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Case-based learning: postnatal depression

Appropriate early recognition and timely treatment of postnatal depression is essential if patients are to make a full recovery.

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Postnatal depression (PND) is a common, but under-reported, condition that can affect both men and women after the birth of a child [1] . PND is an illness and not simply related to hormones or the changes a new baby brings. Unlike the ‘baby blues’, which is self-limiting, PND is longer lasting and often requires treatment.

The symptoms of PND are similar to those of depression, such as low self-esteem and persistent low mood, and can range from being relatively mild to severe. Red flag signs include persistent expressions of incompetency as a parent and suicidal thoughts. The greatest risk factor for developing PND is a history of PND or depression, although other risk factors include financial instability and poor social support. Simple screening tools, such as the Whooley questions or Generalised Anxiety Disorder scale, can help identify people at risk of, or who have, PND [2] , [3] . For more information about recognising PND please see here .

Treatment type should be selected based on the severity of the condition and patient preference. Pharmacists can provide advice to patients prescribed antidepressants for PND, including potential side effects and information about breastfeeding. This article describes management and self-care options for patients, including three worked case studies.

Asking simple open questions, such as “how are you?”, can be a good way to encourage a new parent to talk without being intrusive. Where a parent shows signs of PND, ask them if they would like to talk about their concerns or if would like any further support. Signposting them to groups available in the area (e.g. community baby groups) can be beneficial.

Avoid comparing the patient with other parents because this can exacerbate feelings of failure. Do not use language that may come across as critical, particularly where parents are worried about how they are coping, and do not suggest that these feelings will simply pass or improve by themselves.

It is important to destigmatise PND and reassure parents about seeking help. Encourage all new parents to look after their emotional wellbeing through self-care, getting support from friends or family, undertaking gentle exercise and eating well [4] .

Psychological therapy

Cognitive behavioural therapy (CBT) has been shown to be effective for patients with PND, improving symptoms in both the short- and long-term [5] , [6] , [7] .

CBT aims to challenge unhelpful thinking patterns through practical activities and helps patients understand their symptoms and illness. Patients are normally offered a course of sessions on a one-to-one basis with a healthcare professional. CBT can also be offered via a group, but individual therapy may be more effective [5] , [6] , [7] .

For patients with mild-to-moderate PND, CBT can be recommended. If there are prior episodes of more severe depression, CBT may be offered with antidepressants [8] . For patients with moderate-to-severe depression, high-intensity psychological therapy (e.g. interpersonal therapy) can initially be offered alone or alongside antidepressants.

Pharmacological therapy

There is little evidence to guide selection of medicine specifically in PND. Therefore, guidelines for managing depression should be followed, taking into account the safety of the medicine for both the mother and, where relevant, the child [9] , [10] .

When selecting an antidepressant, the patient’s previous response to these drugs, as well as previous effective antidepressants should be considered (even if the antidepressant would not be considered as first-line treatment in breastfeeding mothers) [9] .

Women with PND who choose not to breastfeed and men with PND can both be treated with any suitable antidepressant. However, it is imperative to counsel parents on taking medicines that may cause sedation because they must not co-sleep with their baby (in-line with safe co-sleeping guidance) [11] , [12] .

Breastfeeding and antidepressants

The World Health Organization recommends children are breastfed exclusively for at least the first four to six months of life; however, this can be complicated if the mother requires treatment for depression [13] , [14] . Women with  mental health problems should be encouraged to breastfeed unless they are taking clozapine or lithium, because these drugs can pass into breast milk and put the infant at risk of toxicity [9] .

There is a lack of robust evidence to guide choice of treatment. However, women who wish to breastfeed should be supported to do so and be provided with all available evidence about the risks of the antidepressant and how to limit exposure of the medicine to the baby via breast milk. For example, the level of antidepressant medicine in breast milk depends on the prescribed drug and it is possible to avoid breastfeeding at the time the medicine peaks in the mother, either by timing the medicine around the longest feed or bottle feeding the baby at that time if a feed is due. This may be difficult to achieve in very young babies, however, owing to the frequency of feeding and since many antidepressants have long half-lives or unpredictable times at which they peak. Therefore, a specialist’s advice should be sought regarding this.

Future perspective

Brexanolone is currently in development as a first-line treatment designed specifically to treat PND. It has recently been licensed in the United States, but it is not yet known whether or when it may be marketed in the UK [15] .

Evidence shows that PND that is not recognised and managed early can become difficult to treat and can lead to longer-term illness [16] . Early psychosocial support is thought to help prevent the development of PND in at-risk mothers [17] , [18] , [19] , [20] . However, limitations of the current evidence base mean that the effectiveness of specific psychological and pharmacological interventions are not yet conclusive [17] , [19] , [20] .

Where women have been taking antidepressants during pregnancy , medication should ideally be continued post-birth owing to the risk of recurrence of depression.

In addition, signposting parents to available groups where they can get professional or peer support may help reduce loneliness and increase social support, which may help prevent PND (see Useful resources).

Case studies

Case study 1: mild postnatal depression in a woman* .

A woman aged 21 years comes into the pharmacy to buy something for her three-month-old baby who has colic. When her baby starts to cry, the mother becomes very irritated. She apologises and says she is very tired as the baby has not been sleeping well. She looks teary and upset.

Questions to ask

Offer to talk in the consultation room and ask the following questions to discuss or highlight any issues the mother is facing:

• How are you managing with the baby?
• How is your baby’s constant crying affecting how you feel?
• What support do you have that allows you a break from your baby?

Advice and recommendations

The patient describes mild symptoms of postnatal depression (PND) and has no previous history of a mental health condition; therefore, self-help measures may be beneficial, such as:

• Taking advantage of available support, such as appropriate family members to take a break from the baby or to help manage household chores;
• Sharing day-to-day care of the baby with their partner;
• Eating well and taking gentle exercise (e.g. a walk);
• Attending classes or groups that may be available locally.

Even if the patient is trying self-help measures, it may still be helpful to refer them to their GP or health visitor. Alternatively, recommend ‘Improving Access to Psychological Therapies’ services in the area (people with PND may be able to self-refer without having to see a GP).

Explain that it is common for mothers to have mood disturbances after the birth of a child and that it is important that they address these feelings, rather than hope that they will pass.

Provide the patient with leaflets on PND and how parents can get help, as well as information on local services, numbers to call in an emergency, children’s centres that may offer drop-in sessions, breastfeeding support and any baby groups that parents can attend (see Useful resources).

Case study 2: risk of severe postnatal depression in a woman*

A woman aged 38 years with bad indigestion comes into the pharmacy. She has been taking antacids to ease the symptoms, but the indigestion is not resolving, and she is worried about it. Several years ago, she was treated with escitalopram for depression and anxiety, but has since stopped it. She is not taking any other medicine, has a baby aged three weeks and is struggling with breastfeeding.

The patient should be assessed for indigestion; however, it is important to notice the risk factors for postnatal depression (PND) in this patient. Persistent physical symptoms are common in anxiety and depression and should warrant further discussion. Some patients will find it easier to discuss physical problems, which can provide a way for them to open up about other difficulties they may be experiencing.

Ask the patient about:

• Their indigestion – what may be causing it or when it is worst, which may lead to a conversation about how she is feeling or coping;
• Previous episodes of depression – this is the major risk factor for developing PND, therefore, if it has not already been brought up, ask how she is feeling and whether she has any support;
• Breastfeeding – difficulty in establishing breastfeeding is a further risk factor for PND and can exacerbate feelings of failure as a mother. PND is linked to reduced rates of breastfeeding, which can have a negative impact on the mother’s mental health [21] .

Since the patient wants to continue to try to breastfeed, signpost her to places where she can get help in the local area or find more information (see Useful resources). Feelings of guilt at being unable to breastfeed are common; however, unnecessary blame and feelings of worthlessness should raise serious concerns. This red flag, coupled with her history of depression, means she should be promptly referred to her specialist perinatal mental health team. Different geographic areas require a GP referral, while some allow patients to self-refer.

Reassure the patient about how she is feeling and that there is help and support available to her. Most mental health trusts have a crisis line that operates 24 hours per day and there are charities providing similar support lines (e.g. Samaritans). However, if the patient expresses thoughts about harming herself or her baby, contact their mental health crisis team or GP for an emergency appointment. If the patient has already harmed themselves, call 999.

Potential outcome of the advice

Where there are signs of severe PND and evidence of good prior treatment with antidepressants, it is likely that the patient will be offered antidepressants and psychological therapy. Most mothers will be treated in primary care with follow-up provided by specialist mental health perinatal services.

The previous antidepressant, escitalopram, would be considered for this patient. Many resources will recommend sertraline as first-line treatment in breastfeeding (owing to its shorter half-life and low levels in breastmilk) [22] . While sertraline will be appropriate for mothers with no prior history of depression, if another antidepressant has had a good response in a previous episode of PND or depression, this will likely be used. In resistant cases, treatment with another antidepressant, lithium or antipsychotic can be considered.

The Specialist Pharmacy Service provides information to healthcare professionals on the safety of medicines in breastmilk [23] .

Case study 3: perinatal mental health problems in a man*

A man aged 30 years whose partner has recently given birth to their first child comes into the pharmacy. He looks tired and worn out as he collects a prescription for sertraline for his wife. He provides the wrong address and makes a comment about how he always seems to be getting things wrong nowadays and needs to pull himself together.

There are fewer opportunities for healthcare professionals to interact with new fathers as most antenatal care involves assessment of the mother and baby. Furthermore, men are also less likely to seek healthcare advice. Therefore, it is important to try and talk to a new father where there is an opportunity.

Ask questions, such as:

• Having a new baby can be stressful – are you both getting some time to rest?
• It can be especially difficult when mum isn’t feeling well – do you have support available to help?
• Are you getting time together with the baby? How are you finding it?

