Etiology and incidence of postpartum depression among birthing women in the scenario of pandemics, geopolitical conflicts and natural disasters: a systematic review

Figures & data

Figure 1. Effects and implications of PPD on mothers and children.

Figure 2. PRISMA flow diagram for the study selection process and iterative steps used in the systematic selection of the pertinent studies for this article.

Table 1. Research studies evaluating the impact of Covid-19 pandemic on PPD pathogeneses (2019–2023).

Year of publication; country of origin	Sample size	Instrument used	PPD prevalence and/or severity	Key findings	First author name	Reference
2020; Italy	192 postpartum women (91 birthing during Covid-19 and 101 who gave birth before the pandemic	Edinburgh Postnatal Depression Scale (EPDS)	Higher EPDS score in Covid-19 group (8.5 ± 4.6; mean ± SD), compared to control women (6.34 ± 4.1), and 26 (28.6%) women with EPDS score >12 in Covid-19 group compared to 12 (11.9%) control women	Quarantine measures and concerns of contracting Covid-19 resulted in increased anhedonia and depressive symptoms	Zanardo, Vincenzo	[9]
2021; China	209 postpartum women	EPDS	PPD symptoms in 119 women (prevalence of 56.9%)	Elevated incidence of PPD during the Covid-19 pandemic; age, previous history of abortion and perceived stress were the major influencers of PPD pathogenesis	An, Ran	[10]
2021; Philadelphia, USA	833 pregnant women	EPDS	Prenatal COVID-19 pregnancy worries in the 3^rd trimeter increased the risk of PPD ((odds ratio of 1.19; 95% CI between 1.08–1.33)	COVID-19-related distress and anxiety, exposure to early-life adverse events, prenatal depression and anxiety were the major determinates of PPD and impaired mother-infant bonding	Kornfield, Sara L.	[11]
2021; Argentina	305 postpartum women	Postpartum Depression Screening Scale-Short Form (PDSS-SF)	PPD diagnosed in 113 women (prevalence of 37%)	Covid-19-related social isolation induced a greater risk for PPD, as well as other mental health dysfunctions such as insomnia, memory and concentration deficits	Miranda, Agustín Ramiro	[12]
2021; Mexico	293 postpartum women	EPDS	PPD diagnosed in 115 women (prevalence of 39.2%; 95% CI between 34–45%)	Increased prevalence of depression, anxiety, and perceived stress in postpartum women during Covid-19 pandemic	Suárez-Rico, Blanca Vianey	[13]
2021; Iran	604 (200 pregnant, 203 lactating and 201 non-pregnant/lactating)	Hospital Anxiety and Depression Scale (HADS)	Depression scores of 5.51 ± 3.75 (mean ± SD) in pregnant women compared to 4.04 ± 3.33 in non-pregnant/lactating women	High incidence of depression, anxiety, sexual dysfunction and perceived quality of life in pregnant and lactating women, compared to the general population	Mirzaei, Negin	[14]
2021; India	408 postpartum women (204 each in Covid-19 suspect and non-suspect hospital zones)	EPDS	Total prevalence of PPD was 11.9%, and prevalence of depression (17.9% vs. 4.85%) and severity of depression (5.01 ± 3.41 vs. 4.14 ± 2.54; mean ± SD) was higher in postpartum women in suspect zones vs. non-suspect zones with an odds ratio of 3.987 (95% CI between 1.952–8.146)	Containment policies in isolated quarantine wards of COVID-19 suspect mother was strongly related with increased incidence of PPD symptoms	Chaudhary, Vidhi	[15]
2021; Japan	618 postpartum women (279 pandemic and 339 pre-pandemic postpartum women)	EPDS	Non-significant difference in PPD prevalence (38/339 or 11% and 41/279 or 15% in pre-pandemic and pandemic women, respectively; with an adjusted odds ratio of 1.48 with 95% CI between 0.885–2.46)	No measurable changes in PPD-like symptoms between birthing women during the pre-pandemic and pandemic periods	Hiiragi, Kazuya	[16]
2021; Russia	2256 postpartum women (1645 pandemic and 611 pre-pandemic postpartum women)	EPDS	Non-significant difference in PPD prevalence (43.9% vs 45.7% in pre-pandemic and pandemic women)	Increased obstetric violence during Covid-19 pandemic, but no significant increase in the manifestation of PPD and PTSD symptoms in birthing women	Yakupova, Vera	[17]
2021; New Jersey, USA	18,531 postpartum women (14,006 pre-pandemic postpartum women, i.e. birthing between Sep 2019–Feb 2020; and 2402 (Mar 2020) and 2123 (April 2020) pandemic postpartum women)	EPDS	PPD severity higher during early pandemic (Mar 2020; 2.72 ± 3.12; mean ± SD), compared to both time- (2.55 ± 3.07) and month- (2.61 ± 3.11) matched controls	Increased severity of depressive symptoms in new mothers during the early phases of the pandemic	McFarland, Michael J.	[18]
2022; Romania	154 postpartum women (88 birthing in the first pandemic wave between 16–31 Mar 2020; and 66 birthing in the fourth wave between 1–14 Oct 2021)	EPDS	PPD (EPDS score > 10) was confirmed in 36 (prevalence of 40.9%) and 31 (47%) birthing women during the first and fourth waves, respectively	Covid-19-related concerns regarding loss of job, hospital visits during the pandemic, social isolation were the major determinants of PPD	Citu, Cosmin	[19]
2022; Brazil	178 postpartum women	EPDS	PPD in 69 subjects (prevalence of 38.8%)	Concerns about lack of hospital beds, loss of partner/family support and other Covid-19-related anxiety underlie PPD manifestation	Galletta, Marco Aurélio Knippel	[20]
2022; Kenya	2086 postpartum women (1072 and 1014 women who birthed during pandemic and pre-pandemic stages, respectively)	World Health Organization’s Maternal WOICE Tool for postnatal care	Prevalence of PPD was significantly higher in women birthing during the pandemic (38.3%; 411/1072) compored to those birthing in pre-pandemic period (16.7%; 169/1014)	Covid-19 resulted in 2.5 times higher odds of PPD development, and economic vulnerabilities strongly aggregated the risk	Sudhinaraset, May	[21]
2022; Israel	140 women 6 months postpartum (Feb 2018–Dec 2019; pre-Covid-19) and 21 months postpartum (Apr 2020–Jan 2021; during Covid-19)	EPDS	EPDS correlated with Covid-19 worry (r = 0.30, p < 0.001)	Covid-19-related worry was significantly associated with PPD development	Handelzalts, Jonathan E.	[22]
2022; Denmark	669 pregnant women in their first trimester, 222 women 8 weeks postpartum and 170 women 5 months postpartum	HADS	No statistical differences between depression levels between the groups, and different time periods of the pandemic	No major mood changes in relation to increased infection pressure or lockdowns during the different periods of Covid-19 pandemic	Overbeck, Gritt	[23]

