Prenatal health behaviors and postpartum depression: is there an association?

Association between history of hookah use and symptoms of postpartum depression: A population-based study

OBJECTIVE

Although several biologic, psychosocial, and behavioral factors have been linked to postpartum depressive symptoms, studies examining the association between non-cigarette tobacco products and symptoms of postpartum depression are currently lacking. This study examined the association between hookah use and postpartum depressive symptoms.

METHODS

A cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System 2016-2020. Self-reported data on hookah use in the last 2 years and maternal mental health were captured using a structured questionnaire. Descriptive and inferential statistics were performed.

RESULTS

The final study sample consisted of 106 894 participants. Approximately 8.2% of the participants reported postpartum depressive symptoms and 4.1% reported hookah use in the past 2 years. Compared with those without postpartum depressive symptoms, participants with postpartum depressive symptoms were more likely to be hookah users (5.5% vs 4.0%, P < 0.001). After adjustment for confounders, the odds of having postpartum depressive symptoms were significantly higher among participants who used a hookah in the past 2 years compared with non-users; adjusted odds ratio (95% confidence interval) 1.20 (1.03-1.40); P = 0.022.

CONCLUSION

In a large, population-based sample of US women, hookah use in the past 2 years significantly increased the odds of having postpartum depressive symptoms, independent of potential confounders. This finding underscores the need for healthcare providers to communicate effectively about the health risks of hookah use.

Risk Factors of Postpartum Depression Among Korean Women: An Analysis Based on the Korean Pregnancy Outcome Study (KPOS)

BACKGROUND

Postpartum depression (PPD) can negatively affect infant well-being and child development. Although the frequency and risk factors of PPD symptoms might vary depending on the country and culture, there is limited research on these risk factors among Korean women. This study aimed to elucidate the potential risk factors of PPD throughout pregnancy to help improve PPD screening and prevention in Korean women.

METHODS

The pregnant women at 12 gestational weeks (GW) were enrolled from two obstetric specialized hospitals from March 2013 to November 2017. A questionnaire survey was administered at 12 GW, 24 GW, 36 GW, and 4 weeks postpartum. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale, and PPD was defined as a score of ≥ 10.

RESULTS

PPD was prevalent in 16.3% (410/2,512) of the participants. Depressive feeling at 12 GW and postpartum factors of stress, relationship with children, depressive feeling, fear, sadness, and neonatal intensive care unit admission of baby were significantly associated with a higher risk of PPD. Meanwhile, high postpartum quality of life and marital satisfaction at postpartum period were significantly associated with a lower risk of PPD. We developed a model for predicting PPD using factors as mentioned above and it had an area under the curve of 0.871.

CONCLUSION

Depressive feeling at 12 GW and postpartum stress, fear, sadness, relationship with children, low quality of life, and low marital satisfaction increased the risk of PPD. A risk model that comprises significant factors can effectively predict PPD and can be helpful for its prevention and appropriate treatment.

The role of stress in perinatal depression and anxiety - A systematic review

Perinatal depression (PND) and anxiety affect around 20% of women, but available pharmacotherapy is not sufficiently effective in 20-60% of them, indicating a need for better understanding of these diseases. Since stress is a significant risk factor for PND, the aim was to examine the role of biological, environmental and psychological stress in PND and anxiety through a systematic literature search. Overall 210 studies were included, among which numerous rodent studies showed that perinatal stress induced depressive-like and anxious behavior, which was associated with HPA-axis alterations and morphological brain changes. Human studies indicated that the relationship between cortisol and perinatal depression/anxiety was not as clear and with many contradictions, although social and psychological stress were clearly positively associated with PND. Finally, oxytocin, synthetic neuroactive steroid and n-3 PUFA diet have been identified as potentially beneficial in the therapy of PND and anxiety, worth to be investigated in the future.

Depression and anxiety disorders during the postpartum period in women diagnosed with attention deficit hyperactivity disorder

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is associated with an increased risk of poor mental health. However, the understanding of ADHD-related burden and impairments in women during the postpartum period is limited. The aim with the present study was to examine the risk of depression and anxiety disorders during the postpartum period among women with and without an ADHD diagnosis.

METHODS

We used register-based data to identify women who gave birth to their first and/or second child between 2005 and 2013 in Sweden (n = 773,047), of which 0.5 % (n = 3515) had a diagnosis of ADHD prior to pregnancy. Diagnoses of depression and anxiety disorders up to one year after delivery were collected from the national patient register.

RESULTS

A total of 16.76 % of the women with an ADHD diagnosis were also diagnosed with depression disorders in the postpartum period, prevalence ratio (PR) 5.09 (95 % confidence interval (CI), 4.68-5.54). A total of 24.92 % of the women with an ADHD diagnosis were also diagnosed with anxiety disorders in the postpartum period, PR 5.41 (5.06-5.78). Stratified results revealed that having a diagnosis of ADHD increased the risk for both depression and anxiety disorders postpartum, beyond other well-known risk factors.