The man explains that he is struggling, feels quite low and that his wife has postnatal depression. Paternal PND has high comorbidity with maternal PND; therefore, children in such families, particularly where PND is left untreated, are at greater risk of emotional and behavioural problems later in life [24] . Although there is no single official diagnostic criteria for paternal PND [24] , the man should be referred to his GP because he is at risk.

Reassure the man that PND is common in men and seeking treatment will help. Most of the advice and support groups aimed at women also provide support to men. Furthermore, there is a specific advice group through the  PANDAS Foundation  for fathers who have PND. In some areas, there are specific baby groups for fathers, which can help to forge peer support, particularly where fathers have limited social networks with other fathers.

It is important to encourage the father to seek help and support. It can be helpful to follow up how he is feeling, particularly if he appears ambivalent about taking advice. There is no specific guidance for treating paternal PND and, therefore, usual depression treatment guidelines should be followed [25] . Treatment may involve psychological interventions or antidepressants. Where antidepressants are used, it is important to consider the effects of medicine and co-sleeping, and to advise that he should not share a bed with a baby [12] .

*All case studies are fictional.

Useful resources

• Association for Post Natal Illness
• MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014–2016  
• Choice and medication  
• LactMed – Drugs and Lactation Database  
• Start 4 Life. Breast feeding support  
• PANDAS helpline 0808 1961 776

How to have effective consultations on contraception in pharmacy

What benefits do long-acting reversible contraceptives offer compared with other available methods? 

Community pharmacists can use this summary of the available devices to address misconceptions & provide effective counselling.

Content supported by Bayer

[1] Gaynes BN, Gavin N, Meltzer-Brody S et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ) 2005;(119):1–8. PMID: 15760246

[2] Howard LM, Ryan EG, Trevillion K et al . Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy. Br J Psychiatry 2018;212(1):50–56. doi: 10.1192/bjp.2017.9

[3] National Institute for Health and Care Excellence. Identifying and assessing common mental health disorders. 2018. Available at: https://pathways.nice.org.uk/pathways/common-mental-health-disorders-in-primary-care/identifying-and-assessing-common-mental-health-disorders#content=view-node%3Anodes-asking-questions-to-identify-anxiety-disorders  (accessed January 2020)

[4] NHS Choices. Postnatal depression. 2018. Available at: https://www.nhs.uk/conditions/post-natal-depression/treatment/ (accessed January 2020)

[5] Kettunen P, Koistinen E & Hintikka J. The connections of pregnancy-, delivery-, and infant-related risk factors and negative life events on postpartum depression and their role in first and recurrent depression. Depress Res Treat 2016;2016:2514317. doi: 10.1155/2016/2514317

[6] Clout D & Brown R. Sociodemographic, pregnancy, obstetric, and postnatal predictors of postpartum stress, anxiety and depression in new mothers. J Affect Disord 2015;188:60–67. doi: 10.1016/J.JAD.2015.08.054

[7] Muraca GM & Joseph KS. The association between maternal age and depression. J Obstet Gynaecol Can 2014;36(9):803–810. doi: 10.1016/S1701–2163(15)30482-5

[8] Sit DKY & Wisner KL. Identification of postpartum depression. Clin Obstet Gynecol 2009;52(3):456–468.  PMID: 19661761

[9] National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance. Clinical guideline [CG192]. 2018. Available at: https://www.nice.org.uk/guidance/cg192  (accessed January 2020)

[10] National Institute for Health and Care Excellence. Postnatal care up to 8 weeks after birth. Clinical guideline [CG37]. 2015. Available at: https://www.nice.org.uk/guidance/cg37  (accessed January 2020)

[11] McMahon CA, Boivin J, Gibson FL et al . Older maternal age and major depressive episodes in the first two years after birth: findings from the Parental Age and Transition to Parenthood Australia (PATPA) study. J Affect Disord 2015;175:454–462. doi: 10.1016/J.JAD.2015.01.025

[12] The Lullaby Trust. Co-sleeping with your baby. 2013. Available at: https://www.lullabytrust.org.uk/safer-sleep-advice/co-sleeping/  (accessed January 2020)

[13] Mcmahon CA, Boivin J, Gibson FL et al. Older first-time mothers and early postpartum depression: a prospective cohort study of women conceiving spontaneously or with assisted reproductive technologies. Fertil Steril 2011;96:1218–1224. doi: 10.1016/j.fertnstert.2011.08.037

[14] World Health Organization. Health topics: Breastfeeding. 2015. Available at: http://www.who.int/topics/breastfeeding/en/  (accessed January 2020)

[15] National Institute for Health Research. Innovation Observatory. Brexanolone for postpartum depression. 2019. Available at: http://www.io.nihr.ac.uk/wp-content/uploads/2019/01/10557-Brexanolone-for-postpartum-depression-V1.0-JAN2019-NONCONF.pdf  (accessed January 2020)

[16] Torres A, Gelabert E, Roca A et al. Course of a major postpartum depressive episode: a prospective 2 years naturalistic follow-up study. J Affect Disord 2019;245:965–970. doi: 10.1016/j.jad.2018.11.062

[17] Boath E, Bradley E & Henshaw C. The prevention of postnatal depression: a narrative systematic review. J Psychosom Obstet Gynecol  2005;26(3):185–192. doi: 10.1080/01674820400028431

[18] Elliott SA, Leverton TJ, Sanjack M et al . Promoting mental health after childbirth: a controlled trial of primary prevention of postnatal depression. Br J Clin Psychol 2000;39(3):223–241. doi: 10.1348/014466500163248

[19] Molyneaux E, Telesia LA, Henshaw C et al. Antidepressants for preventing postnatal depression. C ochrane Database Syst Rev 2018;(4):CD004363. doi: 10.1002/14651858.CD004363.pub3

[20] O’Connor E, Senger CA, Henninger ML et al . Interventions to prevent perinatal depression. JAMA 2019;321(6):588–601. doi: 10.1001/jama.2018.20865

[21] Orsolini L, Valchera A, Vecchiotti R et al . Suicide during perinatal period: epidemiology, risk factors, and clinical correlates. Front Psychiatry 2016;7:138. doi: 10.3389/fpsyt.2016.00138

[22] British Association of Psychopharmacology. BAP consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum. 2017. Available at: https://www.bap.org.uk/pdfs/BAP_Guidelines-Perinatal.pdf  (accessed January 2020)

[23] Specialist Pharmacy Service. UK Drugs in Lactation Advisory Service (UKDILAS). 2019. Available at: https://www.sps.nhs.uk/articles/ukdilas/  (accessed January 2020)

[24] Kim P & Swain JE. Sad dads: paternal postpartum depression. Psychiatry (Edgmont) 2007;4(2):35–47. PMID: 20805898

[25] Siegel RS & Brandon AR. Adolescents, pregnancy, and mental health. J Pediatr Adolesc Gynecol 2014;27(3):138–150. doi: 10.1016/j.jpag.2013.09.008

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• Research article
• Open access
• Published: 06 January 2020

Knowledge on postnatal care among postpartum mothers during discharge in maternity hospitals in Asmara: a cross-sectional study

• Ghirmay Ghebreigziabher Beraki   ORCID: orcid.org/0000-0003-3933-0835 1 ,
• Eyasu H. Tesfamariam 2 ,
• Amanuel Gebremichael 1 ,
• Berhanemeskel Yohannes 1 ,
• Kessete Haile 1 ,
• Shewit Tewelde 1 &
• Simret Goitom 1  

BMC Pregnancy and Childbirth volume  20 , Article number:  17 ( 2020 ) Cite this article

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The early postnatal period is a dangerous time for both mother and baby where morbidity and mortality are highly prevalent if proper care is not done. Post natal care (PNC) knowledge has significant role in reducing such complications. In this study, the knowledge of postpartum mothers on PNC and its determinants were determined.

A cross-sectional quantitative study was conducted in postpartum mothers (PpM) who attended all maternal delivery services in Asmara. Data was collected by a structured questionnaire. All ( n  = 250) PpM who gave birth in December, 2017 were included in the study. Independent samples t-test and one way ANOVA were used to compare the scores in knowledge across categories of background characteristics using SPSS. Bonferroni post-hoc test was performed for variables that were found to be significant while using ANOVA tool. P -values less than 0.05 were considered as significant.

The percentage of PpM who cited vaginal bleeding, as a maternal danger sign, and fever, as a baby danger sign, were 83.2 and 58.8%, respectively. The majority (96%) of PpM responded the correct answer on where to go if they note any danger signs. In addition, more than nine tenth of PpM correctly identified injectable contraceptives (92.7%) and oral contraceptive (91.5%). The percentages of knowledge in recognizing the necessary nutrients ranged from 87.6% for carbohydrates to 46% for minerals. The percentages of correct knowledge regarding first baby bath, frequency of breast feeding, umbilical care, duration of exclusive breast feeding, need and purpose of vaccine were 40.1, 81.9, 77.4, 94.8, and 99.2% respectively. The mean PNC knowledge score was 24.89/60. The score of knowledge on postnatal care was found to significantly differ across the categories of residence ( p  < 0.001) and ethnicity ( p  = 0.015). An increasing trend of knowledge score was observed with increase in age group ( p  < 0.001), educational level ( p  = 0.021), gravida ( p  < 0.001) and para ( p  < 0.001).

Considerable gaps in knowledge regarding postnatal care among postpartum mothers were evident. Special attention should be laid on rural residents, single/living together, junior/below in educational level, primigravida/para, non-Tigrigna ethnicity, and 17 to 25 years old mothers.

Peer Review reports

Post-natal care refers to issues pertaining to the mother and the baby from birth up to 6 weeks [ 1 ]. The goal of care during the early postnatal period is to promote the physical well-being of both mother and baby, as well as support the developing relationship between the baby and his or her parents and family. In addition, it can also support the development of infant feeding skills and strengthen the mother’s knowledge and confidence in her and her baby’s health and well-being. Accordingly, postnatal care knowledge enables mothers to develop parenting skills to fulfill their mothering role within their particular family [ 2 ].

