Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 16, 2020
SYSTEMATIC REVIEW

Postpartum Depression in The Arab Region: A Systematic Literature Review



Khubaib Ayoub1, Amira Shaheen1, *, Shakoor Hajat2
1 Faculty of Medicine and Health Sciences, An-Najah National University, Rafidia Street, P.O.Box 7, Nablus, Palestine
2 Department of Social & Environmental 9 Health Research (SEHR), Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15- 17 Tavistock Place, London, WC1H 9SH, UAE

Abstract

Background:

Postpartum Depression (PPD) is a major public health problem affecting mothers and their babies. However, few studies have investigated the prevalence and risk factors for postpartum depression among Arab mothers. This systematic literature review aims to determine the prevalence of PPD among mothers in Arab countries and identify the main risk factors.

Methods:

A review of all peer-reviewed journal published studies on PPD and its risk factors among Arab mothers until February 2016. The following data bases were searched; PubMed, Springlink, Science direct, EBSCOhost, and Arabpsychnet.

Results:

25 studies were included in the review. PPD rates were high in general but prevalences were close to the rates observed in other low and lower-middle-income countries. Twelve studies reported PPD prevalences in the region of 15-25%, 7 studies reported prevalences< 15% and 6 studies reported prevalences<25%. The most important risk factors for PPD were: low income and socioeconomic status, obstetric complications during pregnancy, unwanted pregnancy, ill infant, formula feeding, low social and husband support, marital and in-laws conflicts, stressful life events during pregnancy and personal or family history of depression.

Conclusion:

Prevalence of PPD is high in most Arab countries, with differences due in part to variations in methods of assessment. This review highlights the problem of PPD and advocates for the adoption of necessary changes in the Arab health systems such as routine screening and efficient referral systems in order to detect and treat this potentially debilitating condition.

Keywords: Postpartum depression, Arab region, Public health problem, Infants, Unwanted pregnancy, Socioeconomic status.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 16
Issue: Suppl-1, M10
First Page: 142
Last Page: 155
Publisher Id: CPEMH-16-142
DOI: 10.2174/1745017902016010142

Article History:

Received Date: 6/4/2020
Revision Received Date: 29/5/2020
Acceptance Date: 30/5/2020
Electronic publication date: 30/07/2020
Collection year: 2020

© 2020 Ayoub et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Faculty of Medicine and Health Sciences, An-Najah National University, Rafidia Street, P.O.Box 7, Nablus, Palestine; E-mail: shaheenamira@yahoo.co.uk





1. INTRODUCTION

Postpartum Depression (PPD) is defined as the occurrence of a major depressive episode within 4 weeks of delivery [1American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th ed. 2013.]. Although PPD commonly begins within the first 4 weeks, onset can occur at any time during the first postnatal year, with the incidence decreasing substantially by 3 months following birth [2Stewart D, Robertson E, Dennis C, Grace S, Wallington T. Postpartum depression: Literature review of risk factors and interventions 2003.]

A Major Depressive Episode (MDE) is defined in the fifth edition of the Diagnostic Statistical Manual of Mental Disorders (DSM-V) [1American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th ed. 2013.] as the presence of at least five of the following symptoms during most of the day, nearly every day for a 2-week period with impairment, or decline of previous levels of functioning: depressed mood, often accompanied by anxiety; markedly diminished pleasure in activities; loss of appetite and weight; sleep disturbances, often insomnia; physical agitation or psychomotor slowing; fatigue and low energy; feelingsof worthlessness or inappropriate guilt; decreased concentration and decision making ability; and recurrent suicidal ideation or thoughts of death. The presence of a depressed mood or loss of interest is necessary for a diagnosis of MDE [1American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th ed. 2013., 3Wisner KL, Parry BL, Piontek CM. Clinical practice. Postpartum depression. N Engl J Med 2002; 347(3): 194-9.
[http://dx.doi.org/10.1056/NEJMcp011542] [PMID: 12124409]
].

