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Epidemiology of postnatal depression and its associated factors in Africa: A systematic review and meta-analysis

  • Abel Fekadu Dadi,

    Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Writing – original draft, Writing – review & editing

    Affiliations Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia, College of Medicine and Public Health, Discipline of Public Health, Flinders University, Adelaide, Australia

  • Temesgen Yihunie Akalu ,

    Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

    temesgenyihunie@gmail.com

    Affiliation Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia

  • Adhanom Gebreegziabher Baraki,

    Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia

  • Haileab Fekadu Wolde

    Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine & Health Sciences, University of Gondar, Gondar, Ethiopia

Epidemiology of postnatal depression and its associated factors in Africa: A systematic review and meta-analysis

  • Abel Fekadu Dadi, 
  • Temesgen Yihunie Akalu, 
  • Adhanom Gebreegziabher Baraki, 
  • Haileab Fekadu Wolde
PLOS
x

Abstract

Introduction

Postnatal depression (PND) is a major cause of negative health-related behaviors and outcomes during infancy, childhood and adolescent period. In Africa, the burden of postnatal depression is high. However, it is under-investigated hence under-treated. To fill this information gap and to advise further interventions, we aimed at analyzing its epidemiology in Africa.

Methods

We searched observational studies conducted in Africa and published in between 01/01/2007 and 30/06/2018 in CINHAL, MEDLINE, PsycINFO, Psychiatry online, PubMed, SCOPES, and Emcare databases. We assessed the quality of the studies using the Newcastle Ottawa Scale (NOS) and included studies with good quality. We evaluated the heterogeneity using the Higgins I2 statistics. We used a random-effects model to pool estimates. We assessed publication bias using the funnel plot and Egger's test statistics and adjusted using Tweedie’s and Duval Trim and Fill analysis. The protocol has been registered in the PROSPERO (Protocol No. CRD42018100461).

Results

Nineteen studies involving 40,953 postnatal mothers were part of this systematic review and meta-analysis. The overall pooled prevalence of PND was 16.84% (95% CI: 14.49% –19.19%). The odds of having PND was higher among women with a poor obstetric condition (POR = 2.11; 95% CI: 1.11–4.01) and history of adverse birth and infant health outcomes (POR = 2.85; 95% CI: 1.29–6.25). Having a history of common mental health disorders (POR = 2.47; 95% CI: 1.51–4.04), poor social support (POR = 2.06; 95% CI: 1.05–4.05), lower economic status (POR = 2.38; 95% CI: 1.75–3.23), and those who had exposure to a different form of intimate partner violence (POR = 2.87; 95% CI: 1.60–5.16) had higher odds of PND.

Conclusion

While robust prevalence studies are scarce, our review indicated a high prevalence rate of postnatal depression. The analysis also identified postpartum women at increased risk of PND. Therefore, there is a need to design and escalate comprehensive strategies to decrease its burden, focusing on those women at risk of PND.

Background

Postnatal depression (PND) is a major depressive episode that occurs after 15 days following delivery and continues for one year [1, 2]. The burden of PND is a significant public health concern in low and middle-income countries [3]. According to the World Health Organization (WHO) 2017 report, more than 322 million people had depression, and of this, about 29.9 million (9%) were in Africa [4]. Globally, the prevalence of PND increased by 18.4% in the year from 2005 to 2015[5]. A PND prevalence of 19.8% was reported in a systematic review conducted in 17 low-and middle-income countries [6]. Africa constitutes a higher burden of PND while on average, one in every ten women had depression [7].

Postnatal depression increases maternal morbidity [8, 9], social problems [10], physical damage [11], and leads to suicide [12]. Similarly, there is a strong relationship between maternal wellbeing and child development [13]. Untreated PND leads to infant growth retardation [14, 15], poor child survival [16], impaired child development [17, 18], behavioral changes [19], repeated diarrheal disease [20], and under-nutrition [21, 22]. Likewise, PND can also affect postnatal mothers' quality of life [23]. In the low-and middle-income countries, about 80% of patients with psychological, neurological, and substance use conditions do not access services [24]. The World Health Organization (WHO) has launched the Mental Health Gap Action Program (mhGAP) that aimed at integrating mental health interventions with the existing maternal health services [7, 24].

The prevalence of PND can be affected by factors such as age [25], low household income [26], unwanted pregnancy [27, 28], having emesis during pregnancy [29], depression during the first two trimesters of pregnancy [27, 30, 31], psychiatric problems during pregnancy [32], delivery by cesarean section [33], lack of satisfaction in marital status [28, 31], co-morbid condition like anemia [34], gestational Diabetic Mellitus (DM) [27], social factors [25, 31], low self-esteem [35], prematurity [23], and behavioral factors such as smoking [36].

Despite its burden, depression during the postnatal period is still under-investigated and undertreated in Africa [37]. Reviews that have been conducted in low-and middle-income countries did not include representative studies from Africa, and they were also outdated. There is a systematic review conducted on perinatal psychological disorders in Africa that incorporated postnatal depression as one specific objective [38]. Therefore, we did the current systematic review and meta-analysis to present the pooled estimate and risk factors of PND in Africa precisely.

