Social determinants of antenatal depression and anxiety among women in South Asia: A systematic review & meta-analysis

A qualitative examination of factors influencing pregnancy-related anxiety in Northern Ghana

INTRODUCTION

Despite high prevalence of anxiety among pregnant women in low- and -middle-income countries, research on context-specific conceptualisation, measurement, and predictors of pregnancy-related anxiety (PrA) is limited in these contexts. We explored local conceptualisations of factors influencing PrA in the Northern Region of Ghana.

METHODS

We conducted 15 focus group discussions with antenatal care seekers in the Mion District, Savelugu Municipality, and Tamale Metropolis of the Northern Region, in July and August 2021. Multistage stratified purposive sampling was used to select respondents (n = 108). The data were audio-recorded and transcribed, and then we conducted a thematic analysis of the data.

RESULTS

At the individual level, fear of anaemia; pre-existing health conditions; challenges with daily activities; and physical, emotional, and sexual abuses from spouses contributed to PrA. Health system failures resulting in unexpected out-of-pocket payments, negative health worker attitudes, diagnostic errors, constraints on birth preparation and birth process, and potential adverse birth outcomes were understood as driving PrA. Socio-cultural factors influencing PrA comprised beliefs and practices around baby naming/outdooring ceremonies, fear of spiritual attacks, social construction of gender roles, and contextual factors such as transportation challenges.

CONCLUSION

Pregnant women in the region understood, experienced, and could identify perceived predictors of PrA. To address PrA, we recommend that mental health services should be integrated into the basic package of antenatal care and rural health services should be improved. Perceived predictors of PrA identified here could be included in the design of a context-specific PrA measure for use in the region.

Are Providers Adequately Screening for Anxiety Symptoms During Pregnancy?

OBJECTIVE

To examine the difference in prevalence of self-reported anxiety symptoms throughout pregnancy compared to clinical diagnosis of an anxiety disorder by a provider.

DESIGN

Secondary data analysis of a prospective cohort study of 50 pregnant individuals.

SETTING/LOCAL PROBLEM

Pregnant individuals commonly experience heightened anxiety symptoms, which are associated with adverse perinatal outcomes. However, a diagnosis of an anxiety disorder by a health care provider is less common, which may result in insufficient mental health intervention.

PARTICIPANTS

Pregnant individuals were recruited at their first prenatal appointment and followed until birth.

INTERVENTION/MEASUREMENTS

We examined anxiety symptoms using the Edinburgh Postnatal Depression Scale Anxiety subscale. We conducted a medical record review to examine if pregnant individuals were clinically diagnosed with an anxiety disorder.

RESULTS

Based on an Edinburgh Postnatal Depression Scale Anxiety subscale cutoff score of ≥5, 40% (n = 20) of individuals experienced anxiety symptoms during pregnancy. However, only 16% (n = 8) of participants were diagnosed with an anxiety disorder by a health care provider.

CONCLUSION

Anxiety symptoms are prevalent throughout pregnancy and may be underdiagnosed by health care providers. An intervention to increase clinical diagnosis of an anxiety disorder and subsequent referral to a mental health specialist may be indicated.

Factors associated with antenatal depression among women attending antenatal care at Mubende Regional Referral Hospital: a cross-sectional study

INTRODUCTION

This study aimed to investigate the prevalence, severity, and factors associated with antenatal depression among women receiving antenatal care at Mubende Regional Referral Hospital (MRRH) in Uganda. Antenatal depression is a critical concern for maternal and child well-being, as it is associated with adverse outcomes such as preterm birth, abortion, low birth weight, and impaired maternal-infant bonding. Despite several international guidelines recommending routine screening for antenatal depression, local Ugandan guidelines often overlook this essential aspect of maternal care.

METHODS

A cross-sectional study involving 353 pregnant women utilized the Patient Health Questionnaire 9 (PHQ-9) to assess antenatal depression. Participants were categorized as having antenatal depression if their total PHQ-9 score was ≥ 5 and met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for either major or minor depression. Psychosocial demographic and obstetric characteristics were recorded. Logistic regression analysis identified factors linked to antenatal depression.

