An Overview of Risk Factors Associated to Post-partum Depression in Asia

Prevalence and associated risk factors of postpartum depression in India: A comprehensive review

Postpartum depression (PPD) is a psychological illness that affects women following delivery. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), PPD is a serious form of depression that begins four weeks following birth and continues for one year. Pregnancy and the period after delivery can be hazardous for women. Mothers undergo significant biological, emotional, financial, and societal changes during this time. Some women are predisposed to mental health disorders such as melancholy and worry. Many postpartum women do not acknowledge the seriousness of their condition, and many depressed mothers go untreated. Untreated PPD is harmful to both the mother and the newborn. The exact cause of PPD is unclear; however, hormonal fluctuations during pregnancy and childbirth, genetic susceptibility, birth trauma as well as psychosocial and demographic factors may serve as potential risk factors. The objective of this study is to determine the prevalence and risk factors of PPD in India. The review evaluates English language literature on PPD using Scopus, PubMed, and Google Scholar databases searched electronically between 2000 and 2022. The keywords "postpartum depression," or "postnatal depression," and "prevalence," and "causes," and "risk factors," or "predisposing factors," or "predictive factors" were used to search the database. The prevalence of PPD varies in different geographical regions and study settings. In India, the overall prevalence of PPD is 22%. However, the greatest prevalence was in the southern regions (26%; 95% confidence interval [CI]: 19-32) and the lowest in the northern regions (15%; 95% CI: 10-21). This study outlines the burden of PPD in India. Comprehensive intervention programs should be implemented to address the disease at a national level. The national authorities should incorporate PPD screening in the National Mental Health Program and emphasize health promotion activities.

Family History of Psychiatric Disorders as a Risk Factor for Maternal Postpartum Depression: A Systematic Review and Meta-analysis

Importance

Current evidence on the association between family history of psychiatric disorders and postpartum depression is inconsistent; family studies have identified familial risk of postpartum depression, whereas systematic reviews and umbrella reviews, compiling all risk factors for postpartum depression, often have not.

Objective

To investigate the association between family history of psychiatric disorders and risk of developing postpartum depression within 12 months post partum.

Data Sources

Literature searches were conducted in PubMed, Embase, and PsycINFO in September 2021 and updated in March 2022, accompanied by citation and reference search.

Study Selection

Studies eligible for inclusion comprised peer-reviewed cohort and case-control studies reporting an odds ratio (OR) or sufficient data to calculate one for the association between family history of any psychiatric disorder and postpartum depression. Study selection was made by 2 independent reviewers: title and abstract screening followed by full-text screening.

Data Extraction and Synthesis

Reporting was performed using the MOOSE checklist. Two reviewers independently extracted predefined information and assessed included studies for risk of bias using the Newcastle-Ottawa Scale. Data were pooled in a meta-analysis using a random-effects model. Heterogeneity was investigated with meta-regression, subgroup, and sensitivity analyses. Publication bias was investigated using a funnel plot, and GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate the overall certainty of the findings.

Main Outcomes and Measures

The primary outcome was the pooled association between family history of psychiatric disorders and postpartum depression.

Results

A total of 26 studies were included, containing information on 100 877 women. Meta-analysis showed an increased OR of developing postpartum depression when mothers had a family history of psychiatric disorders (OR, 2.08; 95% CI, 1.67-2.59; I2 = 57.14%) corresponding to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population. Subgroup, sensitivity, and meta-regression analyses were in line with the primary analysis. The overall certainty of evidence was deemed as moderate according to GRADE.

Conclusions and Relevance

In this study, there was moderate certainty of evidence for an almost 2-fold higher risk of developing postpartum depression among mothers who have a family history of any psychiatric disorder compared with mothers without.

Prevalence and related factors of perinatal depression in Egyptian mothers

Background

Early detection of perinatal depression and its cultural determinants could reduce its sequalae on mothers and their babies. This study investigated the prevalence of perinatal depression in Egyptian mothers and compare women with and without perinatal depression regarding the psychosocial factors.

Three-hundred one women were recruited (166 were pregnant and 135 were in postpartum period) from a primary healthcare unit. Full sociodemographic data, Social Classification Scale, Dyadic Adjustment Scale (DAS), and the Edinburgh Postnatal Depression Scale (EPDS) were completed. Subjects with EPDS score > 9 answered the structured clinical interview (SCID-I) for diagnosis of depression and Hamilton Rating Scale for Depression (HRSD) for depression severity.

Results

Depression with mild to moderate severity was reported in 5.4% and 3.7% of women during pregnancy and postpartum period, respectively. There was a statistically significant association between depression and employment (p = 0.031), mother-in-law disputes (p = 0.002), stigma of being the second wife (p = 0.047), and having financial burdens (p = 0.001). Marital satisfaction was a protective factor for depression (p < 0.001).

