRISMA guidelines, EBSCO, PsychInfo, Scopus, Medline, CINAHL, PubMed, and Google Scholar databases and gray literature including preprints, dissertations and theses were searched for literature where childhood abuse was associated with any adverse perinatal outcome between 1969 and 2022. Exclusion criteria included adolescent samples, abuse examined as a composite variable, editorials, letters to the editor, qualitative studies, reviews, meta-analyses, or book chapters. Using an assessment tool, two reviewers extracted and assessed the methodological quality and risk of bias of each study. From an initial 12,384 articles, 95 studies were selected, and the outcomes were categorized as pregnancy, childbirth, postnatal for the mother, and perinatal for mother and child. The prevalence of childhood abuse ranged from 5–25% with wide variability (physical 2–78%, sexual 2–47%, and emotional/psychological 2–69%). Despite some consistent findings relating to psychological outcomes (i.e., depression and PTSD), most evidence was inconclusive, effect sizes were small, or the findings based on a limited number of studies. Inconsistencies in findings stem from small sample sizes and differing methodologies, and their diversity meant studies were not suitable for a meta-analysis. Research implication include the need for more rigorous methodology and research in countries where the prevalence of abuse may be high. Policy implications include the need for trauma-informed care with the Multi-level Determinants of Perinatal Wellbeing for Child Abuse Survivors model a useful framework. This review highlights the possible impacts of childhood abuse on perinatal women and their offspring and areas of further investigation. This review was registered with PROSPERO in 2021 and funded by an internal grant from Charles Sturt University.

Citation: Brunton R (2024) Childhood abuse and perinatal outcomes for mother and child: A systematic review of the literature. PLoS ONE 19(5): e0302354. https://doi.org/10.1371/journal.pone.0302354

Editor: Abraham Salinas-Miranda, University of South Florida, UNITED STATES

Received: June 7, 2023; Accepted: April 2, 2024; Published: May 24, 2024

Copyright: © 2024 Robyn Brunton. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: This review was funded by an internal grant from Charles Sturt University. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Worldwide, millions of children suffer physical (CPA), sexual (CSA), psychological (CPY), or emotional abuse (CEA) that potentially have long-term deleterious outcomes [ 1 ]. While it is well established that the sequela of childhood abuse can be poor [ 1 , provides a review], an important consideration is the impact of abuse on perinatal women. Certain adverse outcomes consistently linked to abuse could be exacerbated by pregnancy or impact the mother’s well-being and behaviors. For example, if the risk of Post-Traumatic Stress Disorder (PTSD) and substance use is high for abuse survivors in the general population, it is important to know if this risk extends to pregnancy and postpartum. Moreover, particular experiences of pregnancy and postpartum can be exacerbated by child abuse, such as childbirth and breastfeeding [ 2 , 3 ], potentially impacting mother, child, and prenatal care.

Another consideration is that the body of knowledge regarding child abuse and perinatal outcomes needs to be collated to ensure that findings extrapolated globally are generalizable. Child abuse can exacerbate anxieties experienced during pregnancy [ 4 ], but these anxieties have wide cross-cultural variability [ 5 ]. Moreover, conceptions of child abuse can vary cross-culturally, with what constitutes physical abuse in one country deemed acceptable parenting behavior in another country [ 6 ]. Therefore, without a clear understanding of the body of knowledge, assumptions cannot be made that all findings apply to all pregnant women.

Few systematic reviews have synthesized research for all types of child abuse and a broad range of perinatal outcomes. To our knowledge, only one similar review examined CSA and pregnancy outcomes [ 7 ]. Other reviews have focused on child maltreatment more broadly [ 8 ] or specific outcomes such as mood disorders [ 9 ]. However, the distinct characteristics of different abuse types in the context of the unique developmental life stage of pregnancy, warrant separate examination. For example, the experience of CSA differs from other abuses; therefore, an individual with this history may avoid prenatal care for fear of intimate procedures, which may not be triggering for someone with a CPA history. Therefore, understanding the differential impact of child abuse on perinatal women is important in understanding their needs.

This review builds on previous reviews by expanded search criteria (i.e., all child abuse types and perinatal outcomes [i.e., conception to 12 months postpartum]) databases and gray literature. The aim is to provide a focused review of child abuse outcomes for perinatal women by collating and synthesizing the data to provide a comprehensive overview of the current knowledge. This targeted review will provide a clearer understanding of the distinct effect of different abuse types and areas where there may be gaps in our knowledge. Specifically, the following research questions were examined: Do pregnant and postpartum women with a history of child abuse have more adverse pregnancy, childbirth, and postpartum outcomes than other women? Do the offspring of pregnant women with a history of child abuse have more adverse outcomes than other children?

The systematic review and protocol were registered with PROSPERO in 2021. PRISMA and other reporting guidelines guided the review [ 10 , 11 ]. The PICOT search framework mnemonic focused the question: Population = women who experience pregnancy and childbirth; Indicator = child abuse (includes any study that examines child abuse, noting that different studies may use different age limits to define abuse); Comparison = non-abused women; Outcomes = (1) pregnancy, (2) childbirth (3) child development including neonatal and infant, and (4) postpartum maternal outcomes; Time = perinatal (conception to 12 months postpartum).

Reviewer one [RB] and reviewer two ([DC], a research assistant) extracted the data. Studies were selected if they were original quantitative cross-sectional or longitudinal research examining perinatal outcomes for women with a child abuse history. Child abuse could be a predictor or correlate of any adverse perinatal outcome in English-language peer-reviewed articles, dissertations, conference proceedings, or preprints between 1969 and 2022. Two searches were conducted, one in May 2021 and another in January 2023 to update the original 2021 search. However, the additional studies identified in 2023 were not subjected to two reviewers due to budget constraints.

Adolescent samples were excluded as they have unique psychosocial and biological challenges [ 12 ] however papers that included some adolescents in their sample [e.g., Ranchod et al., 2016] were included. Other exclusion criteria included abuse examined as part of a composite variable, editorials, letters to the editor, qualitative studies, reviews, meta-analyses, or book chapters. Databases searched included EBSCO (Academic Search Complete, Psychology and Behavioural Sciences and SocIndex), PsychInfo, Scopus (Elsevier), Medline, CINAHL, PubMed, and Google Scholar. In addition, gray literature searches included preprints (i.e., PrePubMed and OSFPreprints) and theses and dissertations (i.e., the ProQuest Dissertations and Theses Global database and EBSCO Open dissertations).

Reviewer one searched databases using the following search strategy to identify relevant articles: Child* AND (abuse OR maltreatment OR neglect) AND (Pregnan* OR antenatal OR Childbirth OR labour OR labor OR Neonat* OR Postpartum OR postnatal OR Perinatal). In addition, “history of violence against children” was also searched alongside the perinatal search terms, as it is used by many researchers globally [e.g., 13 ]. Consistent with ‘back-in-time’ pearling, reviewer one searched the reference list of each identified article using the ‘find’ function in the pdf viewer and the words child* and pregnan*. This search was conducted on articles after full-text screening. Data from the search results were downloaded into Endnote, which identified exact duplicates. All extracted records were imported into an Excel spreadsheet where reviewers independently used the inclusion/exclusion criteria to screen the records by title, abstract, and full text.

