Exploring predictors and prevalence of postpartum depression among mothers: Multinational study

Using the widely used EPDS to determine the current PPD, we found that the overall frequency of PPD in the total sample was 92 (13.6%). Which significantly (p = 0.001) varied across different countries, being highest among Ghana mothers 13 (26.0%) out of 50 and Indians 28 (21.7%) out of 129. Egyptian 21 (19.1) out of 110, Yemen 14 (8.5%) out of 164, Iraq 13 (7.7%) out of 169, and Syria 1 (2.3%) out of 43 in descending order. This prevalence was similar to that reported by Hairol et al. (2021) in Malaysia (14.3%) [13], Yusuff et al. (2010) in Malaysia (14.3%) [14], and Nakku et al. (2006) in New Delhi (12.75%) [15].

While the frequency of PPD varied greatly based on the timing, setting, and existence of many psychosocial and post-partum periods, for example, it was higher than that reported in Italy (2012), which was 4.7% [16], in Turkey (2017) was 9.1%/110 [17], 9.2% in Sudan [18], Eritrea (2020) was 7.4% [19], in the capital Kuala Lumpur (2001) was (3.9%) [20], in Malaysia (2002) was (9.8%) [21], and in European countries. (2021) was 13–19% [22].

Lower frequencies were than those reported; PPD is a predominant problem in Asia, e.g., in Pakistan, the three-month period after childbirth, ranging from 28.8% in 2003 to 36% in 2006 to 94% in 2007, while after 12 months after childbirth, it was 62% in 2021 [23‐24]. While in 2022 Afghanistan 45% after their first labour [25] in Canada (2015) was 40% [26], in India, the systematic review in 2022 was 22% of Primipara [27], in Malaysia (2006) was 22.8% [28], in India (2019) was 21.5% [29], in the Tigray zone in Ethiopia (2017) was 19% [30], varied in Iran between 20.3% and 35% [31‐32], and in China was 499 (27.37%) out of 1823 [33]. A possible explanation might be the differences in the study setting and the type of design utilized. Other differences should be considered, like different populations with different socioeconomic characteristics and the variation in the timing of post-partum follow-up. It is vital to consider the role of culture, the impact of patients’ beliefs, and the cultural support for receiving help for PPD.

Regarding age, our study found no significant difference between PPD and non-PPD mothers with regard to age. In agreement with our study [12, 34, 35], other studies [36‐38] found an inverse association between women’s age and PPD, with an increased risk of PPD (increases EPDS scores) at a younger age significantly, as teenage mothers, being primiparous, encounter difficulty during the postpartum period due to their inability to cope with financial and emotional difficulties, as well as the challenge of motherhood. Cultural factors and social perspectives of young mothers in different countries could be a reason for this difference. [38‐39] and Abdollahi et al. [36] reported that older mothers were a protective factor for PPD (OR = 0.88, 95% CI: 0.84–0.92].

Regarding marital status, after controlling for other variables, married mothers exhibited a significantly diminished likelihood of experiencing PPD in comparison to single women (0.141; 95% CI: 0.04–0.494; p = 0.002). Also, Gebregziabher et al. [19] reported that there were statistically significant differences in proportions between mothers’ PPD and marital status.

Regarding the mother’s education, in agreement with our study, Ahmed et al. [34] showed that there was no statistically significant difference between PPD and a mother’s education. While Agarwala et al. [29] showed that a higher level of mother’s education. increases the risk of PPD, Gebregziabher et al. [19] showed that the housewives were 0.24 times less likely to develop PPD as compared to the employed mothers (aOR = 0.24, 95% CI: 0.06–0.97; p = 0.046); those mothers who perceived their socioeconomic status (SES) as low were 13 times more likely to develop PPD as compared to the mothers who had good SES (aOR = 13.33, 95% CI: 2.66–66.78; p = 0.002).

Regarding the SES or monthly income, while other studies [18, 40] found that there was a statistically significant association between PPD mothers and different domains of SES, 34% of depressed women were found to live under low SES conditions in comparison to only 15.4% who were found to live in high SES and experienced PPD. In disagreement with our study, Hairol et al. [12] demonstrated that the incidence of PPD was significantly p = 0.01 higher for participants from the low-income group (27.27%) who were 2.58 times more likely to have PDD symptoms (OR: 2.58, 95% CI: 1.23–5.19; p = 0.01 compared to those from the middle- and high-income groups (8.33%), and low household income (OR = 3.57 [95% CI: 1.49–8.5] increased the odds of PPD [41].

