Predictors of Prenatal Depression: A Cross-Sectional Study in Rural Pakistan

Prevalence and risk factors of perinatal depression among mothers and fathers in Pakistan: a systematic review and meta-analysis

Background

Perinatal mental health issues affect approximately 10% of women in high-income countries and 30% in low- or middle-income countries. This review aims to determine the prevalence of perinatal depression among mothers and fathers in Pakistan and identify associated risk factors.

Methods

We conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We included quantitative studies on the prevalence or incidence of maternal and paternal perinatal depression, including antenatal or postnatal depression in Pakistan, with or without associated risk factors. We performed an electronic search, dual-title/abstract and full-text screening, and data extraction. Analysis was conducted on Revman and JBI SUMARI software. The quality of the included studies was assessed with the NHLBI tool. This review updated a previously published review that included 43 studies, with the last search date of 31st May 2019, now extended to literature published up to June 30, 2023.

Results

Consistent with the previous review, our analysis of 61 studies indicated a pooled prevalence of 37% (95% confidence interval (CI): 30.6-43.6) for maternal antenatal depression. Postnatal depression at different time points, revealed rates of 34.2% (95% CI: 22.7-46.7), 40.9% (95% CI: 0-97.4), and 43.1% (95% CI: 24.4-62.9) at 3, 6 and 12 months, respectively. Paternal postnatal depression was observed at 40.5% (95% CI: 14.9-69) based on two studies. Risk factors for maternal perinatal depression include multiparity, contraceptive failure, inadequate antenatal care, pregnancy-induced hypertension, previous psychiatric illness, passive smoking, drug abuse, low socio-economic status, marital problems, family hardships, recent bereavement, housing difficulties, food insecurity, husband's illiteracy, his unemployment, and being blamed for child disability.

Conclusion

The findings reveal a high prevalence of perinatal depression among mothers with very limited evidence of fathers residing in Pakistan, emphasising the need for prospective studies addressing mental health challenges.

Registration

This review is registered on PROSPERO (CRD42023442581).

Non-specialist delivered psycho-social interventions for women with perinatal depression living in rural communities: A systematic review

Evidence from low- and middle-income countries suggests that non-specialist-delivered interventions effectively improve access to perinatal mental health care. However, there have been no systematic attempts to synthesize the evidence on effectiveness, relevance, and application of this strategy to resource-limited settings such as rural areas. The aim of this review is to synthesize the evidence about the effectiveness of non-specialist delivered interventions in improving depression and related outcomes in women with perinatal depression living in rural communities. Seven electronic databases were searched using the following search concepts: perinatal depression (e.g., puerperal depression, antenatal depression), rural areas (e.g., remote, nonmetropolitan, underserved), and non-specialist workers (e.g., lay worker, volunteer aide, informal caretaker. The risk of bias was assessed using RoB-2 and ROBINS-I tools. A narrative synthesis was performed as the high degree of study heterogeneity precluded a meta-analysis. Nine unique studies were eligible for inclusion. Psychoeducation and problem-solving techniques were the most used intervention elements. Two interventions significantly reduced the prevalence of perinatal depression compared to usual care, and three interventions reported effectiveness in reducing depression symptom severity. There was little to no consistent evidence for other outcomes, including but not limited to maternal health care utilization, breastfeeding behaviors, and child health. This review provides limited evidence to suggest that non-specialist delivered interventions effectively improved outcomes among women with perinatal depression living in rural communities. The paucity of high-quality studies included in this review demonstrates that this rural demographic is frequently neglected in the context of maternal mental health research.

Effect of biological, psychological, and social factors on maternal depressive symptoms in late pregnancy: a cross-sectional study

Introduction

Depression commonly occurs during pregnancy and has become a major public health concern. Depression not only affects the individual but also causes adverse consequences for families and children. However, little is known regarding the depression status and its influencing factors in women during late pregnancy in China. This study aimed to assess the prevalence of maternal depressive symptoms in late pregnancy during the coronavirus disease 2019 (COVID-19) pandemic and further explore the effect of biological, psychological, and social factors on depressive symptoms.