Quality assessment

Once inter-rater agreement was achieved, the sample was quality assessed. An assessment tool developed from previous studies [(provided as S1 Appendix , 11 , 14 ] evaluated the methodological quality and risk of bias. Each study was rated on 1) selection procedures, 2) data collection methods, 3) study design, and 4) statistical analyses. Ratings were scored from 4 ( weak ) to 12 ( strong ). Consistency of ratings was confirmed by no substantial differences in the review of an initial ten articles. The remaining studies were individually assessed due to budget limitations. Consistent with Huang et al. [ 15 ], articles rated weak for all four domains were excluded from the review. In addition, the sufficiency of any sample ≤ 200 was checked using G*Power [ 16 ] relative to the analyses conducted (i.e., < 5% chance of a Type 1 error). Those with insufficient power were excluded.

Meta-analysis assessment

The homogeneity of the data was assessed using predefined criteria. Given the heterogeneity of the studies in terms of samples, design, predictors, and outcomes, no studies were deemed suitable [ 17 ]. S1 Table provides the criteria, full details of this assessment, and associated reasons for the unsuitability of the studies.

Fig 1 shows the PRISMA flow diagram. From 12,384 records identified, a sample of 555 studies was derived. For the initial search, the inter-rater agreement was 96.8% (disagreements resolved by discussion). For each iteration of pearling, the inter-rater agreement was 100%. Common reasons for exclusion were duplication of theses with published articles (theses retained for their detail), lifetime or current abuse examined, or using a summary/composite score. The final sample consisted of 95 articles.

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https://doi.org/10.1371/journal.pone.0302354.g001

The data extracted included the type of abuse, the child abuse measure, study details (e.g., longitudinal, country, participant age), perinatal outcomes, and findings. The outcomes were categorized as pregnancy, childbirth, postnatal for the mother, and perinatal for mother and child. Records extracted represented studies from 25 countries with 643,241 participants (excluding duplicate samples); 59 studies were cross-sectional, 36 were longitudinal, and most were conducted in North America or other developed countries. Child abuse was commonly assessed using customized measures and the Childhood Trauma Questionnaire (CTQ) was the most used validated measure. The studies were of good quality ( M = 9.05 SD = 1.42); most were rated low to medium bias (see S2 Table ). S3 Table provides a detailed overview of the studies’ characteristics (e.g., sample, abuse measure, prevalence, outcome measures, and quality rating).

Consistent with Brunton and Dryer’s [ 7 ] approach, prevalence estimates excluded samples < 200 (could lack external validity), with a high risk of abuse (may overestimate) and that utilized the same cohort as another included study. The prevalence of child abuse overall ranged from 5–25% with wide variability for the abuse types: CPA 2–78%, CSA 2–47%, and CEA/CPY 2–69%. The child abuse measure, conceptualization of abuse, and study location contributed to this variability.

Findings from studies

For each subsection of the four main categories of findings, the main findings are summarized (in italics) when multiple studies are reported. Then, the more detailed findings are provided. S4 Table provides the main findings of each study.

Pregnancy outcomes

Unhealthy behaviors..

Disordered eating

Two studies had findings related to pregnancy weight gain or control. The evidence indicates that all abuse types (i.e., CPA, CSA, and CEA) are related to weight or shape concerns or disordered eating. However, in adjusted analyses only CSA significantly predicts lifetime eating disorders and shape and weight concerns .

Ranchod et al. [ 18 ] noted that at least two occurrences of CPA were independently associated with an increased risk of excessive gestational weight gain. Senior et al. [ 19 ] identified that CPA, CSA, and CEA independently predicted lifetime eating disorders and shape and weight concerns. However, only CSA remained significant after adjustment for other childhood factors (e.g., parental depression, support). In addition, CSA and CEA predicted antenatal eating disorder symptoms (e.g., self-induced vomiting), whereas CPA did not. However, these associations were not significant after adjusting for other childhood factors. In addition, all three abuse types were independent risk factors for shape and weight concerns during pregnancy (ORs = 1.56–1.78); however, after adjusting for childhood factors, only CSA remained significant for antennal shape and weight concerns.

Substance use

Four studies examined smoking during pregnancy and predominantly identified CPA and CEA as risk factors for continued smoking. CSA, CSA with force, or CSA and depressive symtoms also predicted antenatal smoking. Fewer studies examined alcohol or drug use during pregnancy, and these indicate that CSA is a risk factor for antenatal drug use, and a history of any CPA or CSA increases the likelihood cocaine use (cf. no abuse) .

Blalock et al. [ 20 ] identified that smoking within five minutes of waking was more than twice as likely for pregnant women who experienced CPA and CEA ( cf . women who reported low/no trauma). Depression did not mediate these relationships. Cammack [ 21 ] identified that non-parental CSA motivated by physical force was associated with continued pregnancy smoking among women with a smoking history. Individuals with depressive symptoms and a history of caregiver CPA or non-caregiver CSA had the same risk level for continued smoking; however, those with 0–1 depressive symptoms and a CPA history were less likely to continue smoking. Nerum et al. [ 22 ] noted that, pregnant women subjected to CSA were more likely to smoke ( cf . adult rape or no child abuse). Racine et al. [ 23 ] found that childhood family violence (i.e., CPA, CEA, and exposure to domestic violence) increased the odds of antenatal smoking, binge drinking, and drug use. A history of CSA was also a risk factor for antenatal drug use. Jantzen et al. [ 24 ], was the only study to examine illicit drugs and showed that women with a history of any CPA or CSA were more likely to use cocaine during their lifetime or perinatally ( cf . no abuse).

Maternal wellbeing.

Psychosocial risks

Psychosocial risks were examined in six studies. Findings suggest that the individual abuse types alone or experienced jointly increased the risk of psychosocial difficulties (e.g., single parenting, being unsupported) relative to no abuse. However, the evidence relating to unplanned pregnancy is mixed with one study identifying child abuse as increasing the risk of unplanned pregnancy yet two studies failed to identify any dose-response relationship related to severity of abuse and unplanned pregnancy .

Racine et al. [ 25 ] noted that women who experienced both CPA and CEA were more likelier to enter pregnancy with health risks and psychosocial difficulties than women who had not suffered abuse. However, no single abuse type significantly increased pre-pregnancy or reproductive health risks. Madigan et al.’s [ 29 ] study of 501 Canadian women identified that CPA or CSA increased the psychosocial risks (e.g., single parent) of pregnant women. One study [ 26 ] identified that women with a CSA history were less likely to participate in childbirth classes and, if they did participate, were unlikely to have a partner with them ( cf . no abuse). These women also felt less prepared for labor and were less likely to have a trusted person with them during labor or feel they could participate in medical decisions. Similarly, Nerum et al. [ 22 ] found thatwomen with a CSA history were more likely to be unemployed or unsupported during pregnancy ( cf . adult rape or no abuse).

Three studies examined unintended pregnancy. Dietz et al. [ 27 ] identified that less frequent abuse attenuated the risk of unintended pregnancy for CPA and CPY with multiple instances of abuse increasing the risk by 50%. Similarly, Drevin [ 28 ] noted that all abuse types, either individually or experienced jointly, and more frequent abuse was associated with an increased risk of unplanned pregnancy. This risk remained even when controlling for other abuses. Finally, Lukasse et al. [ 29 ] identified that CPA, CSA, and child abuse (any CPA, CSA, or CEA) predicted a high incidence of unintended pregnancy but no dose-response effect for severity was identified.

Biomedical risks

Five studies examined five different biomedical risks. CSA was identified as a risk for persistent bacterial vaginosis and increased inflammation in pregnancy. Child abuse history predicted C-reactive protein and increased the risk of gestation diabetes mellitus (GDM). CPA increased the odds of thyroid dysfunction in postpartum women .

