Introduction:

According to the World Health Organization (WHO), depression is the leading cause of disability in the world, with 300 million people suffering from this disorder across all age groups.^{[1, 2, 3,4]}

Depression is frequently associated with the perinatal period with variable prevalence rates. The latter differ according to the adopted screening criteria, as well as the timeframe within which depression is investigated. Depression can occur during pregnancy or after delivery. Depression rates during pregnancy itself were not consistent across the 3 trimesters, the first trimester having the lowest depression rates, which were found to increase in the remainder of the pregnancy^[5]. The prevalence of depression is variable across different age groups, occupations and patient cohorts^{[6, 7, 8]}

According to the NICE clinical guideline for the management of perinatal maternal mental health, depression affects 12% of women during pregnancy, while anxiety is exhibited by approximately 13% of pregnant women. Moreover, the two conditions can coexist, with pregnant women suffering from both depression and anxiety. Mental health disorders are not restricted to the gestational period, but could continue to affect or appear following childbirth. In fact, 15 to 20% of women continue to suffer from depression and anxiety a year after delivery.^[9] Other mental conditions are also associated with pregnancy and the post-partum period and include panic disorder, generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), post traumatic stress disorder (PTSD) and tokophobia. These disorders can exist alone or occur concomitantly with depression and are less frequently observed when compared to depression and anxiety^[9].

Maternal and neonatal outcomes are affected by the incidence of depression or other mental health conditions. The latter lead to 1.27 maternal deaths per 100,000 deliveries between 2006 and 2008 in the UK alone ^{[9, 10]}.

Post-partum affective illness can be divided into 3 subtypes, namely the blues, postpartum depression and postpartum psychosis. Postnatal psychosis is one of the most deleterious disorders known to be induced or exacerbated by pregnancy. It involves symptoms of mania, depression, paranoia, hallucinations as well as delusions and is known to affect 1 to 2 women out of 1000 regardless of previous psychiatric history[9]. Women with a known history of bipolar disorder or a family history of postpartum psychosis are at a significantly greater risk (up to 50%) of developing the disorder^[11].

Although no established criteria are available, baby blues are widely considered to consist of a range of physical discomforts and symptoms. The latter include dysphoric mood, crying, mood lability, anxiety, insomnia, loss of appetite, and irritability. Post-partum blues are commonly observed in women in the first week following delivery, with variable prevalence rates between 26 (12) and 84% (13, 14). Postpartum blues generally subside approximately 10 days or 2 weeks after delivery in the event that symptoms do not evolve into postpartum depression. The risk of developing postpartum depression is thus elevated in women exhibiting postpartum blues, which could be considered a risk factor of this condition^[12].

In postpartum depression, the postpartum period is not limited to the days or weeks after childbirth, but extends to up to 1 year following delivery of the baby^[9]. Depressed mothers can experience feelings of extreme sadness, anxiety, and exhaustion^{[16, 17]}. Other symptoms include appetite and sleep disturbances. However, the aforementioned manifestations of postpartum depression are not exclusively observed in women suffering from this disorder.^{[18, 19]}.

Postpartum depression is a serious public health issue whose management remains challenging. According to the American Mental Health Counselors Association, more than 1 out of 7 women will suffer from postpartum depression or a related disorder. These rates are known to increase in socioeconomically challenged settings, with approximately 1 out of 4 women exhibiting postpartum depression. This reflects the established higher prevalence of depression among women as compared to men, who are half as likely to develop depression than women.^[21].

The global prevalence of postpartum depression to be notably high at 17.7%^[22]. Researchers further noticed the variability of postpartum depression prevalence according to the nation from which the data was generated. The prevalence of postpartum depression was significantly moderated by different factors, including socioeconomic and work factors. In fact, income inequality was significantly associated with a higher rate of postpartum depression. This falls in line with the established higher predilection of individuals from low to middle-income countries to present with depression in general. Moreover, mothers who worked more than 40 hours per week also exhibited higher rates of postpartum depression^[22].

Despite its established repercussions both on maternal, infant and familial outcomes, postpartum depression remains under recognized and undertreated^[23]. Through its effect on maternal productivity and the subsequent loss of income, untreated postpartum depression is estimated to cost $7,200 annually per mother.^{[21, 24]}.