RESULTS

The burden of antenatal depression was notably high, affecting 37.68% of the participants. Among those with antenatal depression, the majority exhibited mild symptoms 94 (70.68%). The significant factors associated with antenatal depression, revealed by multivariate analysis, included younger age (≤ 20 years), older age (≥ 35 years), history of domestic violence, alcohol use, gestational age, history of abortion, history of preeclampsia, and unplanned pregnancies.

CONCLUSION

This study revealed a significantly high prevalence of antenatal depression, emphasizing its public health importance. Most cases were classified as mild, emphasizing the importance of timely interventions to prevent escalation. The identified risk factors included age, history of domestic violence, alcohol use, first-trimester pregnancy, abortion history, previous preeclampsia, and unplanned pregnancy.

Identifying the Health Concerns of Pregnant British Pakistani Women Living in Deprived Areas: A Qualitative Study

INTRODUCTION

Pregnant British Pakistani women have disproportionately poorer health than the wider population. Bradford has a strong Pakistani presence and a wide range of public health problems including high levels of gestational diabetes, high obesity rates and a high infant mortality rate, which is highest for babies of Pakistani origin. For women to be healthy, we need to know what concerns they have about their health so they can be addressed appropriately. The aim of this study, therefore, was to explore the health concerns of pregnant British Pakistani women living in deprived areas.

METHODS

Semi-structured qualitative interviews were conducted with 21 pregnant Pakistani women in a hospital setting. Data were analysed using thematic analysis.

RESULTS

Pakistani women identified safety issues, barriers to undertaking physical activity in the areas where they live, concerns surrounding exercising during pregnancy and cultural and religious constraints that prevented them from engaging in physical activity. They reported issues around food, concerns around a lack of culturally appropriate diet information, the cost of unhealthy food locally, and the lack of healthy food options in their residences. Women were unsure on where to obtain health promotion information and reported a lack of access in obtaining that information. Language barriers in accessing health promotion information were further reported as a concern.

DISCUSSION

Researchers, midwives, health providers, local authority and policy makers interested in improving the health of pregnant Pakistani women may use these findings to develop further research and interventions to improve the poor health of this population.

'Been there, experienced that': A qualitative study on the experiences and perceptions of online peer volunteers in supporting Singaporean mothers at risk of depression

BACKGROUND

Online peer support is a useful source of support for parents during the perinatal period, associated with improved psychological outcomes. Past research has found that peer support providers themselves gain from providing peer support as well, making it mutually beneficial. As current maternity care services are insufficient to meet the support needs of parents, the Supportive Parenting App (SPA) intervention was developed to offer them informational, appraisal and emotional support during the perinatal period. It consists of mobile health application-based educational support and online peer support provided by trained peer volunteers, to prevent the development of postnatal depression.

OBJECTIVE

To explore the experiences of peer volunteers with providing online peer support to parents during the perinatal period, as well as to identify areas of improvement for the SPA intervention.

METHODS

A qualitative descriptive design was adopted. This study took place from October 2020 to August 2021 in two tertiary public healthcare institutions in Singapore. A total of 18 peer volunteers were invited for individual semi-structured interviews. The interviews were audio recorded and transcribed verbatim, and thematic analysis was used to analyse the data.

RESULTS

Four themes were emerged as follows: (1) 'Being there': Reminiscing about and healing of own postnatal depression experience; (2) Building rapport with parents; (3) Parents in mind: Mutual sharing of knowledge and how to support new parents better; (4) Ensuring good quality peer support.

CONCLUSIONS

The peer volunteers felt that their experience was fulfilling and healing. Frequent contact, sharing of SPA resources and self-disclosure were found to help engage the new parents and build rapport between peer volunteers and parents. Challenges described by the peer volunteers have identified possible areas in which the SPA intervention can be improved.

IMPLICATIONS FOR CARE

Communication between peer program facilitators, managers and peer volunteers can be enhanced to ensure that peer volunteers are more sensitive and precise when providing support or information. This can improve rapport building between parents and peer volunteers, which will in turn maximize the benefits that parents can reap through online peer-to-peer support.