Cammack et al. [ 30 ], in a sample of 312 pregnant US women, compared those who suffered CPA, CSA, or CEA to non-abused women and identified only CSA as a risk for persistent bacterial vaginosis (aOR = 3.07). Moreover, when stratified by race (a known risk factor for various adverse perinatal outcomes), the magnitude of this association was stronger for non-black people than black people. Finy and Christian’s [ 31 ] study identified child abuse history as a predictor of C-reactive protein. Pre-pregnancy body mass index (BMI) statistically explained this relationship.

Mason et al. [ 32 ] examined GDM with a large sample ( N = 45,500). In adjusted analyses, different severities, and combinations of exposure of CPA and CSA increased the risk of GDM ( cf . no abuse). Adjustment for pre-pregnancy BMI attenuated these associations slightly. Also, adjustment for not being overweight at 18 years also attenuated these associations and only severe CPA and CSA remaining significant predictors of GDM. CPA was more strongly associated with GDM if it occurred in adolescence than in childhood. Conversely, CSA was more strongly associated with GDM if it occurred in childhood than adolescence. Severe CPA and being overweight at 18 years increased the risk of GDM in a smaller subsample but no similar interaction for CSA was found.

Madigan et al.’s [ 33 ] study identified that CPA or CSA increased the biomedical (e.g., gestational diabetes) risks of pregnant women. Plaza et al. [ 34 ] found that only CPA increased the odds of thyroid dysfunction in postpartum women ( cf . no abuse). Finally, Bublitz et al. [ 35 ] showed that a CSA history was linked to a greater change in the Neutrophil-lymphocyte ratio (NLR, a measure of systematic inflammation) over pregnancy.

Four studies examined cortisol with the evidence indicating that CSA is associated with elevated cortisol awakening response (CAR) in later pregnancy (cf. other or no abuse) and that this association may be moderated by family functioning and abuse severity. Also, experiencing joint CSA and CPA is linked to increased hair cortisol levels however this association was only evident among black women .

CSA was associated with elevated CAR at 30 and 60 minutes after waking after controlling for proximal stressors in a small US study [ 36 ]. Bublitz and Stroud [ 37 ] found that 30 women with CSA histories had higher CAR at 35 weeks gestation than women reporting other or no abuse. In a second study of a similar size drawn from the same cohort, Bublitz et al. [ 38 ] identified that among participants with more experiences of CSA, those with poorer perceived family functioning had increased CAR at 35 weeks but not at 25 or 29 weeks compared to women with fewer CSA experiences and better-perceived family functioning. Schreier et al. [ 39 ] noted that women who experienced joint CPA and CSA had higher hair cortisol levels ( cf . no abuse). When stratified by race/ethnicity, the association between child abuse and hair cortisol levels was only evident for black women.

General health

Seven studies examined aspects of general health or pregnancy-related health. Findings show that CPA or CSA are associated with poor past year health, hospitalization during pregnancy and more pregnancy complications. Also, CPA, CSA or CEA may increase the risk of current (e.g. migraine) or pregnancy-related health complaints or complications (cf. no abuse) .

In a study of postpartum women, Ansara et al. [ 40 ] noted that CPA or CSA did not predict bad headaches (cf. no abuse), however, CSA independently predicted backache, but this was no longer significant in adjusted analyses (e.g., depression). Perineal pain, hemorrhoids, fatigue, or bowel problems were not associated with CPA or CSA. Barrios et al. [ 41 ] identified that a history of child abuse increased the odds of reporting poor past year health or during the current pregnancy ( cf . no abuse history). Similarly, women who reported CPA or CSA were more likely to have poor past year health and over twice as likely to have a poor past year and pregnancy health even after adjustment for current intimate partner violence (IPV).

Drevin [ 28 ], in a large cohort study, identified that women with self-reported CPA reported sacral and pelvic pain more often than those with no CPA. Lukasse et al. [ 42 ] examined 55,776 Norwegian women and found that women with CPA, CSA, or CEA were likelier to report seven or more common pregnancy complaints (e.g., heartburn, backache, cf . no abuse). In addition, joint exposure to different abuses increased this likelihood. Sociodemographic characteristics and other risk factors did not explain this graded association. Finally, Littleton [ 43 ] found that those with a CSA history were more likely than nonvictims to report high levels of past month somatic complaint severity (e.g., headaches, indigestion). Depressive symptoms mediated this relationship (medium effect size). Controlling for sociodemographic variables resulted in similar findings.

Two studies [ 44 , 45 ] found that women exposed to CSA were more likely to be hospitalized during pregnancy ( cf . no abuse). One study identified a link between CSA and reduced antenatal consultations after controlling for demographic and other key factors (e.g., dissociation, adverse childhood experiences). Women with a CSA history also presented more often with complications such as cervical insufficiency than other women. In adjusted analyses, women with a CSA or CPA history were likelier to have pregnancy complications.

Gelaye et al. [ 46 ] identified that any child abuse, CPA, or joint exposure to CPA and CSA increased the likelihood of migraine. In addition, a higher frequency of child abuse increased this risk. Adjusting for lifetime IPV attenuated these associations slightly. Yampolsky et al. [ 47 ] found that CSA survivors were almost twice as likely to have gynecological problems ( cf . other trauma) after adjusting for depression and post-traumatic stress. However, a history of CSA or other trauma was not statistically significant in contributing to high-risk pregnancy.

One study examined sleep and found that child abuse was related to stress-related sleep disturbance. Child abuse or CPA increased the odds of poor pregnancy sleep quality with a dose-response relationship relative to the frequency or joint exposure .

Gelaye et al. [ 48 ] noted that women who experienced child abuse, multiple occurrences of abuse or jointly experienced CPA and CSA were more likely to have stress-related sleep disturbance than non-abused women. These associations remained after adjustment for age, ethnicity, and lifetime IPV. Experiencing CPA or CSA alone was not related to increased odds of stress-related sleep disturbance. When examining sleep quality, women reporting child abuse or CPA were around twice as likely to have poor sleep quality during pregnancy than other women. This risk increased relative to the frequency of abuse or if there was joint exposure to CPA and CSA. In separate analyses, antepartum depression and IPV mediated the relationship between child abuse and stress-related disturbance and sleep quality.

Zhang et al. [ 49 ] examined memory impairment in a community sample. CPA, CSA, and CEA all predicted greater prospective and retrospective memory impairment. In adjusted analyzes, only CEA was independently related to both types of impairment. Women reporting both CEA and CPA had a higher prospective impairment, and those reporting both CEA and CSA or CEA and CPA had higher retrospective memory impairment. Women reporting all three types of child abuse also had higher prospective and retrospective memory impairment.

Miscarriage, stillbirth, and termination

Atkinson [ 50 ] failed to find a relationship between CPA and stillbirth, miscarriage, or termination. Similarly, Freedman et al. [ 51 ] found no association between CPA, CSA, or CEA and stillbirth. However, in a smaller study [ 22 ] of women referred to mental health services, a history of CSA increased the likelihood of a previous termination or miscarriage ( cf . adult rape or no abuse).

Psychological and mental health disorders.

Antenatal depression

Nine studies examined antenatal depression. Findings strongly indicate that child abuse, CPA, CSA or a history of both CPA and CSA are risk factors for depression in pregnancy (cf. no abuse). In addition, race and a positive maternal relationship may influence the severity of depression. Only one study did not find significant results for CSA and depression .