Lack of appropriate postnatal care sometimes may result in death or disability of the mother and/or newborn [ 3 ]. Worldwide, nearly 600,000 mothers between the ages of 15–49 years die every year due to complications arising from pregnancy and childbirth. Hence, maternal death occurs almost every minute of every year, out of which 99% are in the developing countries [ 3 ]. Around two thirds of maternal and newborn deaths occur in the early postpartum period in developing countries and most of them in sub-Saharan Africa [ 1 , 4 ]. Almost half of postnatal maternal deaths occur within the first 24 h and 66% occur during the first week [ 1 , 5 ]. In 2013, 2.8 million newborns died in their first month of life, from which 1 million died on the first day [ 5 ].

There has been great emphasis on skilled attendant delivery and efforts have been made to improve PNC guidelines globally and nationally [ 1 ]. In sub-Saharan Africa, 48% of women give birth with the assistance of skilled personnel [ 5 ]. A review of sub-Saharan Africa demographic and health survey showed that only 13% of women who delivered at home received postnatal care within 2 days of birth [ 5 ]. The majority of health care providers across sub-Saharan Africa, including Eritrea, continue to advise mothers to come back to the facility for a first check-up after 6 weeks [ 6 ]. Despite these services and advice, maternal and neonatal mortality and morbidity in Eritrea were extremely high [ 7 ] . According to a WHO report, infant mortality rate was 36 deaths per 1000 live births and maternal mortality ratio was 501 per 100,000 live births in 2015 [ 7 , 8 ]. In Eritrea, only 34% of the mothers who give birth were served by trained health workers [ 9 ]. Consequently, only 2% of women who had home deliveries receive postnatal care during the first 2 days of post-partum, and another 5 and 7% of such women had postnatal care within 5 to 41 days post-partum [ 10 ]. Hence, providing the needed services and advice might not always necessarily lead to achievement of the required goals.

Maternal and child health is one of the basic needs of a society for it is the cornerstone on which a health community and nation are built. Hence, the ministry of health of Eritrea has postnatal care program with sequence of activities that begins with clean delivery practice, followed by clean umblical cord care, thermal care, special care of low birth weight or preterm birth, early and exclusive breastfeeding, as well as immunization programs. However, postnatal care health education given to postpartum mothers in the maternity health facilities of Eritrea is not based on standard guidelines. On the other hand, while discharging the postpartum mothers from the hospital, list of common postnatal danger signs are given in a piece of paper to inform them that they have to approach a nearby health facility upon their appearance.

Postpartum mothers can pass the critical postpartum period successfully if they have knowledge regarding postnatal care [ 11 ]. A study conducted in Malawi on assessment of the knowledge and practice of postpartum mothers regarding postnatal care showed that almost all the participants were knowledgeable about some aspect of postnatal care [ 12 ]. However, other studies have shown women’s insufficient knowledge on postnatal care [ 13 , 14 ]. As far as the researchers’ knowledge is concerned, no published resource regarding maternal level of knowledge on postnatal care upon discharge in Eritrea exists. Therefore, this study is designed to determine maternal knowledge regarding PNC and to find out the socio-demographic determinants of knowledge scores on postnatal care among postpartum mothers.

Study design and period

Cross-sectional study design with quantitative approach was used to determine the knowledge of postnatal care among postpartum mothers during discharge in maternity hospitals in Asmara. The study was conducted in December, 2017.

Study area and population

The study was conducted in the health facilities which provide delivery service in Asmara. Asmara is the capital city of Eritrea, a country in the horn of Africa. This capital city is located 2325 m above sea level with a total area of 44.97km 2 . According to 2017 Asmara municipality report, it has a population size of 416,367. Maternity hospitals in the city are Orotta National Referral Maternity Hospital, Sembel Hospital, Edaga Hamus Community Hospital, and Betmekae Community Hospital. Postpartum mothers who delivered in these four hospitals during the study period constituted the study population.

Participants

Complete enumeration of the postpartum mothers was undertaken to determine the knowledge of postpartum mothers on postnatal care. This is because all subjects during the specified period of time can be recruited resulting to more accuracy, than that of samples. Hence, all health facilities (4 Hospitals) that render maternity services as well as all eligible postpartum mothers ( N  = 334) who have given birth during the study period in the study area were considered but only 250 were finally included in the study.

The dependent variable in the study was the knowledge of postnatal care among mothers who had given birth. The selected determinants were age, marital status, religion, educational level, and occupation.

Data collection tool and variable measurement

A questionnaire was developed with reference to a guideline prepared by WHO on post-natal care of the mother and new born [ 1 ] and previous similar studies conducted in Kenya [ 15 ] and Tanzania [ 16 ]. After compiling the questionnaire, content validity was assessed using panel of experts from Ministry of Health and Asmara College of Health Sciences. On the other hand, the internal consistency of the tool was computed and found to be within the acceptable range (Richard’s Kurdson = 0.75). Then, the questionnaire was translated from English to Tigrigna, a language most familiar to Eritreans, by experienced researchers, linguists, and midwife experts.

The questionnaire was pre-tested among 30 postpartum mothers in Orotta National Referral Maternity Hospital 1 month before the study period. The interview was done face- to- face by five degree midwife nurses who can speak and understand the language. Pre-designed questions that were not easily understood by the interviewee were simplified after pre-testing the questionnaire. Furthermore, re-arrangement of the questions were made.

The modified questionnaire had two main parts, namely, socio-demographic characteristics and questions that assess knowledge on postnatal care. There were in total 17 questions (with 60 items each having one score) that were used to determine the knowledge on postnatal care encompassing two main components: maternal care, and baby care. Maternal care component consisted of concerns on maternal danger signs (15 items), infection prevention (9 items), bladder care (1 item), sexual activity starting time (1 item), proper nutrition (6 items), delay of menstruation by exclusive breast feeding (1 item), and contraceptive methods (4 items). On the other hand, the baby care component consisted of mechanism of keeping the baby warm (2 items), time of first new born baby bath (1 item), umbilical care (1 item), initiation of breast feeding (1 item), frequency of breast feeding per day (1 item), exclusive breast feeding (1 item), needs and purposes of vaccination (2 items), and baby danger signs (14 items). Every item was scored by assigning one of the following options: “correct” (score = 1), and “wrong” (score = 0). An overall score was obtained by adding the correct responses totaling to 60. The scores indicate that with an increase in score, there is an increase of knowledge regarding postnatal care.

Data entry and analysis

After verification of the collected questionnaires by the researchers, the data was entered into CSPro (Census and Survey processing system) version 7.0 software package. The entered data was then exported to Statistical Package for Social Sciences (SPSS, version 22.0) for analysis. Frequency (percentage), mean (SD), or median (IQR) were used to describe the data, as appropriate. Normality of the knowledge score was assessed using Kolmogorov-Smirnov test. Independent samples t-test (variables with two categories) and one way ANOVA (variables with more than 2 categories) were used to find out the difference in the level of knowledge of post-natal across demographic variables. Bonferroni post hoc test was performed for the significant ANOVA results. P -values less than 0.05 were considered as significant.

Operational definition

Post-natal care refers to issues pertaining to the mother and the baby from birth up to 6 weeks [ 1 ].

Postpartum mothers are those mothers who have given birth in the health facility.

Data collectors were able to approach 334 postpartum mothers in the four hospitals during the study period. However, 27 delivered by caesarean section and 307 by spontaneous vaginal delivery (SVD). In addition, 30 subjects were excluded because they cannot speak Tigrigna (native language), 13 had still birth, and 14 withdrew from the study to arrive at 250 subjects included in the analysis (Fig.  1 ).

Study participants that were eligible and finally included in the analyses

Background characteristics of the postpartum mothers

An overview of the socio- demographic characteristics of 250 postpartum mothers during the study period on postnatal care is shown in Table  1 .

Obstetrical and gynecological history of the mothers revealed that, 28.4, 23.2, 22.8, 8.4, and 17.2% were gravida one, two, three, four, and five and above respectively (Table  2 ). On the other hand, 33.2% of respondents were primi para, 24.4% were para two, 18.8% were para three, 8.4% were para four and 15.2% were para five and above. Only 37(14.8%) of respondents had history of abortion.

Knowledge on maternal care

The percentage distribution of postpartum mothers on maternal danger signs are shown in Fig.  2 . The three most recognized maternal danger signs were heavy vaginal bleeding (83.2%), severe head ache (38.4%), and lower abdominal pain (32.0%).

Knowledge of postnatal mothers on maternal danger signs. Others = vomiting, unconsciousness or edema

Almost all (96.0%) of the respondents responded correctly on where to go if they note any danger signs (Table  3 ). Emptying the bladder every 2 hours, which is the correct response for frequency of urination, was mentioned only by 35 (21.6%) of the postpartum mothers. The majority (74.1%) of the respondents mentioned “if I felt to urinate”. The minimum time for starting sexual intercourse was correctly responded by 114 (45.6%). Six different nutrients which are needed to be taken during postpartum were presented to the postpartum mothers for identification. More than 80 % of the postpartum mothers were able to identify food items rich in carbohydrates (87.6%). Moreover, 81.6% replied high fluid intake. Food rich in proteins (75.2%), vitamins (67.6%), fats (47.2%), and minerals (45.6%) were also mentioned. The percentages of women who responded delay in menstrual period as a result of giving exclusive breast feeding for 3 months, 6 months, 1 year, 2 years, and more than 2 years were 12.0, 26.4, 22.8, 17.6 and 21.2 respectively. More than nine tenth of postpartum mothers correctly identified injectable contraceptives (92.7%) and oral contraceptive (91.5%). The remaining had mentioned IUD (53.6%), LAM (16.9%) and other contraceptives (46.8%) such as condom, Norplant or calendar method.

Nine different infection prevention methods were presented to the postnatal mothers for identification (Table  4 ). Wash perineum with warm water and some salt (70.0%) and general body hygiene (69.6%) were highly known infection prevention methods. The remaining seven infection prevention methods were known by less than half of the postpartum mothers. Among the least known infection prevention methods were hand washing after changing pads (10.8%), hand washing after perineal hygiene (10.4%), and hand washing before perineal hygiene (6.8%).