IMPACT

This study explored the perceptions of peer volunteers who provided online peer support to parents across the perinatal period. Peer volunteers felt that the SPA intervention was meaningful and that providing peer support was a healing experience. They were able to learn about the experiences of other mothers with postpartum depression while sharing their own past experiences. Thus, both parents and peer volunteers can benefit from engaging in online peer support programs. Technology-based interventions like the Supportive Parenting App (SPA) can be a suitable complement to maternity care services by providing parents access to medically accurate information and social support. Additionally, more experienced mothers can engage in fulfilling experiences through volunteering for new mothers who may benefit from informational, appraisal and emotional support.

REPORTING METHOD

This study follows the reporting guidelines as stated by the Consolidated criteria for reporting qualitative research (COREQ) checklist.

PATIENT OR PUBLIC CONTRIBUTION

Parents and peer volunteers contributed ideas that aided with the design of the mobile app. Many topics added to the educational materials were suggested by these parents as well. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: This study showed that sufficient training can be provided to lay peer volunteers to help them support other parents, buffering the pressure exerted on the healthcare industry due to the rising demand for healthcare services. The provision of such support is also beneficial for the peer volunteers themselves, as they find it meaningful and educational. Program developers of parenting and peer volunteering interventions can draw on the findings of this study to improve the effectiveness of these programs.

Women's awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study

BACKGROUND

Mental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women's awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India.

METHODS

Focus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis.

RESULTS

Seven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported.

CONCLUSIONS

Women face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in 'real world' antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.

Integrating nutrition and mental health screening, risk identification and management in prenatal health programs in India

Pregnancy is a period of major physiologic, hormonal, and psychological change, increasing the risk of nutritional deficiencies and mental disorders. Mental disorders and malnutrition are associated with adverse pregnancy and child outcomes, with potential long-standing impact. Common mental disorders during pregnancy are more prevalent in low- and middle-income countries (LMICs). In India, studies suggest the prevalence of depression is 9.8%-36.7% and of anxiety is 55.7%. India has seen some promising developments in recent years such as increased coverage of the District Mental Health Program; integration of maternal mental health into the Reproductive and Child Health Program in Kerala; and the Mental Health Care Act 2017. However, mental health screening and management protocols have not yet been established and integrated into routine prenatal care in India. A five-action maternal nutrition algorithm was developed and tested for the Ministry of Health and Family Welfare, aiming to strengthen nutrition services for pregnant women in routine prenatal care facilities. In this paper, we present opportunities and challenges for integration of maternal nutrition and mental health screening and a management protocol at routine prenatal care in India, discuss evidence-based interventions in other LMICs including India, and make recommendations for public healthcare providers.

Prevalence and associated factors of depression, anxiety, and stress among pregnant women in Herat, Afghanistan: A cross-sectional study

Background and Aims

Pregnancy is an important and natural event in a woman's life. It represents a time of substantial social and bio-psychological challenges for a pregnant woman that may increase vulnerability to emotional disturbances such as depression, anxiety, and stress (DAS). This study aims to assess the prevalence and associated factors of DAS among pregnant women in Herat city of Afghanistan.

Methods

This hospital-based cross-sectional study was conducted between July and November 2019, on 691 Dari-speaking pregnant women aged 15-49 years, who attended the antenatal clinic of Herat Razaei Maternity Hospital. The interview process involved the use of a structured questionnaire that collected data on sociodemographic characteristics of participants, as well as the validated Dari-translated version of DASS-42 questionnaire. A χ 2 test was used to test for association between categorical data. Forward likelihood ratio was used to assess the strength of association between sociodemographic variables and DAS; independently. The significance level was set to 0.05 and the confidence interval to 95% in all statistical analyses. Statistical analyses were performed in IBM SPSS Statistics (version 27).

Results

The mean age of participants was 26.17 ± 6.06. The overall prevalence of DAS among study participants were 42.8%, 40.0%, and 59.5%, respectively. Planning of current pregnancy, women's health, husband's health, women's nutrition, family support, husband's support, women's education, women's employment, and family economy were significantly associated with DAS, while gestational age was not significantly associated with DAS.