Conclusions

Prevalence of perinatal depression was comparable to other developing countries. It was strongly linked to culturally related factors including marital women’s employment, mother-in-law disputes, being the second wife, and socioeconomic burdens. Early detection of perinatal depression and its culturally related factors is important for its management.

Perinatal death triples the prevalence of postpartum depression among women in Northern Uganda: A community-based cross-sectional study

INTRODUCTION

Deaths during the perinatal period remain a big challenge in Africa, with 38 deaths per 1000 pregnancies in Uganda. The consequences of these deaths can be detrimental to the women; some ending up with postpartum depression. We examined the association between perinatal death and postpartum depression among women in Lira district, Northern Uganda.

METHODS

We conducted a community-based cross-sectional study of 1,789 women. Trained research assistants screened women for postpartum depressive symptoms on day 50 postpartum using the Edinburgh postpartum depression scale (EPDS). Socio-demographic, economic, birth and survival status of the neonate were collected during pregnancy and within one week postpartum. We used generalized estimating equation for the Poisson family with a log link using Stata to estimate the prevalence ratio of the association between postpartum depressive symptoms (EPDS scores ≥14) and perinatal death. Mothers who lost their babies between 7-49 days postpartum were excluded.

RESULTS

Of the 1,789 participants symptomatically screened for postpartum depression, 377 (21.1%) [95% confidence interval (95%CI): 17.2%, 23.0%] had probable depressive symptoms. The prevalence of postpartum depressive symptoms among the 77 women who had experienced perinatal death (37 stillbirths and 40 early neonatal deaths (≤7 days of life)) was 62.3% [95% CI: 50.8%, 72.6%] compared to 19.2% [95% CI: 17.4%, 21.2%], among 1,712 with live infants at day 50 postpartum. Women who had experienced a perinatal death were three times as likely to have postpartum depressive symptoms as those who had a live birth [adjusted prevalence ratio 3.45 (95% CI: 2.67, 4.48)].

CONCLUSIONS

The prevalence of postpartum depressive symptoms, assessed by EPDS, was high among women who had had a perinatal death in Northern Uganda. Women experiencing a perinatal death need to be screened for postpartum depressive symptoms in order to intervene and reduce associated morbidity.

Prevalence and Risk Factors for Self-Reported Postpartum Depression Symptoms (SRPDS) in Hawai'i, 2012-2015

Postpartum depression (PPD) affects an estimated 10% to 20% of women in the United States, but little is known about the risk factors for PPD in Hawai'i. This study sought to identify PPD risk factors and examine whether disparities exist in Hawai'i. Aggregated 2012-2015 Hawai'i Pregnancy Risk Assessment Monitoring System (PRAMS) data from 5572 women with a recent live birth were analyzed. Two questions on the PRAMS survey about mood and interest in activities were used to create a brief measure of Self-Reported Postpartum Depression Symptoms (SRPDS). Multivariate generalized logit analysis was conducted to identify risk factors associated with SRPDS or possible SRPDS, adjusting for maternal race and age, intimate partner violence (IPV), prenatal anxiety, prenatal depression, illicit drug use before pregnancy, and stressful life events (SLEs). About 10.0% of women surveyed had SRPDS and 27.7% had possible SRPDS. SRPDS was more common among Native Hawaiians (adjusted odds ratios=1.77; 95% confidence interval: 1.17-2.70), Filipinos (2.16; 1.33-3.50), Japanese (2.88; 1.67-4.98), and other Pacific Islanders (OPI; 3.22; 1.78-5.82), when compared to white. Women aged 20-29 years (0.39; 0.24-0.65) and 30-52 years (0.41; 0.24-0.69) were less likely to have SRPDS than those 19 years and younger. SRPDS was highest among women who experienced IPV (2.65; 1.37-5.13), prenatal anxiety (2.10; 1.28-3.42), prenatal depression (2.78; 1.47-5.25), or used illicit drugs before pregnancy (1.97; 1.21-3.20). There was an upward trend in SRPDS based on the number of SLEs. Possible SRPDS had similar but smaller effects, suggesting the importance of clinical screening and appropriate follow-up for these high-risk groups.