Table 2. Research studies evaluating the impact of geopolitical conflicts on PPD pathogeneses (2019–2023).

Year of publication; geopolitical conflict	Sample size	Instrument used	PPD prevalence and/or severity	Key findings	First author name	Reference
2018; Syrian civil war	1105 postpartum women	EPDS	PPD (EPDS score ≥ 13) was confirmed in 312 subjects (prevalence of 28.2%)	Civil war-induced dislocation was strongly associated with PPD development	Roumieh, Mayada	[24]
2020/2021; Palestine-Israel conflict	50 women exposed to war AND 251 refugee mothers	EPDS	Prenatal and postnatal prevalence of depression (EPDS score ≥ 12) in 54% (27/50) and 60% (30/50) war-exposed women AND PPD prevalence of 49% (123/251; EPDS score ≥ 12) in refugee mothers	Age at birthing, exposure to traumatic war events and PTSD, financial and social insecurities were significantly associated with depressive symptoms and reduced emotional availability in postpartum women	Isosävi, Sanna AND Yoneda, Kyoko	[25, 26]
2020; Myanmar civil war	396 postpartum women	Structured Clinical Interview for the Diagnosis of DSM-IV Disorders (SCID)	Prevalence of any depression and moderate-severe depression were 19.7% (78/396; 95% CI between 15.9–24.0%) and 8.3% (33/396; 95% CI between 5.8–11.5%), respectively	Several risk factors were identified for PPD prevalence among migrant and refugee women at the Thai-Myanmar border; including age of birthing, interpersonal violence, history of traumatic, stressful and depressive episodes, labor migrant status and deficient social support	Fellmeth, Gracia	[27]
2022; Xinjiang Uyghur Autonomous Region (XUAR) conflict	7703 parturient women	Patient Health Questionnaire (PHQ-9)	Prevalence of PPD increased from 9.7% in 2018, 11.1% in 2019, 13.3% in 2020, to 14.2% in 2021	Increased prevalence of depression and anxiety in postpartum women with time (from 2018 to 2021), factors affecting pathogenesis of PPD included occupation, maternal age, feeding pattern and neonatal gender	Abulaiti, Adila	[28]

Table 3. Research studies evaluating the impact of natural calamities on PPD pathogeneses (2019–2023).