Adeyemo et al. (2020),and Al Nasr et al. (2020) revealed that there was no significant difference between the occurrence of PPD and socio-demographic characteristics. This difference may be due to a different sample size and ethnicity [42, 43]. In agreement with our findings, Abdollahi et al. [36] demonstrated that after multiple logistic regression analyses, there were increased odds of PPD with a lower state of general health (OR = 1.08 [95% CI: 1.06–1.11]), gestational diabetes (OR = 2.93 [95% CI = 1.46–5.88]), and low household income (OR = 3.57 [95% CI: 1.49–8.5]). The odds of PPD decreased.

Regarding access to health care, in agreement with studies conducted at Gondar University Hospital, Ethiopia [18], North Carolina, Colorado [21], Khartoum, Sudan [44], Asaye et al. [45], the current study found that participants who did not have free access to the healthcare system were riskier for the development of PPD. the study results may be affected by the care given during the antenatal care (ANC) visits. This can be explained by the fact that PPD was four times higher than that of mothers who did not have ANC, where counseling and anticipatory guidance care are given that build maternal self-esteem and resiliency, along with knowledge about normal and problematic complications to discuss at care visits and their right to mental and physical wellness, including access to care. The increased access to care (including postpartum visits) will increase the diagnosis of PPD and provide guidance, reassurance, and appropriate referrals. Healthcare professionals have the ability to both educate and empower mothers as they care for their babies, their families, and themselves [46].

Regarding nationality, for PPD mothers of Yemeni nationality compared to those of Egyptian nationality, the aOR is 0.318 (95% CI: 0.123–0.821, p = 0.018). Similarly, for Syrian nationality in comparison to Egyptian nationality, the aOR is 0.111 (95% CI: 0.0139–0.887, p = 0.038), and for Iraqi nationality compared to Egyptian nationality, the aOR is 0.241 (95% CI: 0.0920–0.633, p = 0.004). These findings indicated that, while accounting for other covariates, individuals from the aforementioned nationalities were less predisposed to experiencing PPD than their Egyptian counterparts. These findings can be explained by the fact that, in Egypt, the younger age of marriage, especially in rural areas, poor mental health services, being illiterate, dropping out of school early, unemployment, and the stigma of psychiatric illnesses are cultural factors that hinder the diagnosis and treatment of PPD [40].

In the present study, the number of dead children was significantly associated with PPD. This report was supported by studies conducted with Gujarati postpartum women [41] and rural southern Ethiopia [43]. This might be because mothers who have dead children pose different psychosocial problems and might regret it for fear of complications developing during their pregnancy. Agarwala et al. [29] found that a history of previous abortions and having more than two children increased the risk of developing PPD due to a greater psychological burden. The inconsistencies in the findings of these studies indicate that the occurrence of postpartum depression is not solely determined by the number of childbirths.

In obstetric and current pregnancy, there was no significant difference regarding the baby’s age, number of miscarriages, type of last delivery, premature labour, healthy baby, baby admitted to the neonatal intensive care unit (NICU), or feeding difficulties. In agreement with Al Nasr et al. [42], inconsistent with Asaye et al. [45], they showed that concerning multivariable logistic regression analysis, abortion history, birth weight, and gestational age were significant associated factors of postpartum depression at a value of p < 0.05.

However, a close association was noted between the mode of delivery and the presence of PPD in mothers, with p = 0.107. There is a high tendency towards depression seen in mothers who have delivered more than three times (44%). In disagreement with what was reported by Adeyemo et al. [41], having more than five children (p = 0.027), cesarean section delivery (p = 0.002), and mothers’ poor state of health since delivery (p < 0.001) are associated with an increase in the risk of PPD [47]. An increased risk of cesarean section as a mode of delivery was observed (OR = 1.958, p = 0.049) in a study by Al Nasr et al. [42].