Conclusion

The prevalence of DAS among pregnant women in Herat city of Afghanistan is very high. Considering scientific evidence on high prevalence and associated factors of DAS among pregnant women, policymakers, public health authorities, and medical practitioners must devote significant attention in reducing the magnitude of these mental disorders and/or reducing their impact on women, their families, and the society.

Validation of the German version of the pregnancy-related anxiety scale (PrAS): psychometric properties across all trimesters of pregnancy

BACKGROUND

Pregnancy-related anxiety has received greater research attention recently given its association with adverse outcomes (e.g., negative birth experiences). The Pregnancy-related Anxiety Scale (PrAS) offers the possibility to assess pregnancy-related anxiety, but no German version is available. Therefore, the aim of this study was to validate a German version of the PrAS, a comprehensive measure with eight dimensions.

METHODS

Pregnant women of any parity or gestation completed an online survey consisting of the PrAS, PRAQ-R2, and measures of anxiety, depression, and resilience. The PrAS was translated into German (PrAS-G) using the back-translation method. Data were subjected to confirmatory factor analysis and inferential statistics.

RESULTS

Complete data were provided by 443 women. Participants were predominantly German nationals, partnered, and well-educated with a planned pregnancy. Approximately half were nulliparous. The eight-factor model was well fitting and consistent with the development of the original PrAS. Criterion-related validity was demonstrated by strong correlations with similar measures (PRAQ-R2, anxiety, and depression) and lower correlations with resilience scores. Predictive validity was shown by group comparisons for: planned versus unplanned pregnancy, trimester, and parity.

CONCLUSIONS

The PrAS-G provides a broader assessment of pregnancy-related anxiety than existing measures. Initial evaluation has demonstrated convergent, divergent, and predictive validity, excellent internal consistency, and good model fit indicating promising psychometric properties. The PrAS-G offers a comprehensive assessment of pregnancy-related anxiety which will enable tailored interventions aiming to improve birth experience and well-being of expectant mothers.

Cultural collectivism, intimate partner violence, and women's mental health: An analysis of data from 151 countries

Culture, defined as the distinctive, learned beliefs and patterns of behavior that are particular to a given group or community, is a key determinant of mental health. The cultural dimension of individualism-collectivism, which measures the extent to which a given society accords importance to individuals as opposed to larger groups, has been associated with cross-national variations in mental health outcomes such as depression and suicide. However, this cultural dimension is also associated with variations in the frequency of intimate partner violence (IPV), which has a significant and sustained adverse impact on women's mental health. This study examines the relationships between individualism-collectivism, the frequency of IPV, and rates of depression and suicide in women, based on data from 151 countries. In this data set, IPV was significantly associated with age-standardized rates of depression and suicide in women, even after adjusting for demographic variables. Cultural collectivism was positively correlated with IPV, but this relationship was significantly influenced by national income and women's educational attainment. In multivariate analyses, IPV, but not cultural collectivism, remained significantly associated with depression in women. These results highlight the importance of screening for and addressing IPV in women seeking mental health care, particularly in low- and middle-income countries where cultural and economic factors may both increase the risk of IPV and delay or impede its reporting.

The descriptive analysis of depressive symptoms and White Blood Cell (WBC) count between the sexual minorities and heterosexual identifying individuals in a nationally representative sample: 2005-2014

BACKGROUND

Sexual minorities are at a higher risk of suffering from depressive symptoms compared with heterosexual individuals. Only a few studies have examined the conditions of having depressive symptoms within different sexual minority groups, especially people with sexual orientation uncertainty in a nationally representative sample. Furthermore, few studies have explored whether the mean white blood count (WBC) is different between people with and without depressive symptoms among different sexual minority groups in a nationally representative sample.

METHODS

We analyzed the National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2014 with a sample of 14,090 subjects. We compared the prevalence of depressive symptoms in subpopulations stratified by sex, sexual minority status, and race. We also examined the difference in mean WBC count between depressed and non-depressed people among heterosexual individuals and different sexual minority groups. Additionally, two multivariable logistic regression models were used to explore the association between sexual minority status and depressive symptoms, treating sexual minority status as both a binary and categorical variable.