Physical Activity and the Occurrence of Postnatal Depression-A Systematic Review

Background and Objectives: During pregnancy and the postnatal period many changes occur in a woman's body, both in mental and physical spheres. The birth of a child and a new role-of a mother-can sometimes be associated with numerous negative emotions, uncertainty, fear, anxiety, disgust, depression, or sadness. In the puerperium period, the development of baby blues or postpartum depression may occur. Postpartum depression develops within one month of childbirth and may last up to one year. Depressive disorders that may develop in a young mother affect both her and the newborn's health. That is why it is so important to try to search for factors that could significantly reduce the likelihood of developing depression in this period. The study aims at assessing the relationship between physical activity during pregnancy and puerperium or in the postpartum and the development of postnatal depression. Materials and Methods: A review of the literature was carried out in the Medline-PubMed database. The search terms were "pregnancy" AND "physical activity AND postpartum depression". The study included only English-language publications published in the period 2000-2018. Results: A total of 216 references were found. After establishing the inclusion and exclusion criteria based on the analysis of titles and abstracts, 173 articles were excluded from the review. A total of 43 publications were read in full. Finally, 16 articles were included in the review. It was shown that regular physical activity during pregnancy, pregnancy, and puerperium, or in the postnatal period itself as compared to inactivity, reduces the risk of developing depression in pregnant women and after the birth of a child. Conclusions: Physical activity can be an essential factor in the prevention of depressive disorders of women in the postnatal period.

Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 2): Qualitative Study

Background

Social support is known to reduce risks of postnatal depression (PND) and improve maternal emotional well-being. However, the Asian cultural context is often neglected when appraising maternal needs and mothers’ preferences for social support. While many preventive efforts have experimented with technology, professionals, and paraprofessionals in providing social support to mothers in need, most studies determined the effectiveness of their interventions through quantitative measurements of maternal outcomes. Experiences and feedback from both participants and administrators are rarely discussed, especially in an Asian setting.

Objective

The goal of the research was to evaluate the postnatal experiences of Asian mothers at risk of PND and the perceptions of peer volunteers regarding a technology-based peer-support intervention program (PIP).

Methods

A qualitative semistructured interview was conducted with 20 Asian mothers at risk of depression (10 from the control group and 10 from the intervention group) and 19 peer volunteers from a randomized controlled trial. The PIP included weekly correspondence between peer volunteers and mothers through any telecommunication means over 4 weeks. All interviews were approximately 30 to 60 minutes long, audiotaped, transcribed verbatim, and analyzed using thematic analysis. Study findings were reported according to the Consolidated Standards of Reporting Trials checklist.

Results

Two overarching themes comprising five subthemes were generated: postnatal experience (a bouncy ride, a way forward) and evaluation of the PIP (valuable, flexible, and supportive program; building blocks of a good relationship; and lessons learned and the road ahead). Mothers from both the control and interventions groups were generally satisfied with hospital care and the support received from family. They also shared similar breastfeeding challenges and needs for more informed decisions and follow-up support from the hospital. However, mothers who received the PIP tended to have more positive outlooks of their birth experiences. Overall, peer volunteers and mothers involved in the PIP found the PIP useful and expressed satisfaction with the program’s flexibility. They also shared their personal takeaways, the qualities of their friendships, and the need for extended correspondence time and recommended outreach to non–at-risk mothers.

Conclusions

The positive endorsement of the PIP by peer volunteers and mothers suggests the success of the PIP in maintaining positive maternal emotional well-being during the postpartum period. With the help of technology, hospitals can easily provide additional peer support to at-risk mothers in addition to existing standard care offered to these mothers.

Trial Registration

ISRCTN Registry ISRCTN14864807; http://www.isrctn.com/ISRCTN14864807

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.9416

The Relationship Between Vitamin D and Postpartum Depression in Reproductive-Aged Iranian Women

Background: The aim of this study was to evaluate the relationship between vitamin D and postpartum depression in reproductive-aged Iranian women.

Methods and Results: This study was conducted on 120 women (60 with postpartum depression and 60 without) in Izeh, Iran. A socio-demographic questionnaire and Beck Depression Scale were used for data collection. The ELISA method was used for measuring 25-OH vitamin D (ng). The participants were classified according to their vitamin D level as follows: 25-OH-D < 10ng/ml considered as severe deficiency, 10–20n g/ml as moderate insufficiency, 20–30 ng/ml as mild insufficiency and >30ng/ml as normal. Data were analyzed using the independent t-test or Mann-Whitney test, chi-square and logistic regression test. The mean level of vitamin D of women with postpartum depression was lower than that in normal women (16.89±7.05 vs. 21.28±7.13, p=0.001). More than 53% of women with postpartum depression had vitamin D <20 ng/ml compared to 31.7% of women with no depression (p=0.005). Moreover, 16.7% of women with postpartum depression had vitamin D < 10ng/ml compared to only 6.7% in the normal group (p = 0.005). Women with vitamin D less than 20ng/ml compared to vitamin D > 20ng/ml were 3.30 times more likely to have postpartum depression (OR: 3.3, CI: 1.32–8.24, p= 0.01).