PPD is a major public health problem since it affects 13% of mothers worldwide during a very sensitive period of their life, exerting a negative effect on mothers, their babies and families, and potentially their entire society [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G., 5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
]. Different types of risk factors and predictors are found to correlate with PPD. Based on studies from Western societies, strong predictors of PPD are: depression or anxiety during pregnancy, a previous history of depression, stressful recent life events and poor social support. Less powerful or moderate predictors include: stress over childcare issues, low self-esteem and bad infant temperament such as excessive crying. Obstetric and pregnancy complications, poor partner relationship or single mothers, and low socioeconomic status and income are minor predictors of PPD, whilst no significant relationships were previously observed with race, mother’s age, education, number of births (parity) or the baby’s sex [2Stewart D, Robertson E, Dennis C, Grace S, Wallington T. Postpartum depression: Literature review of risk factors and interventions 2003., 5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
].

Some recent studies suggest that PPD is a heterogeneous disorder with more than one distinct phenotype. These subtypes differ between the time of onset, severity of mood worsening and hopelessness, presence of anxiety, suicidal ideation and presence of pregnancy or obstetric complications [6Kettunen P, Koistinen E, Hintikka J. Is postpartum depression a homogenous disorder: time of onset, severity, symptoms and hopelessness in relation to the course of depression. BMC Pregnancy Childbirth 2014; 14: 402.
[http://dx.doi.org/10.1186/s12884-014-0402-2] [PMID: 25491477]
, 7Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium. Heterogeneity of postpartum depression: a latent class analysis. Lancet Psychiatry 2015; 2(1): 59-67.
[http://dx.doi.org/10.1016/S2215-0366(14)00055-8] [PMID: 26359613]
].

The prevalence of PPD is considered to be higher in low- and lower-middle income countries, where the average prevalence of depression was 15.6% (95% CI: 15.4–15.9) during pregnancy and 19.8% (95% CI: 19.5–20.0) during the postnatal period [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G.]. Fisher et al. conclude that risk factors for PPD in these countries are: low socioeconomic status; unplanned or unwanted pregnancy; younger age of the mother; being unmarried; poor family and partner relationships, lack of partner support, empathy, and practical help, having a conflict with the mother-in-law, and experiences of partner violence. History of mental health problems and giving birth to a female are also significant risk factors. However, higher education, permanent employment status and a kind trusted partner were protective factors against PPD, as well as being from the majority ethnic group in some settings [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G.].

Although some Arab populations were included in previous international and regional reviews [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G., 8Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010; 123(1-3): 17-29.
[http://dx.doi.org/10.1016/j.jad.2009.06.027] [PMID: 19635636]
], there is no comprehensive review of postpartum depression prevalence and associated risk factors, specifically in Arab countries. The Arab nations have many features in common, including the Arabic language and cultural and traditional values as conservative societies. On the other hand, Arab countries have a great diversity in terms of socioeconomic conditions ranging from very poor countries like Somalia and Yemen to Gulf countries, which have the highest per capita income in the world [9World Bank. World DataBank: World Development Indicators 2013. Available from: http://databank.worldbank.org/data/views/reports/tableview.aspx?isshared=true&ispopular=series&pid=3]. This diversity and inequity continue to exist within the same community in many settings. Some of these factors may increase vulnerability to depression, and so we conducted a systematic literature review of PPD in Arab settings. This review aims to assess the prevalence of PPD in Arab countries and to ascertain risk factors for PPD in these settings.

2. METHODOLOGY

A comprehensive review of the peer-reviewed published literature was conducted through PubMed in February 2016 using the following terms: “postnatal depression”, “postnatal”, “postpartum depression”, “postpartum” AND”Arab”. In addition, “postnatal depression” and “postpartum depression” were combined with 22 individual Arab countries (Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen).

This review was added to an earlier search of the same terms conducted in February 2016 in PubMed, SpringerLink, science direct, EBSCOhost and Arabpsychnet. The search engine of the Institute for Development, Research, Advocacy and Applied Care (IDRAAC), which is a search engine containing all mental health research in the Arab world from 1966 to July 2007, was also reviewed. (http://www.idrac.org.lb/) Finally, the reference lists of identified articles and the research gate website were searched manually for any further relevant articles from Arab countries.