Methods

Data source and searches

We systematically searched for articles conducted in CINHAL, MEDLINE, PsycINFO, psychiatry online, PubMed, SCOPES, and Emcare databases. The following search terms combined with Boolean operators, wildcard and truncation were used: “postpartum women”, “lactating women”, “postnatal mothers”, “major depression”, “psychological morbidity”, “depressive symptoms”, “major depressive disorder”, “depressed mood”, “clinical depression”, and “depression”. Example of the search strategy in MEDLINE:

(exp POSTPARTUM DEPRESSION/) or (Depress*.tw,id.) AND (postnat* or postnatal wom?n or postpartum wom?n).tw,id.) [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]) AND ((exp Psychosocial Factors/ or exp Risk Factors/) or (risk*.tw,id.)) AND ((prospective cohort* or retrospective cohort* follow up* or longitudinal* or cross-sectional* or case-control* or nested-case control).mp.): all Sort by: PublicationDateFilters: Publication date from 2007/01/01 to 2017/12/31; Humans; English; Female; Field: Title/Abstract

Included studies.

We included all observational studies conducted in Africa, written in the English language, conducted from January 1, 2007, to May 30, 2018, and investigated postnatal depression and/or its associated factors. Studies were included in the current review if they used a standardized and validated tool to diagnose depression and diagnosed depression in the first two years of childbirth.

Excluded studies.

This review excluded studies with poor quality and those conducted in a high-risk population (HIV).

Study selection

The title of all retrieved articles was screened, and those fit were imported to endnote software. The primary author did literature searching, title review, and duplicate removal. After excluding duplicated articles, abstracts and their full-text were independently reviewed by two groups of authors: group one (TYA, AFD) and group two (AGB, HFW). Differences were resolved through discussion. Articles deemed relevant during the abstract and full- text review were assessed for quality assessment.

Data extraction and quality assessment

The quality of included studies was assessed using the Newcastle Ottawa Scale (NOS) by two independent reviewers (TYA and AFD), and the third reviewer (HFW) was a tie break in case of discordance between the two reviewers. Articles that scored ≥7 points were considered as “good” quality and were included in the final review and meta-analysis [39]. Name of author, year of publication, country, study setting, study design, sample size, time of screening, tools used for screening depression, and estimates (prevalence, associated factors with their adjusted odds ratio and 95% confidence interval) information were abstracted and presented in a table.

Data synthesis and analysis

Data abstraction was done using a Microsoft Excel spreadsheet and was exported to Stata 14 for analysis. The prevalence of PND and odds ratios of risk factors obtained from each study were pooled after transforming the original estimates. Sub-group analysis was conducted based on the type of tool used for screening depression [40], geographical location, the income of countries, time of depression measurement, study setting, sample size, and year of publication. The magnitude of heterogeneity among included studies was quantitatively measured by I2 and Higgins test (p-value <0.05). Sensitivity analysis was performed for checking the presence of an influential study. Publication bias was checked using a visual inspection of the funnel plot and Egger’s regression test (P-value < 0.05). In the case of publication bias, Duval and Tweedie’s Trim and Fill analysis in the random effect model was performed as an adjustment [41]. Finally, results were presented using tables and forest plots.

Protocol registration

The protocol for this systematic review and meta-analysis has been registered in the PROSPERO (Protocol No. CRD42018100461).

Data reporting

The PRISMA [42] statement for reporting a systematic review and meta-analysis was used to present the study inclusion, exclusion, and reasons for exclusion in a diagram (Fig 1). Finally, the reporting of this systematic review and meta-analysis result followed the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statement[43].

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Fig 1. PRISMA flow diagram indicating the study selection for inclusion in the systematic review.

https://doi.org/10.1371/journal.pone.0231940.g001

Results

Description of studies

The electronic database search retrieved 965 records and 104 records were duplicates. The titles and abstracts of 861 articles were assessed, and 823 articles were removed. Full text of 38 articles was evaluated, and 18 articles were excluded. The reason for exclusion includes: conducted on restricted population [44, 45], different objective from the current review [46, 47],lack of access to full articles[4853], conducted in a different population with this review [54], the article was written in a non-English language [55], and were reviews and reports [5660]. Twenty articles were assessed for quality, and one study was excluded because it had poor quality on NOS [61]. Finally, 19 articles (40,953 study participants) with good quality were included in this systematic review and meta-analysis (Fig 1).