Several variables emerged as having a significant relationship with the incidence of post-partum depression: the family income^[25] and the stress induced by financial distress or insufficiency as well as that engendered by caring for a child. On the other hand, a significant negative association was established between marital satisfaction and post-partum depression^[25]. The absence or insufficiency of social support during pregnancy lead to postpartum depression following a strong and statistically significant association^[25]. On the other hand, It was established that a strong association existed between depression and anxiety during the gestational period and the incidence of postpartum depression^{[25, 26]}.

In other words, postpartum depression emerges as a significant influencer of maternal behavior. Mothers suffering from postpartum depression have lower performance when it comes to infant care ^{[27, 28, 29]}. The effect of postpartum depression is not limited to the mother, but also affects their children, with a predilection for male babies^{[30, 31, 32, 33, 34]}. The impact of postpartum depression extends into childhood and is not limited to the period immediately after birth ^{[35, 36]}. Postpartum depression is thus a serious pregnancy-related complication necessitating the implementation of preventative as well as curative approaches in prenatal and postnatal care strategies^{[37, 38, 39, 40, 41, 42, 43, 44, 45]}.

Screening for postpartum depression is essential and allows the prevention and treatment of this condition in pregnant women or those who had recently given birth. A variety of screening tools are available in the healthcare settings^[59]. However, no guidelines are available regarding their use and the timeframe in which they should be adopted. The Edinburgh Postnatal Depression Scale (EPDS) was the most widely used screening test, with 68% of examined articles adopting it^[60]. The time frame for the application of the screening process however shows great variability. Despite the specification of 6 weeks after delivery as the upper limit for the diagnosis of postpartum depression, the majority of studies exceeded this timeframe in their screening for the condition^[60]. Concerning its sensitivity in the diagnosis of postpartum depression, the EPDS is significantly more accurate than other screening tests^{[61, 15, 25]}. The EPDS is a screening tool for postpartum depression that is designed to detect this condition in women 6 to 8 weeks following delivery^[18]. This test however is not capable of diagnosing postpartum depression or other serious mental health conditions. The EPDS consists of 10 questions the answers to which are scored from 0 to 3, reflecting the severity of the symptoms^[18]. The addition of the scores provides the final test result, based on which patients are referred for further assessment or deemed healthy. Cut-off scores are the score at which women are deemed positive for postpartum depression. Throughout studies, the cut-off values are variable and range from 10 to 14, with a mean cut-off point of 11.5. Moreover, studies chose 10 most frequently as the cut-off score for the EPDS and detection of postpartum depression^{[60, 62]}.

The EPDS has been employed for the detection of depression in Lebanese mothers at different timepoints. It was actually successfully used for the screening of postpartum depression at day 2, day 30 to 40 as well as 3 to 5 months after delivery^[56,57]. Researchers were thus able to characterize the prevalence and determinants of postpartum depression in the Lebanese population based on the EPDS scores, which renders it valid and applicable in a Lebanese setting.^{[46, 47, 48]}.

Women who experienced stressful life events during pregnancy were significantly more likely to be depressed^{[48, 49]}. On the other hand, pregnancy complications such as previous spontaneous abortion, preterm births, fetal death and early neonatal death were significantly associated with depression and anxiety^{[50, 51]}. Pregnancy-related conditions were similarly found to contribute to postpartum depression. Women with pre-eclampsia exhibited double the prevalence rates of postpartum depression when compared to normal women [52]. On the other hand, vitamin D deficiencies during pregnancy were also correlated with increase risk for postpartum depression. Women with serum 25(OH)D levels below 50 nmol/l were actually 2.67 times more likely to exhibit postpartum depression[53]. The quality of a marital relationship has been frequently investigated as a possible determinant of postpartum depression[46]. A group of investigators examined the association between postpartum depression and polygamy and found that women living in polygamy were significantly more likely to be depressed postpartum when compared to their monogamous counterparts^[49]. The behavior of a mother’s partner could greatly affect her mental health. In fact, partner alcoholism was correlated with the incidence of postpartum depression. Moreover, a violent partner was similarly significantly associated with depressive symptoms in women post-partum^{[47, 48, 49, 54, 55]}.

