Postpartum depression affects 17.22% of the global population(20). Moreover, PPD is becoming more widely acknowledged as a global public health problem that may have far-reaching effects on a person's life, including effects on job, family, and the child. Despite the impact of PPD, only two studies were conducted in West Bank in the previous ten years.
Our study showed that prevalence of postpartum depression (women who scored 13 and more in the EPDS) was much higher than studies that used the EPDS in Nablus and Bethlehem which reported 17% an overall prevalence of PPD ( 8.9% scored 13 and more, 8.1% scored 10–12 on EPDS), 27.7% (score of 11 and more on the EPDS) respectively (10, 9). The rise is is not surprising and may be explained by the continued pressures Palestinians experience due to the restrictions and uncertainties imposed by being an occupied nation. Since the elected Palestinian government was politically and economically boycotted, living circumstances have become worse, leading to increased levels of unemployment, poverty, and internal conflict in Palestine as well as more limitations on access to healthcare (21, 18). These stressors result in mental instability and increase susceptibility to mental illnesses including PPD (1).
The increased prevalence of PPD in Palestine is similar to nearby Arab countries(20). Surprisingly, Palestine’s prevalence of 33.9% is reasonable in comparison to what is published in nearby Arab region; recent systematic review study was held in the Arab region, 2020 and showed 8–40% range of PPD in Arab countries (11). Another meta-analysis across the Middle East countries reported 27% prevalence (22). In Saudi Arabia prevalence of PPD increased from 25.7% in 2017 to 38.5% in 2020 (23, 3). Another study in Damascus, 2017 reported a prevalence of 28.2% (EDPS score 13 and more) (24). Higher prevalence was seen in Jordan; an article was published in 2021 and reported 52.9% prevalence between Jordanian women (EDPS score 12 and more) (25). The global rise of PPD prevalence could be explained by the continuing COVID pandemic impact on health sectors both physically and mentally. Recent studies on the effect of the COVID-19 pandemic on PPD revealed increased levels of post-partum depression caused by increased fear (26, 27).
While reviewing the literature, we found variations in risk factors for PPD.Our study adds lack of social support, the husband’s low level of education, the occurrence of stressful events while pregnant and the use of vacuum as significant risk factors related to PPD. Our first two risk factors were also found in the Middle-East systematic review and meta-analysis (22). However, stressful events in pregnancy or vacuum are new findings.
Vacuum extraction is reported by mothers as a negative experience which indirectly increases the risk of PPD due to trauma to birth canal, post-delivery complications, increased pain and delay of return to normal activities (28). All of this explains the significant association between vacuum and PPD which was reported in our study.
Another negative experience that showed significant association with PPD was stressful events during pregnancy, these includes mother argued with partner more than usual, separation, divorce, mother was in a physical fight, moved to new address, had a lot of unpaid bills, job loss, and close family member sick or died (29). Several studies showed that stress increases amygdala activity which leads to mood changes and increasing probability of depression (30).
This study showed a significant association between low maternal social support and PPD; a new baby comes with many more duties and requirements, but assistance and support help mothers to cope faster (31). Significant association between social support and PPD was also found in studies in nearby Arab countries with the same cultural and religious characteristics of Palestine (32).
Our significant negative association between higher levels of the husband’s education and PPD was also found in other studies across the world, India and East Turkey as an example (33, 34). This can be contributed to the increased knowledge of women’s needs and the ability to provide good strategies of support. Here in Palestine, in order to provide acceptable living conditions, husbands with low educational level spend long working hours away from their wives limiting their ability to provide the needed support.