Of 19 studies, five were from Ghana [6266], three were from Ethiopia [7, 67], two were from Egypt [68, 69], two were from Tanzania [70, 71], two were from South Africa [72, 73], and one was from each of these countries (Malawi [74], Sudan [75], Zimbabwe [76], Zambia [77], and Cotedevior). Included studies were published in the year from 2007 to 2018 with a sample size ranging from 159 in South Africa to 16,560 in Ghana. Twelve (63.16%) and seven (36.84%) studies were cross-sectional and cohort studies, respectively. Nine studies were conducted in the community, while ten studies were conducted in health institutions. The time of screening for PND varied from 4 weeks to 56 weeks. Postpartum depression was measured using PDQ in 1 study, DSM-IV in 2 studies, EPDS in 6 studies, PHQ -9 in 7 studies, CES-D in 2 studies, and SRQ-20 in 1 study (Table 1).

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Table 1. Characteristics of included studies: A systematic review and meta-analysis of postpartum depression in Africa.

https://doi.org/10.1371/journal.pone.0231940.t001

The pooled prevalence of postnatal depression

The pooled prevalence of postnatal depression before adjusting for publication bias was 16.84% (95% CI: 14.49–19.19, I2 = 98.7%, Eggers test = 0.001) (Fig 2). However, after adjustment, the final pooled prevalence was found to be 17.8% (95% CI: 13.9%, 21.7%). There is no significant difference in estimates between the original and the trimmed prevalence (Figs 3 & 4). The extent of heterogeneity among the included studies was high. A meta-regression showed that the effect of the difference in sample size explained 12% (P-value = 0.09) of the total observed variation. We also further did and report estimates from a sub-analysis considering other possible sources of variations.

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Fig 2. Postnatal depression prevalence in Africa, a meta-analysis, sub analyzed by geographical area (N = 19, random effect).

https://doi.org/10.1371/journal.pone.0231940.g002

Accordingly, a pooled prevalence from sub-group analysis showed non-sub-Saharan countries had the highest prevalence of PND (PND = 44.05%: 95% CI; 33.77, 54.33, 2 studies from Egypt). Low-income African countries had higher PND (PND = 19.94%; 95%CI; 15.36, 24.52) prevalence compared with middle-income countries. Depression prevalence was found to be higher in the 1st 96 weeks (PND = 41.46%; 95% CI: 25.78, 57.14) (Table 2). Sensitivity analysis showed that none of the studies substantially influenced the pooled estimates (Fig 5).

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Fig 5. Sensitivity analysis between postnatal depressions studies included in a meta-analysis.

https://doi.org/10.1371/journal.pone.0231940.g005

Factors affecting postnatal depression

In the random effect model, the following factors were identified as a risk factor for PND. The odds of PND was higher among women with a history of the poor obstetric condition (such as Hyperemesis Gravidurum and cesarean section delivery) (Pooled odds Ratio (POR) = 1.72;95% CI: 1.36, 2.17; I2 = 70.7%). A history of adverse birth and infant health outcomes (such as low birth weight, preterm, stillbirth or infant loss after delivery) (POR = 2.38; 95% CI: 1.56, 3.64; I2 = 74.5%) were associated with an increased odds of PND. A history of maternal health problems during pregnancy (such as hypertension, gestational diabetes, HIV/AIDS, TB, and other health problems during pregnancy) (POR = 2.75; 95% CI; 1.89, 3.98; I2 = 81.7%) was associated with the risk of PND. Women with inadequate support from husband, family or any other source during pregnancy (POR = 2.06; 95% CI; 1.05, 4.05; I2 = 83.2%) were more likely to had PND compared to those who had good support.

The result also showed that low economic status (explained by financial hardship or low perceived wealth, experienced hunger in the past months) was significantly increased the odds of PND (POR = 2.57; 95% CI: 1.97, 3.34; I2 = 12.9%). Exposure to different forms of violence, such as physical, sexual, and psychological, was also significantly affected the occurrence of PND. Accordingly, the odds of depression among mothers who had exposure to a different form of IPV was 2.68 (POR = 2.68; 95% CI: 1.84, 3.89; I2 = 85.5%) times higher (Figs 5 & 6).

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Fig 6. Factors affecting the occurrence of postnatal depression in Africa (N = 19; random effect).

https://doi.org/10.1371/journal.pone.0231940.g006

Discussion

This systematic review and meta-analysis assessed the prevalence and factors affecting postnatal depression among postnatal women in Africa. In this review, a small number of studies with a high level of heterogeneity found that one in five postpartum mothers were likely to have PND in the continent. A history of the poor obstetric condition, adverse birth, and infant health outcomes, exposure to a different form of IPV, poor maternal health condition, and social support was found to increase the odds of PND.

This estimated prevalence was in line with a review conducted on perinatal depression in low and middle-income countries that showed nearly one-fifth (19%) of postnatal women had depression [26]. However, this review differs from the current in terms of geographical coverage, population, and year of publication. The highest pooled prevalence was reported from two studies in Egypt that might be due to a small sample size and their cross-sectional nature [78]. The Sub-Saharan countries had a high prevalence of PND likely due to economic struggle that leads to stress [79]. Postnatal depression prevalence appeared to increases the time of screening after delivery increased. It has been implicated that depression symptoms increased in the first two to 12 weeks because of hormonal fluctuation and the new environment of maternity [35, 80]. However, the interpretation for these estimates should account for the window of measurement as a more comprehensive window predicts more significant prevalence.