Many researchers have undertaken the characterization of postpartum depression in the Lebanese population. It was found that 33.3% of women suffered from postpartum depression on the second day after delivery, while 12.8% exhibited this condition when assessed 30 to 40 days postpartum[56]. The EPDS score >9 was considered indicative of postpartum depression and when assessed at day 2, EPDS score was found to significantly and positively predict the score 30 to 40 days after delivery. Thus, women with high scores 2 days postpartum were likely to present with high EPDS scores when assessed 1 month later, which allows the prediction of postpartum depression and its early detection. As for postpartum depression risk factors in this Lebanese cohort, it was found that previous personal but not familial history of depression and an EPDS score greater than 9 at day 2 postpartum were the only significant correlates of postpartum depression one month after delivery[56]. Another study established the prevalence and determinants of postpartum depression among Lebanese mothers 3 to 5 months after delivery. This was achieved through the application of the EPDS over the telephone, which revealed that the prevalence of postpartum depression was high overall and differed between regions. In fact, while the overall prevalence was 21%, women from the Bekaa Valley had 26% prevalence of postpartum depression as compared to 16% in Beirut^[57]. The determinants of postpartum depression were similarly variable in each examined region, with lack of social support and prenatal depression predicting postpartum depression in both women from Beirut and Bekaa Valley. On the other hand, lifetime depression, and delivery type were significantly associated with postpartum depression in Beirut only. As for Bekaa Valley, postpartum depression could be predicted by stressful life events, chronic maternal health problems, and low educational level[57]. Badr (2018) investigated the risk factors associated with postpartum depression and impaired mother-infant bonding in a Lebanese population. History of alcohol use, pregnancy and infant-related complications, bad marital relationship, a history of depression and low social support emerged as significant predictors of postpartum depression. Moreover, women who were older, had a past history of depression and who received little social support were significantly associated with impaired mother-infant bonding^[58].

However, extant evidence from Lebanon regarding the prevalence and determinants of postpartum depression as well as its risk factors remain scarce. Further research and epidemiological studies are therefore required. The generation of such data would allow the guidance of prenatal and postnatal care in order to ensure optimal maternal and neonatal outcomes. The deleterious effects on postpartum depression affect mothers on the physical, mental, social, familial as well as professional level. Children and families of affected mothers are similarly affected, with documented impairment of child cognitive and emotional development, in addition to poor marital relationships. Moreover, untreated postpartum depression is associated with significant costs, which highlights the need for the inclusion of adequate screening and treatment interventions in normal prenatal and antenatal care. The establishment of the risk factors and predictors of postpartum depression is necessary on the national level in order to account for socioeconomically and cultural differences in the manifestation of this phenomenon. The primary objective of our study is to identify the prevalence of the postpartum depression during the first 2 weeks postpartum. The Secondary objectives are: - to identify risk factors associated with the diagnosis of PPD.

Subjects and Methods

This is a cross-sectional, uni-center, study conducted in 1 hospital in Lebanon (Rafic Hariri University Hospital), using data from a direct survey with a sample of Two hundred womenwere recruited in August and September 2017in Beirut receiving their care and follow-up.

-

Women who gave birth at RHUH to a singleton healthy baby at term between 1 August 2017 till 30 September 2017

- The women complicated by mental disorders currently undergoing psychotherapy or on medications.
- Women giving birth to an unhealthy baby (premature baby or necessitating NICU admission or having any chromosomal aneuploidy).
Demographic data was collected using a short questionnaire, using a telephone interview.
The data collection includes the following:
- Age
- Parity
- History of mental disorders
- Delivery mode
- Educational status of the mother
- PMS
- Edinburgh postpartum depression scale (EPDS) at 0 and 2 weeks postpartum between 1 August 2017 and 30 September 2017.The EPDS is a 10 item self-reported questionnaire where each item is rated on a 4-points scale giving maximum score of 30. scores more than 12 or 13 is considered a significant case of postpartum depression while scores between 10-12 are borderline and between 0-10 are not depressed, this scale is designed specifically for the detection of depression in postpartum period (Appendix 3). This protocol was reviewed and granted a written study approval from the institutional review board (IRB) at Mount of Lebanon Hospital and approved by the rest three hospitals where the study was enrolled. This study wasconducted in accordance with the US Code of Federal Regulation 45- CFR -46.107, 21-CFR-56.107, Good Clinical Practice ICH Section 3 and the principles laid down by the 18th World Medical Assembly (Helsinki, 1964) and all applicable amendments. All patients signed an informed consent in Arabic (Appendix 4) before the recruitment in the study. Names and information of participant individuals will not be shared with third parties. All participants will have a designated code to conceal their name and identity. No further written permission is needed for use of this Health Survey (SF36) and the VAS score.
Data collection forms will be stored and none can access the sheets except the researchers. All the Data collection forms will damaged be after 10 years of the study results submission.
Data was analyzed using the SPSS version 22.
The primary endpoint “EPDS” was presented as the frequency, mean and standard deviation of participants.
Secondary endpoints were presented as per the variable category. The categorical variables will be presented as frequency and proportions. The continuous variables will be presented as the frequency, mean and standard deviation. The primary endpoint “EPDS” was be statistically compared to:
the demographic variables using ANOVA test and t-Test
the medical conditions using ANOVA test
the pregnancy characteristics
Significance level will be set at 5% (p-value less than 0.05

Results

Two types of analysis were performed: the descriptive analysis and the analytical Analysis.