Knowledge on baby care

Table 5 shows the percentage distribution of mothers by their knowledge on baby care. Knowledge on keeping the baby warm by wrapping the baby with cloth was almost universal (99.6%). Few (6.8%) also mentioned skin to skin contact. Correct response on the time at which first bath can be given for a new born baby was obtained from 67(26.8%) of the study participants. More than three fourths (77.4%) of the women responded umbilical care should be simply keeping clean and dry. Most of the respondents (88.40%) mentioned the correct answer on initiation of breast feeding after delivery which is within 30 min. Almost three fourths (74.0%) of the women correctly responded to the frequency need of breast feeding per day (eight per day); however, 10.4% said ‘if the baby cries’. The majority (94.8%) of respondents correctly answered that duration of exclusive breast feeding needs to be for 6 months. Almost all respondents (99.2%) correctly knew the needs of vaccine for a newborn baby. With regards to the purpose of vaccine, most of the respondents (94.8%) mentioned ‘to prevent disease’ and 13 (5.2%) did not know.

More than half of the respondents mentioned fever (58.8%), severe vomiting (53.2%), and difficulty in breathing (50.8%) as baby danger signs (Table  6 ). Almost one third of the women were able to identify the inability to breast feed (32.8%) and irritability (33.2%). Less than one fourth of the respondents cited umbilical problems (14.0%), abdominal distention (9.2%), convulsion (8.4%), lethargy (7.6%), yellowness of eyes (7.6%), eye problem (6.8%), yellowness of palms (2.8%), and yellowness of sole (1.6%). However, 19 (7.6%) of the respondents mentioned “I don’t know” and 101 (40.4%) responded vomiting/unconsciousness/ edema.

Comparison of knowledge scores

The results showed that the mean knowledge score was 24.89/60 (SD = 5.66). Independent sample t-test has revealed that the categories in residence ( p  < 0.001) and ethnicity ( p  = 0.015) had shown significant difference in score of knowledge on postnatal care among postpartum mothers (Table 7 ). However, occupation ( p  = 0.210), religion ( p  = 0.476), number of abortion ( p  = 0.783) have not shown significant difference in score of knowledge on postnatal care among postpartum mothers.

Result from one way ANOVA (Table  8 ), revealed that there was significant difference in the average score of knowledge regarding post natal care among the postpartum mothers across different age groups ( p  < 0.001), marital status ( p  = 0.045), educational level ( p  = 0.014), gravidity ( p  < 0.001) and parity ( p  < 0.001). An increasing trend of knowledge score was observed with increase in age group ( p  = 0.001), educational level ( p  = 0.021), gravidity ( p  < 0.001) and parity ( p  < 0.001).

Bonferroni post-hoc comparison showed that the postnatal knowledge score among mothers aged 17–25 was significantly less than 26–30, and 31–42 years old. Moreover, significantly higher knowledge score was observed among married and divorced as compared to single and living together. Postpartum mothers who are junior or below were also found to have significantly lower postnatal knowledge score as compared to mothers who are secondary and higher level. No significant difference in knowledge score was observed among mothers who were gravidity two, three, four, and five or above, however, mothers of gravidity one had significantly less knowledge score than mothers of the aforementioned gravidity. Similar results with that of the gravidity were observed for parity.

There are maternal and child health programs to safeguard maternal and child health in Eritrea. Nonetheless, maternal and neonatal mortality ratio still remain as high as 501/100,000 and 36/1000 live births, respectively, in the country [ 8 ]. Studies regarding utilization of maternal health services such as antenatal care and skilled delivery at birth are not infrequent; however, there still exists paucity of studies on knowledge regarding postnatal care in the country. One of the fundamental activities that needs to be instigated for the improvement of maternal and neonatal health is postnatal care because the majority of maternal and newborn death happen during this period [ 1 ]. Among others, one dimension of initiating postpartum care constitutes enhancing the knowledge of the mothers in order to enable them to properly handle themselves and the neonates in times of difficulty [ 17 ].

In this study, vaginal bleeding (83.2%) was the most frequently mentioned danger sign during the postpartum period. This finding is similar to a research conducted in Ethiopia (89.2%) [ 18 ] but lower than another study done in Nepal (98.47%) [ 3 ]. When compared with the study conducted in Ethiopia, a similar result observed is foul-smelling vaginal discharge (23.3%) as a danger sign [ 18 ]. However, in the Ethiopian study, relatively higher percentages of postnatal mothers identified severe headache (38.4% Vs 23.1%), blurred vision (19.2% Vs 8.9%), convulsion (13.6% Vs 7.9%) and lower abdominal pain (32.0% Vs 2.9%) as danger signs as compared to this study [ 18 ]. This could be due to the long standing public health campaigns given in Eritrea that bleeding either during pregnancy or post-partum period puts the mother’s health at danger.

In this study, the most identified infection prevention methods were washing perineum with warm water and some salt (70.0%) and changing pads frequently (36.4%). These findings are lower than those yielded in the study done in Nepal, in which 91.33% of PpM had prior knowledge of washing perineum with warm water and 83.16% changing pads frequently [ 3 ]. This discrepancy could be due to differences in the availability of health facilities and maternal training in the two study populations.

Around half (45.6%) of the postpartum mothers were aware about the appropriate time for restarting sexual intercourse in this study. However, it is difficult to say whether the postpartum mothers’ knowledge on this issue has been obtained through proper and methodical mechanisms, such as trainings and educational interventions, or from tradition. However, it is worth remembering that the scientific and traditional reason of commencing sexual intercourse after 6 weeks has the same ground. Lochia stays up to 6 weeks postpartum putting the mother at risk of postpartum infection and the pain as well as discomfort associated with the childbirth. Besides, the majority (87.6%) of participants in this study were Christians, and specifically belonged to the Orthodox Christian religion, where women are traditionally obliged to abstain from sexual intercourse for a minimum of 40 days because they are considered as polluted (tainted) after childbirth.

Worldwide, unwanted pregnancy is a major cause of death in children less than 5 years of age and a death of pregnant women attempting abortion (650 per100,000 pregnant women) each year [ 11 , 19 ]. Hence, a reliable contraceptive method is needed for mothers to avoid unwanted pregnancy as early as possible because menstruation period usually restarts at 3 to 9 weeks [ 11 ]. In the current study, knowledge of PpM on contraceptive methods shows that injectable contraceptives (92.7%) and oral contraceptives (91.5%) were highly mentioned. These findings are higher than the study done in Nepal that indicated injectable or Depo-Provera (78.0%) followed by oral contraceptive pills (74.0%) as the most common methods [ 20 ]. Therefore, it seems that maternal training and consultation about contraceptive methods in Eritrea is properly addressed and should be maintained.

In the present study, regarding knowledge of postpartum mothers on keeping baby warm after delivery, almost all participants (99.6%) had a higher knowledge when compared to a study conducted in Nepal which showed that 82% had knowledge on wrapping the baby with warm clothes. However, in this study, lower level of knowledge (6.8%) was scored on keeping baby warm by skin to skin contact than the study done in Nepal (58%) [ 21 ] .

Almost one-fourth of the PpM knew the correct answer for ‘when to give a bath to a newly born baby’ which is similar to a study conducted in India (30%) [ 22 ]. Around three-fourths of the postpartum mothers in the current study responded that umbilical cord is taken care of by simply keeping the umbilicus clean and dry. However, the study in Nepal showed that 59% were knowledgeable about keeping the umbilicus clean and dry [ 21 ]. The culture-driven beliefs and practices have also led 14.7% of the postpartum mothers in this study to indicate that butter is to be applied for umbilical care.

Health education provision by health workers at the health facilities and through the mass media could be the possible reason behind the correct knowledge (88.4%) of postpartum mothers regarding initiation of breastfeeding within 30 min. However, in a study done in Nepal, the percentage of mothers who mentioned that breastfeeding needs to be initiated within 1 hour was 48% [ 21 ]. Fever, as a new born danger sign, was identified by only 58.8% of the postpartum mothers in this study. This can be said to be relatively lower than the findings in Ethiopia (76.6%) [ 18 ] and Kenya (74.9%) [ 15 ]. Moreover, the difficulty of breathing as a baby danger sign was mentioned by almost half (50.8%) of the postpartum mothers. The same danger sign, was known by 46.6% of the participants in Kenyan study [ 15 ], whereas the current study finding was higher than that of Ethiopian study (19.7%) [ 14 ].

Results regarding new-born danger signs on umbilical cord problem (14, 5.4, 35%), convulsion (8.4, 19.3, 15%), and eye problem (6.8, 16.7, 21%) were not similar in this study, Ethiopia, and Nepal respectively [ 14 , 21 ]. Yellow palm as baby danger sign was the most highly unidentified (97.2%) by the postpartum mothers in this study, which is similar to the findings in Ghana (93.6%) [ 23 ]. However, inconsistent results on jaundice as baby danger sign were obtained in a study done in Nepal (21%) [ 21 ].

Comparison of the knowledge scores by categories of residence has revealed that urban residents had significantly greater knowledge score than the rural residents. The main reason for the difference could be the regularity in health education in urban places. Another possible reason could be the easy access to transport in urban places to go to the place where health education is offered. The lower level of knowledge among mothers who were in the age group 17 to 25, or primipara could be due to practical lessons that multipara mothers gain each time birth occurs.

Limitations of the study

The use of a cross sectional design in this study did not allow for causal relationships to be established, thus the reasons why postpartum mothers reported certain maternal and baby care more so than others is not known.

The average knowledge score on PNC of the postpartum mothers was low for it was below half of the overall score. Moreover, significant association between the mothers’ knowledge and their age group, residence, educational background, and parity was observed. Therefore, special attention should be given to mothers living in rural areas, junior or below in educational level, single or living together, primigravida/primipara, ethnic groups other than Tigrigna, and those between 17 to 25 years of age to improve PNC knowledge.

