To date, this review and meta-analysis on depression and the related factors in women in the postnatal period are the first of its kind in the context of Ethiopia. Therefore, the pooled effect size of postpartum depression and related factors would add a body for the scientific community and other diverse stakeholders who are intended to intervene in this significant public health issue. We gathered data from a total of 11400 postpartum women and a total of sixteen studies from both institutional and community settings and the estimated pooled prevalence of postpartum depression were 21.9% (95% CI: 18.98, 24.77).
The result of the pooled estimated prevalence of postpartum depression in this study (21.9%) was in line with a systematic review and meta-analysis of depression in the postpartum period in India (22%) which analyzed 38 studies and 20043 women(10). It was also consistent with the result of a systematic review and meta-analysis study in women from low and middle-income countries which assessed 34 studies and 19.8% were having a postpartum common mental disorder(9). Furthermore, another study that incorporated 38412 women and 23 studies in low and middle-income countries (6) reported 19.2% of women as having postpartum depression which was also supportive of the current finding.
However, the result of the pooled estimated prevalence of postpartum depression in Ethiopia exceeds the worldwide estimated prevalence of postpartum depression; 17% reported in 2018 by S Shorey et al.2018 (8). The possible reason for the higher estimated prevalence in the earlier study as compared to our study could be due to the inclusion of a larger number of studies and participants in the included studies in the analysis (26 cross-sectional, 30 prospective cohort and 2 case-control studies with an overall of 58 studies and 37294 participants) but only 16 studies in our study. Moreover, women in the previous study were healthy subjects having no history of depression previously but our study found that a previous history of depression was among the factors responsible for the increased prevalence of postpartum depression. Moreover, our study was higher than the result of a systematic review and meta-analysis study in 11 high-income countries reported in 2005 in which the pooled estimated prevalence of postpartum depression was 12.9%(72).
Possible grounds for the difference could be due to a long time gap between the previous study and the present study. The difference in the time point for the assessment of postpartum depression could also bring the difference. The previous study includes studies that screened PPD only in the three months of the postpartum period but in the present study assessment period was far beyond this. Moreover, a socio-economic and cultural difference between high-income study subjects of the earlier study and low-income study subjects of the present study could happen and sources the variation.
Contrary to the subgroup analysis result of a worldwide meta-analysis study (8) that obtained that the pooled estimated prevalence of postpartum depression to be similar across the different measurement tools for PPD, the present study revealed that pooled prevalence of postpartum depression was higher in studies as measured with SRQ-20 (24.6%%) (95% CI: 18.42, 30.84) than the result with PHQ-9 (18.9%) (95% CI: 11.52, 26.28). This could be because most studies that utilized SRQ-20 delineated a lower cut off point (SRQ-20 score ≥ 6) which might result in overestimation of postpartum depression.
In line with the result of an earlier meta-analysis study (8), the pooled estimated size of postpartum depression showed a geographical difference. The pooled estimated post-partum depression was slightly higher in studies from the southern part of Ethiopia (22.6%) than the central region (Addis Ababa) (21.2%) which could be due to the relatively improved socio-economic and cultural advances in the central region of Ethiopia. This was however in contrary to the result of a meta-analysis in India(10).
However, no significant variation in the magnitude of PPD was noticed between the community and institutional settings of the studies. This was consistent with a review and meta-analysis study in India(10) in which little but insignificant variation was observed across the community and institutional setting studies.
Regarding the associated factors of postpartum depression, fourteen studies (21, 22, 24, 26–35, 59) had reported different factors and poor marital relation (27, 29, 32, 34, 35, 59), unplanned pregnancy (21, 22, 24, 27, 29, 32, 34), previous history of depression (21, 27, 28, 34), domestic violence (21, 22, 27, 34), poor social support (21, 32–35), family history of mental illness (24, 28, 31), use of substance (21, 27, 34) and low income (27, 28, 59) were among the most commonly reported factors.
The pooled odds ratio of the poor marital relationship among the above-mentioned studies was 3.56 that implies women with poor marital relationships were 3.56 times at higher risk of developing PPD than women who good marital relationships. A meta-analysis study in India has a similar conclusion supporting this(10). The possible reason for this could be poor marital relationship increasing the burden of psycho-social responsibility of child care and other household responsibility in the postpartum period as compared to the shared psychosocial responsibility in women which good marital relation.
Besides, the pooled odds ratio for unplanned pregnancy for the nine studies reported above was found to be 3.48. This showed that women who gave birth from an unplanned pregnancy were 3.5 times more likely to be depressed than women with a planned pregnancy. A consistent finding was reported in studies in turkey (17), Qatar (14), northwestern Brazil (73), and Iran (74). The possible reason for this could be the absence of psychological readiness in mothers with unplanned pregnancy predisposing them to be vulnerable to physiological, psycho-social challenges of pregnancy and the postpartum period.
The previous history of depression (21, 27, 28, 34) and stressful life events (22, 59) was also an associated factor for the development of PPD with a pooled estimate odds ratio of 4.33 and 3.5 respectively. A consistent finding was observed in an Indian meta-analysis study(10). Furthermore, other several studies (6, 75, 76) reported that the presence of depression during pregnancy, facing stressful life events during pregnancy, and prior history of depression as related to postpartum depression which was also in line with the current study.
Besides domestic violence was also having a significant association with the development of PPD with the estimated pooled odds ratio of 3.77 (21, 22, 27, 34). A report by world health organization in 2013 (77) suggested a similar conclusion in that intimate partner violence in women predisposes to various mental health problems in the postpartum period.
Poor social support with a pooled odds ratio of 4.5 (21, 32–35) also increases the vulnerability of postpartum depression. This was also supporting the findings of the Indian review study(10). Multiple earlier studies also reported that good interpersonal relationships across the social support networks increase flexibility to stress and subsidize enormously women from developing postpartum depression (78–81) hence decreasing the risk of Postpartum depression. A study in Ghana on interventions for women with postpartum depression revealed that psychosocial support interventions are the most effective treatments implying an underling psychosocial deficit in this target population(82).
Furthermore, the pooled odds ratio of family history of mental illness (24, 28, 31), use of a substance (21, 27, 34) and low income (27, 28, 59) and perinatal complications (28, 59) was 4, 4.67, 2.87, 3.5 and 3.8 respectively. A systematic review and meta-analysis study in which 17 articles were reviewed and postpartum depression between 3 and 52 weeks postpartum periods were assessed (83) reported that substance use as a contributing factor for postpartum depression in line with the current study.