Year of publication; Country of original; Type of natural disaster	Sample size	Instrument used	PPD prevalence and/or severity	Key findings	First author name	Reference
2021; Calgary, Canada; Flood (2013)	26,956 women with infants during 2013 (7339 women pregnant during flood, and 5788 controls);and 2014 (7641 women pregnant during flood, and 6188 controls)	Secondary data; International Classification of Diseases, 9^th and 10^th Revisions, with Canadian Enhancements (ICD-9-CM and ICD-10-CA)	Prevalence of depression was did not change during 2013 (10.1%; 738/7339 and 10.5; 606/5788) and 2014 (9.7%; 742/7641 and 9.8; 604/6188) for women pregnant during flood and controls, respectively	No effect on post-partum mental health, universal prenatal care in Canada potentially minimized this impact	Hetherington, Erin	[29]
2021; Queensland, Australia; Flood (2011)	183 women pregnant at the time of flood, measured at 16 months, 30 months, 4 years and 6 years after birthing	Depression, Anxiety and Stress Scales (DASS)	Prevalence of depressive symptoms were 9.03%, 8.67%, 12.71% and 11.48% 16 months, 30 months, 4 years and 6 years after birthing	Severity of hardship from disasters, peri-traumatic distress, cognitive appraisal	Paquin, Vincent	[30]
2021; Fukushima, Japan; Earthquake (2011)	77,644 pregnant women (11,481 from Fukushima and 66,163 from other centers)	EPDS	Combined prevalence of PPD (EPDS score ≥ 9) was 14.3% and total median proportion of high EPDS score was 14.1 (95% CI between 10.4–17.7); and for Fukushima women was 16.7, corresponding to 95 percentile	Feeling negatively about the pregnancy due to possibility of affected maternal bonding, confusion about pregnancy, traumatic experience due to Great East Japan Earthquake (GEJE), near death experiences and witnessing other deaths	Kuroda, Yujiro	[31]
2023; Japan; Great Tōhoku Earthquake (2011)	11,403 pregnant women	EPDS	Prevalence of PDS at 1 month postpartum was 13.3 % (1515/11403)	Association of traumatic experiences with increased PPD risk	Murakami, Keiko	[32]

Figure 3. Flowchart depicting the procedure for a typical interpersonal psychotherapy session.

Figure 4. Multiple facets of art-based therapy for PPD.

Zanardo V, Manghina V, Giliberti L, et al. Psychological impact of COVID-19 quarantine measures in northeastern Italy on mothers in the immediate postpartum period. Int J Gynaecol Obstet. 2020;150(2):184–188. doi:10.1002/ijgo.13249

 PubMed Web of Science ®Google Scholar

An R, Chen X, Wu Y, et al. A survey of postpartum depression and health care needs among Chinese postpartum women during the pandemic of COVID-19. Arch Psychiatr Nurs. 2021;35(2):172–177. doi:10.1016/j.apnu.2021.02.001

 PubMed Web of Science ®Google Scholar

Kornfield SL, White LK, Waller R, et al. Risk and resilience factors influencing postpartum depression and mother-infant bonding during COVID-19. Health Aff (Millwood). 2021;40(10):1566–1574. doi:10.1377/hlthaff.2021.00803

 PubMed Web of Science ®Google Scholar

Miranda AR, Scotta AV, Cortez MV, et al. Triggering of postpartum depression and insomnia with cognitive impairment in Argentinian women during the pandemic COVID-19 social isolation in relation to reproductive and health factors. Midwifery. 2021;102:103072. doi:10.1016/j.midw.2021.103072

 PubMed Web of Science ®Google Scholar

Suárez-Rico BV, Estrada-Gutierrez G, Sánchez-Martínez M, et al. Prevalence of depression, anxiety, and perceived stress in postpartum Mexican women during the COVID-19 lockdown. IJERPH. 2021;18(9):4627. doi:10.3390/ijerph18094627

 Web of Science ®Google Scholar

Mirzaei N, Jahanian Sadatmahalleh S, Bahri Khomami M, et al. Sexual function, mental health, and quality of life under strain of COVID-19 pandemic in Iranian pregnant and lactating women: a comparative cross-sectional study. Health Qual Life Outcomes. 2021;19(1):66. doi:10.1186/s12955-021-01720-0

 PubMed Web of Science ®Google Scholar

Chaudhary V, Puri M, Kukreti P, et al. Postpartum depression in covid-19 risk-stratified hospital zones: a cross-sectional study from India. J Affect Disord Rep. 2021;6:100269. doi:10.1016/j.jadr.2021.100269

 PubMedGoogle Scholar

Hiiragi K, Obata S, Misumi T, et al. Psychological stress associated with the COVID-19 pandemic in postpartum women in Yokohama, Japan. J Obstet Gynaecol Res. 2021;47(6):2126–2130. doi:10.1111/jog.14776

 PubMed Web of Science ®Google Scholar

Yakupova V, Suarez A, Kharchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. IJERPH. 2021;19(1):335. doi:10.3390/ijerph19010335

