Maternal anxiety, depression and posttraumatic stress disorder (PTSD) after natural disasters: a systematic review

Figures & data

Figure 1. systematic literature search and study selection.

Table 1. Studies of maternal mental health morbidities organized by type of natural disaster.

#	Maternal Psychiatric Disorder	Study	Author	Country	Design	Population/ Exposure	Outcome	Findings	Tools Used	Data Quality Assessment
Pandemic: COVID-19, SARS, HIV
1	Depression, Anxiety	Effects of the COVID-19 pandemic on anxiety and depressive symptoms in pregnant women: a preliminary study	Durankus et al.	Turkey	Case control, online survey	COVID-19, N = 260	EPDS score (postpartum depression), BDI (depression), BAI (anxiety)	35.4% (n = 92) pregnant women scored higher than 13 on EPDS. Significant correlation with effect of COVID-19 on psychology and EPDS score and with effect of social isolation and EPDS score (p < .001). Significant positive correlations between BDI, BAI, and EPDS scores.	EPDS (Edinburgh Postpartum Depression Scale) (0-30) >13 cutoff BDI (Beck Depression Inventory) 0–63 range, BAI (Beck Anxiety Inventory) 0-63 range	2
2	Depression, Anxiety	Moms Are Not OK: COVID-19 and Maternal Mental Health	Davenport et al.	Australia	Case control, online survey	COVID-19, N = 900	Moderate to high anxiety (STAI-state score > = 40), depression (EPDS score > = 13)	EPDS > = 13 in 15% respondents pre-pandemic, 40.7% during pandemic STAI-state scores > = 40 in 29% of women before pandemic, 72% during pandemic. At least 150 min moderate intensity physical activity had significantly lower anxiety and depression scores than those who did not	EPDS >/= 13 cutoff State-Trait Anxiety Inventory (STAI-State) >/=40 moderate to high anxiety	1
3	Anxiety	Psychological impact of coronavirus disease 2019 in pregnant women	Saccone et al.	Napoli, Italy	Cross-sectional survey	COVID-19, N = 100	Psychological impact using Impact of Event Scale - Revised (IES-R), Anxiety using State Trait Anxiety Inventory (STAI) Italian version, Visual Analog Scale (VAS)	Mean IES-R score of 36.9 +/– 10.1. 53 of 100 rated psychological impact as severe. Mean STAI score was 45.2 +/– 14.6, overall incidence of STAI >36 of 68%. Psychological impact of COVID-19 outbreak more severe in women in 1st trimester of pregnancy: higher mean STAI, higher rate of STAI >36, higher mean score at VAS for anxiety for COVID vertical transmission, and higher rate of VAS score > =50	Impact of Event Scale - Revised (IES-R) 0-88 range, 0-23 normal, 24–32 mild impact, 33-36 moderate impact, >37 severe psychological impact STAI 20–80 range, 34–36 normal, VAS 0-100 range, >50 high	2
4	Depression	Reliability and validity of the center for epidemiologic studies-depression scale in screening for depression among HIV-infected and -uninfected pregnant women attending antenatal services in northern Uganda: a cross-sectional study	Natamba et al.	Northern Uganda	Cross-sectional	HIV infection, N = 123	Major depressive disorder (MDD)	Greater proportion of HIV + (52.9%) were likely to have MDD than HIV - (28.7%, p = .011). Adjusting for maternal age and marital status, HIV + scored 6.2 points higher on CES-D than HIV - (p = .032)	Center for Epidemiologic Studies Depression (CES-D) scale, cutoff score of 17	1
5	Depression, PTSD	Maternal post-traumatic stress disorder, depression and alcohol dependence and child behavior outcomes in mother-child dyads infected with HIV: a longitudinal study	Nöthling et al.	Cape Town, South Africa	Longitudinal cohort	HIV Infection, N = 70	Children’s behavior	Depression was 50% (n = 35), PTSD was 22.9% (n = 16), alcohol abuse was 7.1% (n = 5) and alcohol dependence was 2.9% (n = 2). Children with problematic behavior prevalence was 44.3% (n = 31). Children of mothers with depression were more likely to display behavior problems (p = .035) compared to children of mothers without depression.	Life Events Checklist (LEC) Harvard Trauma Scale (HTS) Alcohol Use Disorders Identification Test (AUDIT) Center for Epidemiological Studies Depression Scale (CESD Scale) Sheehan Disability Scale (SDS) Child Behavior Checklist (CBCL)	2