Barrios et al. [ 41 ] identified child abuse, CPA, or a history of both CPA and CSA as more than doubling the risk of depression in early pregnancy ( cf . no abuse). This risk remained after adjusting for current IPV. CSA alone was not a significant risk factor. Likewise, Corona et al. [ 52 ] found a two-fold risk of depression in a sample of 382 low-income Hispanic/Latina women who reported child abuse. However, when stratified by country of birth, foreign-born Hispanic/Latina women had a lower depression risk (aOR = 1.96) than US-born women (aOR = 2.40).

Rich-Edwards et al. [ 53 ] also identified that a history of CPA or CSA increased the risk for antenatal depression in mid-pregnancy after adjusting for age and race. In addition, Yampolsky et al. [ 47 ] found that CSA survivors had a higher risk of depressive symptoms than others. Similarly, Chung et al. [ 54 ] noted that CPA and CSA increased the risk of depression ( cf . no/other abuse). Of note, for CSA survivors without a positive maternal relationship, their risk of depressive symptoms more than tripled compared to women with no CSA and a positive maternal relationship.

Benedict et al. [ 55 ] found that contact or non-contact CSA was unrelated to antenatal depression symptoms but when they examined severe depressive symptoms, women who experienced CSA had a two-fold risk. Samia et al.’s [ 56 ] Kenyan study demonstrated that contact CSA predicted antenatal depression, consistent from early to mid-pregnancy. Galbally et al. [ 57 ] identified moderate-to-severe forms of child abuse increased the risk of an early pregnancy depression diagnosis but when examined separately, CSA posed over a four-fold risk. Only one study did not find a relationship between CSA and depression [ 58 ].

Anxiety, worries and common mental disorders (CMDs)

Four studies had findings related to pregnancy-related anxiety, worries, and CMDs. Brunton et al. [ 4 ] demonstrated that CPA, CSA, and CPY all independently predicted pregnancy-related anxiety mediated by resilience and social support. Eide et al. [ 59 ] noted that women who reported CPA, CSA, or joint exposure were more likely to have strong worries about the baby’s health than other women. Samia et al. [ 56 ] had no significant findings concerning CSA, pregnancy-related anxiety, and stress. Lydsdottir et al. [ 60 ] showed that CSA nearly tripled the odds of CMDs in pregnancy (i.e., depression or anxiety) after controlling for other traumas (e.g., poverty, being bullied). For CPA, however, the risk of CMD diagnosis was over five-fold.

Suicide ideation

Two studies examined suicide ideation finding that pregnant women who experienced any child abuse, CPA, CSA, or CEA had an increased risk of suicide ideation. The severity and frequency of abuse increased the risk exponentially. For women with a history of child abuse, depression or IPV potentially moderates this risk .

Zhang et al. [ 61 ] identified that pregnant women who experienced any child abuse had over a three-fold risk of suicide ideation; controlling for depression slightly attenuated this. When examined independently, child abuse was associated with an increased risk of suicide ideation during pregnancy ranging from around a three-fold risk for CPA and CSA to close to five-fold for CEA. The severity and frequency of abuse increased the risk exponentially. Of note, women with a history of child abuse and depression had the greatest risk of suicide ideation (aOR = 17.78) than women without abuse or depression or women with only depression and no abuse history. Likewise, Zhong et al. [ 62 ] noted that any CPA or CSA nearly quadrupled the risk of suicide ideation in pregnancy compared to other women. This risk was attenuated by controlling for IPV and depression. Experiencing only CPA or only CSA increased the risk more than two-fold; however, joint exposure to CPA and CSA or multiple instances of abuse increased the risk more than four-fold, even after controlling for IPV and depression. The lack of a depression diagnosis did not reduce the risk of suicide ideation for those with a child abuse history.

Post Traumatic Stress Disorder (PTSD)

Five studies examined PTSD during pregnancy. A history of CSA, CPA, CEA or joint CPA and CSA increased the risk for PTSD or related symptomology and this risk increased exponentially for those who experienced child abuse and IPV. Only one study failed to find any significant findings related to the individual abuse types and PTSD .

Yampolsky et al. [ 47 ] found that a history of CSA doubled the risk for high post-traumatic stress symptoms. Sanchez et al. [ 63 ], in models adjusted for age, ethnicity, and lifetime IPV, showed that women who experienced CPA or CSA had an increased risk of PTSD ( cf . other women). This risk increased eightfold when CPA and CSA were experienced together. Also, women who experienced child abuse were more than five times more likely to have PTSD and experiencing child abuse and IPV increased the odds of PTSD to more than twenty-fold.

Seng et al. [ 64 ] examined primiparous women using cluster analysis. CPA was associated with an increased likelihood of affect/relational dysregulation, and CSA doubled the odds of comorbid PTSD. In addition, the odds of being in the healthy cluster for both abuse types were low (aOR < 0.62). Huth-Bocks’ [ 65 ] smaller study examined women in late pregnancy. After controlling for age and income, there were no significant findings related to the individual abuse types and PTSD. Finally, Diestel et al. [ 66 ] examined child abuse and PTSD symptoms with women from an IPV and epigenetic risk study. All types of child abuse were associated with PTSD symptomology, with the strongest findings for CEA. This abuse type was strongly associated with social isolation with weaker associations for intrusive thoughts and negative emotionality.

Childbirth outcomes

Birth complications..

Four studies examinend bith complications with the findings indicating that women with a CPA or CSA history had increased risk of perinatal and obstetrical complications and more likely to have a difficult birth, medical interventions during birth, or their child transferred to intensive care. CPA and CSA were also independent risk factors for complicated delivery .

Shamblaw et al. [ 67 ] found that women with a CSA or CEA history ( cf . no abuse) had around a two-fold increased risk of perinatal and obstetrical complications. However, after adjustment for lifetime psychiatric disorders, only CSA was significant. Heimstad et al. [ 68 ] noted that CPA and CSA were independent risk factors for complicated delivery (i.e., operative vaginal delivery or caesarean); both posed around a 2.5 increase in risk than women with no abuse history. Leeners et al. [ 26 ] showed that pregnant women with a history of CSA were more likely to have a difficult birth and less likely to deliver spontaneously. Finally, Nerum et al. [ 22 ] found that relative to women who experienced adult rape or no abuse, women with a CSA history were more likely to have obstetric risks, induced or augmented labor, epidural analgesia, or their child transferred to intensive care.

Fear of childbirth.

Three studies had findings related to a fear of childbirth. Consistently, child abuse survivors have been shown to have more childbirth fear than other women regardless of parity. A previous negative birth experience increases the risk exponentially. CSA history increases the likelihood of intense fear of delivery, negative birth perceptions, and a greater fear of delivery .

Lukasse et al. [ 3 ] found that regardless of parity, child abuse survivors feared childbirth more than other women. However, primiparas with a CPA, CSA, or CEA history were more likely to fear childbirth severely ( cf . no abuse). The severity of abuse also increased the odds of the severity of fear of childbirth. Experiencing simultaneous abuse increased the odds, and a collective history of all three abuse types posed the greatest risk for severe fear of childbirth (aOR = 5.30). For multiparas, only non-contact, and mild CSA (e.g., humiliation) increased the odds of severe fear of childbirth. CPA, severe CPA, CEA, and any child abuse likewise were risk factors. Also, when adjusted (e.g., demographics, adult abuse, previous negative birth experience), the association between child abuse and severe fear of childbirth attenuated slightly for primiparas but was not significant for multiparas. However, multiparas who experienced any child abuse and had a negative birth experience were nearly six times more likely to have a severe fear of childbirth than women with a history of child abuse and a positive birth experience. However, no child abuse and a negative birth experience posed a much higher risk (nearly nine times) for severe fear of childbirth.