Methods

An institution-based cross-sectional survey was conducted among eligible women in the late pregnancy stage and underwent prenatal examination at Lianyungang Maternal and Child Health Hospital in Jiangsu Province, Eastern China from December 2022 to February 2023. Data regarding depressive symptoms and biological, psychological, and social factors of the pregnant women were collected via a structured questionnaire. Chi-square test, Fisher's exact tests, and binary logistics regression were used to analyze the data.

Results

In total, 535 women in the late pregnancy stage were included in this study, 75 (14.0%) of whom exhibited depressive symptoms. A binary logistic regression analysis revealed that pregnant women who were multiparous (OR: 2.420, 95% CI: 1.188-4.932) and had moderate or severe insomnia symptoms (OR: 4.641, 95% CI: 1.787-12.057), anxiety (OR: 8.879, 95% CI: 4.387-17.971), high fear of COVID-19 (OR: 2.555, 95% CI: 1.255-5.199), moderate or severe family dysfunction (OR: 2.256, 95% CI: 1.141-4.461), and poor social support (OR: 2.580, 95% CI: 1.050-6.337) tended to show depressive symptoms. Conversely, pregnant women who received regular prenatal care (OR: 0.481, 95% CI: 0.243-0.951) and had good drinking water quality at home (OR: 0.493, 95% CI: 0.247-0.984) were more likely to avoid developing depressive symptoms.

Conclusion

This study found that the prevalence of maternal depressive symptoms during late pregnancy was high and had multiple influencing factors. Thus, screening for depressive symptoms in women in the late pregnancy stage and providing special intervention programs are necessary, especially for those with risk factors.

Joint effects of recent stressful life events and adverse childhood experiences on perinatal comorbid anxiety and depression

BACKGROUND

Stressful life events (SLEs) and adverse childhood experiences (ACEs) have been reported to be associated with perinatal depression (PND) or perinatal anxiety (PNA) alone; however, in most cases, majority of PND and PNA coexist and could lead to more serious health consequences. The independent effect of recent SLEs and their joint effects with ACEs on perinatal comorbid anxiety and depression (CAD) remain inadequately explored.

METHODS

Based on a longitudinal study, 1082 participants receiving prenatal care in Ma'anshan, China were included. Women were recruited in the first trimester (T1: ≤14^+ 6 weeks) and followed up at 15 ~ 27 weeks (T2), 28 ~ 40 weeks (T3), and postpartum (T4). Depression and anxiety status were assessed at all time points, while recent SLEs and ACEs were measured at T1. Logistic regression was conducted to examine the associations of SLEs with the risks of CAD at different time points, as well as their joint effects with ACEs on CAD.

RESULTS

Approximately 38.5% of women experienced at least one SLE, which was significantly associated with higher risks of CAD at all time points (p < 0.05). As the number of SLEs increased, the risk of CAD increased (p for trend < 0.05). Specific types of SLEs were associated with CAD in different periods, while only interpersonal events were consistently associated with risks of CAD throughout the whole perinatal period. The joint effects of SLEs with ACEs on CAD were identified throughout the perinatal period, with the highest observed in the first trimester (aOR = 7.47, 95% CI: 3.73-14.95; p for trend < 0.001).

CONCLUSION

Our study demonstrated independent associations of recent SLEs and their joint effects with ACEs with risks of perinatal CAD. SLEs combined with ACEs should be recognized as a major risk factor for perinatal CAD and managed at the earliest time to prevent and control CAD.

The prevalence and associated factors of prenatal depression and anxiety in twin pregnancy: a cross-sectional study in Chongqing, China

Background

Pregnant women expecting twins are more likely to experience stress, which can lead to anxiety and depression. Our aim was to investigate the prevalence of prenatal anxiety and depressive symptoms in women with twin pregnancies and the associated factors.

Methods

In a cross-sectional survey, 210 women with twin pregnancies who satisfied the inclusion and exclusion criteria in two tertiary centers in Southwestern China were asked to complete a basic information form, the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS). To compare statistics with normal distribution in distinct characteristic groups, a paired t-test, and one-way ANOVA were utilized. Binary logistic step regression was used to analyze the associated factors of antenatal anxiety and depressive symptoms.