6	Depression, Anxiety	Psychological responses of pregnant women to an infectious outbreak: A case-control study of the 2003 SARS outbreak in Hong Kong	Lee et al.	Hong Kong	Case control	SARS, N = 235	Behavioral and psychological response	Anxiety level of SARS cohort higher than controls (37.2+/–9.7 vs 35.5+/-9.3, p = .02). No statistical difference between depression levels of two cohorts. Women of SARS cohort had significantly better social support. Significant negative correlation between BDI score and total social support score (r=–0.41, p < .0001).	BDI - depression, cutoff 14.5 STAI - anxiety, no cutoff SSS (Medical Outcomes Study Social Support Study) - measures social support	1
Earthquake
7	Depression	Health impact of disaster-related stress on pregnant women living in the affected area of the Noto Peninsula earthquake in Japan	Hibino et al.	Noto Peninsula, Japan	Cohort	Earthquake 3/25/2007, N = 99	EPDS scores, physical abnormality during pregnancy or childbirth	Mean EPDS for study participants after delivery was 3.8 +/– 4.1. Existing anxiety about earthquake and Parity were the two significant factors that predicted postnatal depression (EPDS) (existing anxiety: eta = 0.33, p < .01, and parity: eta = 0.36, p < .01) SOC during pregnancy significantly moderated between existing anxiety about an earthquake and EPDS.	EPDS cutoff at 9 SOC (sense of coherence scale) range of 7-91	2
8	Depression, PTSD	Posttraumatic stress disorder and depression among new mothers at 8 months later of the 2008 Sichuan earthquake in China	Qu et al.	Sichuan province, China	Cross-sectional	2008 earthquake, N = 317	PTSD and postpartum depression prevalence	Women with high earthquake exposure had higher risks of PTSD (odds ratio 5.91, 95% CI 1.75–19.97, p < .001) and postpartum depression (odds ratio 7.28, 95% CI 2.51–21.08, p < .001) than women without earthquake experience. Low monthly income and farm workers had higher risk of PTSD, unemployed or lower income and poor sleep had higher risk of depression	CESD (Center for Epidemiological Studies Depression) Scale, <16 little or no symptoms, 16-20 mild symptoms, 21-25 moderate symptoms, >26 severe depression IES-R - Impact of Event Scale - Revised, equal to or greater than 1.8 for 3 subscales = full PTSD symptoms, 1 or 2 subscales > =1.8 partial PTSD symptoms	1
9	Depression, PTSD	The impact of the catastrophic earthquake in China’s Sichuan province on the mental health of pregnant women	Qu, Tian, et al.	Sichuan province, China	Cross-sectional	2008 earthquake, N = 311	PTSD symptoms using IES-R, symptoms of antenatal depression using EPDS	Prevalence of PTSD was 12.2% (95%CI 9.0–16.4), major depression was 40.8% (95%CI 35.5–46.4). Risk of PTSD symptoms grew with increased pregnancy-related stress (OR 1.19, 95%CI 1.07–1.32, p = .001) and increased severity of earthquake experience (OR 1.80, 95%CI 1.43–2.26, p < .001). Risk of depression grew as stresses of pregnancy increased (OR 1.19, 95%CI 1.12–1.27 and decreased as quality of family relationship improved (OR 0.84, 95%CI 0.73–0.98, p = .022)	IES-R for PTSD, cutoff of 2.0 EPDS for antenatal depression, cutoff of 10	1
10	Depression, Anxiety, PTSD	Psychiatric morbidity and pregnancy outcome in a disaster area of Taiwan 921 earthquake	Chang et al.	Pu-Li Christian Hospital, Taiwan	Cohort	1999 earthquake, N = 115	Minor psychiatric morbidity prevalence	29.2% (n = 50 of 171) of women scored higher than 3 on CHQ-12, identified as suffering from minor psychiatric disease. 9.3% of women rated “profound" in impact on mood on CHQ questionnaire. Significant associations were found between low neonatal birth weight and maternal abdominal injury or spouse casualty during earthquake or instability in living condition.	CHQ-12: adapted from General Health Questionnaire (GHQ) to identify minor psychiatric disorders, >3 = minor psychiatric disease PTSD measured by Earthquake Exposure Checklist (EEC) and Posttraumatic Stress Reaction Checklist (PTSRC)	1
Hurricane
