A Systematic Review and Meta-Analysis of Depression in Postnatal Women in the Case of a Low-Income Country; Ethiopia, 2020

Abstract

Background

Maternal mental health in the postpartum period is essential for the optimal development of the newborn and appropriate breastfeeding practices. Despite this, a shortage of concrete evidence exists regarding the magnitude of postpartum depression and associated factors. This meta-analysis study was therefore done to fill such a gap.

Methods

PubMed, Scopus, and EMBASE were investigated with no time limitation. A manual search for a reference list of articles was also done. Relevant data were extracted using Meta XL package and analysis was done Stata-11 meta-prop package. Heterogeneity was checked with Cochran's Q-statistics and the Higgs I² test. Furthermore, sub-group and sensitivity analyses were done. Egger's test and funnel plots tests were engaged to identify publication bias.

Results

A total of 16 studies that assessed 11400 postpartum women in Ethiopia were included. The average estimated prevalence of postpartum depression was 21.9% (95% CI: 18.98, 24.77). The pooled prevalence of postpartum depression was higher in studies that used SRQ-20; 24.6% (95% CI: 18.42, 30.84) than studies that used PHQ-9; 18.9% (95% CI: 11.52, 26.28). Moreover, the pooled estimated prevalence of postpartum depression was slightly higher in the southern part of Ethiopia (22.6%) than Addis Ababa (21.2%). Poor marital relation (pooled aOR = 3.56) (95% CI: 2.50, 4.63), unplanned pregnancy (pooled aOR = 3.48) (95% CI: 2.18, 4.79), previous history of depression (pooled aOR = 4.33) (95% CI: 2.26, 6.59), poor social support (pooled aOR = 4.5) (95% CI: 3.34, 5.56), domestic violence (pooled aOR = 3.77) (95% CI: 2.62, 4.92), family history of mental illness (pooled aOR = 4) (95% CI:1.56, 6.56), use of substance (pooled aOR = 4.67) (95% CI:4.00, 5.34), low income (pooled aOR = 2.87) (95% CI: 1.59, 4.14), stressful life event (pooled aOR = 3.5) (95% CI: 1.39, 5.87) and perinatal complications (pooled aOR = 3.8)( 95% CI: 1.45, 6.15) were among the associated factors for postpartum depression in Ethiopia.

Conclusion

More than one in five women was with postpartum depression and factors such as poor marital relations, history of depression, poor social support, domestic violence, unplanned pregnancy, family history of mental illness were related to it. Therefore, maternal postnatal care services should be geared to incorporate this public essential health concern.

Plain English Summary

To date evidences showed that 10–20% of postpartum women develop depressive disorders worldwide and this is much higher in low income countries like Ethiopia. Therefore it is essential to have a pooled estimated data regarding depressive symptoms and related factors in postnatal women so that initiation of early intervention would be implemented. In this meta-analysis study we incorporated 16 studies that assessed 11400 postnatal women which were obtained from a detailed search of pub-med, Scopus and EMBASE databases.

From the sixteen studies data was extracted using a meta-XL package and main meta-analysis was done with STATA-11 meta-prop-package. Since Higgs I² statistics was suggestive of heterogeneity between included studies, further sub-group and sensitivity analysis was done.

The pooled estimated prevalence of depression among postnatal women was high; slightly higher than 1 in 5 women in Ethiopia were with postpartum depression. This pooled estimated prevalence was higher in studies assessed with SRQ-20 than those assessed with PHQ-9. Besides, postpartum depression was higher in the southern region of the country than Addis Ababa.

We also established that poor marital relation, unplanned pregnancy, previous history of depression, poor social support and domestic violence were among the top contributing factors for depression in postnatal women in Ethiopia. Therefore, postnatal maternal care services should integrate depression in postpartum period and also it’s associated factors.

Background

Women with depression in the postpartum period show manifestations like sleep disturbance, change in appetite patterns, feeling of sadness, recurrent guilty feeling, crying, low energy, and unease feelings of anxiety and suicidal ideas(1). Nowadays postpartum depression is increasingly taking a lion share in the burden of disease among women of 15 to 49 years of age (2). Globally,10–20% of postnatal women develops depression at a point in time (3). A survey by the World Health Organization(WHO) identified that 20–40% of childbearing age women in the developing world sustained depression in the antepartum and postpartum period at a given time (4). Besides, 19% of postnatal women in low and middle-income countries(5, 6) and one among twenty postnatal women in Ethiopia (7) develops postpartum depression.

Different studies across the world reported different prevalence rates for postpartum depression.