LIMITATIONS

There is a potential risk of surveillance bias as women diagnosed with ADHD are more likely to have repeated visits to psychiatric care and might have an enhanced likelihood of also being diagnosed with depression and anxiety disorders postpartum, compared to women without ADHD.

CONCLUSIONS

ADHD is an important risk factor for both depression and anxiety disorders postpartum. Therefore, ADHD needs to be considered in the maternal care, regardless of sociodemographic factors and the presence of other psychiatric disorders.

American Indian Motherhood and Historical Trauma: Keetoowah Experiences of Becoming Mothers

Background: American Indian/Alaskan Native (AI/AN) women disproportionally experience postpartum depression in the United States as compared to the rest of the population. Despite being disproportionately represented, the current body of knowledge lacks research on depression in this particular population. Specifically, the current literature lacks research pertaining to the experiences of postpartum AI/AN women, their culture, birthing and mothering expectations, and trauma. This qualitative study used the theories of becoming a mother, historical-trauma framework, and reproductive justice as they relate to Indigenous women’s personal and historical trauma to assess their lived experiences of becoming a mother. Methods: Keetoowah mothers (N = 8) were interviewed by using a story inquiry method to understand the perinatal experiences of members of one Indigenous tribe in the US. Findings: The story inquiry coding resulted in two main themes, namely maternal mental health challenges and inadequacies of perinatal care. Conclusion: The subthemes illuminate the intersection of historical trauma and the perinatal experience, continued colonization of mothering, and the resilience of tribal culture during the postpartum period. Implications include advocacy for increasing culturally derived perinatal interventions, increased healthcare coverage of culturally appropriate birthing practices, and future research evaluating the correlation between historical trauma and maternal mental health challenges.

Postpartum Diet and the Lifestyle of Korean and Chinese Women: A Comparative Study

Objective

The study investigated and compared postpartum diet and behaviors, nutrition education, and psychological health status among Korean and Chinese postpartum women (0-6 months after delivery).

Methods

A total of 221 Korean mothers in Gyeonggi-do (South Korea) and 221 mothers in Jinhua (China) participated in the survey between November and December 2018, and the results were statistically analyzed using the SPSS Statistics 25.0 software.

Results

Many postpartum behaviors, such as postpartum diet pattern and care duration differed between Korean and Chinese mothers. The former showed a stronger desire for nutrition education compared with the latter (p < 0.001). Korean mothers' life and meal satisfaction, and contentment with their husband's support were all ~0.5 points higher compared with Chinese mothers, particularly regarding spousal support (p < 0.001). Postpartum depression stresses positively correlated with postpartum infant care stress and negatively correlated with life satisfaction. In addition, primipara mothers were more in need of infant care support and guidance concerning appropriate baby-feeding techniques compared with multipara mothers.

Conclusion

Traditional culture was a crucial factor that influenced the perceptions of postpartum women in South Korea and China. Culturally tailored nutrition education and exercise programs may benefit Korean and Chinese women after childbirth.

Risk factors of perinatal depression in women: a systematic review and meta-analysis

BACKGROUND

Perinatal depression in women is associated with high morbidity and mortality, and has attracted increasing attention. The investigation of risk factors of perinatal depression in women may contribute to the early identification of depressed or depression-prone women in clinical practice.

MATERIAL AND METHODS

A computerized systematic literature search was made in Cochrane Library, PubMed, Web of Science, and EMBASE from January 2009 to October 2021. All included articles were published in English, which evaluated factors influencing perinatal depression in women. Based on the recommendations of the Cochrane Collaboration protocols, Review Manager 5.3 was used as a statistical platform.

RESULTS

Thirty-one studies with an overall sample size of 79,043 women were included in the review. Educational level (P = 0.0001, odds ratio [OR]: 1.40, 95% CI: [1.18,1.67]), economic status of families (P = 0.0001, OR: 1.69, 95%CI: [1.29,2.22]), history of mental illness (P < 0.00001, OR: 0.29, 95% CI: [0.18, 0.47]), domestic violence (P < 0.00001, OR: 0.24, 95% CI: [0.17,0.34]), perinatal smoking or drinking (P = 0.005, OR: 0.63; 95% CI [0.45, 0.87]; P = 0.008, OR: 0.43, 95% CI, [0.23 to 0.80]; respectively), and multiparity(P = 0.0003, OR: 0.74, 95% CI: [0.63, 0.87]) were correlated with perinatal depression in women. The stability of our pooled results was verified by sensitivity analysis and publication bias was not observed based on funnel plot results.