11	Depression, Anxiety, PTSD	Association of complementary and alternative therapies with mental health outcomes in pregnant women living in a post-disaster recovery environment	Barcelona de Mendoza et al.	New Orleans	Cross-sectional	Complementary and Alternative Medicine (CAM) therapies, N = 402	Mental health (depression, pregnancy-specific anxiety, PTSD, and perceived stress)	30.7% likely had depression, 17.4% had anxiety, 9% had post-traumatic stress. No significant associations between CAM and PTSD or perceived stress.	EPDI -Edinburgh Postnatal Depression Index, cutoff 12 Revised prenatal distress questionnaire - prenatal anxiety, cutoff 17 PCL-S - post-traumatic stress, cutoff 50 PSS - perceived stress, cutoff 25	2
12	Depression, PTSD	Exposure to Hurricane Katrina, Post-Traumatic Stress Disorder and Birth Outcomes	Xiong et al.	New Orleans and Baton Rouge	Cohort	High hurricane exposure, N = 301	Low birth weight, mental health	Frequency of LBW higher in women with high hurricane exposure than women without (14% vs 4.7%, aOR 3.3 95% CI 1.13–9.89 p < .01). Frequency of preterm birth higher in women with high hurricane exposure (14% vs 6.3%, aOR 2.3, 95% CI 0.82–6.38 p > .05 - not significant. No significant differences in frequency of LBW or preterm birth between women with PTSD or depression and women without PTSD or depression (p > .05). Rate of PTSD 4.4%, Rate of Depression was 14.4%	Post-traumatic Stress Checklist (PCL) – Civilian Version - PTSD symptoms, cutoff 50 Edinburgh Depression Scale (EDS) - cutoff 12	1
13	Depression, PTSD	Hurricane Katrina Experience and the Risk of Post-Traumatic Stress Disorder and Depression among Pregnant Women	Xiong, Harville, et al.	New Orleans and Baton Rouge	Cohort	High hurricane exposure, N = 301	PTSD, depression	PTSD higher in women with high hurricane exposure (13.8% vs 1.3%, aOR 16.8 95% CI 2.6–106.6), frequency of depression higher in women with high hurricane exposure (32.3% vs 12.3%, aOR 3.3 95% CI 1.6–7.1. Risk of PTSD and depression increased with increasing number of severe experiences of the hurricane	Post-traumatic Stress Checklist (PCL) – Civilian Version - PTSD symptoms, cutoff 50 Edinburgh Depression Scale (EDS) - cutoff 12	1
14	Depression	Hurricane Katrina: Maternal Depression Trajectories and Child Outcomes	Lai et al.	Southern Louisiana	Cohort	Hurricane Katrina, N = 142	Maternal mental health and infant distress outcomes	Three maternal depression trajectories among women exposed to hurricane: low (61%), resilient (29%), and chronic (10%). Social support identified as protective factor. Identified trajectories not associated with children’s distress outcomes. Mean posttraumatic stress (PTS) symptoms: 26.99, SD 17.51 indicating moderate-severe levels.	Brief Symptom Inventory (BSI) subscale for depression Posttraumatic Stress Diagnostics Scale (PDS): 1-10 mild, 11-20 moderate, 21-35 moderate-severe, 36 and greater severe, Interpersonal Support and Evaluation List (ISEL) - social support, 0-120	1
15	Depression, PTSD	Hurricane Katrina-related maternal stress, maternal mental health, and early infant temperament	Tees et al.	New Orleans and Baton Rouge, LA	Cohort	High hurricane exposure, N = 288	Infant temperament	Women more likely to report difficult infant temperament at 1 year if screened positive for PTSD (aOR 1.82 CI .61–5.41) depression (aOR 3.16 CI 1.22-8.20) or hostility (aOR 2.17 CI 0.81–5.82) at 2 months. Maternal mental health was associated with reporting difficult temperament.	Post-traumatic Stress Checklist (PCL) – Civilian Version - PTSD symptoms Edinburgh Depression Scale (EDS) - cutoff 12 Early Infant Temperament Questionnaire (EITQ) - behavior 1-4 months of age	1
16	Depression, Anxiety, PTSD	Mental health and worries of pregnant women living through disaster recovery	Giarratano et al.	Greater New Orleans area	Cross-sectional	Hurricane Katrina, N = 402	Women’s mental health, psychosocial concerns	Significant number reported depression symptomology (30.67%), PTSD (8.75%), and higher scores on pregnancy-related anxiety (17.41) and perceived stress (17.66). Social support played a key role in risk for mental health problems. Depression, PTSD, and perceive stress significantly associated with poor social support indicators.	EDSI (Edinburgh Postnatal Depression Index) – likely depression symptoms (>12), at risk for depression symptoms (>8)	2