Results

The 210 women with twin pregnancies (age = 30.8 ± 4.2 years) were between 7 and 37 gestational weeks (29.2 ± 1.2 weeks), were typically well-educated (72.4% had a post-high-school degree), and reasonably affluent (88.1% were above the low-income cutoff). Among them, 34.8% had symptoms associated with clinical levels of anxiety, and 37.1% had symptoms indicating possible depression. The prevalence of co-morbid anxiety and depressive symptoms was 24.3%. Binary stepwise logistic regression analysis showed that previous health status and sleep disturbance during pregnancy were the associated factors of anxiety symptoms in women with twin pregnancies (P < 0.05), whereas age, previous health status, negative life events, and physical activity during pregnancy were the associated factors of depressive symptoms in women with twin pregnancies (P < 0.05).

Conclusion

About one-third of women with twin pregnancies had symptoms of anxiety or depression; these were most strongly predicted by some modifiable factors, suggesting that early preventive mind-body interventions may be a promising strategy to protect against mental health issues for women with twin pregnancies.

Path analysis of influencing factors for prenatal depressive symptoms in pregnant women

OBJECTIVES

To explore the influencing factors and relationships associated with prenatal depressive symptoms in pregnant women.

METHODS

This study was a survey based cross-sectional investigation conducted on 750 pregnant women who underwent pregnancy and delivery examinations in a third class hospital in Urumqi City, and their general information was collected and a patient health questionnaire using a depression scale (Patients' Health Questionnaire Depression Scale - 9 item, PHQ - 9). Spss25.0 was used to compare the differences between the maternal depressive symptoms group and the non-depressed group, and Amos23.0 was used to construct a structural equation model to explore the influencing factors.

RESULTS

The incidence of depressive symptoms in 750 pregnant women was 13.6 % (102/750) and maternal prenatal depressive symptoms was related to occupation, total monthly income, physical exercise, psychological preparation for pregnancy, residence status, couple relationship, knowledge about pregnancy and other factors (P < 0.05). Binary logistic regression analysis showed that the independent risk factors for prenatal depressive symptoms in pregnant women included occupation (OR = 2.492), monthly gross income (OR = 1.293), psychological preparation for pregnancy (OR = 1.882), residential status (OR = 1.831), knowledge about pregnancy (OR = 2.028), prenatal anxiety (OR = 1.415), and pregnancy stress (OR = 4.590). The constructed path analysis model had good a fit (x²/DF = 3.805, GFI = 0.976, AGFI = 0.946, NFI = 0.902, CFI = 0.924, RMSEA = 0.061) and the path analysis showed that pregnancy stress had only a direct effect on prenatal depressive symptoms (effect value 0.169).

DISCUSSION

The binary logistic regression model showed that knowledge about pregnancy had the greatest influence on prenatal depressive symptoms, and the popularization of pregnancy knowledge reduced prenatal depressive symptoms.

Antenatal depression and its associated factors among women of Godawari Municipality, Lalitpur, Nepal: a cross-sectional study

OBJECTIVES

To estimate the prevalence of antenatal depression and identify its associated factors among pregnant women of Godawari Municipality, Lalitpur, Nepal.

DESIGN

Community-based cross-sectional study.

SETTING

Godawari Municipality, Lalitpur, Nepal, between September and November 2021.

PARTICIPANTS

250 randomly selected pregnant women of Godawari Municipality, Lalitpur, Nepal.

MAIN OUTCOME MEASURES

The level of antenatal depression was assessed using Edinburgh Postnatal Depression Scale. χ² test and multivariate logistic regression analysis were applied to determine the association between antenatal depression and related variables at 95% level of confidence.

RESULTS

The prevalence of antenatal depression was found to be 24.8% (95% CI: 19.2 to 30.7). Multigravida (AOR: 2.219, 95% CI: 1.113 to 4.423), unintended pregnancy (AOR: 2.547, 95% CI: 1.204 to 5.388), male sex preference of child by family (AOR: 2.531, 95% CI: 1.204 to 5.321) and intimate partner violence (AOR: 2.276, 95% CI: 1.116 to 4.640) were found to be the positive predictors of antenatal depression.

CONCLUSION

This study showed a high prevalence of depression among pregnant women. The results suggest a need for mental health assessment during pregnancy. Screening for depression should be part of routine antenatal checkups for early detection and management of mental health concerns during this vulnerable period.

Resilience and prenatal mental health in Pakistan: a qualitative inquiry

Background

Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention.

Methods

The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes.

Result

A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health.