Lukasse et al. [ 69 ] examined multiparas (second pregnancy). Child abuse increased the risk for fear of childbirth after adjusting for sociodemographics, adult abuse, previous birth experience, and perception of first pregnancy. However, only CEA was a significant risk factor for fear of childbirth. Finally, Leeners et al. [ 26 ] demonstrated that women with a CSA history were more likely to have an intense fear of delivery than other women, twice as likely to have a negative birth perception, and nearly three times more likely to fear delivery.

Low birthweight.

Hyle’s [ 70 ] study of low-income women found that a history of CSA (broadly defined), predicted birth weight, whereas CPA did not ( cf . no abuse). Additionally, specific abuse characteristics (e.g., onset age) predicted birth weight. Leeners et al. [ 45 ] identified that women with a CSA history were more likely to have a low birthweight baby (< 2800 grams) than non-abused women. In contrast, Benedict et al. [ 55 ] did not find differences in birth weight or baby characteristics for women exposed to CSA compared to those who were not.

Mode of delivery.

Five studies examined the mode of delivery. The finidngs show that regardless of parity, a history of abuse was not associated with operative delivery, but CPA was associated with a significant increase in emergency cesareans for multiparas. Moreover, any child abuse or CSA was linked to increased cesarean during labor and women who suffered CPA or CSA were more likely to desire a cesarean before their second pregnancy birth .

Schei et al. [ 71 ] utilized data from a multi-country study, finding that regardless of parity, a history of abuse was not associated with any operative delivery. However, for multiparas, a history of CPA was associated with a significant increase in emergency cesareans, and this association attenuated after controlling for previous cesarean. There was no association between CPA and non-obstetrically indicated cesarean. In contrast, Nerum et al. [ 22 ] found that women with a CSA history were no more likely to have an operative vaginal delivery or cesarean than women with a history of adult rape or no abuse. Benedict et al. [ 55 ] failed to find significant differences between CSA and no CSA for the type of delivery (e.g., caesarean, induction). Lukasse et al. [ 72 ] identified that more women with an abuse history had an increased chance of caesarean during labor than other women. However, none of the distinct categories of child abuse was significantly associated with a cesarean before childbirth; however, any child abuse and mild CEA were associated with increased cesarean during labor compared with women with no child abuse. After adjustment, only any child abuse remained a risk factor for cesarean during labor. Using a smaller subsample from the same cohort [ 69 ], women who suffered any CPA or CSA were more likely to desire a cesarean before their second pregnancy birth than women with no abuse.

Preterm birth (PTB).

Six studies have findings related to PTB however most have failed to identify child abuse or specific types (e.g., CPA or CSA) as risk factors for PTB. In contrast one study found that a CSA history was associated with an increased risk of PTB (cf. no abuse), and this risk was heightened for women from a race other than Hispanic, black, or white. Only one study identified that the frequency of child abuse or exposure to child abuse and IPV, doubled the risk of placental abruption .

Cammack [ 21 ] found that women with CSA perpetrated by a non-parent and motivated by non-physical threats had nearly double the risk of very PTB (before 34 weeks) than women with no child abuse. Further, women from a race other than Hispanic, black, or white were nearly eight times more likely to have a very PTB. Moreover, the risk for ‘other race’ and birth before 37 weeks nearly quadrupled when they had experienced the same type of CSA ( cf . no abuse). Leeners et al. [ 44 , 45 ] conducted two studies with the same sample. Women with a CSA history were more likely to have a PTB or premature contractions.

In contrast, studies have more consistently not identified child abuse or specific types (e.g., CPA or CSA) as risk factors for PTB [ 70 , 73 , 74 ]. However, Hyle [ 70 ] showed specific abuse characteristics (e.g., more than three incidents) predictive of lower gestational age in a sample of low-income women. Specifically, there was an associated decrease in gestational age for each additional abuse incident. Only one study found that any child abuse and CSA increased the chances (1.5 times) of late PTB at 35–36 weeks [ 74 ].

Mitro et al. [ 75 ] conducted the only study on placental abruption. Child abuse did not increase the odds of placental abruption in adjusted models for demographics and parity. However, experiencing three or more instances of child abuse increased the odds of placental abruption by just over 1.5 times. In addition, joint exposure to severe child abuse and IPV doubled this risk compared to rare or no abuse. When examined among women delivering preterm, experiencing three or more child abuse events almost doubled the risk for placental abruption. Similarly, among women delivering full-term babies, experiencing joint and severe exposure to childhood abuse and IPV was associated with close to a three-fold risk of placental abruption.

Postnatal outcomes for mothers

Mother-child relationship..

Five studies examined attachment/bonding with the evidence suggesting that CEA and CSA are associated with less maternal-fetal attachment or bonding disturbances. However, postpartum no specific abuse types predict mother-infant bonding impairment .

Two studies identified CEA as a predictor of lower maternal-fetal attachment [ 76 ] and mother-infant bonding disturbances [ 77 ]. Also, Nieto et al. [ 78 ] found that CSA ( cf . no CSA) nearly tripled the odds of lower maternal attachment. In contrast, Lehnig et al. [ 79 ] did not identify specific abuse types that predicted mother-infant bonding impairment at two months postpartum. However, their result may reflect their sample’s low prevalence of abuse. Choi’s [ 80 ] study of South African mothers did not identify any abuse type significantly affecting maternal-infant bonding in analyses controlling for other abuse types.

Parental practice.

Self-efficacy and parenting morale

Two studies examined parenting outcomes. Kunseler et al. [ 81 ] identified that postpartum women who reported child abuse did not differ in parenting self-efficacy or changes in their efficacy after positive feedback (than other women). However, for those who reported child abuse, their parenting self-efficacy decreased after exposure to a difficult-to-soothe infant ( cf . non-abused women). Malta et al. [ 82 ] noted that women with a child abuse history were nearly twice as likely to have low parenting morale.

Child abuse harm or potential

Three studies examined child abuse potential or harm. Findings indicate that a history of CPA, CSA or CEA are associated with an increased likelihood of harm to the infant/toddler and this association may be mediated by substance abuse or depression. Moreover, for first-time mothers those with a history of CPA or CEA, they may be less responsive or have reduced empathic awareness in parenting, have harsher punishment attitudes and be more accepting of child abuse/neglect .

Appleyard et al. [ 83 ] demonstrated that a maternal history of CPA or CSA increased the likelihood that the mother would victimize their infant/toddler. Maternal substance abuse mediated this relationship. Bert et al. [ 84 ] noted that CEA predicted less responsivity/empathic awareness in parenting, harsher punishment attitudes, more acceptance of child abuse/neglect, and greater child abuse potential in first-time mothers. CPA predicted the same outcomes except for child abuse potential, which was only significant for mothers older than 21 with some college education. Choi [ 80 ] identified CEA as indirectly influencing child harm exposure through postpartum depression (PPD). CPA or CSA were not significant contributors.

Postpartum psychological outcomes.

Postpartum depression (PPD)

Ten studies had findings relating to PPD. Women who experienced child abuse may be more likely to have PPD with the risk increasing exponentially for multiple types of abuse or experiencing child abuse and pregnancy IPV. Three studies found that CEA increased the risk of PPD. In contrast, one study failed to find any association between CPA, CSA, and CEA and PPD but may have been limited by its sample .