Availability of data and materials

Data set is available in electronic form which can be accessed upon a reasonable request from the corresponding author.

Abbreviations

Analysis Of Variance

Cesarean Section

Interquartile range

Post Natal Care

Postpartum Mothers

Standard Deviation

Statistical Package for Social Sciences

Spontaneous vaginal delivery

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Acknowledgments

We thank the staffs at the study areas for their assistance and collaboration. We would like also to express our heartfelt appreciation to the mothers who have participated in this study.

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Department of Nursing, Orotta College of Medicine and Health Sciences, Asmara, Eritrea

Ghirmay Ghebreigziabher Beraki, Amanuel Gebremichael, Berhanemeskel Yohannes, Kessete Haile, Shewit Tewelde & Simret Goitom

Department of Statistics, Biostatistics and Epidemiology Unit, College of Science, Eritrea Institute of Technology, Mai-Nefhi, Eritrea

Eyasu H. Tesfamariam

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Each author contributed substantially to manuscript. GGB conceived, designed, wrote, analyzed and interpreted the manuscript. AG, BY, KH, ST, and SG collected the data and analyzed and wrote the first draft of the paper. EHT designed, analyzed and critically revised the manuscript for important intellectual content the final paper. All authors have read the manuscript for publication. All authors read and approved the final manuscript.

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Ethical approval was obtained from Asmara College of Health Sciences with a ref. No.: 019/09/17 and Eritrean Ministry of Health research and ethics committee with a ref. No.: 002/10/17. The participants’ rights were protected by ensuring voluntary participation and supported by written consent; after explaining the purpose, nature, potential benefits and risks of the study and data collection techniques. The anonymity and confidentiality of the participants were assured and treated as strictly confidential. Furthermore, they were given a full right to drop from participating in the study.

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Beraki, G.G., Tesfamariam, E.H., Gebremichael, A. et al. Knowledge on postnatal care among postpartum mothers during discharge in maternity hospitals in Asmara: a cross-sectional study. BMC Pregnancy Childbirth 20 , 17 (2020). https://doi.org/10.1186/s12884-019-2694-8

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DOI : https://doi.org/10.1186/s12884-019-2694-8

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Case Study: 29-Year-Old Female with Postpartum Hemorrhage

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A 29-year-old female (G1P1) is readmitted two weeks post–vaginal delivery due to increased vaginal bleeding. She reports that the bleeding began on the tenth day after delivery and has increased in severity each subsequent day. The delivery was uncomplicated with minimal blood loss and the patient did not receive any epidural anesthesia. She has taken 200 mg of ibuprofen daily since delivery. The patient reports a medical history of iron deficient anemia due to menorrhagia. She is adopted and does not know her family history.

Since admission, the patient has received three units of blood. The obstetrics team has ruled out retained placental tissue and uterine atony as the cause of bleeding. Her laboratory values are as follows:

What hematologic disease is most likely contributing to her bleeding?

• NSAID-induced platelet dysfunction
• Acquired factor VIII inhibitor
• von Willebrand disease
• Disseminated intravascular coagulation
• Microangiopathy hemolytic anemia

Explanation

This patient is presenting with secondary postpartum hemorrhage with a clinical and laboratory history suggestive of von Willebrand disease (vWD). Overall, there is a 20 percent risk of peripartum bleeding with vWD, and 75 percent of women with moderate to severe vWD can experience severe bleeding. Bleeding can be seen from any type of vWD. For women with mild forms of vWD, the peripartum period can be the first manifestation of the disease. 1 Furthermore, since peripartum bleeding unrelated to a bleeding disorder is common, the diagnosis of an underlying bleeding diathesis may not be considered.

During pregnancy both factor VIII and von Willebrand factor (vWF) levels increase, with peaks at 29 to 32 weeks gestation and at 35 weeks gestation, respectively. 2 Following delivery, vWF levels may fall precipitously within the first few weeks resulting in delayed uterine bleeding. 3 Management of women with known vWD includes monitoring vWF levels during pregnancy and for three to four weeks post-partum to ensure return to baseline. Prophylaxis and treatment of vWD during pregnancy is based upon the severity of disease and specific type of vWD.

Acquired factor VIII inhibitors are a rare but serious cause of secondary postpartum hemorrhage. 4 The activated partial thromboplastin time (aPTT) is typically significantly prolonged if there is a factor VIII inhibitor. Disseminated intravascular coagulation is an important cause of post-partum hemorrhage. Significant prolongations of the aPTT and PT as well as low fibrinogen levels are necessary to make the diagnosis. Microangiopathic hemolytic anemia may occur in the peripartum period and is associated with low hemoglobin and platelets. However, this diagnosis results in manifestations of microvascular thrombosis rather than hemorrhage.

Case study submitted by James N. Cooper, MD, of the National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD.

• Ragni MV, Bontemp FA, Hassett AC. von Willebrand disease and bleeding in women . Haemophilia. 1999; 5:313-317
• Sié P, Caron C, Azam J, et el. Reassessment of von Willebrand factor (VWF), VWF propeptide, factor VIII:C and plasminogen activator inhibitors 1 and 2 during normal pregnancy . Br J Haematol. 2003; 121:897-903.
• Kujovich JL. von Willebrand disease and pregnancy . J Thromb Haemost. 2005; 3:246-253.
• Paidas MJ, Hossain N. Unexpected postpartum hemorrhage due to an acquired factor VIII inhibitor . Am J Perinatol. 2014 31:645-654

American Society of Hematology. (1). Case Study: 29-Year-Old Female with Postpartum Hemorrhage. Retrieved from https://www.hematology.org/education/trainees/fellows/case-studies/female-postpartum-hemorrhage .

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"American Society of Hematology." Case Study: 29-Year-Old Female with Postpartum Hemorrhage, 27 Mar. 2024 , https://www.hematology.org/education/trainees/fellows/case-studies/female-postpartum-hemorrhage .

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Postpartum depression in India: a systematic review and meta-analysis

Dépression post-partum en inde: revue systématique et méta-analyse, depresión posparto en india: una revisión sistemática y un metaanálisis, اكتئاب ما بعد الولادة في الهند: مراجعة منهجية وتحليل تَلوي ملخص, 印度产后抑郁症： 系统评价和元分析, Послеродовая депрессия в Индии: систематический обзор и метаанализ, ravi prakash upadhyay.

a Department of Community Medicine, Room 517, 5th floor, College Building, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India.

Ranadip Chowdhury

b Independent Researcher, New Delhi, India.

Aslyeh Salehi

c School of Health and Human Sciences, Southern Cross University, Queensland, Australia

Kaushik Sarkar

d Directorate of National Vector Borne Disease Control Programme, New Delhi, India.

Sunil Kumar Singh

Bireshwar sinha.

e Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India.

Aditya Pawar

f Department of Psychiatry, Drexel University College of Medicine, Philadelphia, United States of America.

Aarya Krishnan Rajalakshmi

Amardeep kumar.

g Department of Psychiatry, Patna Medical College, Patna, Bihar, India.

To provide an estimate of the burden of postpartum depression in Indian mothers and investigate some risk factors for the condition.

We searched PubMed®, Google Scholar and Embase® databases for articles published from year 2000 up to 31 March 2016 on the prevalence of postpartum depression in Indian mothers. The search used subject headings and keywords with no language restrictions. Quality was assessed via the Newcastle–Ottawa quality assessment scale. We performed the meta-analysis using a random effects model. Subgroup analysis and meta-regression was done for heterogeneity and the Egger test was used to assess publication bias.

Thirty-eight studies involving 20 043 women were analysed. Studies had a high degree of heterogeneity ( I 2  = 96.8%) and there was evidence of publication bias (Egger bias = 2.58; 95% confidence interval, CI: 0.83–4.33). The overall pooled estimate of the prevalence of postpartum depression was 22% (95% CI: 19–25). The pooled prevalence was 19% (95% CI: 17–22) when excluding 8 studies reporting postpartum depression within 2 weeks of delivery. Small, but non-significant differences in pooled prevalence were found by mother’s age, geographical location and study setting. Reported risk factors for postpartum depression included financial difficulties, presence of domestic violence, past history of psychiatric illness in mother, marital conflict, lack of support from husband and birth of a female baby.

The review shows a high prevalence of postpartum depression in Indian mothers. More resources need to be allocated for capacity-building in maternal mental health care in India.

Résumé

Fournir une estimation de la charge de la dépression post-partum chez les mères indiennes et étudier certains facteurs de risque liés à cette maladie.

Méthodes

Nous avons recherché dans les bases de données PubMed®, Google Scholar et Embase® des articles, publiés entre l'année 2000 et le 31 mars 2016, sur la prévalence de la dépression post-partum chez les mères indiennes. Nous avons articulé nos recherches autour de vedettes-matière et de mots-clés, sans restrictions de langues. La qualité a été évaluée au moyen de l'échelle d’évaluation de la qualité Newcastle-Ottawa. Nous avons réalisé la méta-analyse à l'aide d'un modèle à effets aléatoires. Une analyse par sous-groupes et une méta-régression ont été effectuées à l'égard de l'hétérogénéité et le test Egger a été utilisé pour évaluer le biais de publication.

Résultats

Trente-huit études portant sur 20 043 femmes ont été analysées. Les études présentaient un degré élevé d'hétérogénéité (I2 = 96,8%) et l'existence de biais de publication a été démontrée (bais Egger = 2,58; intervalle de confiance, IC, à 95%: 0,83-4,33). L'estimation combinée globale de la prévalence de la dépression post-partum était de 22% (IC à 95%: 19-25). Après exclusion de 8 études rendant compte de dépressions post-partum dans les 2 semaines suivant l'accouchement, la prévalence combinée a été estimée à 19% (IC à 95%: 17-22). Quelques petites différences négligeables au niveau de la prévalence combinée ont été constatées selon l'âge de la mère, la situation géographique et le cadre de l'étude. Les facteurs de risques associés à la dépression post-partum qui ont été identifiés incluaient des difficultés financières, la présence de violence domestique, des antécédents de maladie psychiatrique chez la mère, des conflits conjugaux, une absence de soutien de la part du mari et la naissance d'une fille.