We reported breastfeeding mothers had a lower, non-significant frequency of PPD compared to non-breast-feeding mothers (36.6% vs. 45%). In agreement with Ahmed et al. [34], they showed that with respect to breastfeeding and possible PPD, about 67.3% of women who depend on breastfeeding reported no PPD, while 32.7% only had PP. Inconsistency with Adeyemo et al. [41], who reported that unexclusive breastfeeding (p = 0.003) was associated with PPD, while Shao et al. [40] reported that mothers who were exclusively formula feeding had a higher prevalence of PPD.

Regarding postnatal problems, our results revealed that postnatal problems display a significant association with PPD. In line with our results, Agarwala et al. [29] and Gebregziabher et al. [19] showed that mothers who experienced complications during childbirth, those who became ill after delivery, and those whose babies were unhealthy had a statistically significant higher proportion of PPD.

Hormone-related contraception methods were found to have a statistically significant association with PPD, consistent with the literature [46]; this can be explained by the hormones and neurotransmitters as biological factors that play significant roles in the onset of PPD. Estrogen hormones act as regulators of transcription from brain neurotransmitters and modulate the action of serotonin receptors. This hormone stimulates neurogenesis, the process of generating new neurons in the brain, and promotes the synthesis of neurotransmitters. In the hypothalamus, estrogen modulates neurotransmitters and governs sleep and temperature regulation. Variations in the levels of this hormone or its absence are linked to depression [19].

Participants whose last pregnancy was unplanned were 3.39 times more likely to have postpartum depression (aOR = 3.39, 95% CI: 1.24–9.28; p = 0.017). Mothers who experienced illness after delivery were more likely to develop PPD as compared to their counterparts (aOR = 7.42, 95% CI: 1.44–34.2; p = 0.016) [40]. In agreement with Asaye et al. [45] and Abdollahi et al. [36], unplanned pregnancy has been associated with the development of PPD (aOR = 2.02, 95% CI: 1.24, 3.31) and OR = 2.5 [95% CI: 1.69–3.7] than those of those who had planned, respectively.

Mothers with a family history of mental illness were significantly associated with PPD. This finding was in accordance with studies conducted in Istanbul, Turkey [47], and Bahrain [48]. Other studies also showed that women with PPD were most likely to have psychological symptoms during pregnancy [43‐49]. A meta-analysis of 24,000 mothers concluded that having depression and anxiety during pregnancy and a previous history of psychiatric illness or a history of depression are strong risk factors for developing PPD [50‐52]. Asaye et al. [45], mothers whose relatives had mental illness history were (aOR = 1.20, 95% CI: 1.09, 3.05 0) be depressed than those whose relatives did not have mental illness history.

This can be attributed to the links between genetic predisposition and mood disorders, considering both nature and nurture are important to address PDD. PPD may be seen as a “normal” condition for those who are acquainted with relatives with mood disorders, especially during the CBP. A family history of mental illness can be easily elicited in the ANC first visit history and requires special attention during the postnatal period. There are various risk factors for PPD, including stressful life events, low social support, the infant’s gender preference, and low income [53].

Concerning familial support and possible PPD, a statistically significant association was found between them. We reported that mothers who did not have social support (a partner or the father of the baby) had higher odds (aOR = 5.8, 95% CI: 1.33–25.29; p = 0.019) of experiencing PPD. Furthermore, Al Nasr et al. [42] revealed a significant association between the PPD and an unsupportive spouse (P value = 0.023). while it was noted that 66.5% of women who received good familial support after giving birth had no depression, compared to 33.5% who only suffered from possible PPD [40]]. Also, Adeyemo et al. [41] showed that some psychosocial factors were significantly associated with having PPD: having an unsupportive partner (p < 0.001), experiencing intimate partner violence (p < 0.001), and not getting help in taking care of their baby (p < 0.001). Al Nasr et al. (2020) revealed that the predictor of PPD was an unsupportive spouse (OR = 4.53, P = 0.049) [48].

Regarding the perceived stigma, in agreement with our study, Bina (2020) found that shame, stigma, the fear of being labeled mentally ill, and language and communication barriers were significant factors in women’s decisions to seek treatment or accept help [53]. Other mothers were hesitant about mental health services [54]. It is noteworthy that some PPD mothers refused to seek treatment due to perceived insufficient time and the inconvenience of attending appointments [55].