 Web of Science ®Google Scholar

McFarland MJ, McFarland CAS, Hill TD, et al. Postpartum depressive symptoms during the beginning of the COVID-19 pandemic: an examination of population birth data from Central New Jersey. Matern Child Health J. 2021;25(3):353–359. doi:10.1007/s10995-020-03116-w

 PubMed Web of Science ®Google Scholar

Citu C, Gorun F, Motoc A, et al. Prevalence and risk factors of postpartum depression in Romanian women during two periods of COVID-19 pandemic. J Clin Med. 2022;11(6):1628. doi:10.3390/jcm11061628

 PubMed Web of Science ®Google Scholar

Galletta MAK, Oliveira AdS, Albertini JGL, et al. Postpartum depressive symptoms of Brazilian women during the COVID-19 pandemic measured by the Edinburgh postnatal depression scale. J Affect Disord. 2022;296:577–586. doi:10.1016/j.jad.2021.09.091

 PubMed Web of Science ®Google Scholar

Sudhinaraset M, Landrian A, Mboya J, et al. The economic toll of COVID-19: a cohort study of prevalence and economic factors associated with postpartum depression in Kenya. Int J Gynaecol Obstet. 2022;158(1):110–115. doi:10.1002/ijgo.14142

 PubMed Web of Science ®Google Scholar

Handelzalts JE, Hairston IS, Levy S, et al. COVID-19 related worry moderates the association between postpartum depression and mother-infant bonding. J Psychiatr Res. 2022;149:83–86. doi:10.1016/j.jpsychires.2022.02.039

 PubMed Web of Science ®Google Scholar

Overbeck G, Rasmussen IS, Siersma V, et al. Mental well-being during stages of COVID-19 lockdown among pregnant women and new mothers. BMC Pregnancy Childbirth. 2022;22(1):92. doi:10.1186/s12884-021-04374-4

 PubMed Web of Science ®Google Scholar

Roumieh M, Bashour H, Kharouf M, et al. Prevalence and risk factors for postpartum depression among women seen at primary health care centres in Damascus. BMC Pregnancy Childbirth. 2019;19(1):519. doi:10.1186/s12884-019-2685-9

 PubMed Web of Science ®Google Scholar

Isosävi S, Diab SY, Qouta S, et al. Caregiving representations in war conditions: associations with maternal trauma, mental health, and mother–infant interaction. Infant Ment Health J. 2020;41(2):246–263. doi:10.1002/imhj.21841

 PubMed Web of Science ®Google Scholar

Yoneda K, Hababeh M, Kitamura A, et al. Prevalence and characteristics of Palestine refugee mothers at risk of postpartum depression in Amman, Jordan: a cross-sectional study. Lancet. 2021;398:s 28. doi:10.1016/S0140-6736(21)01514-2

 Web of Science ®Google Scholar

Fellmeth G, Plugge E, Fazel M, et al. Prevalence and determinants of perinatal depression among labour migrant and refugee women on the Thai-Myanmar border: a cohort study. BMC Psychiatry. 2020;20(1):168. doi:10.1186/s12888-020-02572-6

 PubMed Web of Science ®Google Scholar

Abulaiti A, Abudurexiti M, Nuermaimaiti A, et al. Analysis of the incidence and influencing factors of postpartum depression and anxiety: a cross-sectional study in Xinjiang from 2018 to 2021. J Affect Disord. 2022;302:15–24. doi:10.1016/j.jad.2022.01.069

 PubMed Web of Science ®Google Scholar

Hetherington E, Adhikari K, Tomfohr-Madsen L, et al. Birth outcomes, pregnancy complications, and postpartum mental health after the 2013 calgary flood: a difference in difference analysis. PLoS One. 2021;16(2):e0246670. doi:10.1371/journal.pone.0246670

 PubMed Web of Science ®Google Scholar

Paquin V, Elgbeili G, Laplante DP, et al. Positive cognitive appraisal “buffers” the long-term effect of peritraumatic distress on maternal anxiety: the Queensland flood study. J Affect Disord. 2021;278:5–12. doi:10.1016/j.jad.2020.09.041

 PubMed Web of Science ®Google Scholar

Kuroda Y, Goto A, Koyama Y, et al. Antenatal and postnatal association of maternal bonding and mental health in Fukushima after the great east Japan earthquake of 2011: the Japan environment and children’s study (JECS). J Affect Disord. 2021;278:244–251. doi:10.1016/j.jad.2020.09.021

 PubMed Web of Science ®Google Scholar

Murakami K, Ishikuro M, Obara T, et al. Traumatic experiences of the great east Japan earthquake and postpartum depressive symptoms: the Tohoku medical megabank project birth and three-generation cohort study. J Affect Disord. 2023;320:461–467. doi:10.1016/j.jad.2022.09.139

 PubMed Web of Science ®Google Scholar