La revue a révélé une prévalence élevée de la dépression post-partum chez les mères indiennes. Il est nécessaire d'allouer davantage de ressources au renforcement des capacités en ce qui concerne les soins de santé mentale destinés aux mères indiennes.

Ofrecer una estimación de la carga de la depresión posparto en madres indias e investigar algunos factores de riesgo de la enfermedad.

Métodos

Se realizaron búsquedas en las bases de datos de PubMed®, Google Scholar y Embase® para encontrar artículos publicados desde el año 2000 hasta el 31 de marzo de 2016 sobre la prevalencia de la depresión postparto en madres indias. En la búsqueda se utilizaron epígrafes temáticos y palabras clave sin restricciones de lenguaje. La calidad se evaluó con la escala de evaluación de calidad de Newcastle‒Ottawa. Se realizó un metaanálisis utilizando un modelo de efectos aleatorios. El análisis y la metarregresión de los subgrupos se realizaron con fines de heterogeneidad y se utilizó la prueba de Egger para evaluar las tendencias de las publicaciones.

Se analizaron treinta y ocho estudios que incluían 20 043 mujeres. Los estudios tuvieron un alto grado de heterogeneidad (I2 = 96,8%) y se encontraron pruebas de tendencias de publicaciones (tendencia de Egger = 2,58; intervalo de confianza, CI, del 95%: 0,83–4,33). La estimación general calculada sobre la prevalencia de la depresión posparto fue del 22% (IC del 95%: 19–25). La prevalencia obtenida fue del 19% (IC del 95%: 17–22), salvo en 8 estudios que informaron de depresión posparto dentro de las 2 primeras semanas después del parto. Se descubrieron pequeñas diferencias con poca importancia en la prevalencia obtenida según la edad de la madre, la ubicación geográfica y el marco del estudio. Los factores de riesgo descubiertos sobre la depresión posparto incluían dificultades financieras, violencia doméstica, historial pasado de enfermedad psiquiátrica, conflicto marital, ausencia de apoyo por parte del marido y nacimiento de una niña.

Conclusión

El análisis muestra una alta prevalencia de depresión posparto en madres indias. Es necesario asignar más recursos para aumentar la capacidad de la atención de salud mental de las madres en la India.

ملخص

الغرض.

توفير تقدير للعبء الناتج عن الإصابة باكتئاب ما بعد الولادة بين الأمهات الهنديات والنظر في بعض عوامل الخطورة لتلك الحالة.

الطريقة

لقد بحثنا في قواعد بيانات PubMed®‎ وGoogle Scholar وEmbase®‎ عن مقالات نشرت من عام 2000 حتى 31 مارس/آذار 2016 عن انتشار الإصابة باكتئاب ما بعد الولادة بين الأمهات الهنديات. وقد استخدم البحث عناوين الموضوع والكلمات الرئيسية دون قيود لغوية. وتم تقييم الجودة النوعية من خلال مقياس Newcastle‒Ottawa لتقييم الجودة النوعية. كما قمنا بإجراء تحليل تَلوي مستخدمين نموذجًا للمؤثرات العشوائية. وتم إجراء تحليل المجموعة الفرعية والتحوف التلوي لعدم التجانس، وتم استخدام اختبار Egger لتقييم عامل التحيز في نشر البحوث العلمية.

النتائج

تم تحليل 38 دراسة شملت 20043 امرأة. وكانت الدراسات على درجة عالية من عدم التجانس (حيث بلغ مربع معامل عدم التجانس I2: = ‏96.8‏٪) وكان هناك دليل على وجود تحيز في المنشورات العلمية (حيث بلغ مقدار التحيز وفقًا لمعيار Egger‏ = 2.58؛ بنطاق ثقة بنسبة 95‏٪: 0.83–4.33). وكان التقدير المجمع الكلي لمعدل انتشار الاكتئاب بعد الولادة ‏‏22٪ (بنطاق ثقة مقداره ‏95‏٪: 19–25). وباستثناء ثماني دراسات، فإن التقارير المتعلقة باكتئاب ما بعد الولادة في غضون أسبوعين من الولادة قد حققت انتشارًا مجمعًا بنسبة ‏‏‏19٪ (بنطاق ثقة مقداره ‏95‏٪: 17–22). ووُجدت فروق صغيرة ولكن غير ملموسة في الانتشار المجمع تبعًا لعمر الأم، والموقع الجغرافي، ومحيط الدراسة. وشملت عوامل الخطر المبلغ عنها لاكتئاب ما بعد الولادة الصعوبات المالية، ووجود العنف المنزلي، والتاريخ السابق للأمراض النفسية في الأم، والصراع الزوجي، ونقص الدعم من الزوج، وولادة طفلة أنثي.

الاستنتاج

أظهرت المراجعة معدلاً مرتفعًا لانتشار اكتئاب ما بعد الولادة بين الأمهات الهنديات. ويلزم تخصيص مزيد من الموارد لبناء القدرات في مجال الرعاية الصحية العقلية للأمهات في الهند.

摘要

目的.

对印度产妇产后抑郁症负担进行估计，调查此情况下的风险因素。

方法

我们检索了 PubMed®、Google 学术 (Google Scholar) 和 Embase® 数据库中从 2000 年至 2016 年 3 月 31 日发布的关于印度产妇产后抑郁症患病率的文章。 检索采用没有语言局限性的主题词和关键词。 通过纽卡斯尔-渥太华质量评估量表评估质量。 我们使用随机效应模型进行元分析。 对异质性进行分组分析和元回归分析，并采用 Egger 测试来评估发布偏倚。

结果

我们分析了涉及 20043 名女性的 38 项研究。 研究具有高异质性（I2 = 96.8％），有证据显示存在发布偏差（Egger 偏差 = 2.58；95％ 置信区间，CI： 0.83–4.33). 产后抑郁症患病率的汇总估计值为 22％ （95％ CI： 19–25). 排除报告称在产后 2 周内患有产后抑郁症的 8 项研究后的汇总患病率为 19％（95％ CI： 17–22)。 不同产妇年龄、地理位置和研究背景会出现细微（非显著）差别。 据报告，产后抑郁症的风险因素包括经济困难、家庭暴力、产妇精神病史、夫妻矛盾、缺乏丈夫的支持和生出女婴。

结论

本次考察显示印度产妇产后抑郁症患病率很高。 需要为印度产妇精神健康护理的能力建设配置更多资源。

Резюме

Цель.

Дать оценку бремени послеродовой депрессии у матерей в Индии и изучить некоторые факторы риска для этого состояния.

Методы

Авторы провели поиск в базах данных PubMed®, Google Scholar и Embase® на предмет статей, опубликованных с 2000 года по 31 марта 2016 года, которые посвящены распространенности послеродовой депрессии у матерей в Индии. При поиске использовались предметные указатели и ключевые слова без языковых ограничений. Качество исследований оценивалось по шкале оценки качества Ньюкасл-Оттава. Авторы провели метаанализ с использованием модели со случайными эффектами. Для определения гетерогенности проводился анализ данных в подгруппах и метарегрессия. Кроме того, с помощью теста Эггера была выполнена оценка на предмет систематической ошибки, связанной с предпочтительной публикацией положительных результатов исследования (публикационная ошибка).

Результаты

Был проведен анализ тридцати восьми исследований, в которых принимали участие 20 043 женщины. Исследования имели высокую степень гетерогенности (I2 = 96,8%), также имелись признаки систематической публикационной ошибки (отклонение Эггера = 2,58, 95% доверительный интервал, ДИ: 0,83–4,33). Согласно объединенной оценке с использованием всех имеющихся данных, распространенность послеродовой депрессии составила 22% (95% ДИ: 19–25). После исключения 8 исследований, сообщающих о случаях послеродовой депрессии в течение 2 недель после родов, объединенная распространенность составила 19% (95% ДИ: 17–22). Различия в объединенной распространенности, обусловленные возрастом матерей, географическим расположением и условиями проведения исследования, были незначительны. Выявленные факторы риска для послеродовой депрессии включали: финансовые трудности, домашнее насилие, историю психических заболеваний у матери, супружеские конфликты, отсутствие поддержки от мужа и рождение ребенка женского пола.

Вывод

Обзор свидетельствует о высокой распространенности послеродовой депрессии у матерей в Индии. Необходимо выделить больше ресурсов для создания потенциала в области охраны психического здоровья матерей в Индии.

Introduction

Postpartum psychiatric disorders can be divided into three categories: postpartum blues; postpartum psychosis and postpartum depression. 1 , 2 Postpartum blues, with an incidence of 300‒750 per 1000 mothers globally, may resolve in a few days to a week, has few negative sequelae and usually requires only reassurance. 1 Postpartum psychosis, which has a global prevalence ranging from 0.89 to 2.6 per 1000 births, is a severe disorder that begins within four weeks postpartum and requires hospitalization. 3 Postpartum depression can start soon after childbirth or as a continuation of antenatal depression and needs to be treated. 1 The global prevalence of postpartum depression has been estimated as 100‒150 per 1000 births. 4

Postpartum depression can predispose to chronic or recurrent depression, which may affect the mother‒infant relationship and child growth and development. 1 , 5 – 7 Children of mothers with postpartum depression have greater cognitive, behavioural and interpersonal problems compared with the children of non-depressed mothers. 5 , 6 A meta-analysis in developing countries showed that the children of mothers with postpartum depression are at greater risk of being underweight and stunted. 6 Moreover, mothers who are depressed are more likely not to breastfeed their babies and not seek health care appropriately. 5 A longitudinal study in a low- and middle-income country documented that maternal postpartum depression is associated with adverse psychological outcomes in children up to 10 years later. 8 While postpartum depression is a considerable health issue for many women, the disorder often remains undiagnosed and hence untreated. 1 , 9

The current literature suggests that the burden of perinatal mental health disorders, including postpartum depression, is high in low- and lower-middle-income countries. A systematic review of 47 studies in 18 countries reported a prevalence of 18.6% (95% confidence interval, CI: 18.0‒19.2). 10 Scarcity of available mental health resources, 11 inequities in their distribution and inefficiencies in their utilization are key obstacles to optimal mental health, especially in lower resource countries. Addressing these issues is therefore a priority for national governments and their international partners. The impetus for this will come from reliable scientific evidence of the burden of mental health problems and their adverse consequences.