Demographic Characteristics

The mean participant age was 30 years with a minimum of 18 years and a maximum of 45 years. (Table 1)

Parturient participating in the study were distributed between Syrian (56%) and Lebanese (44%). (Figure 1)

Pregnancy Characteristics

The mean participant Gravida was 2.8 (3) pregnancies with a minimum of 1 pregnancy and a maximum of 9 pregnancies. The mean participant Para was 1.87 (2) babies with a minimum of 0 baby and a maximum of 8 babies. The mean Aborta was 0.3 abortion with a minimum of 0 abortion and a maximum of 3 abortions. (Table 2).

The mean pregnancy days was 271 days (38.7 weeks) with a minimum of 242 days (34.6 weeks) and a maximum of 291 days (41.6 weeks). (Table 3)

The delivery was NVD (normal vaginal delievery) in 77% of cases while 23% of parturient underwent C-section. (Figure 2)

Newborn babies were distributed between boys (43%) and girls (57%). (Figure 3)

The majority of parturient are non-smokers (82%) and 18% were smokers. (Figure 4)

EPDS

The following results describe the most frequent answers given by participants regarding the EPDS statements: (Table 4)

• 47.5% of participants said that they have been able to laugh and see the funny side of things as much as they always could.
• 48.4% of participants said that they have looked forward with enjoyment to things rather less than they used to.
• 44.3% of participants said that they have never blamed themselves unnecessarily whenthings went wrong.
• 36.9% of participants saidthat they have been sometimes anxious or worried for no good reason.
• 39.3%of participants said that they have never felt scared or panicky for no very good reason.
• 34.4% of participants said that things have been sometimes getting on top of them.
• 40.2% of participants said that they have never been so unhappy that they have had difficulty sleeping.
• 36.1% of participants said that they have never felt sad or miserable.
• 38.5% of participants said that they have never been so unhappy that they have been crying.
• 95.9% of participants said that they have never thought of harming themselves has occurred to them.
Edinburgh Postnatal Depression Scale (EPDS)was developed to identify women who may have postpartum depression. Each answer is given a score of0 to 3. The maximum score is 30.
The mean EPDS score was 10.94 over 30 with a minimum of 0over 30 and a maximum of 25 over 30. (Table 5)

The EDPS results show that 32.8% of the participants have depression, 24.6% have a significant risk of depression and 42.6% have no depression. (Figure 5)

Bivariate Analysis

There was no statistical significant correlation between the nationality of the participants and the depression status (Chi-Square test; p-value > 0.05). (Table 6)

There was no statistical significant correlation between the age of the participants and the depression status (ANOVA; p-value > 0.05). (Table 7)

There was no statistical significant correlation between the smoking status of the participants and the depression status (Chi-Square test; p-value > 0.05). (Table 8)

A statistical significant correlation exists between the type of the delivery and the depression status (Fisher Exact test; p-value = 0.048 < 0.05).The analytical analysis shows that women who underwent a C-section were more depressed (43%) comparing to women who underwent a normal delivery (29.8%). (Table 9)

There was no statistical significant correlation between the sex of the baby and the depression status (Chi-Square test; p-value > 0.05). (Table 10)

No statistical significant correlation exists between the pregnancy characteristics and the depression status (ANOVA test; p-value > 0.05). A statistical significant correlation exists between the patients’ pregnancy days and the depression status (ANOVA test; p-value = 0.010< 0.05). The analytical analysis shows that women are at high risk of depression when the pregnancy duration is increasing. (Table 11)

Discussion

The mother’s nationality is not frequently investigated as a predictor of postpartum depression. In our study, Lebanese and Syrian mothers did not exhibit significant differences in the presentation of postpartum depression.

Similarly, a study investigating postpartum depression among Lebanese women found no significant association between the mother’s nationality and the EPDS score at day 2 and 30-40 postpartum. It can therefore be deduced that Lebanese mothers were not more likely to be depressed when assessed at different time points after delivery than non-Lebanese mothers^[56].