Mahenge et al. [ 85 ] identified that women who experienced child abuse were between 2.5 and over five times more likely to have PPD. The risk nearly quadrupled for those with a joint history of CSA and CPY and increased to more than nine times if they experienced child abuse and IPV during pregnancy. Bahadur et al. [ 86 ] noted that CEA increased the risk of PPD nearly seven-fold after adjusting for sociodemographic factors, whereas CPA and CSA were not significant. However, a larger Australian study [ 87 ] showed a similar but lower risk for CEA (aOR = 1.4). Nagl et al. [ 88 ] found that women with severe CEA were nearly 20 times more likely to have PPD. Severe CPA or CSA, slight and moderate CPA, or CEA were lesser risk factors. Most of these associations remained even after controlling for other abuses. One Ethiopian study [ 89 ] identified that a history of CSA was a stronger predictor of PPD than other sociodemographic variables. In studies that examined all abuse types, CPA, CSA, and CEA independently predicted PPD; however, only CPA remained significant when controlling for other abuses [ 34 ]. CEA and CSA were also risk factors for early-onset PPD, and CEA, CPA, and CSA were all risk factors for late-onset. The risk remained for CSA and early-onset PPD and CEA and late-onset PPD after adjusting for sociodemographic factors and other abuse types [ 90 ]. In contrast, a South African study showed that only CSA and CEA predicted PPD [ 80 ]. Finally, Cohen et al. [ 91 ] demonstrated that CPA, CSA, and CEA was not predictive of PPD however insufficient participants with abuse experiences may have impacted this result.

Postnatal anxiety, stress and PTSD

Three studies examined postnatal anxiety or stress finding that child abuse was not linked to postnatal anxiety or stress. However, when examined by subtype CPA, CSA and CEA were independent risk factors for postnatal anxiety. One study failed to find any association between CSA and PTSD symptoms hypothesising an indirect effect .

Malta [ 82 ] did not identify any association between child abuse and postnatal anxiety or stress. In contrast, Nagl et al. [ 88 ] identified CPA and CEA as independent risk factors for postpartum anxiety with severe CSA associated with a nearly seven-fold risk. These associations were lower after controlling for other abuses. Mayhew and Thomas [ 92 ] noted that prenatal anxiety was the strongest predictor for postnatal anxiety. CEA and distressing childbirth were also significant predictors in the same model.

Oliveira et al. [ 93 ] conducted the only study of postnatal PTSD symptoms noting that CSA was related to other traumatic events such as IPV and fear of childbirth but not directly related to PTSD symptoms suggesting an indirect effect.

Swanson et al. [ 94 ] found that women with a CPA or a joint history of CPA and CSA had greater difficulty falling asleep. Of interest, the risk was greater for CPA alone (aOR = 9.20) than for experiencing CPA and CSA jointly (aOR = 5.95). In addition, women with a history of CPA or those who experienced CPA and CSA simultaneously were more than three times more likely than other women to have difficulty staying asleep.

Perinatal outcomes for mothers and newborns

Offspring asthma and autism..

Only one study examined asthma but did not identify significant associations with maternal CPA or CSA [ 95 ]. Roberts et al. [ 96 ], the only study to examine autism risk, found that severe CSA doubled the risk for offspring autism, with severe joint exposure to CPA and CEA a lesser risk ( cf . no abuse). In addition, experiencing multiple instances of child abuse tripled the risk of autism regardless of the child’s biological sex. In adjusted models, gestational diabetes, previous abortion, and smoking mediated the relationship between child abuse and autism.

Breastfeeding.

Breastfeeding was examined by three studies with the findings indicating that women who experienced child abuse were more likely to stop breastfeeding earlier than other women. Also, a history of CSA increased the likelihood of mastitis or painful breastfeeding which may be a contributing factor to early cessation .

Sorbo et al. [ 97 ], using a large sample, noted that women who experienced child abuse or CSA were more likely to stop breastfeeding before four months. The odds of breastfeeding cessation by four months were lower for CPA and/or CEA. Coles et al. [ 2 ] identified CSA survivors as less likely to breastfeed for longer than six months however, this result was no longer significant after adjustment for adult violence and other factors (e.g., smoking, partner status). Elfgen et al. [ 98 ] noted that a history of CSA nearly tripled the likelihood of mastitis or experience painful breastfeeding (OR = 5.77). However, there was no difference in breastfeeding prevalence between these women and those with no CSA history.

Intimate Partner Violence (IPV).

Three studies examined IPV identifying that CPA, CSA, and CEA increased the likelihood of IPV in the past-year with specific abuse types linked to specific IPV subtypes. Child abuse, CPA, and CSA were risk factors for any IPV with joint exposure (i.e. CPA and CSA) increasing the risk. However, when other types of violence are controlled, the results were non-significant suggesting a mediating effect. Only one study did not identify child abuse (CPA and CSA) predictive of IPV in a sample of HIV-positive women .

Barnett’s [ 99 ] longitudinal study (pregnancy and postpartum) demonstrated that CPA, CSA, and CEA increased the likelihood of high past-year IPV. When specific IPV subtypes were analyzed, a CPA history was a higher risk for moderate emotional and sexual IPV and high physical IPV ( cf . women with low/no child abuse). CSA and CEA were associated with high emotional or physical IPV and high/moderate sexual IPV.

Barrios et al. [ 41 ] identified that child abuse, CPA, and CSA were risk factors for any IPV and physical lifetime IPV; joint CPA and CSA posed the highest risk. Child abuse also predicted lifetime sexual IPV, and a history of both CPA and CSA posed a five-fold risk of this IPV type. Child abuse and CSA predicted both physical and sexual lifetime IPV. A history of CPA and CSA increased this risk more than seven-fold. Comparable results were evident for IPV in the past year. CPA and CSA were associated with greater odds of revictimization of physical IPV. CSA was also related to sexual IPV revictimization. Experiencing both CPA and CSA increased the risk of physical and sexual lifetime IPV revictimization. However, the greatest risk of revictimization was for those who experienced CPA and CSA and combined physical and sexual IPV, aOR = 6.88.

Castro et al. [ 100 ] identified a higher prevalence of pregnancy IPV for those who experienced moderate to high CPA or CEA ( cf . no/low abuse). Both abuse types more than doubled the risk of IPV; however, when other types of violence were controlled, the results were non-significant. Only one study did not identify child abuse (CPA and CSA) predictive of IPV in a sample of HIV-positive women [ 101 ].

Maternal psychological outcomes.

Depression and anxiety

Seven studies examined depression across the perinatal period. The findings show that child abuse, CPA, CSA, and CEA all increased the risk of antenatal or postnatal distress or depression or high depressive symptoms. One longitudinal examination showed that women who experienced CSA had higher anxiety symptoms during pregnancy and postpartum than non-abused women.

Kang et al. [ 102 ] demonstrated that child abuse nearly doubled the risk of peripartum depression in a large Turkish study. Li et al. [ 103 ] found that women who experienced CSA or CEA were more than four times more likely to have antepartum depression than non-abused women. Also, women with a CEA history had higher depression scores in pregnancy which lessened over the perinatal period than women with no CEA, whose scores started lower but increased postpartum. In fact, the depression scores for women with a CEA history, while higher in pregnancy, were much lower than those with no CEA by four weeks postpartum. Also, no significant effects for any abuse or frequency of abuse was found for PPD scores, or between abuse types and chronic depression risk.

Akinbode’s [ 104 ] study showed that CSA predicted PPD symptoms in pregnancy, six and 12 weeks postpartum. CPA predicted depression in pregnancy and 12 weeks postpartum but not six weeks postpartum. Experiencing both CPA and CSA also predicted antenatal depression, but there was no significant finding for PPD. In contrast, Robertson-Blackmore et al. [ 105 ] found that women who reported CSA were more likely to report antenatal depressive symptoms than other women but were not more likely to report PPD. CPA/parental neglect was not significant for antenatal depression or PPD.