CONCLUSION

Lower educational level, poor economic status of families, history of mental illness, domestic violence, perinatal smoking or drinking, and multiparity serve as risk factors of perinatal depression in women.

Smoking status: A tacit screen for postpartum depression in primary care settings

BACKGROUND

Universal screening for postpartum depression (PPD) remains an unachieved national priority. A tacit screen that requires no additional resources for administration can help to achieve this priority. We examine the predictive utility of using smoking as a tacit screen for PDD. We first establish smoking is a valid proxy for more prominent psychosocial determinants of PPD and is a predictor for PPD.

METHODS

We analyzed PRAMS data (2012-2015; N=134,435). Time of smoking was categorized as nonsmoker, during the prenatal period, the postpartum, or continuously; PPD was assessed using two PHQ-2 style questions.

RESULTS

Compared to nonsmokers, women who smoked only during the prenatal period (OR: 1.41; 95% CI: 1.06 - 1.86), only during the postpartum (OR: 1.33; 95% CI: 1.18 - 1.49), and continuously throughout both periods (OR: 1.54; 95% CI: 1.41 - 1.69) were more likely to experience PPD. Smoking assessed at a prenatal visit (SN: 0.90, SP: 0.21), postpartum visit (SN: 0.86, SP: 0.25), or assessed at both visits (SN: 0.90, SP: 0.19) performed relatively well as a tacit screen for PPD, performing better among unmarried women (SN: 0.75 - 0.81; SP: 0.29 - 0.36).

LIMITATIONS

In this study, the criterion of positivity used was PRAMS' adapted version of the PHQ-2. This tacit screen may perform differently relative to a clinical diagnosis.

CONCLUSIONS

Time of smoking predicts risk of PPD and can be used to tacitly screen for PPD with reasonable accuracy without requiring any additional time in settings with limited resources for routine screening of PPD.

Prenatal tobacco exposure and the risk of conduct disorder symptoms in offspring at the age of 14 years: Findings from the Raine Study

BACKGROUND

Emerging epidemiological evidence suggests that offspring born to mothers who smoked tobacco during pregnancy may have elevated risk of developing conduct disorder (CD) symptoms. We examined associations between maternal and paternal tobacco smoking during pregnancy and CD symptoms in offspring at the age of 14 years.

METHODS

We obtained data from the Raine Study, a multi-generational cohort study based in Western Australia. DSM-oriented scale of the Child Behavior Checklist (CBCL) was used to measure CD symptoms in offspring. Negative binomial regression was used to estimate the rate ratio (risks) (RR) of CD symptoms in offspring. We also produced the E-values to investigate the extent of unmeasured confounding. Paternal smoking during pregnancy was used as a proxy for environmental tobacco smoke exposure.

RESULTS

Complete data were available for 1747 mother-offspring and 1711 father-offspring pairs. After adjusting for potential confounders, we found elevated risks (rates) of CD symptoms in offspring born to mothers smoking tobacco during the first trimester [RR 1.52 (95 % CI: 1.24-1.87)], third trimester [RR 1.36 (95 % CI: 1.09-1.69)] and during both trimesters of pregnancy [RR 1.50 (95 % CI: 1.19-1.90)]. The rates of CD symptoms in offspring increased with the level of exposure to maternal smoking during pregnancy. However, we noted insufficient statistical evidence for an association between paternal smoking during pregnancy and CD symptoms in offspring.

CONCLUSION

The associations we found for maternal but not paternal smoking may suggest a biological mechanism for intrauterine tobacco exposure on the risk of CD symptoms in offspring. Early interventions assisting pregnant mothers to quit tobacco smoking, or avoid smoking initiation, have potential to contribute health benefits to both mothers and their offspring.

The Role of Father Involvement and Intimate Partner Violence on Postnatal Depression Among Women With Unintended Pregnancy

This study set out to fill the research gap by including various aspects of father involvement and intimate partner violence (IPV) in the examination of the association between unintended pregnancy and maternal postnatal depression (PND). This study aimed to examine the effect of father involvement and IPV on the association between unintended pregnancy and PND. A sample of 1,083 pregnant women who attended antenatal clinic at selected hospitals in Hong Kong completed two surveys to report on their pregnancy intention, antenatal depression, PND, IPV during pregnancy, their partner's (i.e., father's) involvement during pregnancy and after childbirth, and perceived social support. Comparisons were made between women with unintended pregnancy and those with intended pregnancy, and the effects of unintended pregnancy, father involvement, IPV, and other factors on maternal PND were examined. Results show that women with unintended pregnancy were more likely to report PND, IPV, fear, postnatal stress, lower degree of father involvement, and lower level of social support. Unintended pregnancy independently increased the risk of PND by 1.95 times (95% confidence interval [CI] = [1.15, 3.28]), after adjustment for all other variables. When father involvement was included in the regression model, the negative effects of IPV and the related fear on PND became nonsignificant. The positive association between unintended pregnancy and PND was robust. Father involvement might help promote maternal health by reducing the negative effects of IPV on PND.