17	Depression, PTSD	Postpartum mental health after Hurricane Katrina: A cohort study	Harville et al.	New Orleans and Baton Rouge, LA	Cohort	Hurricane Katrina, N = 292	Depression and PTSD	Black women and women with less education were more likely to have had serious experience with hurricane. 18% met depression criteria, 13% met PTSD criteria at 2 months postpartum. Two or more severe experiences associated with increased risk of depression (RR 1.77, CI 1.08–2.89) and PTSD (RR 3.68, CI 1.80-7.52).	Post-traumatic Stress Checklist (PCL) - PTSD symptoms, cutoff 50 Edinburgh Depression Scale (EDS) - cutoff 13	1
18	Depression	Influence of in-utero exposure to maternal depression and natural disaster-related stress on infant temperament at 6 months: The children of Superstorm Sandy	Nomura et al.	New York, NY	Longitudinal Cohort	Superstorm Sandy, N = 301	Infant activity, distress, approach, duration of attention, temperament	Prenatal maternal depression was associated with greater activity (p = 0.02), greater distress (p = .03), greater sadness (p =.05) and greater approach (p = .05). Prenatal depression associated with infant temperament related to emotion dysregulation and distressed emotion.	EPDS -Edinburgh Postnatal Depression Scale, cutoff 12 IBQ-R - Infant Behavior Questionnaire-Revised, 7 point scale	1
Political
19	Depression	Migration and Perinatal Mental Health in Women from Low- and Middle- Income Countries: A Systematic Review and Meta-Analysis	Fellmeth et al.	Varied	Systematic Review	Migration	Prevalence of depression, mean anxiety and depression scores	Prevalence was 31% for MDD. Previous depression and lower social support associated with perinatal depression. Insufficient data to assess anxiety, PTSD, or psychosis in this population.	N/A because systematic review	1
20	PTSD	Post-traumatic stress disorder and association with low birth weight in displaced population following conflict in Malakand division, Pakistan: a case control study	Rashid et al.	Tertiary care hospitals of district Peshawar, Khyber Pakhtunkhwa, Pakistan	Case control	PTSD, N = 450	Low birthweight (<2.5 kg)	PTSD independently associated with LBW. Univariate analysis factors significantly associated with LBW: less than 5 years of paternal schooling (p = .017) and PTSD (p <0.001). 31.6% of the mother of cases (LBW) were diagnosed with PTSD compared to 5.8% of controls (OR 7.52, 95%CI 4.02–14.07)	MINI Neuropsychiatric Interview 5.0 - PTSD measurement LBW cutoff 2.5 kg or less	1
21	Depression	Postpartum depression symptoms in newcomers	Stewart et al.	10 hospitals in main receiving cities for immigrants to Canada (Montreal 21%, Toronto 32.8% and Vancouver 7.7%)	Case control	Refugee, nonrefugee immigrant, or asylum-seeking, N = 341	Postpartum depression symptoms on Edinburgh Postnatal Depression Scale (EPDS)	21.7% (n = 74) women scored greater than or equal to 10 on EPDS. Percentage of newcomer women (immigrant 35.1%, asylum seeker 31.1%, refugee 25.7%) compared to Canadian-born women (8.1%) with EPDS >/=10 was significant (p = .008, chi^2 = 17.4, df3).. Visible minority status was associated with 75% increased risk for EPDS >/=10, but did not reach statistical significance (OR 1.75, 95%CI 0.95–3.21)	Edinburgh Postnatal Depression Scale (EPDS), cutoff 10 for postpartum depression	2
22	Depression, Anxiety, PTSD	Maternal depression in Syrian refugee women recently moved to Canada: a preliminary study	Ahmed et al.	Saskatoon, Canada, focus group discussion	Cross-sectional	Migration to Saskatoon in 2015–2016, N = 12	Depression symptoms, Anxiety symptoms, PTSD symptoms	2/3 of participants were pregnant (n = 8) and 1/3 (n = 4) were postpartum. More than half (7/12) screened positive for possible depression (EPDS score 10 or greater). Half (n = 6) screened positive for possible anxiety (EPDS anxiety score of 4 or greater). Those with both depression and anxiety symptoms were half pregnant and half postpartum (6 total) and 2 also screened positive for PTSD.	Edinburgh Postnatal Depression Scale (EPDS), cutoff 10 for postpartum depression EPDS-A subscale for anxiety, cutoff of 4 Primary Care PTSD screening tool, cutoff of 3	2