The present study found no significant correlation between maternal smoking and postpartum depression. This was inconsistent with a study conducted in Nepal, which found a significant association between smoking and postpartum depression. In fact, mothers who were smokers were significantly more likely to have high EPDS scores^[49]. In other words, smoking was correlated with post-partum depression in this population.

Our study established a significant correlation between delivery type and postpartum depression and found that women who delivered by C-section are more likely to be depressed, while those who deliverednaturally were at a higher risk to be depressed. Interestingly, results from a Lebanese study showed that C-section actually decreased the risk of postpartum depression assessed 3 to 5 months after delivery. Inconsistently with our findings, women who delivered vaginally had significantly higher rates of postpartum depression^[57]. On the other hand, a Moroccan study investigating the potential association between delivery type and postpartum depression and could not establish statistical significance. Women who delivered by caesarian section, or by natural vaginal delivery actually showed equal rates of postpartum depression^[46], as opposed to our study.

A study in Nepal investigated the correlation between postpartum depression and a variety of social and clinical factors. It was consequently found that the baby’s gender was not significantly associated with post-partum depression^[49]. Mothers of girls and those of boys had thus comparable risk to develop depression after delivery, consistently with our study. These results were also reflected in a Lebanese study investigating postpartum depression, which was not significantly correlated with baby gender at both 2 days and 30 to 40 days after delivery^[56].

That being said, researchers have determined that delivering a female baby was a significant predictor of postpartum depression among Jordanian mothers^[48]. This is most likely a reflection of Arab culture, in which male babies are valued and desired more than female babies. Mothers are therefore often pressured into delivering a male baby in order to ensure a family heir and the continuation of the family line.

Our study found no significant association between age and postpartum depression. When consulting the literature, maternal age emerged as a non-significant predictor of postpartum depression. This was validated in a study conducted among mothers in Nepal which found no association between maternal age and an EPDS score greater than 12[49]. This was consistent with a Lebanese study, where age was not a significant predictor of postpartum depression 2 and 30-40 days after delivery, as determined by an EPDS score greater than 9^[56].

No significant correlation emerged in our study between gravida or parity and postpartum depression. This was consistent with a meta-analysis of the causative factors associated with post-partum depression. In fact, it was established that the number of children and gravida were not significant predictors of postpartum depression0^[25]. Evidence from Morocco also established the lack of significant relationship between parity and postpartum depression[46]. Primiparous women, i.e. women who are giving birth for the first time, were not found to be significantly more likely to be depressed after delivery. The number of children was also investigated and did not significantly affect the incidence of postpartum depression in the sample of Moroccan mothers. A study in Indonesia similarly found comparable parity in mothers who suffered from postpartum depression and those who did not[47]. Evidence from Lebanon also validated our results through the established non-significant association between primiparity and multiparity and the detection of postpartum depression^[56,57].

On the other hand, multiparity was associated with higher EPDS scores among mothers in Nepal. In fact, women with 4 or more children were more likely to exhibit depression after delivery, as reflected by a high score on the EPDS^[49].

A history of spontaneous abortion was actually associated with depression and anxiety in pregnant women, as opposed to our results. This was established in a study investigating quality of life and mental health in pregnant Iranian women. It was consequently found that women who have experienced abortions had impaired quality of life as well as mental health when compared to women who had no such experiences^[51].

In our study, longer gestation was significantly associated with postpartum depression.

Researchers in Lebanon were actually unable to establish a statistically significant correlation between gestational weeks or pregnancy term and postpartum depression[56,57]. More specifically, Women who had less than 36 weeks of gestation, between 36 and 40, as well as over 40 weeks of gestation were thus equally likely to exhibit depressive symptoms when assessed for postpartum depression^[56].

Impact Of The Study

Postpartum depression (PPD) is a significant health problem, it is estimated that depression costs the United States 30 billion dollars to 50 billion dollars in lost productivity and direct medical costs each year. The longer a woman is incapacitated by PPD, the more she is at risk for lifelong and recurrent depression and suicide, and if left Untreated it may seriously damage the mother-infant relationship and result in cognitive, emotional, and behavioral deficits in her growing child[5]. Therefore, postpartum depression screening must be mandatory in our country to reduce the psychological damage and its deadly effect (suicide, evolving to psychosis ...) and in turn cost reduction in a developing country (similar to Lebanon) especially after the large influx of Syrian refugees.