The pooled estimate of PND in Africa also differed by sample size included in the studies. Studies with larger sample size estimated lower prevalence as compared to studies with small sample sizes, and this is mostly true as precise estimation depends on the adequacy of sample size. The other variation in pooled estimate was accounted for the study type, cross-sectional and community-based studies relatively estimated bigger prevalence. Overestimation is a major limitation of cross-sectional studies. Similarly, as depression affects health-seeking behavior, women with depression tend to stay at home, and this might slightly increase prevalence estimates in community-based studies. The current estimate was higher compared with a review of longitudinal studies on perinatal depression that showed 13.1% of postnatal women had signs of depression [81]. In the previous review, longitudinal studies that followed women starting from pregnancy to postpartum period were included. During this course of follow-up, those who were depressed during pregnancy might have treated, and this might reduce the risk of recurrent depression in the postnatal period.

In this review, a history of poor obstetric and adverse birth and infant health conditions has significantly increased the odds of PND. This finding is supported by a systematic review and meta-analysis conducted in low-and middle-income countries [3]. The possible reason might be women with poor obstetric conditions are likely to feel guilty or ashamed [82], which leads to depression. Similarly, a history of adverse birth and infant conditions conceptualized as a stressful experience is mostly linked with depressive symptoms [1, 83, 84].History of maternal mental health problems significantly increased the odds of current PND. This finding was in line with a systematic review and meta-analysis of common perinatal mental disorders conducted in low and middle-income countries [6]. Women with a history of mental disorder are more likely to lose their positive affect [85], practice rumination and develop a negative cognitive style in their life that could also persist throughout the continuum of pregnancy [86, 87].

In the current review, poor social support was positively associated with the odds of PND. This finding was supported by a systematic review and meta-analysis carried out on the prevalence of postpartum depression and its effect in low and middle-income countries [57]. It has also been found that women who had weak support from close families at delivery or in the care of the newborn are less satisfied, stressful, and at a higher risk of depression [31].Being in lower economic status increased the risk of postnatal depression in this review. This finding was replicated in a systematic review and meta-analysis conducted in low and middle-income countries [3]. Women in low socio-economic status could become underprivileged due to scarcity of financial resources and insufficient health insurance, which leads to stress [27].

Exposure to different forms of IPV has increased the odds of postnatal depression in this review. This finding was supported by a systematic review and meta-analysis conducted in low and middle- income countries [88]. Exposure to IPV (physical, sexual, economical) could result in physical and social isolation; emotionally affect the abused women leading to low self-esteem, and disgusting lives [89, 90]that end up with depression. Depression during the postnatal period affects infant growth [14], breastfeeding practice [91] and under nutrition[22] through negatively affecting women’s interpersonal and parenting behavior [92]. The intimacy and interaction of the mother with her child would be affected, and the mother would fail to cope with her caring responsibility [9395]. As a result, the child might suffer from diarrheal and other common childhood diseases [3]that might also lead to death. Depression also affects the mother’s quality of life [49].

So, depression screening during the postpartum period has significant importance. Findings from the current study, therefore, are helpful for clinicians, programmers, and policymakers to think of ways to integrate maternal mental health with routine maternal health services. The screening and treatment of depression should start by identifying an appropriate screening tool and setting the ideal time of testing. Early detection and treatment of PND would help to minimize its further re-occurrence and potential adverse health outcomes among the mothers and their children.

This review has the following limitations. Only English language reviews were included, and this might introduce publication bias. Moreover, the extent of heterogeneity among the included studies was high, which can be attributed to differences in methodology, study period, type of screening tool, and other unexplained variations. The other limitation of this review is that as only studies from 10 African countries were included, it might be difficult to generalize to the whole countries in Africa.

Conclusion

This systematic review and meta-analysis found that PND could be arguably prevalent in the African continent based on a small number of published studies with inherently heterogeneous estimates. We also found that the prevalence of PND varied across different characteristics of the studies included in the review. Postnatal women with a history of the poor obstetric condition, adverse birth and infant health outcomes, mental health conditions, poor social support, and exposure to a different form of IPV were more likely to have PND. Based on this review, an early screening of postnatal depression and taking prompt intervention would save the mother and her baby from different forms of morbidity. This review also implicated that there is a shortage of robust studies in Africa to produce generalisablity evidence.