Who is the main caregiver of the mother during the doing-the-month: is there an association with postpartum depression?

BACKGROUND

To examine the relationship between the main caregiver during the "doing-the-month" (a traditional Chinese practice which a mother is confined at home for 1 month after giving birth) and the risk of postpartum depression (PPD) in postnatal women.

METHODS

Participants were postnatal women stayed in hospital and women who attended the hospital for postpartum examination, at 14-60 days after delivery from November 1, 2013 to December 30, 2013. Postpartum depression status was assessed using the Edinburgh Postnatal Depression Scale. Univariate and multivariable logistic regressions were used to identify the associations between the main caregiver during "doing-the-month" and the risk of PPD in postnatal women.

RESULTS

One thousand three hundred twenty-five postnatal women with a mean (SD) age of 28 (4.58) years were included in the analyses. The median score (IQR) of PPD was 6.0 (2, 10) and the prevalence of PPD was 27%. Of these postnatal women, 44.5% were cared by their mother-in-law in the first month after delivery, 36.3% cared by own mother, 11.1% by "yuesao" or "maternity matron" and 8.1% by other relatives. No association was found between the main caregivers and the risk of PPD after multiple adjustments.

CONCLUSIONS

Although no association between the main caregivers and the risk of PPD during doing-the-month was identified, considering the increasing prevalence of PPD in Chinese women, and the contradictions between traditional culture and latest scientific evidence for some of the doing-the-month practices, public health interventions aim to increase the awareness of PPD among caregivers and family members are warranted.

Labor Analgesia reduces the risk of postpartum depression: A cohort study

Background

Postpartum depression (PPD) is a frequent mental disorder after delivery. In China, most parturients give birth with the assistance of labor analgesia (LA) or by cesarean section (CS); however, it is still unclear whether these two approaches reveal different effects on PPD.

Methods

One hundred and ninety-eight patients with single pregnancy at full term were allocated to receive either group LA or group CS. Maternal and neonatal variables in the perinatal period were recorded. Multivariate logistical regression analysis was conducted to evaluate the associated factors of PPD.

Results

The incidence of PPD in group LA was lower than in group CS. Besides, eight factors were found to be potential predictors of PPD. Multivariate logistic model showed that LA was a protective factor against PPD. However, high family income and Edinburgh postnatal depression scale (EPDS) scores at 3 days postpartum were associated with an increased risk of PPD.

Conclusion

LA could reduce the incidence of PPD in women with single pregnancy at full term. Family income and EPDS scores in the early postpartum period were also related with PPD. Large sample size studies are needed to verify the impact of LA on the psychological states of postpartum women.

Examining Rates of Postpartum Depression in Active Duty U.S. Military Servicewomen

Background: Postpartum depression (PPD) is understudied in military populations. The present descriptive transversal study evaluated the incidence of PPD diagnoses in U.S. military electronic health records, based on International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes, among active duty military servicewomen between 2001 and 2018. Methods: Data on 3,724 active duty military servicewomen who served between 2001 and 2018 were drawn from the Defense Medical Epidemiological Database and stratified by race, age, marital status, service branch, and military pay grade. Single sample chi squares were used to examine observed versus expected differences in diagnosis rates. Results: The incidence rate of PPD among all U.S. military servicewomen was the lowest in 2001 (1.96 per 1,000) and the highest in 2018 (29.95 per 1,000). Servicewomen most often diagnosed with PPD were white (60%), married (74%), in the enlisted pay grades of E-1 to E-4 (60%), in the Army (43%), and were between 20 and 24 years old (46%). Statistically significant differences (p < 0.001) were found between observed and expected counts across all five demographic variables. Conclusions: This is the first population-based study to assess the incidence rates of PPD among all active duty military servicewomen. Findings that some groups were over- and underdiagnosed within each demographic category, and that PPD incidence rates have increased between 2001 and 2018, underscore the importance of further research to inform policies and interventions supporting this vulnerable population.

Prenatal tobacco smoking is associated with postpartum depression in Japanese pregnant women: The japan environment and children's study

INTRODUCTION

Previous studies in Western countries have examined the association between prenatal smoking and risk for Postpartum depression (PPD). However, evidence from Japan is lacking, despite the high prevalence of smoking among pregnant women. Therefore, we examined the association between prenatal smoking and PPD among pregnant Japanese women.

METHODS

We analyzed data for up to 1 month after childbirth from the Japan Environment and Children's Study (JECS), a nationwide birth cohort study. Among the 103,070 pregnant women recruited, 80,872 eligible participants were included in the analysis. PPD was defined as a score of ≥9 on the Edinburgh Postnatal Depression Scale (EPDS). Prenatal smoking and length of smoking cessation among ex-smokers were obtained using self-administered questionnaires at second/third trimester.