PTSD: post-traumatic stress disorder; Data quality assessment: 1: strong; 2: moderate; 3: weak.

Table 2. Rates of depression, anxiety and ptsd in each type of natural disaster.

Mental Health Morbidity	Incidence of Psychopathology	Country	Baseline National Prevalence	Cumulative Prevalence		p value*	DOF**
Pandemic				Unexposed	Exposed
Depression	35.4–52.9%	Turkey	24% [26]		92/260 (35.4%) [27]	<.001	4
		Canada	8.69% [28]	135/900 (15%) [29]	366/900 (40.7%) [30]
		Uganda	21.1% [31]		19/36 (52.8%) [32]
		South Africa	18.3% [33]		35/70 (50%) [34]
		China	13.5% [35]	112/939 (11.9%) [30]	29/235 (12.3%) [36]
Anxiety	68–72%	Canada	17.1% [28]	261/900 (29%) [29]	648/900 (72%) [30]	<.001	2
		China	20.6% [35]		68/100 (68%) [29]
PTSD	Not reported	South Africa	5.9% [33]		16/70 (22.8%) [34]
Earthquake				Unexposed	Exposed
Depression	29.2–40.8%	Japan	14.3% [37]	13/99 (13.1%) [38]	8/99 (8.1%) [38]	.070	2
		China	13.5% [39]	54/97 (55.7%) [40]	38/220 (17.3%) [40]
		China	13.5% [39]		127/311 (40.8%) [41]
Anxiety	29.2%			Not reported	Not reported	–	–
PTSD	12.2–29.2%	China	6.3% [42]	30/97 (30.9%) [40]	33/220 (15%) [40]	<.001	1
		China	6.3% [42]		38/311 (12.2%) [41]
Hurricane				Unexposed	Exposed
Depression	14.4–30.7–32.3%	USA	13% [43]		123/402 (30.6%) [19]	–	–
		USA	13% [43]		43/301 (14.3%) [21]	–	–
		USA	13% [43]		53/292 (18.2%) [17]	–	–
Anxiety	17.4%	USA	20.7% [3]		70/402 (17.4%) [19]	–	–
		USA	20.7% [3]		13/301 (4.32%) [21]	–	–
PTSD	4.4–9–13.8%	USA	1.1% [3]		35/402 (8.71%) [19]	–	–
		USA	1.1% [3]		13/301 (4.32%) [21]	–	–
		USA	1.1% [3]		38/292 (13.0%) [17]	–	–
Political Conflict				Unexposed	Exposed
Depression	Not reported	Middle/low-income countries	28% [44]		1096/3492 (31.4%) [45]	<.001	1
		Canada	8.69% [46]	6/73 (8.22%) [23]	90/268 (33.6%) [23]
		Canada	8.69% [46]		7/12 (58.3%) [22]
Anxiety	Not reported	Australia	8% [47]		15/31 (48.4%) [45]	–	–
		Canada	17.1% [48]		6/12 (50.0%) [22]	–	–
PTSD	Not reported	Australia	3% [47]		5/31 (16.1%) [45]	–	–
		Pakistan	6.3% [42]		84/450 (18.7%) [24]	–	–
		Canada	6.3% [42]		2/12 (16.7%) [22]	–	–

*p-Value calculated using chi-square for categorical (nominal) data comparing cumulative prevalence in the exposed and unexposed cohorts.

**DOF: Degrees of freedom.

Table 3. Secondary outcomes.

Outcome	Cumulative Prevalence
Alcohol abuse	7.1% (5/70) [32]
Pre-term birth	9.6% (29/301) [20]
Moderate-Severe Psychological Impact	50.2% (743/1481) [49,29,38]
Low Birth Weight	9.6% (29/301) [38]
Difficult infant temperament	44.3% (31/70) [32]
Cesarean delivery	67.8% (227/335) [49,40]

Table 4. Protective Factors.

Mental Health Morbidity	Protective Factors
Pandemic
Depression	Physical activity, [29] social support [18,36]
Anxiety	Physical activity [17]
PTSD	Information sessions, [36] treatment [19],counseling [19]
Earthquake
Depression	Multiparous, [34] higher family income, [40] more sleep per day [28]
Anxiety	None
PTSD	Higher education [27]
Hurricane
Depression	Massage therapy, [55] social support [30–36]
Anxiety	Social support^30, [19]
PTSD	Social support, [15–17,19–21,55] higher education, [17,21] living with partner [35]
Political
Depression	Social support [39–42] living with partner, [45] local language ability, [45] exercise, [22] prenatal care [41]
Anxiety	None
Depression	None

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