References

  1. 1. Alasoom LI, Koura MR. Predictors of Postpartum Depression in the Eastern Province Capital of Saudi Arabia. Journal of Family Medicine and Primary Care. 2014;3(2):146–50. pmid:25161973
  2. 2. Gjerdingen D, Crow S, McGovern P, Miner M, Center B. Changes in Depressive Symptoms over 0–9 Months Postpartum. Journal of Women's Health (15409996). 2011;20(3):381–6.
  3. 3. Gelaye B, Rondon M, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. The lancet Psychiatry. 2016;3(10):973–82. pmid:27650773
  4. 4. Organization WH. Depression and other common mental disorders: global health estimates. 2017.
  5. 5. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet (London, England). 2016;388(10053):1545–602.
  6. 6. Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization. 2012;90(2):139–49H.
  7. 7. Azale T, Fekadu A, Hanlon C. Treatment gap and help-seeking for postpartum depression in a rural African setting. BMC Psychiatry. 2016;16(1).
  8. 8. Antelman G1, Kaaya S, Wei R, Mbwambo J, Msamanga GI, Fawzi WW, et al. Depressive Symptoms Increase Risk of HIV Disease Progression and Mortality Among Women in Tanzania. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2007;44(4):470–7 ·. pmid:17179766
  9. 9. Atif N, Lovell K, Rahman A. Maternal mental health: The missing "m" in the global maternal and child health agenda. Seminars in Perinatology. 2015;39(5):345–52. pmid:26164538
  10. 10. Bécares L, Atatoa-Carr P. The association between maternal and partner experienced racial discrimination and prenatal perceived stress, prenatal and postnatal depression: findings from the growing up in New Zealand cohort study. International Journal for Equity in Health. 2016;15(1):1–12.
  11. 11. Beck CT. Postpartum depression: it isn't just the blues. The American journal of nursing. 2006;106(5):40–50; quiz -1. pmid:16639243
  12. 12. Bertolote JM, Fleischmann A, De Leo D, Wasserman D. Psychiatric diagnoses and suicide: revisiting the evidence. Crisis. 2004;25(4):147–55. pmid:15580849
  13. 13. Black MM, Surkan . Child development and maternal wellbeing: Family perspectives for low-income and middle-income countries. The Lancet Global Health. 2015;3(8):e426–e7. pmid:26144388
  14. 14. Avan B, Richter LM, Ramchandani PG, Norris SA, Stein A. Maternal postnatal depression and children's growth and behaviour during the early years of life: exploring the interaction between physical and mental health. Archives of Disease in Childhood. 2010;95(9):690–5. pmid:20660522
  15. 15. Lewis AJ, Austin E, Galbally M. Prenatal maternal mental health and fetal growth restriction: A systematic review. Journal of Developmental Origins of Health and Disease. 2016;7(4):416–28. pmid:26983652
  16. 16. Adewuya AO, Hanlon C, Medhin G, Dewey M, Alem A, Worku B, et al. Perinatal common mental disorders and child survival in Ethiopia. Journal of Paediatrics and Child Health. 2014;50(1):57–63. pmid:24168558
  17. 17. Bell AF, Andersson E. The birth experience and women's postnatal depression: A systematic review. Midwifery. 2016;39:112–23. pmid:27321728
  18. 18. Bennett IM, Schott W, Krutikova S, Behrman JR. Maternal mental health, and child growth and development, in four low-income and middle-income countries. Journal of Epidemiology and Community Health. 2015;70(2):168–73. pmid:26359503
  19. 19. Agnafors S, Sydsjö G, deKeyser L, Svedin C. Symptoms of Depression Postpartum and 12 years Later-Associations to Child Mental Health at 12 years of Age. Maternal & Child Health Journal. 2013;17(3):405–14.
  20. 20. Adewuya AO, Ola BO, Aloba OO, Mapayi BM, Okeniyi JA. Impact of postnatal depression on infants' growth in Nigeria. 2008.
  21. 21. Annagür A, Annagür BB, Şahin A, Örs R, Kara F. Is maternal depressive symptomatology effective on success of exclusive breastfeeding during postpartum 6 weeks? Breastfeeding Medicine. 2013;8(1):53–7. pmid:23039400
  22. 22. Ashaba S, Rukundo GZ, Beinempaka F, Ntaro M, Leblanc JC. Maternal depression and malnutrition in children in southwest Uganda: A case control study. BMC Public Health. 2015;15(1).
  23. 23. Bener A, Burgut FT, Ghuloum S, Sheikh J. A Study of Postpartum Depression in a Fast Developing Country: Prevalence and Related Factors. The International Journal of Psychiatry in Medicine. 2012;43(4):325–37. pmid:23094465
  24. 24. WHO Guidelines Approved by the Guidelines Review Committee. mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings: Mental Health Gap Action Programme (mhGAP). Geneva: World Health Organization World Health Organization.; 2010.