RESULTS

Female sex (OR: 1.96, 95% CI: 1.72-2.22) and sexual minority status (OR: 1.79, 95% CI: 1.47-2.17) were both independently associated with depressive symptoms. Within the sexual minority population, subjects who were unsure about their sexual identities had the highest odds of having depressive symptoms (OR: 2.56, 95% CI: 1.40-4.68). In the subgroup analysis considering intersectionality, black sexual minority females had the highest rate of depressive symptoms (19.4%, 95% CI: 7.72-40.98). Finally, the mean WBC count differed significantly between people with and without depressive symptoms among male heterosexual individuals, female heterosexual individuals, and female sexual minorities, but not among male sexual minorities.

CONCLUSIONS

Based on sex, race, and sexual minority status, black females of sexual minority status had the highest rate of depressive symptoms. Within sexual minority groups, participants who were unsure about their sexual identities had the highest odds of having depressive symptoms. Finally, the mean WBC count was significantly higher among people with depressive symptoms than those without depressive symptoms only among male heterosexuals, female heterosexuals, and female sexual minorities, but not among male sexual minorities. Future research should investigate the social and biological mechanisms of the differences.

Social Determinants and Prevalence of Antenatal Depression among Women in Rural Bangladesh: A Cross-Sectional Study

The prevalence of antenatal depression in Bangladesh ranges from 18 to 33%. Antenatal depression has negative impacts on the mother and child such as suicidal ideations, low birth weight, and impaired fetal development. This cross-sectional study aims to determine the prevalence and social determinants of antenatal depression in rural Sylhet, Bangladesh. Data were collected from 235 pregnant women between March and November 2021. The validated Bangla Edinburgh Postnatal Depression Scale was used to measure antenatal depressive symptoms (ADS). Background information was collected using a structured questionnaire including the Duke Social Support and Stress Scale, pregnancy choices, and WHO Intimate Partner Violence questions. Point-prevalence of antenatal depression was 56%. Intimate partner violence (IPV) before pregnancy (adjusted odds ratio (AOR) 10.4 [95% confidence interval (CI) 2.7-39.7]) and perceived husband's male gender preference (AOR 9.9 [95% CI 1.6-59.6]) were significantly associated with increased odds of ADS among pregnant women. Increased family support was a significant protective factor for ADS (AOR 0.94 [95% CI 0.91-0.97]). Antenatal depression commonly occurs in rural Sylhet, Bangladesh, highlighting the need for improved screening and management within these settings. The findings suggest the need for community-based interventions for women with low family support and experiencing intimate partner violence, and educational programs and gender policies to tackle gender inequalities.

A phenomenological study of the lived experiences of partner relationship breakup during pregnancy: Psychosocial effects, coping mechanisms, and the healthcare providers' role

Background

Pregnancy is a state of continuous changes in feelings and emotions, and highly stressful experiences such as a relationship breakup during this period may result in additional stress for the woman, making pregnancy and motherhood challenging. This study aimed to investigate pregnant women's lived experiences of partner relationship breakup during pregnancy, their coping mechanisms, and the role of healthcare providers in breakup cases during their Antenatal care visits.

Methods

A phenomenological study approach was followed to seek an understanding of the lived experiences of pregnant women who encountered partner relationship breakup. The study was carried out in Hawassa, Ethiopia, and eight pregnant women were involved in in-depth interviews. The data meanings found from participants' experiences were described in a meaningful text and organized into themes. Key themes were developed in reference to the research objectives, and thematic analysis was used to analyze the data.

Results

Pregnant women in such situations faced serious psychological and emotional distress, feelings of shame/embarrassment, prejudice and discrimination, and severe economic struggles. To cope with this multifaceted situation, pregnant women sought social support from family/relatives or close friends, and if they had no other options, from supporting organizations. The participants also revealed that they received no counseling from healthcare providers during their Antenatal care visits, and there was no further discussion to address their psychosocial problems.

Conclusions

Community-level information, education, and communication should be initiated to aware communities about the psychosocial consequences of relationship breakup during pregnancy, address cultural norms and discrimination, and promote supportive environments. Women's empowerment activities and psychosocial support services should also be strengthened. In addition, the need for more comprehensive Antenatal care to address such unique risk conditions is indicated.

