Introduction

Depression is a widespread mental health disorder characterized by persistent low mood, concentration difficulties, low self-esteem, changes in appetite and sleep patterns, loss of interest in activities, significant weight fluctuations, feelings of hopelessness, and recurrent thoughts of death. It is one of the top five contributors to the global disease burden [1]. Projections indicate that by 2030, depressive disorders will be among the three leading causes of the global health burden [2].

In 2015, the World Health Organization (WHO) reported that 322 million people were affected by depressive disorders globally, with 27% from the Southeast Asian region [1]. The risk of mental disorders, especially depression, is higher in women than in men [3]. During pregnancy, this risk further increases due to certain hormonal changes in the body [4]. The global prevalence of antenatal depression varies widely, ranging from 15% to 65% [5]. In high-income countries, the prevalence ranges between 5% to 30% [6–8], while in low-income countries, it ranges from 15.6% to 31.1% [9–11]. Among South Asian women, 17.5% suffer from antenatal depression [12]. A recent study found a 78.5% prevalence among Afghan pregnant women aged 15–45 years, with associated factors including 30–45 years of age, unemployment, low socioeconomic condition, no traumatic incidence in the previous month, and last week’s sex deprivation [13].

The prevalence of prenatal depression in Bangladesh ranges from 18% to 33% [14,15], making it a significant public health concern. A recent study conducted in a rural sub-district in Matlab, Bangladesh, reported a 33% prevalence of depression among women in their 34^th to 35^th week of gestation. Associated factors included lack of support from husband or mother-in-law, domestic violence, and family pressure to give birth to a male child [14]. Similarly, a cross-sectional study in rural Sylhet identified husbands’ preferences for male babies, low family support, and sexual violence as major contributors to antenatal depression [16].

Prenatal depression can have severe consequences, affecting both mothers and newborns. Depressed pregnant women may produce elevated levels of cortisol, a hormone that can negatively impact fetal growth and brain development [17]. Additionally, women experiencing prenatal depression face a higher risk of developing hyperemesis gravidarum, which increases the likelihood of a miscarriage, low birth weight, and preterm birth [18]. They are also more prone to substance abuse, preeclampsia, hemorrhage, edema, postpartum depression, and severe headaches [19, 20]. Infants born to mothers with prenatal depression are at a greater risk of low birth weight (LBW), low mean APGAR scores at 1 and 5 minutes after birth, and even premature mortality [21,22].

Antenatal depression presents a significant challenge for expectant mothers and their babies, particularly in Bangladesh. While some studies examined prenatal depression in urban areas, research on rural populations remains limited. Furthermore, there is a lack of comprehensive data on depression and its effects across different trimesters in pregnancy in Bangladesh. In this study, we explored the prevalence of antenatal depression and factors associated with its development in rural Bangladesh. Findings from this study can play a pivotal role in formulating specific policies and interventions and organizing health promotional and educational programs aiming at raising awareness among rural communities, stakeholders, and policymakers to prevent prenatal depression.

Materials and methods

Result

Prevalence of depression among pregnant women

After calculating the total EPDS score, it was found that about 38.9% (95% CI = 33.9% to 44%) of women experienced depression during pregnancy Table 1.

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Table 1. Prevalence of antenatal depression among pregnant women attending antenatal checkups (n=350).

https://doi.org/10.1371/journal.pone.0321965.t001

Fig 1 presents that about 42.9% (150) of women had minimal or no depression (EPDS score 0–7), and 40.3% (141) had mild depression (EPDS score 7–13). Additionally, 12.2% (43) had an EPDS score between 14 and 19, indicating moderate depression, while 4.6% () scored over 19 signifying severe depression [28].

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Fig 1. Extent of depression among pregnant women.

https://doi.org/10.1371/journal.pone.0321965.g001

Factors associated with antenatal depression

Table 2 depicts that among the variables, gestational week (p= 0.026), the number of pregnancies (p=0.005), type of pregnancies (p= 0.002), relationship with husband (p= 0.017), and in-laws (p= 0.001), history of domestic (p=0.047) and sexual violence (p= 0.007), having multiple-married husbands (p= 0.002), and history of previous diseases (p= 0.007) were found statistically significant with a p-value <0.05 in the chi-square test.

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Table 2. Associated factors of antenatal depression (n=350).

https://doi.org/10.1371/journal.pone.0321965.t002

Table 3 presents that after multivariate analysis, 60% less likelihood of depression was observed in the second trimester (AOR = 0.4, 95% CI = 0.2, 0.8) compared to the first. Mothers who experienced intimate partner violence were more likely (AOR = 3.3, 95% CI = 1.1, 9.7) to develop antenatal depression than those who didn’t. The adjusted odds ratio was about two times higher in women having unwanted pregnancies (AOR = 1.8, 95% CI = 1, 3) and 2.4 times higher in those with a history of previous diseases (AOR = 2.4, 95% CI = 1.1, 5.2). Additionally, the odds of antenatal depression were more than thirteen times greater in women having multiple married husbands (AOR = 13.6, 95% CI = 1.1, 164).