  25. 25. deCastro F, Hinojosa-Ayala N, Hernandez-Prado B. Risk and protective factors associated with postnatal depression in Mexican adolescents. J Psychosom Obstet Gynaecol. 2011;32(4):210–7. pmid:22050327
  26. 26. Hanlon C. Maternal depression in low- and middle-income countries. International Health. 2013;5(1):4–5. pmid:24029837
  27. 27. Abdollahi F, Zarghami M, Azhar MZ, Sazlina SG, Lye MS. Predictors and incidence of post-partum depression: a longitudinal cohort study. The journal of obstetrics and gynaecology research. 2014;40(12):2191–200. pmid:25132641
  28. 28. Ahmet GÜRhan P, ÖZlem Erden A, Ayse Huriye ParlakgÜMÜ S, ÇIĞDem G, Anil Barak D. THE INCIDENCE OF AND RISK FACTORS FOR POSTPARTUM DEPRESSION AT AN URBAN MATERNITY CLINIC IN TURKEY. International Journal of Psychiatry in Medicine. 2013;46(2):179–94. pmid:24552041
  29. 29. Goker A, Yanikkerem E, Demet MM, Dikayak S, Yildirim Y, Koyuncu FM. Postpartum depression: Is mode of delivery a risk factor?: ISRN Obstetrics and Gynecology. (no pagination), 2012. Article Number: 616759. Date of Publication: 2012.; 2012.
  30. 30. Ajinkya S, Jadhav PR, Srivastava NN. Depression during pregnancy: Prevalence and obstetric risk factors among pregnant women attending a tertiary care hospital in Navi Mumbai. Industrial Psychiatry Journal. 2013;22(1):37–40. pmid:24459372
  31. 31. Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. Eastern Mediterranean Health Journal. 2012;18(5):432–8.
  32. 32. Gupta S, Kishore J, Mala YM, Ramji S, Aggarwal R. Postpartum depression in North Indian women: Prevalence and risk factors. Journal of Obstetrics and Gynecology of India. 2013;63(4):223–9. pmid:24431646
  33. 33. Baghianimoghadam MH, Shodjaee Zadeh D, Aminian AH. Caesarean section, vaginal delivery and post natal depression: Iranian Journal of Public Health. 38 (3) (pp 118–122), 2009. Date of Publication: 2009.; 2009.
  34. 34. Alharbi AA, Abdulghani HM. Risk factors associated with postpartum depression in the Saudi population. Neuropsychiatric disease and treatment. 2014;10:311–6. pmid:24570584
  35. 35. Beck CT. State of the science on postpartum depression: what nurse researchers have contributed-part 2. MCN Am J Matern Child Nurs 33, 151e156. 2008. pmid:18453904
  36. 36. Alvarado-Esquivel C, Sifuentes-Alvarez A, Salas-Martinez C. Unhappiness with the fetal gender is associated with depression in adult pregnant women attending prenatal care in a public hospital in Durango, Mexico. International Journal of Biomedical Science. 2016;12(1):36–41. pmid:27127452
  37. 37. Baron EC, Hanlon C, Mall S, Honikman S, Breuer E, Kathree T, et al. Maternal mental health in primary care in five low- and middle-income countries: A situational analysis. BMC Health Services Research. 2016;16(1).
  38. 38. Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord. 2010;123(1–3):17–29. pmid:19635636
  39. 39. Bae J-M. A suggestion for quality assessment in systematic reviews of observational studies in nutritional epidemiology. Epidemiology and Health. 2016;38:e2016014. pmid:27156344
  40. 40. Moraes GPdA, Lorenzo L, Pontes GAR, Montenegro MC, Cantilino A. Screening and diagnosing postpartum depression: when and how? Trends in Psychiatry and Psychotherapy. 2017;39:54–61. pmid:28403324
  41. 41. Fletcher J. What is heterogeneity and is it important? BMJ: British Medical Journal. 2007;334(7584):94–6. pmid:17218716
  42. 42. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Bmj. 2009;339:b2700. pmid:19622552
  43. 43. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. Jama. 2000;283(15):2008–12. pmid:10789670
  44. 44. Dow A, Dube Q, Pence BW, Van Rie A. Postpartum depression and HIV infection among women in Malawi. Journal of acquired immune deficiency syndromes (1999). 2014;65(3):359–65.
  45. 45. Ganann R, Sword W, Thabane L, Newbold B, Black M. Predictors of Postpartum Depression Among Immigrant Women in the Year After Childbirth. 2016.
  46. 46. Garcia-Flores JR, Peregalli S, Garrido S, Garcia-Diaz S, Espada M, Sainz De La Cuesta R. Immediate postpartum evaluation of clinical markers for depression symptoms by means of the Edinburgh Postnatal Depression Scale. 2016.
  47. 47. Sharifi F, Nouraei S, Shahverdi E. The Relation of Pre and Postnatal Depression and Anxiety with Exclusive Breastfeeding. 2016.
  48. 48. Cheng CY, Pickler RH. Perinatal stress, fatigue, depressive symptoms, and immune modulation in late pregnancy and one month postpartum. Thescientificworldjournal. 2014;2014:652630. pmid:24587741
  49. 49. de Tychey C, Briancon S, Lighezzolo J, Spitz E, Kabuth B, de Luigi V, et al. Quality of life, postnatal depression and baby gender. 2008.