Despite the launch of India’s national mental health programme in 1982, maternal mental health is still not a prominent component of the programme. Dedicated maternal mental health services are largely deficient in health-care facilities, and health workers lack mental health training. The availability of mental health specialists is limited or non-existent in peripheral health-care facilities. 12 Furthermore, there is currently no screening tool designated for use in clinical practice and no data are routinely collected on the proportion of perinatal women with postpartum depression. 12

India is experiencing a steady decline in maternal mortality, 13 which means that the focus of care in the future will shift towards reducing maternal morbidity, including mental health disorders. Despite the growing number of empirical studies on postpartum depression in India, there is a lack of robust systematic evidence that looks not only at the overall burden of postpartum depression, but also its associated risk factors. Our current understanding of the epidemiology of postpartum depression is largely dependent on a few regional studies, with very few nationwide data. The current review was done to fill this gap, by providing an updated estimate of the burden of postpartum depression in India, to synthesize the important risk factors and to provide evidence-based data for prioritization of maternal mental health care.

Data sources and search strategy

Two authors (RPU and AP) independently searched PubMed®, Google Scholar and Embase® databases for articles on the prevalence of postpartum depression in India, published until 31 March 2016. The search strategy ( Box 1 ) used subject headings and keywords with no language restrictions. Any discrepancy in the search results was planned to be discussed with a third author (AKR). We also searched the bibliographies of included articles and government reports on government websites to identify relevant primary literature to be included in the final analysis. For studies with missing data or requiring clarification, we contacted the principal investigators.

Box 1

Search keywords used for identification of articles for the review of the prevalence of postpartum depression, india, 2000–2015.

• (“depression” OR “depressive disorder” OR “blues” OR “distress” OR “bipolar” OR “bi-polar” OR “mood disorder” OR “anxiety disorder”)
• (“postpartum” OR “postnatal” OR “perinatal” OR “post birth” OR “after delivery” OR “after birth” OR “puerperium” OR “puerperal”)
• (“prevalence” OR “incidence” OR “burden” OR “estimate” OR “epidemiology”)
• (“India” OR “South East Asia”)
• (#1 AND #2 AND #3 AND #4)
• (Addresses[ptyp] OR Autobiography[ptyp] OR Bibliography[ptyp] OR Biography[ptyp] OR pubmed books[filter] OR Case Reports[ptyp] OR Congresses[ptyp] OR Consensus Development Conference[ptyp] OR Directory[ptyp] OR Duplicate Publication[ptyp] OR Editorial[ptyp] OR Systematic reviews OR Meta analysis OR Festschrift[ptyp] OR Guideline[ptyp] OR In Vitro[ptyp] OR Interview[ptyp] OR Lectures [ptyp] OR Legal Cases[ptyp] OR News[ptyp] OR Newspaper Article[ptyp] OR Personal Narratives [ptyp] OR Portraits[ptyp] OR Retracted Publication[ ptyp] OR Twin Study[ptyp] OR Video-Audio Media[ptyp])
• (#5 NOT #6) Filters: Original research; published in the past 15 years; humans

Study selection and data extraction

For a study to be included in the systematic review, it had to be original research done in India, within a cross-sectional framework of a few weeks to 1 year post-birth. We excluded research done in a specific population, such as mothers living with human immunodeficiency virus; research including mothers with any current chronic disease. To have a fairly recent estimate of the burden of postpartum depression, we considered only studies published from the year 2000 and later. After initial screening of titles and abstracts, we reviewed the full text of eligible publications. Decisions about inclusion of studies and interpretation of data were resolved by discussion among the reviewers. Data from all studies meeting the inclusion criteria were extracted and tabulated.

Study quality assessment

We used the Newcastle‒Ottawa quality assessment scale adapted for cross-sectional studies. 14 , 15 The scale is used to score the articles under three categories: (i) selection (score 0‒5); (ii) comparability (score 0‒2 ); and (iii) outcome (score 0‒3); total score range 0‒10. The selection category consists of parameters, such as representativeness of the sample, adequacy of the sample size, non-response rate and use of a validated measurement tool to gather data on exposure. The comparability category examines whether subjects in different outcome groups are comparable based on the study design and analysis and whether confounding factors were controlled for or not. The outcome category includes whether data on outcome(s) were collected by independent blind assessment, through records or by self-reporting. The outcome category also includes whether the statistical tests used to analyse data were clearly described and whether these tests were appropriate or not. Two authors (RPU and KS) made separate quality assessments of the included studies. In case of any discrepancy, a third author (AP) was consulted. We grouped the studies into those with quality scores ≤ 5 and > 5.

Data analysis

We did a meta-analysis of the reported prevalence of postpartum depression in the included studies. Heterogeneity between studies was quantified by the I 2 statistic. We considered I 2 values > 50% to represent substantial heterogeneity. 16 The degree of heterogeneity among the studies was high (> 95%), and thus we used a random effects model to derive the pooled estimate for postpartum depression in mothers. The final estimates of prevalence were reported as percentages with 95% CI.

We did a subgroup analysis by excluding articles in which depression was assessed within 2 weeks postpartum, 1 , 17 , 18 since some researchers argue that it is difficult to differentiate postpartum depression from postpartum blues within 2 weeks of birth. In addition, the Edinburgh postnatal depression scale, which was used in the majority of studies we identified, can give false-positive results in the early postpartum period.

We also did separate subgroup analyses on each of the following factors: place of study (geographical location; rural or urban; hospital or community); study instrument used; quality score of the articles; time of publication; and age of mothers. Not all the studies provided data on the mean age of the study participants that was required for subgroup analysis; however, the proportion of mothers in specific age ranges were available. Using this information, we estimated the mean age of the study participants. For studies that reported the prevalence of postpartum depression in mothers at different time points, we used the prevalence reported in the earliest time point to reduce the effect of lost to follow-up. We used meta-regression analysis to identify factors contributing to the heterogeneity in effect size, i.e. the pooled proportion of mothers with postpartum depression.

We assessed publication bias with the Egger test and used a funnel plot to graphically represent the bias. Finally, we listed the risk factors for postpartum depression. We used Stata software, version 14 (StataCorp. LLC, College Station, United States of America) for all analyses.

Characteristics of the studies

Of the 1285 articles we identified in our search, we screened 1248 titles of unique articles. Out of these, we reviewed 211 relevant abstracts, assessed 62 full-text articles for eligibility and included 38 articles in our final analysis. 19 – 56 ( Fig 1 ). These 38 studies included data from 20 043 mothers in total. More of the articles (26 studies) were published in the most recent five-year period 2011‒2015 than in the earlier periods 2000–2005 (6) and 2006–2010 (6). The majority of studies were from south India (16 studies), followed the western (9) and northern regions (7) of the country; 24 studies were done in an urban setting and 29 in hospitals ( Table 1 ; available at: http://www.who.int/bulletin/volumes/94/10/17-192237 ). In 19 studies, the mean age of the study mothers was ≤ 25 years. The Edinburgh postnatal depression scale was the most commonly used study instrument (29 studies). The median quality score for the studies was 5 (21 articles had a score of ≤ 5 and 17 had a score >  5).

Flowchart showing the selection of studies for the systematic review of the prevalence of postpartum depression, India, 2000–2015

BDI: Beck depression inventory; CIS-R: clinical interview schedule-revised; DSM-IV: diagnostic and statistical manual of mental disorders 4th edition; DSM-IV-TR: “text revision” of diagnostic and statistical manual of mental disorders 4th edition; EPDS: Edinburgh postnatal depression scale; MINI: M.I.N.I. international neuropsychiatric interview; NR: not reported; PHQ-9: 9-item patient health questionnaire; PRIME-MD: primary care evaluation of mental disorders; RCT: randomized controlled trial; SD: standard deviation.

a We used the Newcastle–Ottawa quality assessment scale with a maximum score of 10. 14

b Reported average age of participants > 25 years.

c Range is 95% confidence interval.

d Range of ages.

Prevalence of postpartum depression

Based on the random effects model, the overall pooled estimate of the prevalence of postpartum depression in Indian mothers was 22% (95% CI: 19–25; Fig. 2 ). Eight studies included women reporting depression within 2 weeks of delivery. After excluding these, the pooled prevalence for the remaining 30 studies (11 257 women) was 19% (95% CI: 17–22; Fig. 3 ).

Estimated prevalence of postpartum depression, pooling all selected studies ( n  = 38), India, 2000–2015

CI: confidence interval.

Notes: Results from random effect analysis. Studies included a total of 20 043 women. The dashed line passing through the midpoint of the diamond denotes the point estimate of the overall pooled effect size and the lateral tips of the diamond represent 95% confidence intervals.

Estimated prevalence of postpartum depression after excluding studies reporting depression within 2 weeks postpartum (n=30), India, 2000-2015

Notes: Results from random effect analysis. Studies included a total of 11 257 women. The dashed line passing through the midpoint of the diamond denotes the point estimate of the overall pooled effect size and the lateral tips of the diamond represent 95% confidence intervals.