RESULTS

Among 80,872 pregnant women, 9.0% reported PPD. Multivariable-adjusted odds ratios (OR) (95% confidence intervals) for PPD (reference: never smoked) were 1.24 (1.12-1.37) for women who quit smoking after becoming pregnant, and 1.38 (1.21-1.56) for those who smoked during pregnancy. Compared with women who had never smoked, those who quit smoking ≤5 years before childbirth had a higher occurrence of PPD, with a multivariable-adjusted OR of 1.10 (1.00-1.22).

LIMITATIONS

Questionnaire data was self-reported by participants, thus smoking status might be under-reported.

CONCLUSIONS

Women who smoked during pregnancy, quit smoking after becoming pregnant, and quit smoking ≤5 years before childbirth are more likely to experience PPD than those who had never smoked.

Prevalence of Depression Among Women of Reproductive Age in the United States

OBJECTIVE

To describe the prevalence, use of antidepressants, and predictors of major and minor depression among nonpregnant women of childbearing age.

METHODS

Using data from the National Health and Nutrition Examination Surveys 2007-2014, we performed a cross-sectional study of 3,705 nonpregnant women of childbearing age. The primary outcome is the prevalence of major depression, and secondary outcomes are the prevalence of minor depression, rates of antidepressant use, and predictors of major and minor depression. Major and minor depression were classified using the Patient Health Questionnaire 9. Univariate and multivariate associations between major depression and minor depression with potential predictors were estimated using multinomial logistic regression.

RESULTS

The overall prevalences of major and minor depression were 4.8% (95% CI 4.0-5.7%) and 4.3% (95% CI 3.5-5.2%), respectively. The prevalences of antidepressant use among women with major depression and minor depression were 32.4% (95% CI 25.3-40.4%) and 20.0% (95% CI 12.9-29.7%), respectively. Factors most strongly associated with major depression were government insurance (adjusted relative risk [RR] ratio 2.49, 95% CI 1.56-3.96) and hypertension (adjusted RR 2.09, 95% CI 1.25-3.50); for minor depression, these were education less than high school (adjusted RR 4.34, 95% CI 2.09-9.01) or high school education (adjusted RR 2.92, 95% CI 1.35-6.31).

CONCLUSION

Our analysis indicates that 1 in 20 nonpregnant women of childbearing age experience major depression. Antidepressants are used by one third of those with major depression and one fifth of those with minor depression.

A scoping review to determine themes that represent perceptions of self as mother ('ideal mother' vs 'real mother')

Background: Postnatal depression (PND) is a key cause of maternal morbidity, with current systems of initial recognition in the UK detecting only 50% of cases. In attempts to predict those potentially at risk, this review suggests a novel approach. Aim: Implementing the concept of 'ideal mother' versus 'real mother', and asking the woman to compare their 'ideal self' against 'existent self', the aim of this instrument development review was to determine themes from the literature that relate to women's perceptions of self as a mother, and from this identification develop questions for inclusion within a proposed new measure entitled the Self-Image as Mother Scale (SIMS). Method: A scoping review of the literature was carried out to identify themes considered to affect perception of self as mother, and from this identification, evidence-based questions for inclusion in the SIMS were developed. Findings: Themes identified included (1) marital dissatisfaction, (2) inadequate partner support, (3) lack of family support, (4) socioeconomic status and associated poverty, (5) concern about infant, (6) antenatal/postnatal complications, (7) acceptance of infant gender, (8) history of mental health problems, (9) unplanned pregnancy. Conclusions: From this scoping review 18 questions were developed for inclusion in the SIMS, which will then be evaluated for psychometric properties, scale refinement and validation.

Review of the prevalence of postnatal depression across cultures

The purpose of this review was to examine articles related to recent epidemiological evidence of the prevalence of maternal postnatal depression (PND) across different countries and cultures and to identify specific epidemiological studies that have been carried out exclusively in Malaysia on the prevalence of maternal PND. The review was undertaken in two stages, an initial review and an updated review. At both stages systematic literature searches of online databases were performed to identify articles on the prevalence of maternal PND. A total of 124 articles concerning research conducted in more than 50 countries were included in the final analysis. There were wide variations in the screening instruments and diagnostic tools used although the Edinburgh Postnatal Depression Scale (EPDS) was the most common instrument applied to identify PND. The prevalence of maternal PND ranged from 4.0% to 63.9%, with Japan and America recording the lowest and highest rates, respectively. Within continents, a wide variation in reported prevalence was also found. The reported rates of maternal PND in Malaysia were much higher than that previously documented with a range of 6.8–27.3%. This review indicated that the widely cited prevalence of maternal PND of 10–15% underestimates rates of PND worldwide. The reasons for this variability may not be fully explained by review methods. Future studies should evaluate the nature of women's PND experiences across cultures to explain these wide variations.