PPD was significantly higher among mothers with financial problems or problems with their husbands. This came in agreement with Ahmed et al. [34], who showed that, regarding stressful conditions and PPD, there was a statistically significant association with a higher percentage of PPD among mothers who had a history of stressful conditions (59.3%), compared to those with no history of stressful conditions (40.7%). Furthermore, Al Nasr et al. (2020) revealed that stressful life events contributed significantly (P value = 0.003) to the development of PPD in the sample population. Al Nasr et al. stressful life events (OR = 2.677, p = 0.005) [42].

Feeling at ease discussing mental health topics with one’s husband, family, community, and physician and experiencing cultural stigma or judgment regarding PPD within the community was significantly associated with the presence of PPD. In the current study, there were different reasons for not receiving the treatment, including cultural or traditional beliefs, language or communication barriers, social norms, and geographical or regional disparities in mental health resources. Haque and Malebranche [56] portrayed culture and the various conceptualizations of the maternal role as barriers to women seeking help and treatment.

In the present study, marital status, nationality, current pregnancy status, healthy baby, postnatal problems, receiving support or treatment for PPD, having awareness of symptoms and risk factors of PPD, suffering from any disease or mental or psychiatric disorder, comfort discussing mental health with family, and experiencing cultural stigma or judgment about PPD in the community were the significant predictors of PPD. In agreement with Ahmed et al. [34], the final logistic regression model contained seven predictors for PPD symptoms: SES, history of depression, history of PPD, history of stressful conditions, familial support, unwanted pregnancy, and male preference.

PPD has been recognized as a public health problem and may cause negative consequences for infants. It is estimated that 20 to 40% of women living in low-income countries experience depression during pregnancy or the postpartum period. The prevalence of PPD shows a wide variation, affecting 8–50% of postnatal mothers across countries [19].

Strengths of our study include its multinational scope, which involved participants from six different countries, enhancing the generalizability of the findings. The study also boasted a large sample size of 674 participants, increasing the statistical power and reliability of the results. Standardized measures, such as the Edinburgh Postnatal Depression Scale (EPDS), were used for assessing postpartum depression, ensuring consistency and comparability across diverse settings. Additionally, the study explored a comprehensive range of predictors and associated factors of postpartum depression, including demographic, obstetric, health-related, and psychosocial characteristics. Rigorous analysis techniques, including multiple logistic regression analyses, were employed to identify significant predictors of postpartum depression, controlling for potential confounders and providing robust statistical evidence.

However, the study has several limitations that should be considered. Firstly, its cross-sectional design limits causal inference, as it does not allow for the determination of temporal relationships between variables. Secondly, the reliance on self-reported data, including information on postpartum depression symptoms and associated factors, may be subject to recall bias and social desirability bias. Thirdly, the use of convenience sampling methods may introduce selection bias and limit the generalizability of the findings to a broader population. Lastly, cultural differences in the perception and reporting of postpartum depression symptoms among participants from different countries could influence the results.

Moreover, the variation in sample size and response rates among countries can be attributed to two main variables. (1) The methodology showed that the sample size was determined by considering several parameters, such as allocating proportionately to the mothers who gave birth and fulfilling the selection criteria during the data collection period served by each health center. (2) The political turmoil in Syria affects how often and how well people can use the Internet, especially because the data was gathered using an online survey link, leading to a relatively low number of responses from those areas. (3) Language barrier in Ghana: as we used the Arabic and English-validated versions of the EPDS, Ghana is a multilingual country with approximately eighty languages spoken. Although English is considered an official language, the primarily spoken languages in the southern region are Akan, specifically the Akuapem Twi, Asante Twi, and Fante dialects. In the northern region, primarily spoken are the Mole-Dagbani ethnic languages, Dagaare and Dagbanli. Moreover, there are around seventy ethnic groups, each with its own unique language [57]. (4) At the end of the data collection period, to avoid seasonal affective disorders, the meteorological autumn season began on the 1st day of September, which may be associated with autumm depressive symptoms that may confound or affect our results. Furthermore, the sampling methods were not universal across all Arabic countries, potentially constraining the generalizability of our findings.