Khanlari et al. [ 106 ] compared women with a maternal history of abuse with other women, noting that child abuse increased the risk for antenatal and postnatal distress and depression. The highest risk was for antenatal depression (aOR = 3.2). Similarly, Ogbo et al. [ 107 ] examined a large sample of culturally and linguistically diverse (CALD) Australian women. Those with a child abuse history had nearly double the risk for antenatal distress and were more than twice as likely to have antenatal or PPD than non-abused CALD women. Giallo et al. [ 108 ] noted that CPA and CSA independently increased the risk for subclinical and persistently high depressive symptoms for nulliparous women. However, CPA was the only significant risk factor for subclinical and persistently high depressive symptoms after controlling for sociodemographic factors.

Akinbode [ 104 ] conducted the only longitudinal examination of anxiety, noting that women who experienced CSA had higher anxiety symptoms during pregnancy, six and 12 weeks postpartum, than non-abused women. CPA and experiencing both CPA and CSA were not significant predictors.

Three studies examined PTSD. The evidence shows that women with a CSA history or those who experienced CPA and neglect have a higher risk of lifetime PTSD. Greater exposure to child abuse also predicts antenatal PTSD symptoms and a history of CSA predicts greater PTSD symptomology, postpartum .

Robertson-Blackmore et al. [ 105 ] showed a higher risk of lifetime PTSD for women with a CSA history (aOR = 9.21) or those who experienced CPA and neglect (12.16) in models adjusted for demographics. Also, in adjusted analyses, Sumner et al. [ 109 ] found that higher exposure to child abuse predicted antenatal PTSD symptoms but not postpartum symptoms. Finally, Lev-Wiesel et al. [ 110 ] noted that a history of CSA predicted greater disassociation at two months postpartum and more birth-related PTSD symptoms, avoidance, and arousal levels at seven months postpartum.

Summary of findings

Despite some variability in the findings, predominantly studies confirm that a history of child abuse is a significant risk factor for poor pregnancy outcomes. CSA was the most examined abuse type consistently linked to pregnancy and childbirth outcomes. These outcomes included substance use (i.e., alcohol, smoking) which is of critical concern given the harmful teratogens introduced into the prenatal environment. However, none of the studies examined alcohol as an independent outcome; this area requires more attention. Poor mental health was the focus of several studies conducted in various countries, supporting the generalization of the findings. There were consistent findings that CPA and CSA, independently or jointly, represent a greater risk of antenatal depression and PTSD symptoms during pregnancy.

Studies examining biomedical outcomes confirm that child abuse increases the risk for certain conditions (e.g., enhanced inflammatory states) linked to poor maternal and neonatal health and perinatal complications. Also, CSA was associated with higher cortisol levels, whereas child abuse overall or different subtypes had less consistent findings. High cortisol levels may increase the HPA axis’ sensitivity to maternal distress, shorten gestation and increase antenatal health problems such as preeclampsia or gestational diabetes [ 38 ]. For the child, increased prenatal cortisol is associated with poor developmental outcomes [e.g., restricted growth, 111 ]. However, the findings should be viewed cautiously, given the small samples used.

Several studies established a link between child abuse and aspects of poor general health but not all types of poor health were linked to abuse, suggesting that the type of health condition may play a pivotal role. For example, a history of CSA is linked to gynecological problems in areas consistent with the foci of that abuse type. In contrast, CPA is associated with greater pelvic or sacral pain; these are areas that could be targeted during physical abuse. Also, findings that abuse survivors can have more common health complaints are consistent with trauma leading to a vulnerability for poorer mental and physical health and, for some, unexplained complaints [ 112 ]. Related to health is sleep disturbance, with studies establishing that women with a history of child abuse are more likely to have poorer sleep quality. Despite sleep disruption normative during pregnancy, poor sleep can contribute to poor outcomes [ 113 , provides a review]. Finally, findings regarding care indicate that women with a CSA history are more likely to be hospitalized during pregnancy or have reduced consultations. While these results may seem contradictory, it is conceivable that a lack of standard care may lead to more serious problems requiring hospitalization. However, caution is warranted in interpreting these findings due to the small effect sizes.

All abuse types increase the risk of delivery complications, and these have largely been studied for CSA. Child abuse survivors also have a greater preference for a cesarean; however, while this preference exists, the chances that it occurs are low. Multiparous women with a CPA history are also more likely to have an emergency cesarean which may be related to previous abdominal trauma. The finding that controlling for any previous caesarean attenuated this risk supports this proposition.

PTB and low birthweight have attracted the most interest from North American researchers using obstetric data (than self-report), which adds certainty to the findings. Predominantly CSA is associated with low birthweight more than other abuses. However, studies are limited by not considering the influence of other related factors identified in this review (e.g., self-care, eating disorders, and substance use) which could contribute to less nourishment for the fetus. Therefore, the mechanisms by which low birthweight occurs are unclear. Likewise, the association between CSA and PTB is inconsistent, suggesting there may be significant mediators or moderators of this relationship. However, again there are limited studies in this area.

Bonding and attachment are critical developmental tasks of motherhood [ 114 ], yet findings are inconsistent and require cautious interpretation (from single studies with small effects or unrepresentative samples). Given that several factors have been identified that result in a woman psychologically distancing from her pregnancy and newborn [e.g., anxiety and depression, 115 ], an examination of other indirect influences is needed.

Child abuse is a risk factor for low parenting morale [ 82 ] and predicts less parenting self-efficacy after exposure to a difficult-to-soothe infant. This large effect size for self-efficacy in nulliparous women indicates that these mothers may lose belief in themselves more readily in stressful parenting situations [ 81 ]. Relatedly, CPA, CSA, and CEA predicted exposure or potential to harm their child. Of note, substance use and PPD mediated the relationship between CEA and child harm exposure between the ages of five and 12. The authors explained that this delayed onset of maltreatment of abused mothers’ offspring is due to the persistence of depression beyond the postpartum period. These findings are particularly important given that vicarious learning may model later parenting behaviors [ 116 ], contributing to a generational cycle of violence.

Similarly, there are consistent links between CPA, CSA, and PPD. Less consistent are the findings for CEA, CPY and PPD. Only one study [ 91 ] did not find a relationship between CSA and PPD and CEA and PPD; however, their smaller sample and modified abuse measure may have limited findings. There were some consistent findings that CPA, CSA or CEA increase the risk of perinatal anxiety, with contradictory findings likely due to the purpose-created abuse measures used [e.g., 82 ].

Only one study examined CSA and postnatal PTSD symptoms, with the results trending toward significance ( p = .07), consistent with longitudinal studies across pregnancy and postpartum. Of interest, while identifying that PTSD symptoms have a downward trajectory from pregnancy to postpartum, Lev Weisel and colleagues’ comprehensive study also showed that CSA predicts significant PTSD symptoms seven months postpartum. Prima facie, this downward trajectory does not seem consistent with theorizing that childbirth for abuse survivors is retraumatizing; however, symptoms relating to intrusion and arousal, which had a time interaction, may indicate a delayed response to childbirth. Alternatively, the thought of childbirth may be retraumatizing for some abuse survivors, and the effects of this may lessen if the experience was not traumatic.