Antenatal diet and postpartum depressive symptoms: A prospective study

Postnatal depression is a critical public health concern, and gaining a better understanding of possible causes is paramount. Recently, diet quality during pregnancy has emerged as a possible preventative measure in ameliorating postnatal depression, however the evidence-base exploring this association is immature. The aim of this study was to examine the association between consumption of food groups characteristic of a quality diet during pregnancy (that is fruit, vegetable and fish intake) and postnatal depressive symptoms at 12 months postpartum. Pregnant women were recruited at 10-18 weeks gestation via advertising on online pregnancy forums, pregnancy and parenting magazines, and two Australian maternity clinics. Participants (n = 253) completed self-report questionnaires assessing fruit, vegetable and fish intake as well as depressive symptoms at early- to mid- pregnancy. Path analyses were conducted to examine whether fruit, vegetable and fish intake during pregnancy were associated with depressive symptom scores at 12 months postpartum. There were no associations between fruit, vegetable or fish intake in pregnancy and postnatal depressive symptoms. Antenatal diet quality as measured by intake of food groups associated with a healthy diet was not associated with postpartum depressive symptoms at 12 months postpartum. Future research should consider the exploration of dietary quality as a measure of overall adherence to evidence-based dietary guidelines.

Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries

BACKGROUND

Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence.

METHODS

We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence.

FINDINGS

291 studies of 296284 women from 56 countries were identified. The global pooled prevalence of PPD was 17.7% (95% confidence interval: 16.6-18.8%), with significant heterogeneity across nations (Q = 16,823, p = 0.000, I2 = 98%), ranging from 3% (2-5%) in Singapore to 38% (35-41%) in Chile. Nations with significantly higher rates of income inequality (R2 = 41%), maternal mortality (R2 = 19%), infant mortality (R2 = 16%), or women of childbearing age working ≥40 h a week (R2 = 31%) have higher rates of PPD. Together, these factors explain 73% of the national variation in PPD prevalence.

INTERPRETATION

The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

Psychometric properties of the Prenatal Health Behavior Scale in mid- and late pregnancy

INTRODUCTION

Psychometrically sound self-report measures are important tools to advance research on health behaviors in pregnancy. The Prenatal Health Behavior Scale (PHBS) has been used in prior studies to quantify health behaviors and examine their associations with relevant variables, but its psychometric properties have not been carefully investigated.

METHODS

In a sample of low-risk women, we examined the factor structure, reliability, and validity of the PHBS at mid- (N = 138) and late (N = 102) pregnancy.

RESULTS

In confirmatory factor analysis, items on the PHBS loaded onto a single reliable factor, but separating health-promoting and health-impairing behavior into two factors had better model fit. The scales defined by these two factors had good internal consistency in mid- and late pregnancy, were only moderately correlated, and were predicted by somewhat different sets of sociodemographic and psychological variables. Pregnancy-specific stress was a robust predictor of health-promoting and health-impairing behavior across time.

DISCUSSION

Results bolster confidence in the reliability and validity of the PHBS and its appropriateness as a self-report tool for investigation of health behaviors among pregnant women. This study is one of the first investigations to examine patterns and predictors of health behavior practices at two time periods of pregnancy.

Risk factors for postpartum depression among Chinese women: path model analysis

Background

Postpartum depression causes harm to both mothers and infants. The purpose of this study was to find out several potential risk factors, and to identify the intrinsic interrelationships between factors and postpartum depression by constructing a path model. The results of this study may help to control the increasing incidence of maternal postpartum depression.

Methods

The study was based on a sample of mothers from a cross-sectional study which was set up at 4 weeks after a mother had childbirth and was conducted in three streets at Kaifu District of Changsha in Hunan province from January to December 2015. Questionnaires were distributed to subjects who responded to questions concerning factors related to pregnancy, delivery and infants within 4 weeks after childbirth. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure postpartum depression. Chi-square test was used to detect significant differences between non-postpartum depression group and postpartum depression group. A path model was constructed to explore the interrelationships between variables, and to verify the relationships between variables and postpartum depression.

Results

The proportion of maternal postpartum depression was 6.7%. Univariate analysis showed that there were significant differences between non-postpartum depression group and postpartum depression group (all P-values <0.05) on the part of maternal age, parity, frequent exposure to mobile phone during pregnancy, gestational hypertensive disorders, fetus number, premature delivery, birth weight, initiation of breastfeeding, mode of feeding, infant illness within 4 weeks after delivery and infant weight at 4 weeks. Path analysis results showed that the final model could be fitted well with sample data (P = 0.687, CMIN/DF = 0.824, NFI = 0.992, RFI = 0.982, IFI = 1.002, TLI =1.004, CFI = 1.000 and RMSEA < 0.001). Frequent exposure to mobile phone during pregnancy, maternal age and gestational hypertensive disorders had both direct and indirect effects on postpartum depression. Mode of feeding and infant weight at 4 weeks, which was the most total effect on postpartum depression, had only a direct impact on postpartum depression. Fetus number, premature delivery, initiation of breastfeeding and birth weight had only an indirect influence on postpartum depression.