A systematic review and meta-analysis study in 2018 by S Shorey et al.2018 (8) reported the worldwide estimated prevalence of postpartum depression to be 17%. Besides, a study including low and middle-income countries and assessed 34 studies reported that 19.8% of postpartum women have a 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. Another systematic review and meta-analysis study in India which assessed 38 studies reported a pooled prevalence of postpartum depression to be 22%(10). Moreover, other individual studies reported earlier showed that postpartum depression was 17.6% in Portugal (11), 27.3% in China(12), 61.4% in Korea(13), 18.6% in Qatar(14), 34.8% in Iraq(15), 34% in Jamaica(16) ,15.4% in Turkey (17), 13.5% and 10.3% in Oman(18), 31.7% in South Africa(19), and 43% in Uganda(20).In Ethiopia, the prevalence of postpartum depression varies between 12.2–33.8% (21–36).

Poor social support(37), poverty(38), and childbirth without the presence of relatives(39), history of depression (40), and poor woman autonomy (41) from socio-demographic variables, multi-parity (42), prime-parity (43, 44), multiple children at home (45), negative attitude toward to one’s pregnancy (22, 46–49), depression during pregnancy(42, 50), premarital pregnancy(51, 52), miscarriage(53), and prenatal high anxiety(47) from pregnancy and newborn related factors, alcohol use in the husband(54), intimate partner violence (22, 55, 56), poor husbands education (45),

husbands unemployment (46, 57), and psychiatric problems in the husband (58) among husband related factors were among the associated factors for the development of postpartum depression. In the context of Ethiopia too, 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), and family history of mental illness (24, 28, 31) were among the documented factors responsible for the development of postpartum depression (PPD).

Postpartum depression in women has a great impact on the health of both the mother and her baby. Early discontinuation of breastfeeding (60), negative emotion and poor health care utilization (61), cognitive impairment, and behavioral defects (62), poor mother-infant bonding resulting in rejection of the infant (63), and suicidal behaviors (64) are common complications of postpartum depression. Furthermore, a community-based cross-sectional study in Ethiopia(23) revealed that maternal postnatal depression strongly affects a child's nutritional status leading to stunting and underweight as well as inappropriate complementary feeding practices of infants.

Even though maternal mental health problems in the postpartum period are much more prominent in poorly developed nations including Ethiopia, there still exists a gap in the pooled magnitude of postpartum depression and the associated factors. The objective of the present meta-analysis was, therefore (1): To determine the pooled estimated prevalence of postpartum depression among women in the postnatal period in Ethiopia and (2): To determine the pooled odds ratio of the associated factors for postpartum depression in Ethiopia.

Methods

Results

Discussion

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.

Strengths And Limitations

To start with the strength, this study utilized a prespecified search strategy through the mentioned libraries that are intended to reduce the assessor's bias. The subsequent strength was that the independent extraction of data and quality assessment of the included studies by two autonomous reviewers also lessen the reviewer's bias. Furthermore, the employment of subgroup analysis and sensitivity analysis to distinguish the foundation of heterogeneity was also strength. On the opposing side, the limits of this meta-analysis study emanate from the presence of a high difference between the included studies that might upset the deduction of the study results. Besides, the use of two or three studies in the sub-group analysis might diminish the soundness of estimate.

Conclusion

This review and meta-analysis study obtained a high pooled estimated prevalence of postpartum depression (21.9%) suggesting that more than one in five women were having postpartum depression. The pooled estimate of postpartum depression was higher in studies that used SRQ-20 (24.6%) than studies that used PHQ-9 (18.9%. Moreover, the pooled prevalence of postpartum depression was slightly higher in the southern part of Ethiopia (22.6%) than Addis Ababa (21.2%). However, no significant difference in pooled prevalence was noticed across study settings (community versus Institutional). Poor marital relations, unplanned pregnancy, previous history of depression, poor social support, domestic violence, family history of mental illness, use of the substance, low income, stressful life event, and perinatal complications were among the associated factors for postpartum depression. Therefore, postnatal antenatal care services should integrate this significant mental health problem of women and its associated factors basically by delivering integrated postnatal care services for women.

Abbreviations

Declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of Data and Materials

All relevant data concerning this systematic review and meta-analysis study is incorporated in the manuscript.

Competing Interests

We authors have no competing interests for this meta-analysis study.

Funding

The cost afforded for this research work was covered by the authors themselves.

Authors' Contributions

MN premeditated the review idea on the prevalence and associated factors of postpartum depression in Ethiopia and defined the search strategies and manages the analysis of the research. MN and MA extracted the relevant data from included articles. Both authors participated in the quality assessment of included studies. MN writes the manuscript first draft and both of the authors revised and approved the final version of the manuscript.

Acknowledgment

We acknowledge the authors of included studies for their original contribution.

Authors Information

Mogesie Necho, Lecturer at Wollo University, College of Medicine and Health Sciences, Dessie, Ethiopia; Email: [email protected]
Merid Abadisharew, Lecturer at Wollo University, College of social science and humanities, Department of sociology, Ethiopia; Email:[email protected]

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