  50. 50. Kossakowska-Petrycka K, Walecka-Matyja K. [Psychological causative factors in postpartum depression amongst women with normal and high-risk pregnancies]. 2007.
  51. 51. Kurth E. [Postnatal infant crying and maternal tiredness: examining their evolution and interaction in the first 12 weeks postpartum]. 2011.
  52. 52. Lakra AJ, Thomas S. Identify risk factors for postnatal depression among antenatal mothers—A hospital based study: International Journal of Nursing Education. 6 (1) (pp 100–103), 2014. Date of Publication: 2014.; 2014.
  53. 53. Hullfish KL, Fenner DE, Sorser SA, Visger J, Clayton A, Steers WD. Postpartum depression, urge urinary incontinence, and overactive bladder syndrome: is there an association? 2007.
  54. 54. Lovlie AL, Madar AA. Postpartum Depression Among Somali Women in Norway. 2017.
  55. 55. Molero KL, Machado JRU, Charles SV, Zambrano NB, Benitez AC, Quiroz EA, et al. Prevalence of postpartum depression in postpartum adolescents and adults: Revista Chilena de Obstetricia y Ginecologia. 79 (4) (pp 294–304), 2014. Date of Publication: 01 Jul 2014.; 2014.
  56. 56. Wittkowski A, Gardner PL, Bunton P, Edge D. Culturally determined risk factors for postnatal depression in Sub-Saharan Africa: a mixed method systematic review. 2014.
  57. 57. Parsons CE, Young KS, Rochat TJ, Kringelbach ML, Stein A. Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries. British Medical Bulletin. 2012;101(1):57–79.
  58. 58. O'Hara MW, Wisner KL. Perinatal mental illness: definition, description and aetiology. Best practice & research Clinical obstetrics & gynaecology. 2014;28(1):3–12.
  59. 59. O'Hara MW. Postpartum depression: what we know. Journal of Clinical Psychology. 2009;65(12):1258–69. pmid:19827112
  60. 60. Miller LJ, LaRusso EM. Preventing Postpartum Depression. Psychiatric Clinics of North America. 2011;34(1):53–65. pmid:21333839
  61. 61. Kakyo TA, Muliira JK, Mbalinda SN, Kizza IB, Muliira RS. Factors associated with depressive symptoms among postpartum mothers in a rural district in Uganda. Midwifery. 2012;28(3):374–9. pmid:21601966
  62. 62. Wemakor A, Mensah KA. Association between maternal depression and child stunting in Northern Ghana: A cross-sectional study. BMC Public Health. 2016;16(1).
  63. 63. Wemakor A, Iddrisu H. Maternal depression does not affect complementary feeding indicators or stunting status of young children (6–23 months) in Northern Ghana. BMC Res Notes. 2018;11(1):408. pmid:29941023
  64. 64. Weobong B, Ten Asbroek AH, Soremekun S, Danso S, Owusu-Agyei S, Prince M, et al. Determinants of postnatal depression in rural ghana. Depression and anxiety. 2015;32(2):108–19. pmid:24272979
  65. 65. Guo N, Bindt C, Te Bonle M, Appiah-Poku J, Hinz R, Barthel D, et al. Association of antepartum and postpartum depression in Ghanaian and Ivorian women with febrile illness in their offspring: a prospective birth cohort study. Am J Epidemiol. 2013;178(9):1394–402. pmid:24013202
  66. 66. Anokye R, Acheampong E, Budu-Ainooson A, Obeng EI, Akwasi AG. Prevalence of postpartum depression and interventions utilized for its management. Ann Gen Psychiatry. 2018;17:18. pmid:29760762
  67. 67. Adamu AF, Adinew YM. Domestic Violence as a Risk Factor for Postpartum Depression Among Ethiopian Women: Facility Based Study. Clinical practice and epidemiology in mental health: CP & EMH. 2018;14:109–19.
  68. 68. Hassanein IMA, Fathalla MMF, Abdel Rahim T. The role of newborn gender in postpartum depressive symptoms among women in Upper Egypt. International Journal of Gynecology & Obstetrics. 2014;125(2):138–40.
  69. 69. Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health. 2014;128(9):817–24. pmid:25213100
  70. 70. Mahenge B, Stockl H, Likindikoki S, Kaaya S, Mbwambo J. The prevalence of mental health morbidity and its associated factors among women attending a prenatal clinic in Tanzania. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2015;130(3):261–5.
  71. 71. Rogathi JJ, Manongi R, Mushi D, Rasch V, Sigalla GN, Gammeltoft T, et al. Postpartum depression among women who have experienced intimate partner violence: A prospective cohort study at Moshi, Tanzania. Journal of Affective Disorders. 2017;218:238–45. pmid:28477502
  72. 72. Stellenberg EL, Abrahams JM. Prevalence of and factors influencing postnatal depression in a rural community in South Africa. African journal of primary health care & family medicine. 2015;7(1):874.
  73. 73. Ramchandani P, Richter L, Stein A, Norris S. Predictors of postnatal depression in an urban South African cohort. J Affect Disord. 2009;113.