Conclusion

The findings of this study suggest that constructing a path analysis model could identify potential factors and explore the potential interrelations between factors and postpartum depression. It is an effective way to prevent maternal postpartum depression by taking appropriate intervention measures and carrying out health education for pregnant women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1320-x) contains supplementary material, which is available to authorized users.

Breastfeeding and postpartum depression: Assessing the influence of breastfeeding intention and other risk factors

BACKGROUND

Risk and protective factors for postpartum depression have been extensively studied, and in recent studies an association between breastfeeding and maternal mood has been reported. The present retrospective, cross-sectional study was conducted to evaluate the association between breastfeeding-related variables and postpartum depression (based on Edinburgh Postnatal Depression Scale threshold criteria) within the context of other known risk factors.

METHOD

Breastfeeding information, demographic information, and scores on the Edinburgh Postnatal Depression Scale were examined from the Canadian Maternity Experience Survey. This survey contains data collected from 6421 Canadian mothers between October 2006 and January 2007, and 2848 women between five and seven months postpartum were included in the current analyses.

RESULTS

In contrast to previous research, logistic regression analyses revealed that when considered within the context of other risk factors, breastfeeding attempt and duration were not associated with postpartum depression at five to seven months postpartum. Although a relationship between the prenatal intention to combination feed and postpartum depression was observed, these variables were no longer related once other potential risk factors were controlled for. Factors that were associated with postpartum depression included lower income, higher perceived stress, lower perceived social support, no history of depression, or no recent history of abuse.

LIMITATIONS

A clinical diagnostic instrument was not used and variable selection was restricted to data collected as part of this survey.

CONCLUSION

These findings suggest that the association between breastfeeding and postpartum depression reported by previous researchers may in fact be due to alternative risk factors.

Racial/Ethnic Differences in Unintended Pregnancy: Evidence From a National Sample of U.S. Women

INTRODUCTION

Racial and ethnic minorities experience greater burden of unintended pregnancy in the U.S. This study examined the factors associated with racial and ethnic disparities in unintended pregnancy among women in the U.S. using the social ecological model.

METHODS

This study utilized the National Survey of Family Growth data from 2006 to 2010. Data were analyzed in Autumn 2014 and Winter 2015. Decomposition analyses examined which intrapersonal, interpersonal, institutional, community, and public policy factors explained racial and ethnic disparities in unintended pregnancy.

RESULTS

Unadjusted analyses found that black and Hispanic women had a greater likelihood of unintended pregnancy compared with white women. Decomposition models explained 51% of the disparity in unintended pregnancy between black and white women and 73% of that between Hispanic and white women. Factors contributing to the disparity between black and white women included age, relationship status, respondent's mother's age at first birth, Federal Poverty Level, and insurance status. Between Hispanic and white women, these factors included age, U.S.-born status, education, and relationship status.

CONCLUSIONS

Given that the results showed factors at different levels of the social ecological model contribute to racial and ethnic disparities in unintended pregnancy, interventions that aim to reduce these disparities should target at-risk groups of women such as younger, unmarried, lower-income, less-educated, non-U.S. born women and uninsured or publicly insured women.

Maternal Health Factors as Risks for Postnatal Depression: A Prospective Longitudinal Study

PURPOSE

While previous studies have identified a range of potential risk factors for postnatal depression (PND), none have examined a comprehensive set of risk factors at a population-level using data collected prospectively. The aim of this study was to explore the relationship between a range of factors and PND and to construct a model of the predictors of PND.

METHODS

Data came from 5219 women who completed Survey 5 of the Australian Longitudinal Study on Women's Health in 2009 and reported giving birth to a child.

RESULTS

Over 15% of women reported experiencing PND with at least one of their children. The strongest positive associations were for postnatal anxiety (OR = 13.79,95%CI = 10.48,18.13) and antenatal depression (OR = 9.23,95%CI = 6.10,13.97). Positive associations were also found for history of depression and PND, low SF-36 Mental Health Index, emotional distress during labour, and breastfeeding for less than six months.

CONCLUSIONS

Results indicate that understanding a woman's mental health history plays an important role in the detection of those who are most vulnerable to PND. Treatment and management of depression and anxiety earlier in life and during pregnancy may have a positive impact on the incidence of PND.

