Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis
Introduction
The postpartum period is a challenging transition period for mothers, leaving them highly susceptible to psychiatric disorders (Vesga-López et al., 2008). The likelihood of depressive episodes can be twice as high as during other periods of a woman's life (Cox et al., 1993), and they often go undetected and untreated (Pearlstein et al., 2009), which can adversely affect the wellbeing of mothers, new born infants (Soe et al., 2016), and other family members (Letourneau et al., 2012). Mothers suffering from postpartum depression often display hostility and negligence, have lower tolerance, and are less responsive to their infants' needs (Murray et al., 1996; Stein et al., 2014). This not only disrupts mother-infant bonding and reduces breastfeeding (Pope and Mazmanian, 2016) but also impairs the cognitive, behavioural, and social-emotional development and physical health of the child (Letourneau et al., 2012; Stein et al., 2014). Moreover, maternal postpartum depression (PPD) was found to be the strongest risk factor for paternal depression, affecting 24–50% of all fathers (Goodman, 2004a, Goodman, 2004b). This leads to increased marital conflicts associated with communication breakdown, feelings of isolation and frustration, and limited interaction with the child (Davey et al., 2006). Therefore, the early diagnosis, management, and possible prevention of maternal postpartum affective disorders are important in establishing an optimal and healthy family environment for the child's upbringing.
PPD refers to non-psychotic depressive episodes during the postpartum period that persist for more than two weeks, which has an estimated prevalence of 13% (O’Hara and Swain, 1996). In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5, American Psycholgical Association, 2013), PPD shares the same diagnostic criteria as major depressive disorder, with an additional postpartum onset specifier of four weeks (American Psycholgical Association, 2013). PPD is commonly characterised by transient mood lability, insomnia, disorganised behaviour, irritability, and agitation (Monzon et al., 2014). While studies have suggested a multifactorial aetiology of PPD, such as psychosocial stressors (Beck, 2001; O’Hara and Swain, 1996) and biological factors (Brummelte and Galea, 2016), the specific aetiology of PPD still remains unclear.
Many studies have shown substantial interest in the prevalence of PPD and their predictors, with most reporting the significance of history of psychiatric illnesses on the prevalence of PPD (O’Hara et al., 1991; Patel et al., 2012). In addition, women with a history of PPD have an increased risk of experiencing a recurrence in subsequent deliveries (Banti et al., 2011; Cox et al., 1993; Rasmussen et al., 2017). Results from Rasmussen’s et al (2017) study reported a 15–21% recurrence risk of affective disorders in women who had no prior psychiatric disorders but were diagnosed with PPD after their first childbirth. This recurrence risk is 27–46 times higher in women with history of PPD after first birth. Since having a history of depression is a high risk factor of PPD, many studies included and focused on the population of mothers with a history of depression, resulting in a negligence of mothers without a prior history of depression (including PPD). In previous studies (Banti et al., 2011; Chee et al., 2005), women without a history of depression are shown to be as likely to have subsequent depressive episodes during the perinatal period as those with prior history. This rate of depression was 7.7% in the postpartum period. As mothers without prior history of depression are at a similar risk of PPD, the effects of PPD are equally detrimental to them and their family; hence, knowing the prevalence of first onset of PPD among healthy mothers is vital in preventing further elevations of symptoms and reducing the recurrence risk.
Reviews specifically on depression in the postpartum period were largely available; however, either meta-analysis or meta-regression was lacking in most of the reviews (Andrews-Fike, 1999; Leahy-Warren and McCarthy, 2007; Patel et al., 2012) or focused on specific countries (Jones and Coast, 2013; Ozcan et al., 2017; Upadhyay et al., 2017); hence, a global prevalence of PPD and their moderating factors were hardly reported in those postpartum reviews. The most recent review by Hahn-Holbrook et al. (2018) reported a pooled global prevalence of 17.7% for PPD from 291 studies, and identified significant risk factors like maternal mortality, infant mortality, long working hours of women at the childbearing age, and nations with high income inequality. However, the review was limited in its inclusivity of using only the Edinburgh Postnatal Depression Scale (EPDS), and study samples of mothers who were less than one year postpartum were included. As self-reported measures tend to report higher PPD prevalence than clinical interviews (O’Hara and Swain, 1996), this may have resulted in an overestimation of global prevalence. A postpartum review by Leahy-Warren (2007) reported a wide range of prevalence estimates (4.4–73.7%) in the postpartum period and attributed it to the difference in sampling methods, measurement instruments, and sociodemographic variances across the studies. However, no meta-analysis and meta-regression have been conducted thus far to account for the heterogeneity of the studies statistically, and the moderators of heterogeneity had been based on assumption.
Other available reviews were mostly focused on perinatal depression or specific population groups (i.e. immigrants, ethnic minorities, mothers living in rural areas, first time mothers) (Falah-Hassani et al., 2015; Jones and Coast, 2013; Ozcan et al., 2017; Upadhyay et al., 2017; Vigod et al., 2010; Villegas et al., 2011). To the best of our knowledge, no review has been done among mothers without prior psychiatric history and who had given birth to healthy infants during the postpartum period. As this period is a stressful transition period for new mothers, it is important to see the development of depression among healthy mothers. This group has been often neglected, and it has been shown that mothers with PPD influence the future development of their healthy newborns (Ali et al., 2013; Letourneau et al., 2012; Soe et al., 2016). Hence, this review aims to provide new insights on the prevalence and incidence of PPD among healthy mothers, without prior history of mental illnesses, including PPD, with healthy infants during the stressful postpartum period so that appropriate interventions can be planned for this specific group of mothers, which may benefit not only mothers but also their newborn and family.
Section snippets
Search strategy
The meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009) (Appendix 1). A three-step strategy was used to identify relevant studies: (i) a systematic search of electronic databases, (ii) a manual search of the reference lists of the included articles, and (iii) consultation with an expert panel. The electronic databases searched were ClinicalTrials.gov, CINAHL, EMBASE, PsycINFO, and PubMed.
Results
Thirty prospective cohort studies, 26 cross sectional studies, and two case-control studies covering a total of 37,294 women in the postpartum period were included in the analysis. This review included 17 studies that adopted clinical interviews to diagnose PPD and 39 studies that used varied validated self-report measurement tools to determine the presence of PPD. When stratified according to time points of assessment for depression, 25 studies reported prevalence in the first three months
Discussion
Results from the meta-analysis of 58 studies suggest that the overall prevalence of PPD is 17% (95% CI 0.15–0.20). This estimate falls within previously published estimates of 13%–19.2% (Gavin et al., 2005; O’Hara and Swain, 1996) and is similar to Hanhn-Holbrook’s (2018) finding of 17.7%. However, it is higher than the prevalence of 0.6% reported in Rasmussen’s et al (2017) study on postpartum affective disorders among 457,317 primiparous mothers without prior psychiatric history. Unique to
Conclusion
The findings from this review presented the prevalence and incidence of PPD for a specific group of healthy mothers without prior history of mental illnesses including PPD. This group is often neglected in previous research; however, given that the PPD prevalence among this group of mothers is similar to those with a history of psychiatric illnesses, equal emphasis should be placed on them. Despite the lack of significant common predictors like age, parity, and marital status on PPD prevalence,
Declaration of interest
None.
Acknowledgments
The authors would like to thank the National University Health System, Medical Publications Support Unit, for assistance in the language editing of this manuscript.
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