Study Limitations

The present study was not without its limitations. Although it was a prospective study, only 122 patients were included and recruited from select regions. Further studies could aim to include a higher number of patients from all geographical regions in Lebanon. This would ensure higher representability of the results and would therefore better reflect the pregnancy in the Lebanese community.

Study Perspectives

The present study aimed to identify the prevalence of the postpartum depression during the first 2 weeks postpartum. It was shown that 32.8% of women have depression and that the depression was correlated with the pregnancy duration and the type of delivery (C-Section). Further investigational studies should be enrolled in order to provide women with psychotherapy support during the pregnancy and especially long pregnancies and pregnancy where the prognostic of the delivery is known to be C-Section.

Conclusion

The current study established the significant correlation between postpartum depression and delivery type as well as gestation period. Other investigated variables, namely nationality, smoking status, baby gender, age, gravida, parity, and abortion, did not reach statistical significance in the present research.

The inconsistencies observed between our results and those reported in different studies that were conducted in comparable low to middle-income countries highlight the necessity of establishing national Lebanese postpartum data. This is important considering the heterogeneity of the characteristics and risk factors of postpartum depression across countries, possibly due to cultural and socioeconomical differences.

That being said, the results reported in our study could serve for the modification and improvement of clinical practice for the prevention and treatment of postpartum depression. Clinicians could thus implement screening interventions as well as educational sessions for the prevention of depression in Lebanese mothers, especially those choosing to deliver through C-section.

Moreover, women with longer gestational periods can be closely monitored for the appearance of depressive symptoms. This would ensure the early detection and management of postpartum depression in this high-risk cohort and the prevention of the deleterious effects of this disorder.

References:

1. WHO. Depression [Internet]. 2018 [cited 2019 Apr 7]. Available from: https://www.who.int/news-room/fact-sheets/detail/depression
2. Sadock BJ, Sadock VA. Kaplan & Sadock Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Wolters Kluwer, Philadelphia, Pa. 2015.
3. Whitton SW, Kuryluk AD. Relationship satisfaction and depressive symptoms in emerging adults: Cross-sectional associations and moderating effects of relationship characteristics. J Fam Psychol. 2012;
4. Harvey SB, Glozier N, Henderson M, Allaway S, Litchfield P, Holland-Elliott K, et al. Depression and work performance: An ecological study using web-based screening. Occup Med (Chic Ill). 2011;
5. Vilagut G, Forero CG, Barbaglia G, Alonso J. Screening for depression in the general population with the center for epidemiologic studies depression (ces-d): A systematic review with meta-analysis. PLoS ONE. 2016.
6. Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. Journal of Psychiatric Research. 2013.
7. Yatham S, Sivathasan S, Yoon R, da Silva TL, Ravindran A V. Depression, anxiety, and post-traumatic stress disorder among youth in low and middle income countries: A review of prevalence and treatment interventions. Asian Journal of Psychiatry. 2018.
8. Semenkovich K, Brown ME, Svrakic DM, Lustman PJ. Depression in type 2 diabetes mellitus: Prevalence, impact, and treatment. Drugs. 2015;
9. NICE. Antenatal and postnatal mental health: clinical management and service guidance. NICE; 2014 [cited 2019 Apr 8]; Available from: https://www.nice.org.uk/guidance/cg192
10. Fisher J, de Mello MC, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: A systematic review. Bulletin of the World Health Organization. 2012.
11. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. The Lancet. 2014.
12. O’Hara MW, Schlechte JA, Lewis DA, Wright EJ. Prospective Study of Postpartum Blues: Biologic and Psychosocial Factors. Arch Gen Psychiatry. 1991;
13. Oakley A, Chamberlain G. Medical and social factors in postpartum depression. J Obstet Gynaecol (Lahore). 1981;
14. O’Hara MW. Postpartum Blues. In: Postpartum Depression Causes and Consequences [Internet]. New York: Springer-Verlag; 1995 [cited 2019 Apr 8]. p. 121–35. Available from: http://link.springer.com/10.1007/978-1-4613-8416-8_7
15. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence of depression during pregnancy: Systematic review. Obstetrics and Gynecology. 2004.
16. Buttner MM, O’Hara MW, Watson D. The Structure of Women’s Mood in the Early Postpartum. Assessment. 2012;
17. NIMH. Postpartum Depression Facts [Internet]. [cited 2019 Apr 12]. Available from: https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml
18. Cox JL, Holden JM, Sagovsky R. Detection of Postnatal Depression: Development of the 10-item Edinburgh Postnatal Depression scale. Br J Psychiatry. 1987;
19. Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry. 2000;
20. Williamson JA, O’Hara MW, Stuart S, Hart KJ, Watson D. Assessment of Postpartum Depressive Symptoms: The Importance of Somatic Symptoms and Irritability. Assessment. 2015;
21. American Mental Health Counselors Association. Depression Screenings for Pregnant and Postpartum Women Recommended [Internet]. [cited 2019 Apr 12]. Available from: http://connections.amhca.org/blogs/joel-miller/2016/01/27/depression-screenings-for-pregnant-and-postpartum-women-recommended
22. Hahn-Holbrook J, Cornwell-Hinrichs T, Anaya I. Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries. Front Psychiatry. 2018;
23. Di Florio A, Putnam K, Altemus M, Apter G, Bergink V, Bilszta J, et al. The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale. Psychol Med. 2017;
24. Wilkinson A, Anderson S, Wheeler SB. Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis. Matern Child Health J. 2017;
25. O’Hara MW, Swain AM. Rates and risk of postpartum depression - A meta-analysis. Int Rev Psychiatry. 1996;
26. Silva CS, Lima MC, Sequeira‐de‐Andrade LAS, Oliveira JS, Monteiro JS, Lima NMS, et al. Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life. J Pediatr (Versão em Port. 2017;
27. Alvarenga P, Dazzani MVM, Da Rocha Lordelo E, Dos Santos Alfaya CA, Piccinini CA. Predictors of sensitivity in mothers of 8-month-old infants. Paideia. 2013;
28. Sockol LE, Battle CL, Howard M, Davis T. Correlates of impaired mother-infant bonding in a partial hospital program for perinatal women. Arch Womens Ment Health. 2014;
29. Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behavior: A meta-analytic review. Clin Psychol Rev. 2000;
30. Alimonos LA, Simpkins G, DeAngelo M, Chernoff S, Hunter K, Khandelwal M. Feasibility of Psychoeducational Sessions in Pregnant Women at Risk for Postpartum Depression. Obstet Gynecol. 2015;
31. Mirhosseini H, Moosavipoor , Seyed Ahmad, Nazari MA, Dehghan A, Mirhosseini S, Bidaki R, et al. Cognitive Behavioral Development in Children Following Maternal Postpartum Depression: A Review Article. Electron physician. 2016;
32. Sharmin KN, Sarwar N, Mumu SJ, Taleb DA, Flora MS. Postnatal depression and infant growth in an urban area of Bangladesh. Midwifery [Internet]. 2019 Jul 22 [cited 2019 Apr 11];74:57–67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30927633
33. Madeghe BA, Kimani VN, Vander Stoep A, Nicodimos S, Kumar M. Postpartum depression and infant feeding practices in a low income urban settlement in Nairobi-Kenya. BMC Res Notes [Internet]. 2016 Dec 8 [cited 2019 Apr 11];9(1):506. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27931248
34. Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: A cohort study. Arch Gen Psychiatry. 2004;
35. Park M, Brain U, Grunau RE, Diamond A, Oberlander TF. Maternal depression trajectories from pregnancy to 3 years postpartum are associated with children’s behavior and executive functions at 3 and 6 years. Arch Womens Ment Health. 2018;
36. Moore Simas TA, Huang MY, Patton C, Reinhart M, Chawla AJ, Clemson C, et al. The humanistic burden of postpartum depression: a systematic literature review. Curr Med Res Opin. 2019;
37. Bobo W V., Yawn BP. Concise review for physicians and other clinicians: Postpartum depression. Mayo Clinic Proceedings. 2014.
38. Morrell CJ, Sutcliffe P, Booth A, Stevens J, Scope A, Stevenson M, et al. A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. Health Technology Assessment. 2016.
39. Fortinguerra F, Clavenna A, Bonati M. Psychotropic Drug Use During Breastfeeding: A Review of the Evidence. Pediatrics. 2009;
40. Di Blasio P, Camisasca E, Caravita SCS, Ionio C, Milani L, Valtolina GG. The Effects of Expressive Writing on Postpartum Depression and Posttraumatic Stress Symptoms. Psychol Rep. 2015;
41. Chang SM, Chen CH. Effects of an intervention with drinking chamomile tea on sleep quality and depression in sleep disturbed postnatal women: A randomized controlled trial. J Adv Nurs. 2016;
42. Poyatos-León R, García-Hermoso A, Sanabria-Martínez G, Álvarez-Bueno C, Cavero-Redondo I, Martínez-Vizcaíno V. Effects of exercise-based interventions on postpartum depression: A meta-analysis of randomized controlled trials. Birth. 2017.
43. Rabiei L, Amidi Mazaheri M, Masoudi R, Hasheminia SAM. Fordyce happiness program and postpartum depression. J Res Med Sci. 2014;
44. Gjerdingen DK, McGovern P, Pratt R, Johnson L, Crow S. Postpartum Doula and Peer Telephone Support for Postpartum Depression: A Pilot Randomized Controlled Trial. J Prim Care Community Heal. 2013;
45. Dennis CL, Hodnett E, Kenton L, Weston J, Zupancic J, Stewart DE, et al. Effect of peer support on prevention of postnatal depression among high risk women: Multisite randomised controlled trial. BMJ. 2009;
46. Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Womens Ment Health. 2005;
47. Edwards GD, Shinfuku N, Gittelman M, Ghozali EW, Haniman F, Wibisono S, et al. Postnatal Depression in Surabaya, Indonesia. Int J Ment Health. 2006;
48. Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery. 2011;
49. Ho-Yen SD, Bondevik GT, Eberhard-Gran M, Bjorvatn B. Factors associated with depressive symptoms among postnatal women in Nepal. Acta Obstet Gynecol Scand. 2007;
50. Couto ER, Couto E, Vian B, Gregório Z, Nomura ML, Zaccaria R, et al. Quality of life, depression and anxiety among pregnant women with previous adverse pregnancy outcomes. Sao Paulo Med J. 2009;
51. Abbaspoor Z, Razmju PS, Hekmat K. Relation between quality of life and mental health in pregnant women with prior pregnancy loss. J Obstet Gynaecol Res. 2016;
52. Chen L, Wang X, Ding Q, Shan N, Qi H. Development of Postpartum Depression in Pregnant Women with Preeclampsia: A Retrospective Study. Biomed Res Int [Internet]. 2019 Feb 27 [cited 2019 Apr 11];2019:1–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30937313
53. Wang J, Liu N, Sun W, Chen D, Zhao J, Zhang W. Association between vitamin D deficiency and antepartum and postpartum depression: a systematic review and meta-analysis of longitudinal studies. Archives of Gynecology and Obstetrics. 2018.
54. Rogathi JJ, Manongi R, Mushi D, Rasch V, Sigalla GN, Gammeltoft T, et al. Postpartum depression among women who have experienced intimate partner violence: A prospective cohort study at Moshi, Tanzania. J Affect Disord. 2017;
55. Lin P-Y, Chiu T-H, Ho M, Pei-Chen Chang J, Hui-Chih Chang C, Su K-P. Major depressive episodes during pregnancy and after childbirth: A prospective longitudinal study in Taiwan. J Formos Med Assoc [Internet]. 2019 Mar 27 [cited 2019 Apr 12]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/30928189
56. El-Hachem C, Rohayem J, Bou Khalil R, Richa S, Kesrouani A, Gemayel R, et al. Early identification of women at risk of postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) in a sample of Lebanese women. BMC Psychiatry. 2014;
57. Chaaya M, Campbell OMR, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: Prevalence and determinants in Lebanon. Arch Womens Ment Health. 2002;
58. Badr LK. Is the effect of postpartum depression on mother-infant bonding universal? Infant Behav Dev. 2018;
59. ACOG Committee Opinion No. 757: Screening for Perinatal Depression. Obstet Gynecol. 2018;
60. Moraes GP de A, Lorenzo L, Pontes GAR, Montenegro MC, Cantilino A. Screening and diagnosing postpartum depression: when and how? Trends Psychiatry Psychother. 2017;
61. Hanusa BH, Scholle SH, Haskett RF, Spadaro K, Wisner KL. Screening for Depression in the Postpartum Period: A Comparison of Three Instruments. J Women’s Heal. 2008;
62. Shrestha SD, Pradhan R, Tran TD, Gualano RC, Fisher JRW. Reliability and validity of the Edinburgh Postnatal Depression Scale (EPDS) for detecting perinatal common mental disorders (PCMDs) among women in low-and lower-middle-income countries: A systematic review. BMC Pregnancy Childbirth. 2016;