Antenatal depression and its correlates - a cross-sectional study in an urban resettlement colony of Delhi

Background- Antenatal depression is affecting 10% pregnant women worldwide with higher prevalence in developing countries. This causes poor maternal and foetal outcome and also affects cognitive development of the child. Aim and objective: To estimate magnitude of antenatal depression and its risk factors. Methodology- A cross-sectional survey was done at the antenatal clinic of community health department catering to an urban resettlement colony, East Delhi. Estimated sample size was 216 (including 10% non-response rate). Pregnant women attending the ANC clinic from October 2019 to February 2020 were enrolled. EPDS questionnaire was used to assess depression during pregnancy. Results-The antenatal depression was found in 11.8% subjects as per EPDS score. Working female and belonging to Muslim religion, past history of abortion, complications in previous pregnancy, financial debt, physical violence and substance use in family showed significant association with antenatal depression. Conclusion –Depression was prevalent among antenatal women and was found to be associated with various risk factors.

Gender Transformative Interventions for Perinatal Mental Health in Low and Middle Income Countries-A Scoping Review

Perinatal mental health problems are linked to poor outcomes for mothers, babies and families. In the context of Low and Middle Income Countries (LMIC), a leading risk factor is gender disparity. Addressing gender disparity, by involving fathers, mothers in law and other family members can significantly improve perinatal and maternal healthcare, including risk factors for poor perinatal mental health such as domestic violence and poor social support. This highlights the need to develop and implement gender-transformative (GT) interventions that seek to engage with men and reduce or overcome gender-based constraints. This scoping review aimed to highlight existing gender transformative interventions from LMIC that specifically aimed to address perinatal mental health (partner violence, anxiety or depression and partner support) and identify components of the intervention that were found to be useful and acceptable. This review follows the five-stage Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Six papers that met the inclusion criteria were included in the review (four from Africa and two from Asia). Common components of gender transformative interventions across studies included couple-based interventions and discussion groups. Gender inequity and related factors are a strong risk for poor perinatal mental health and the dearth of studies highlights the strong need for better evidence of GT interventions in this area.

Perceptions and attitudes around perinatal mental health in Bangladesh, India and Pakistan: a systematic review of qualitative data

BACKGROUND

Perinatal mental health (PMH) is a worldwide public health issue crossing cultural boundaries. However, the prevalence of PMH conditions vary considerably. These disparities stem in part from poor understanding and stigma surrounding PMH which hinder pregnant women from seeking mental health care and may exacerbate their conditions. Bangladesh, India and Pakistan are South Asian countries with a higher burden of PMH conditions than in the Global North-West and very different social and cultural norms around gender and mental health. The aim of this systematic review (PROSPERO Ref: CRD42020167903) was to identify, synthesise and appraise the available literature on perceptions and attitudes of perinatal (pregnant and postpartum) women, their families and healthcare providers surrounding PMH in Bangladesh, India and Pakistan.

METHODS

Five electronic databases, MEDLINE, Embase, PsycINFO, Scopus and Web of science, and grey literature were searched using predefined search terms. Qualitative or quantitative articles with a qualitative component reporting perceptions and attitudes surrounding PMH in Bangladesh, India and Pakistan were eligible for inclusion, if published in English between January 2000 and January 2021. The Critical Appraisal Skills Programme Qualitative Research Checklist and Newcastle-Ottawa Scale for cross-sectional studies were used to assess study quality. Findings were synthesised using thematic synthesis, as described by Thomas and Harden 2008.

RESULTS

Eight studies were included. Five overarching themes comprising 17 sub-categories were identified. These descriptive themes were: perceived causes of PMH, perceived symptoms of PMH, perceptions of motherhood, accessing PMH care and emotional sharing and coping strategies. Sociocultural expectations underpin many of the themes identified in this review including the importance of familial and societal causes of PMH, emphasis on physical symptoms, sacredness of motherhood, lack of awareness, stigma, shame, limited resources allocated for mental health and lack of emotional sharing.

CONCLUSIONS

There is a complex range of perceptions and attitudes around PMH which influence women's experiences and access to PMH care. These findings will inform policy and practice through targeted interventions to tackle stigmatising attitudes and increasing education and training for healthcare providers.