Conclusion

In conclusion, these themes were the core components of pregnant women’s resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

Longer wait time after identification of peripartum depression symptoms is associated with increased symptom burden at psychiatric assessment

Untreated peripartum depression (PD) affects one in seven women and is associated with negative maternal outcomes. This retrospective observational study used health record data from an integrated health system in Texas to assess the extent to which time to access reproductive psychiatry influences the mental health of peripartum women. Women with at least one screening for depression symptoms conducted in obstetric or pediatric settings between May 2014 and October 2019 and subsequently seen by the reproductive psychiatry clinic (n=490) were included. Descriptive and inferential statistics were used to assess timing and factors related to psychiatry follow-up. Findings from this study demonstrated that the average time between a positive screen and a psychiatry assessment was 5 weeks. At psychiatry referral appointments, 85% of women continued to screen positive for PD symptoms. Depression symptom scores at the psychiatry appointment were significantly higher than scores precipitating the referral (p = 0.002). Wait time between initial positive screen and referral appointment was positively correlated with clinically meaningful increases in depression symptom scores (p < 0.001). Each week spent waiting for an appointment produced a 13% increase in odds of clinically meaningful worsening of PD scores and 9% increase in odds of developing new self-harm ideation. Given the findings that a longer period between primary care referral and subspecialty appointment has a negative impact on the mental health of women, this study supports the need for earlier psychiatric assessment to minimize decompensation. Expansion of reproductive psychiatry services are needed to support peripartum women and improve maternal outcomes.

Technology-assisted peer therapy: a new way of delivering evidence-based psychological interventions

In low-income settings, ninety percent of individuals with clinical depression have no access to evidence-based psychological interventions. Reasons include lack of funds for specialist services, scarcity of trained mental health professionals, and the stigma attached to mental illness. In recent years there have been many studies demonstrating effective delivery of psychological interventions through a variety of non-specialists. While these interventions are cost-effective and less stigmatising, efforts to scale-up are hampered by issues of quality-control, and what has been described by implementation scientists as ‘voltage-drop’ and ‘programme-drift.’ Using principles of Human Centred Design in a rural setting in Pakistan, we worked with potential users to co-design a Tablet or Smartphone-based App that can assist a lay-person deliver the Thinking Healthy Programme, a World Health Organization-endorsed evidence-based intervention for perinatal depression. The active ingredients of this cognitive-therapy based intervention are delivered by a virtual ‘avatar’ therapist incorporated into the App which is operated by a ‘peer’ (a woman from the neighbourhood with no prior experience of healthcare delivery). Using automated cues from the App, the peer reinforces key therapeutic messages, helps with problem-solving and provides the non-specific but essential therapeutic elements of empathy and support. The peer and App therefore act as co-therapists in delivery of the intervention. The peer can deliver the intervention with good fidelity after brief automated in-built training. This approach has the potential to be applied to other areas of mental health and help bridge the treatment gap, especially in resource-poor settings. This paper describes the process of co-development with end-users and key features of the App.

Pregnant women's coping strategies, participation roles and social support in the online community during the COVID-19

Pregnant women are experiencing enormous physical changes and suffering pregnancy-related losses, which may lead to depression symptoms during pregnancy. Given that the onslaught of COVID-19 had exacerbated pregnant women's anxiety because of disruptions in antenatal care and concerns regarding safe delivery, it is worth exploring how they obtain social support to cope with stress during COVID-19. Although many works have explored the impact of coping resources that people have on coping strategies, few studies have been done on the relationship between people's coping strategies and their acquisition of coping resources such as social support. To fill this gap, based on the stress and coping theory (SCT) and social penetration theory (SPT), this study investigates the impacts of pregnant women's different coping strategies on the acquisition of social support and the moderating role of the adverse impacts of COVID-19 and their online participation roles (support providers vs. support seekers) using the data of 814 pregnant women's online behavior from a parenting community in China1. Our study indicates that both women's superficial level disclosure and personal level disclosure positively affect online social support received. Moreover, self-disclosure about the adverse impacts of COVID-19 negatively moderates the relationship between personal level disclosure and social support received. Participation role positively moderates the relationship between personal level disclosure and social support received, but negatively moderates the relationship between superficial level disclosure and social support received. This paper makes theoretical contributions to the literature of SCT, SPT and the literature about social support in online communities.