The estimated overall pooled prevalence was highest in the southern region of the country (26%; 95% CI: 19–32), followed by eastern (23%; 95% CI: 12-35), south-western (23%; 95% CI: 19–27) and western regions (21%; 95% CI: 15–28; Table 2 ). The northern region of India had the lowest prevalence (15%; 95% CI: 10–21). The pooled prevalence was higher, but not significantly so, for studies conducted in hospital settings (23%; 95% CI: 19–28) than in community settings (17%; 95% CI: 13–22); Fig. 4 ; Table 2 ) and in urban versus rural areas (24%; 95% CI: 19–29 versus 17%; 95% CI: 14–21). Prevalence was 20% (95% CI: 16–24) and 21% (95% CI: 16–26) when studies with mean maternal age of ≤ 25 years and > 25 years were pooled respectively.

CI: confidence interval; EPDS: Edinburgh postnatal depression scale; Ref.: reference category.

a Prabhu 51 et al. and Affonso et al. 56 did not provide information on study setting.

b Includes diagnostic and statistical manual of mental disorders 4th edition (DSM-IV); 9-item patient health questionnaire; primary care evaluation of mental disorders; Beck depression inventory; M.I.N.I. international neuropsychiatric interview plus DSM-IV; Kessler 10-item scale; and clinical interview schedule‒revised.

c Numbers do not total 20 043 as the number of women varies according to the time of assessment postpartum.

d Dhiman et al., 34 Prakash et al., 36 Manjunath et al. 44 and Prabhu et al. 51 either did not provide the age of mothers or sufficient data for the analysis.

Estimated prevalence of postpartum depression from hospital- and community-based studies ( n  = 36), India, 2000–2015

Notes: Results from random effect analysis. Studies included a total of 19 455 women (11 898 in hospital-based studies and 7557 in community-based studies). Two studies (Prabhu 51 et al. and Affonso et al. 56 ) did not provide information on study setting. The dashed line passing through the midpoint of the diamond denotes the point estimate of the overall pooled effect size and the lateral tips of the diamond represent 95% confidence intervals. The three diamonds from the top represent the pooled estimate for hospital-based studies, community-based studies and overall pooled estimate respectively.

Pooling of studies that used the Edinburgh postnatal depression scale as the study instrument produced a prevalence of 24% (95% CI: 20–28) compared with 17% (95% CI: 13–22) in those that used other study instruments ( Table 2 ).

Studies with a quality score ≤ 5 had a pooled prevalence of 22% (95% CI: 18–27) and those with a score > 5 had a prevalence of 21% (95% CI: 18–25).

The studies had a high degree of heterogeneity ( I 2  = 96.8%). Both the Egger plot (Egger bias = 2.58; 95% CI: 0.83–4.33; Fig. 5 ) and the funnel plot ( Fig. 6 ) showed evidence of publication bias.

Egger plot for publication bias in the meta-analysis of studies ( n  = 38) on the prevalence of postpartum depression, India, 2000–2015

Funnel plot of publication bias in the meta-analysis of studies ( n  = 38) on the prevalence of postpartum depression, India, 2000–2015.

Notes: The outer dashed lines indicate the triangular region within which 95% of studies are expected to lie in the absence of both biases and heterogeneity. The solid line represents the log of the total overall estimate of the meta-analysis.

Risk factors

A total of 32 studies reported risk factors for postpartum depression. The risk factors most commonly reported were financial difficulties (in 19 out of 21 studies that included this variable), domestic violence (6/8 studies), past history of psychiatric illness in the mother (8/11 studies), marital conflict (10/14 studies), lack of support from the husband (7/11 studies) and birth of a female baby (16/25 studies). Other commonly reported risk factors were lack of support from the family network (8/14 studies), recent stressful life event (6/11 studies), family history of psychiatric illness (7/13 studies), sick baby or death of the baby (6/13 studies) and substance abuse by the husband (4/9 studies). Preterm or low birth-weight baby, high parity, low maternal education, current medical illness, complication in current pregnancy and unwanted or unplanned pregnancy and previous female child, were some of the other reported risk factors ( Table 3 ).

a High maternal age reported as > 30–35 years. Low maternal age reported as < 25 years.

b Total number of studies that analysed maternal age as a risk factor for postpartum depression.

c Studies that analysed maternal education as a risk factor for postpartum depression.

The pooled prevalence of postpartum depression in India in our meta-analysis was 22% (95% CI: 19–25). A systematic review of studies in 11 high-income countries showed that, based on point prevalence estimates, around 12.9% (95% CI: 10.6–15.8) of mothers were depressed at three months postpartum. 57 Data from 23 studies conducted in low- and middle-income countries, which included 38 142 women, was 19.2% (95% CI: 15.5–23.0). 58 Another systematic review from 34 studies found that the prevalence of common mental disorders in the postpartum period in low- and lower-middle income countries was 19.8% (95% CI: 19.2–20.6). 10 These estimates in low- and middle-income countries are similar to ours and, taken together, they support an argument for placing greater importance on maternal mental health as part of overall efforts to improve maternal and child health.

Although facility-based deliveries are increasing in many low- and middle-income countries, a high proportion of pregnant mothers still deliver at home. 59 Beyond the lack of awareness of postpartum depression by health professionals, there are issues that may be barriers to prompt recognition and management of the illness. 60 – 62 In India, women who deliver at a health facility often stay for less than 48 hours after delivery. 63 This leaves little opportunity for health personnel to counsel the mother and family members on the signs and symptoms of postpartum depression and when to seek care. In low- and middle-income countries, the proportion of women who visit the health facility for postpartum visits is generally low and consequently mental disorders often remain undetected and unmanaged, especially for those delivering at home. 64 Analysis of demographic and health survey data from 75 countdown countries showed that postnatal care visits for mothers have low coverage among interventions on the continuum of maternal and child care 65 Postnatal traditions, such as the period of seclusion at home observed in many cultures, can negatively affect care-seeking behaviour in the postpartum period. Furthermore, mothers may be reluctant to admit their suffering either because of social taboos associated with depression or concerns about being labelled as a mother who failed to deliver the responsibilities of child care. In the current public health system in most low- and middle-income countries, including India, primary-care workers are supposed to be in regular contact with recently delivered mothers. However, at postnatal visits community health workers tend to focus on promoting essential infant care practices, with lower priority given to the mother’s health. 63 , 66 These factors might explain, to some extent, the lack of availability of reliable, routine data on the burden of postpartum depression in low- and middle-income countries.

A strength of our study is the large sample of recently delivered mothers included in the review. This is probably the first review that documents the overall estimated prevalence of postpartum depression in India. The study has its limitations as well. Most of the studies included in the review did not provide effect sizes against the risk factors for postpartum depression and this precluded pooling of risk factors to provide an estimate. Most of the studies included in the review used the Edinburgh postnatal depression scale and the cut-offs used to label postpartum depression varied among studies. This could limit the internal validity of our findings. We observed significant heterogeneity in the results and performed subgroup analysis and meta-regression. The meta-regression analysis was able to explain < 10% of the heterogeneity and suggests that unidentified factors were causing such heterogeneity.

Among the studies included in our review, risk factors for postpartum depression included financial difficulties, birth of a female child, marital conflict, lack of support from the family, past history of psychiatric illness, high parity, complications during pregnancy and low maternal education. Previous studies from low- and middle-income countries report similar risk factors. 58 , 67

We found relatively higher pooled proportion of postpartum depression in mothers residing in urban than in rural areas. This may be due to factors such as overcrowding, inadequate housing, breakdown of traditional family structures leading to fragmented social support systems, increased work pressure, high cost of living and increased out-of-pocket expenditure on health care. 68 Pooling of hospital-based studies found comparatively higher estimates of postpartum depression than studies in community settings. It is likely that mothers suffering from any illness during the postnatal period, including postnatal depression, will seek care at a health facility, compared to physically healthy mothers and babies who may not visit a facility at all. Moreover, being in a hospital environment provides an opportunity for the mother to express her concerns and problems to the health personnel, but when interviewed at her home she may not admit to having depressive symptoms, owing to the presence of other family members or neighbours and the social stigma attached to mental health conditions.

On subgroup analysis, we found a slightly higher proportion of postpartum depression in mothers who were aged > 25 years compared with those aged ≤ 25 years. Moreover, high maternal age emerged as a risk factor for depression in 4/28 studies which included this variable compared with 3/28 studies reporting low maternal age as a risk. Older mothers may suffer more from depression because they lack peer support or because they have more obstetric complications and multiple births or greater use of assisted reproductive technologies. 69 – 71 On the other hand, it is possible that depression among older mothers is simply a biological phenomenon.

In our meta-analysis, geographical variation in the prevalence of postpartum depression was observed, with the highest prevalence in the southern regions. The observed differences in prevalence were not statistically significant on meta-regression and therefore more data are needed to document any significant geographical variations. The southern parts of the country have high literacy rates, which could lead to increased awareness about this health issue and therefore increased care-seeking. 72 Moreover, the health system in southern India is more organized and there is comparatively better primary health-care provision than in other parts of the country and this could be a factor in greater care-seeking. 73 South India also has a higher proportion of people living in urban slums compared with the northern parts of the country and greater rates of intimate partner violence. 74 , 75

We found that the number of studies on postpartum depression has seen an upward trend in the last five years. There were 26 published studies between 2011‒2016, compared with six each in the periods 2000‒2005 and 2006‒2010. This reflects a recent interest of the medical research community towards this important issue.

There are a lack of data on perinatal mental health problems from low- and middle-income countries 76 and this gap in the evidence hinders the process of establishing interventions to promote maternal psychosocial health. Gathering data on perinatal mental health issues will be essential in these countries, not only to gauge the magnitude of the problem, but also to inform policy-makers. Such evidence can stimulate governments to allocate resources for capacity-building in maternal mental health care, such as developing and implementing guidelines and protocols for screening and treatment, and setting targets for reducing the burden of postpartum depression.

Acknowledgements

We thank Mary V. Seeman (Department of Psychiatry, University of Toronto, Canada) and Meenakshi Bhilwar (Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi). Aslyeh Salehi is also affiliated with the Menzies Health Institute, Queensland, Australia.

Competing interests:

None declared.