Discussion: There is a significant relationship between a low level of vitamin D and postpartum depression among reproductive-aged Iranian women. Health policy makers should pay attention to the measuring vitamin D level as one of the primary tests of pregnant women.

Postpartum Depression and Subsequent Autoimmune Diseases in Taiwan

Postpartum depression (PPD) is one of the most common examples of postnatal morbidity, but the subsequent risks of autoimmune diseases in patients with PPD have yet to be fully investigated. This nationwide population-based study utilized data of the National Health Insurance Research Database of Taiwan for the period from 1996 to 2013. In total, 45,451 women with primiparity were identified. Among them, 542 patients with PPD were enrolled as a study group while 2165 matched patients without PPD were enrolled as a control group. The demographic characteristics and comorbidities of the patients were analyzed, and Cox regression analysis was applied to calculate the hazard ratios for the risk of autoimmune diseases. Of the 2707 women enrolled in this study, 469 (17.3%) patients with newly diagnosed autoimmune diseases were identified, including 123 (22.7%) in the PPD group and 346 (16%) in the non-PPD group. After adjusting for confounding factors, it was determined that the patients with PPD had a significantly higher risk of subsequent autoimmune diseases (adjusted hazard ratio (aHR): 1.61, 95% confidence interval (CI): 1.30–1.99; p < 0.001). Specifically, increased risks of pernicious anemia (aHR: 3.85, 95% CI: 2.06–7.22), rheumatoid arthritis (aHR: 2.62, 95% CI: 1.28–5.39), and Graves’ disease (aHR: 1.57, 95% CI: 1.05–2.33) were observed in the PPD group. This study demonstrated that patients with PPD have higher risks of subsequent autoimmune diseases, especially pernicious anemia, rheumatoid arthritis, and Graves’ disease. This useful information provides physicians with clues regarding the associations between autoimmune diseases and PPD.

Contraceptives as possible risk factors for postpartum depression: A retrospective study of the food and drug administration adverse event reporting system, 2004-2015

Aim

Postpartum depression is a mood disorder that commonly affects women during the early postpartum period. The objective of this study was to analyse the association of postpartum depression with drugs (including contraceptive devices and implants) with spontaneously reported adverse events reported in the US Food and Drug Administration Adverse Event Reporting System database.

Design

Retrospective study.

Method

Reports of postpartum depression events between 2004–2015 were analysed with a reporting odds ratio (ROR) algorithm. The Medical Dictionary for Regulatory Activities was used to identify postpartum depression.

Results

The reporting odds ratios (95% confidence intervals, CI) of levonorgestrel (an intrauterine device with progestogen), etonogestrel (a hormonal contraceptive implant), sertraline and drospirenone (an oral contraceptive) were 12.5 (8.7–18.0), 14.0 (8.5–22.8), 12.2 (6.5–23.1) and 5.4 (2.7–10.9) respectively. Among the drugs in the US Food and Drug Administration Adverse Event Reporting System database, the use of contraceptives or an intrauterine device with progestogen might convey risk for postpartum depression.

Prevalence and factors associated with depressive symptoms among post-partum mothers in Nepal

Background

Post-partum depression is a common complication of women after childbirth. The objective of this study was to determine the prevalence of and factors associated with depressive symptoms among post-partum mothers attending a child immunization clinic at a maternity hospital in Kathmandu, Nepal.

Methods

This cross-sectional study was conducted among 346 post-partum mothers at six to ten weeks after delivery using systematic random sampling. Mothers were interviewed using a semi-structured questionnaire. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for depressive symptoms. Logistic regression analysis was used to calculate the association of post-partum depressive symptoms with socio-demographic and maternal factors.

Results

The prevalence of post-partum depressive symptoms among mothers was 30%. Mothers aged 20 to 29 years were less likely to have depressive symptoms (adjusted odds ratio (aOR) = 0.40; 95% CI: 0.21-0.76) compared to older mothers. Similarly, mothers with a history of pregnancy-induced health problems were more likely to have depressive symptoms (aOR = 2.16; CI: 1.00-4.66) and subjective feelings of stress (aOR = 3.86; CI: 1.84-4.66) than mothers who did not.

Conclusions

The number of post-partum mothers experiencing depressive symptoms was high; almost one-third of the participants reported having them. Pregnancy-induced health problems and subjective feelings of stress during pregnancy in the post-partum period were found to be associated with depressive symptoms among these women. Screening of depressive symptoms should be included in routine antenatal and postnatal care services for early identification and prevention.