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Table 3. Bivariate and multivariate associations of prenatal depression.

https://doi.org/10.1371/journal.pone.0321965.t003

Discussion

This study identifies the prevalence of antenatal depression and its associated factors, including sociodemographic, obstetric, psychosocial, psychological, and disease and treatment-related factors in rural Bangladesh. The findings reveal a 39% (38.9%, 95% CI = 33.9% to 44%) point prevalence of antenatal depression, with key contributing factors including experiences of sexual violence, unplanned pregnancy, being married to a polygamous husband, pre-existing diseases or health conditions (diabetes mellitus, hypertension, bronchial asthma, and thyroid disorders), and gestational age.

The prevalence observed in this study aligns with findings from other low (34.0%, 95% CI = 33.1% to 34.9%) and middle-income countries (22.7%, 95% CI = 20.1% to 25.2%) [29]. It is similar to the prevalence reported in Pakistan (32.2%, 95% CI = 23.11% to 42.87%) but lower than those in Nepal (50%, 95% CI = 35.64% to 64.36%) and Afghanistan (78.5%) [13, 30]. However, it is higher than that in India (17.74%, 95% CI = 11.19% to 26.96%), and Sri Lanka (12.95%, 95% CI = 8.29% to 19.68%) [30].

The results also correspond with previous research in Bangladesh by Gausia et al. (33%, 95% CI = 27.6% to 37.5%) (14) and Tasnim et al. (36.2% in patients with GDM) [31]. However, it is higher than the prevalence observed in the study by Nasreen et al. (18.3%, 95% CI = 15.9% to 20.7%) (15). A potential explanation for this discrepancy might be differences in the study period, sample size, and location. While this study was conducted in a southern subdistrict of Bangladesh, the study by Nasreen et al. was conducted more than a decade ago in Mymensingh, the north-central region of Bangladesh [15].

Violence remains a significant issue in Bangladesh, where a high proportion of women experience sexual violence [32]. Approximately 37% of urban women and half of rural women experience lifetime sexual violence [33]. Alarmingly, many women believe their husbands have the right to discipline them physically. This study identifies sexual violence as a major contributor to antenatal depression, consistent with research by Peltzer et al. in Thailand [34], Maria Atif et al. in Pakistan [35], and Insan et al. in Bangladesh [16].

Unplanned pregnancy is recognized as a significant factor contributing to antenatal depression among Indian women [36]. Studies by Surkan et al. in northwestern Bangladesh and Gausia et al. in eastern Bangladesh have found a significant association between unwanted pregnancies and antenatal depression, aligning with the findings of this study [14,37].

Among obstetric factors, gestational age is significantly associated with prenatal depression. This study reveals a 60% lower likelihood of depression during the second trimester compared to the first. A systematic review and meta-analysis by Okagbue et al. highlight that the prevalence tends to decrease between the 13^th and 28^th weeks of gestation [38], similar to our study. These findings reveal valuable information about the participants’ marital and reproductive histories, providing a comprehensive understanding of factors influencing antenatal depression in this population.

While some studies link inadequate family support and male-child preference to antenatal depression [14,16,39], our study finds no such associations. It suggests that, over time, families may have become more attentive and supportive of pregnant mothers. Additionally, the preference for male children appears less pronounced in present-day society. Notably, 82% of women report feeling no pressure to have a male child.

Apart from previous research, this study identifies significant associations between a pre-existing disease and depression during pregnancy. It highlights that having a polygamous husband is also associated with prenatal depression. While Nasreen et al. found a positive correlation between prior depression and prenatal depression [15], our findings show that not only previous mental health disorders but also other pre-existing medical conditions such as diabetes mellitus, hypertension, bronchial asthma, and thyroid disorders contribute to the development of antenatal depression.

With nearly two in five women in rural Bangladesh affected by antenatal depression, these findings underscore the urgent need to raise awareness among healthcare professionals and families to provide enhanced mental health support to pregnant women, particularly during the first and last trimesters of gestation. Targeted interventions should focus on reducing intimate partner violence, discouraging polygamy, and providing additional care for expectant mothers with pre-existing health conditions. Additional counseling for women with unplanned pregnancies is also crucial to improving maternal mental health.

Limitations

This study has certain limitations, primarily due to a small sample size resulting from time and resource constraints. Participants were recruited from selected government and private hospitals in a remote subdistrict in Bangladesh. However, it is vital to consider that a subset of women might not attend antenatal check-ups unless they experience severe health challenges. Therefore, the findings may not fully capture the diversity of the population, leaving a generalizability bias to the obtained results.

Conclusion

In conclusion, the prevalence and associated factors of antenatal depression in rural Bangladesh highlight a significant public health concern due to its adverse effects on both maternal and neonatal health. Antenatal depression remains a common issue in rural areas of Bangladesh. To effectively tackle this issue, the government, stakeholders, and policymakers should collaborate on organizing national programs and health education campaigns to raise community awareness. By addressing root causes and developing effective policies and interventions, we can work towards reducing the burden of antenatal depression and ensuring a more positive pregnancy experience for expectant mothers.

Supporting information

Acknowledgments

I am profoundly thankful to Almighty for the opportunity to pursue an MPH in Epidemiology. I am grateful to North South University for allowing me to conduct this research as part of the requirements for my MPH degree. My gratitude extends to Dr. S M Mashud, UH&FPO, Upazila Health Complex, Lohagara, Narail, for his kind guidance and support throughout the study.