CSA posed the greatest risk for breastfeeding cessation, with CEA or CPA also identified as a risk for earlier cessation. One study identified that a history of CSA was related to painful breastfeeding, which may contribute to decisions to stop breastfeeding earlier, although this outcome was not examined. In addition, the link between child abuse, particularly CSA and breastfeeding, could be related to breastfeeding involving skin-to-skin contact, triggering memories of abuse. Given the importance of breastfeeding for at least six months to optimize an infant’s growth, development, and health and the benefits for the mother [e.g., reduces cancer risks, 117 ], this is an understudied area that requires more attention.

The risk of revictimization of survivors of child abuse is high with consistent links between child abuse, its subtypes and lifetime, past year, or current IPV [ 41 , 99 , 100 ]. These findings are consistent with child abuse, a known risk factor for adult revictimization [ 118 ]. The one study that did not identify abuse as a risk of revictimization utilized an HIV-positive sample and a comparison of no or low abuse, possibly limiting their findings [ 101 ]. During pregnancy, this risk for IPV may increase, potentially endangering the expectant mother and the unborn baby. This risk is explained by experiential avoidance, which proposes that dissociation and PTSD symptoms influence revictimization [ 119 ].

Results indicate that CSA may be a more consistent predictor of depression across the perinatal period than CPA or CEA. One study identified an interaction between CEA and time with women who experienced emotional abuse; their depression scores decreased across the perinatal period compared to women who had not suffered this abuse, whose scores increased. There was no similar interaction for other abuse types. No studies examined CPY.

Methodological issues and implications for research

The CTQ was the most common child abuse measure utilized by 24% of studies. This questionnaire has adequate psychometric data; however, the short-form version, used more frequently, needs further validity evidence [ 7 ]. Many studies relied on purpose-created measures or tools without documented reliability and validity to assess child abuse. This significant issue potentially impacting findings and cross-study comparisons.

Despite consistent findings across the studies, effect sizes were small or negligible in some cases, likely due to the samples used or the methodology employed. Some studies used small convenience samples that can amplify effects or are unrepresentative of the population. In contrast, several studies analyzed data as part of large-scale projects. Despite the common belief that larger sample sizes are superior to small samples, excessive sample sizes can exaggerate small or even non-significant effects [ 120 ]. To provide more certainty for future findings, researchers should determine the sample size a priori to ensure it is adequate for the planned analyses. Indeed, this review excluded 36 studies with insufficient sample sizes relative to the power to conduct their analyses. Also, it is important to acknowledge that some of the pathways between child abuse and the outcomes reported are complex. However, few studies identified in this review examined mediation/moderation or interact effects, focussing instead on the direct relationship however the influence of other variables needs to be considered when examining the sequalae of child abuse.

Eighteen studies examined only one type of abuse, yet child abuse is rarely isolated, with many victims subjected to multiple maltreatment [ 121 ]. In contrast, when examining multiple types of abuse, there was a failure to partition other abuse types statistically [e.g., 40], which could overestimate findings as it cannot be assumed that the effects noted are specific to the abuse examined. Moreover, the propensity to examine abuse as a combined variable limits our understanding of the impacts of certain abuses in the perinatal period. Relatedly, few studies included adequate control of other variables, such as socioeconomic status or family environment previously identified as risk factors for child abuse [ 122 ]. These variables could interact or account for some of the variance, and when not included, effect sizes may be overestimated. This highlights that the design of child abuse studies requires careful consideration to ensure that the findings reflect the population of interest.

The studies captured by this review were predominantly North American, with an over-focus on CSA. This focus is likely an artifact of historical understandings of abuse, with CSA considered part of battered child syndrome some 45 years ago [ 123 ]. However, child abuse is a worldwide phenomenon with wide variability in the prevalence of abuse types across different countries. Generally, CPA is more prevalent in countries such as South America and Africa, CSA in North America and Australia, and CEA and CPY in South America and Australia [ 124 ]. While this disparity may relate to differing conceptualisations of abuse (e.g., [punitive parenting practices may be acceptable in some cultures and not others), or differing methodologies for assessing abuse [ 125 ] they also highlight the disparity between the countries where child abuse is predominantly studied and the absence of studies in countries with a higher abuse prevalence (e.g., Africa and South America).

Also, CPY and CEA are often treated as synonymous, likely stemming from cognition and emotion considered interdependent [ 126 ]; examining them independently or statistically controlling them may clarify inconclusive findings. Indeed it can be argued that CPY and CEA are inherent in all abuse types and may even be more prevalent than CPA or CSA [(see 42, for example].

Implications for policy

Child abuse outcomes related to pregnancy (e.g., poor physical and mental health and unhealthy behaviors), highlight the importance of early prenatal screening. Australian, UK, and US guidelines recommend screening for abuse or trauma, but not all specifically name child abuse [ 127 ]. However, given the identified barriers and challenges of child abuse screening (e.g., the need for sensitive inquiry), many researchers and clinicians advocate trauma-informed care for perinatal women [ 127 , 128 ].

The Multi-level Determinants of Perinatal Wellbeing for Child Abuse Survivors model [ 129 ] provides a framework for this care using these principles that engender empowerment, safety, and trust. All women can have a supportive environment through universal screening, leading to referral and intervention. Importantly this model includes the needs of both the survivor and clinician. For example, a child abuse survivor requires a safe and appropriate environment to help facilitate disclosure, whereas a clinician needs training, time, and setting considerations. Therefore, policies around screening need to be based on trauma-informed principles that address the needs of the clinician, survivor, and environment [ 127 – 129 ].

While identifying women with a history of child abuse is important in affording more sensitive antenatal care, for many women, postpartum care is focused on physical recovery and less on psychosocial or psychological factors [ 130 ]. However, child abuse is also a risk factor for postpartum outcomes such as poor mental health, child abuse potential, and IPV. However, there is limited opportunity to identify child abuse and intervention without continuity of care extending to the postpartum period.

Strengths and limitations of the review

The strength of this review was its comprehensive examination of a wide range of databases and grey literature. In addition, the double screening of search results and rigorous quality assessment contributed to the accuracy of the data. This search strategy enabled a wide range of evidence to be synthesized, thus contributing to the body of knowledge. Notwithstanding this, the review was potentially limited by excluding non-English language studies limiting the generalizability of the findings. Also, the quality assessment was mostly conducted by one rater (due to budgetary constraints) which is a limitation that should be noted. Furthermore, as detailed above, many studies reviewed had methodological limitations and used retrospective and self-report data for child abuse/maltreatment, limiting the ability to draw causal conclusions.

This comprehensive review examined outcomes related to child abuse for perinatal women. Notwithstanding this, this review demonstrated that maternal child abuse has implications for perinatal women. Perinatal women may be at higher risk for poorer mental health, difficulties with childbirth, and the experience of prenatal care and motherhood. For the child, their mother’s previous history may have implications for their healthy growth and development and intergenerational implications through the transmission of violence. Identifying women at risk is the first step in positive interventions, which may best be achieved through care based on trauma-informed principles.

Supporting information

S1 appendix. data extraction sheet for quality assessment and risk of bias..

https://doi.org/10.1371/journal.pone.0302354.s001

S1 Table. Assessment of the studies for inclusion in the meta-analysis.

https://doi.org/10.1371/journal.pone.0302354.s002

S2 Table. Overview of the included studies.

https://doi.org/10.1371/journal.pone.0302354.s003

S3 Table. Characteristics of included studies.

https://doi.org/10.1371/journal.pone.0302354.s004

S4 Table. Main findings of included studies.

https://doi.org/10.1371/journal.pone.0302354.s005

Acknowledgments

Author note.

Dr Robyn Brunton was the sole contributor and responsible for all aspects of this manuscript. The contribution of Dr Denise Corboy, who assisted with the data extraction and quality assessment, is acknowledged.

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