The Relationship Between Postpartum Depression and Perinatal Cigarette Smoking: An Analysis of PRAMS Data

INTRODUCTION

This study examines the relationship between postpartum depression (PPD) and cigarette smoking from prior to pregnancy to postpartum.

METHODS

The study sample consisted of 29,654 U.S. women who reported smoking in the 3months prior to pregnancy and for whom data on PPD were available from the Pregnancy Risk Assessment Monitoring System (PRAMS). Two sets of analyses were conducted. The first compared smoking at 2 time points (prior to pregnancy and postpartum) and the second at 3 time points (prior to pregnancy, during pregnancy, and postpartum). PPD was defined as responses of "often" or "always" to 2 questions: "Since your baby was born, how often have you felt down, depressed, or sad?" and "Since your new baby was born, how often have you had little interest or little pleasure in doing things?"

RESULTS

Overall, 22% of the sample endorsed PPD symptoms. In the 2 time-point analysis, controlling for known confounders, participants whose smoking was reduced or unchanged postpartum were about 30% more likely to have PPD compared to those who quit (OR: 1.34; 95% CI=1.10-1.60, p=0.001; OR:1.32; 95% CI: 1.10-1.50, p<0.001 respectively). Participants who increased smoking postpartum were 80% more likely to have PPD compared those who quit (OR: 1.80; 95% CI: 1.50-2.30, p<0.001). In the 3 time-point analysis, participants who continued smoking at any level during pregnancy and postpartum had 1.48 times the odds of reporting PPD (95% CI: 1.26, 1.73) compared to those who quit during pregnancy and remained quit postpartum. Participants who quit during pregnancy but resumed postpartum had 1.28 times the odds of reporting PPD (95% CI: 1.06, 1.53) compared to those who quit during pregnancy and remained quit postpartum.

CONCLUSION

Results suggest an association among women who smoke cigarettes prior to pregnancy between PPD and continued smoking during pregnancy and postpartum.

Magnitude and risk factors for postpartum symptoms: a literature review

BACKGROUND

The prevalence of postpartum depression worldwide varies from 0.5% to 60.8% in the first 12 months postpartum using self-reported questionnaire. This review aims to update the current magnitude of postpartum depression based on self-reported questionnaire and clinical interview and explore its associated factors in developed and developing countries.

METHODS

A literature search conducted between 2005 and 2014 identified 203 studies, of which 191 used self-reported questionnaire in 42 countries and 21 used structured clinical interview in 15 countries. Nine studies used a combination of self-reported questionnaire and clinical interview.

RESULT

The prevalence of postpartum depression varies from 1.9% to 82.1% in developing countries and from 5.2% to 74.0% in developed countries using self-reported questionnaire. Structured clinical interview shows a much lower prevalence range from 0.1% in Finland to 26.3% in India. Antenatal depression and anxiety, previous psychiatric illness, poor marital relationship, stressful life events, negative attitude towards pregnancy, and lack of social support are significant contributors to postpartum depression.

LIMITATION

All studies are included irrespective of the methodological quality, such as small sample size and their inclusion could affect the generalizability of the results.

CONCLUSION

The current prevalence of postpartum depression is much higher than that previously reported, and similar risk factors are documented. A culturally sensitive cut-off score with adequate psychometric properties of the screening instruments should be available. In future studies, examining the physical, biological, and cultural factors in qualitative studies and in those with adequate methodological qualities is recommended.

Unintended pregnancy and postpartum depression among first-time mothers

BACKGROUND

Postpartum depression is a mental disorder that occurs after birth and has negative consequences for the mother, infant, and family. The objective of this secondary analysis was to examine whether pregnancy intention was associated with postpartum depression among first-time mothers.

METHODS

The First Baby Study is a prospective cohort study of women aged 18-35 having a first singleton birth in Pennsylvania. Baseline data were collected during the third trimester. Postpartum depressive symptoms were measured at 1-month postpartum using the Edinburgh Postnatal Depression Scale. Logistic regression was performed to examine the association between unintended pregnancy and postpartum depression, controlling for prepregnancy anxiety/depression and sociodemographic data.

RESULTS

Of 2972 first-time mothers, 83.4% were white, 70.7% were married, and 56.9% were college educated. Nine hundred fifty-two women (32.0%) reported their pregnancy was unintended and 151 (5.1%) met the threshold for postpartum depression. The prevalence of postpartum depression was higher in women with unintended pregnancies compared to women with intended pregnancies (6.7% vs. 4.3%, p<0.01). However, after controlling for confounders, unintended pregnancy was no longer associated with postpartum depression (adjusted OR 1.41; 95% CI 0.91-2.18). Variables independently associated with postpartum depression included prepregnancy anxiety/depression, Asian race, and Hispanic ethnicity.

CONCLUSION

Pregnancy intention was not independently associated with postpartum depression among first time mothers in Pennsylvania.