  74. 74. Stewart RC, Bunn J, Vokhiwa M, Umar E, Kauye F, Fitzgerald M, et al. Common mental disorder and associated factors amongst women with young infants in rural Malawi. Social Psychiatry and Psychiatric Epidemiology. 2010;45(5):551–9. pmid:19609476
  75. 75. Khalifa DS, Glavin K, Bjertness E, Lien L. Postnatal depression among Sudanese women: Prevalence and validation of the Edinburgh Postnatal depression scale at 3 months postpartum: International Journal of Women's Health. 7 (pp 677–684), 2015. Date of Publication: 08 Jul 2015.; 2015. pmid:26185471
  76. 76. Shamu S, Zarowsky C, Roelens K, Temmerman M, Abrahams N. High-frequency intimate partner violence during pregnancy, postnatal depression and suicidal tendencies in Harare, Zimbabwe. General Hospital Psychiatry. 2016;38:109–14. pmid:26607330
  77. 77. Ndokera R, MacArthur C. The relationship between maternal depression and adverse infant health outcomes in Zambia: A cross-sectional feasibility study. Child: Care, Health and Development. 2011;37(1):74–81.
  78. 78. Kestenbaum B. Cross-Sectional Studies. Epidemiology and Biostatistics: An Introduction to Clinical Research. Cham: Springer International Publishing; 2019. p. 39–43.
  79. 79. Ahmed A, Bowen A, Feng CX, Muhajarine N. Trajectories of maternal depressive and anxiety symptoms from pregnancy to five years postpartum and their prenatal predictors. BMC Pregnancy Childbirth. 2019;19(1):26. pmid:30642277
  80. 80. Affonso DD, De AK, Horowitz JA, Mayberry LJ. An international study exploring levels of postpartum depressive symptomatology. J Psychosom Res. 2000;49(3):207–16. pmid:11110992
  81. 81. Underwood L, Waldie K, D’Souza S, Peterson ER, Morton S. A review of longitudinal studies on antenatal and postnatal depression. Archives of Women's Mental Health. 2016;19(5):711–20. pmid:27085795
  82. 82. Dibaba Y, Fantahun M, Hindin MJ. The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia. BMC pregnancy and childbirth. 2013;13.
  83. 83. Diniz E, Volling BL, Koller SH. Social support moderates association between depression and maternal-fetal attachment among pregnant Brazilian adolescents. Journal of Reproductive and Infant Psychology. 2014;32(4):400–11.
  84. 84. Ege E, Timur S, Zincir H, Geckil E, Sunar-Reeder B. Social support and symptoms of postpartum depression among new mothers in Eastern Turkey. The journal of obstetrics and gynaecology research. 2008;34(4):585–93. pmid:18937713
  85. 85. Raes F, Smets J, Wessel I, Van Den Eede F, Nelis S, Franck E, et al. Turning the pink cloud grey: dampening of positive affect predicts postpartum depressive symptoms. J Psychosom Res. 2014;77(1):64–9. pmid:24913344
  86. 86. Lo CS, Ho SM, Hollon SD. The effects of rumination and negative cognitive styles on depression: a mediation analysis. Behaviour research and therapy. 2008;46(4):487–95. pmid:18316063
  87. 87. Barnum SE, Woody ML, Gibb BE. Predicting Changes in Depressive Symptoms from Pregnancy to Postpartum: The Role of Brooding Rumination and Negative Inferential Styles. Cognitive therapy and research. 2013;37:71–7. pmid:25401383
  88. 88. Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. The Lancet Psychiatry. 2016;3(10):973–82. pmid:27650773
  89. 89. Kabir ZN, Nasreen HE, Edhborg M. Intimate partner violence and its association with maternal depressive symptoms 6–8 months after childbirth in rural Bangladesh. Global health action. 2014;7:24725. pmid:25226416
  90. 90. Kita S, Haruna M, Matsuzaki M, Kamibeppu K. Associations between intimate partner violence (IPV) during pregnancy, mother-to-infant bonding failure, and postnatal depressive symptoms. Archives of Women's Mental Health. 2016;19(4):623–34. pmid:26803782
  91. 91. de Jager E, Broadbent J, Fuller-Tyszkiewicz M, Skouteris H. The role of psychosocial factors in exclusive breastfeeding to six months postpartum. Midwifery. 2014;30(6):657–66. pmid:23932036
  92. 92. Della Vedova AM, Ducceschi B, Cesana BM, Imbasciati A. Maternal bonding and risk of depression in late pregnancy: A survey of Italian nulliparous women. Journal of Reproductive and Infant Psychology. 2011;29(3):208–22.
  93. 93. Figueiredo B, Canario C, Field T. Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychological Medicine. 2014;44(5):927–36. pmid:23822932
  94. 94. Flores-Quijano ME, Cordova A, Contreras-Ramirez V, Farias-Hernandez L, Cruz Tolentino M, Casanueva E. Risk for postpartum depression, breastfeeding practices, and mammary gland permeability. Journal of human lactation: official journal of International Lactation Consultant Association. 2008;24(1):50–7.
  95. 95. Donaldson F. Postnatal depression and infant feeding: A review of the evidence. British Journal of Midwifery. 2011;19(10):619–24.