Inclusion criteria were: 1) original studies about postpartum depression published in peer-reviewed journals; 2) concerning prevalence and/or risk factors for PPD; 3) conducted in one of the mentioned Arab countries or among Palestinians in Israel; 4) published in the English language; 5) scoring at least 5 on the methodological assessment criteria mentioned below. Exclusion criteria were: 1) MSc and PhD thesis and books; 2) Studies about treatment methods or interventions; 3) Studies about biological and genetic risk factors; 4) studies about antepartum depression unless they were about both ante- and postpartum depression; 5) Studies about immigrants or Non-Arab populations (e.g., American army in Iraq); 6) Studies where the population is mixed Arab and Non-Arab; 7) Studies where we could not access the full article; and 8) review studies. One Tunisian study was originally in French but was added following translation to English in order to include more relevant studies. Fig. (1) shows the flow of the search process.

Two of the review authors (K.A. and A.S.) assessed the methodological quality of the retrieved papers using criteria previously developed by Mirza and Jenkins.(4, 8, 10) These criteria evaluate the studies in relation to the following points: 1) clear study objectives, 2) adequate sample size with justification (either calculated or the population size mentioned), 3) sample representative of the population, 4) clear inclusion and exclusion criteria, 5) depression measure used is reliable and valid, 6) reported response rate and/or losses explained, 7) adequate description of data, and 8) appropriate statistical analyses. Fisher et al. added a ninth criterion of signing a consent form.(4) Grades out of 9 were assigned to individual studies based on their fulfillment of the above criteria (Table 1).

As the Palestinian Arab community in Israel is a large community of 1.8 million and shares the Arab and Palestinian context, another PubMed search using postpartum depression in Israel was done and yielded 68 studies. Of these, 60 were irrelevant and only 3 articles remained after the exclusion, but they were already identified from the previous search. Further manual searches retrieved additional 4 studies, but one of them was excluded as the methodology and other details were obscure.

Fig. (1)
Schematic diagram of the literature search process.


Table 1
Methodological quality assessment of the studies about postpartum depression in Arab countries. (1 = yes; 0 = no)


3. RESULTS

A total of 88 studies about postpartum depression in Arab countries were retrieved through PubMed, 45 of them were duplicates and 22 studies were excluded after reading the abstract of the full article. Of these, 3 were exclusively about antenatal depression, 4 about interventions for PPD or studying specific hormonal or genetic predisposing factor, 5 were about non-Arab populations such as Kurdish people or the American Army in Iraq, 5 were investigating mixed Arab and non-Arab populations in Israel or comparing mixed immigrant populations, and a further 3 were a literature review, a tool validation study and a study investigating PPD among the Jordanian army. Another 2 were excluded because the full text could not be retrieved despite repeated attempts at communication with the authors.

The total number of included studies was 25 (Table 2). Of these, 21 investigated the prevalence of depression only during the postnatal period, and 4 investigated depression during both pregnancy and after birth (Table 2). Moreover, 24 out of 25 studies investigated probable risk factors associated with the occurrence of postpartum depression. The earliest study was published in 1997, but only 5 studies were published before 2010. Four studies were published in 2011 and 4 in 2012, but the dramatic increase was in 2014 when7 studies were published, reflecting the increased attention paid to this important condition by Arab researchers. Lastly, 3 studies were published in 2015. Six studies were conducted in Egypt, 3 studies were in each of the UAE, Saudi Arabia and Palestinians in Israel, 2 studies were from Lebanon and Morocco, and one study in each of Tunisia, Jordan, Bahrain, Qatar, Oman and Sudan.

Table 2
Summary of the included studies with prevalence and tool used.


4. COMPARISON OF THE USED METHODOLOGIES

The quality of the included studies, according to the previously mentioned criteria, ranged from 6 to 9 out of a maximum score of 9, reflecting the high methodological quality of these studies in general. The details of this assessment are presented in Table 2.

4.1. Time and Place of Recruitment

Twenty studies recruited participants at various times during the postpartum period, and 5 recruited mothers during pregnancy and followed them at different times after birth (Table 2), making a comparison of prevalence rates more difficult. The place of recruitment also differed between the studies. Whilst 11 studies chose to recruit mothers from hospitals(which are mostly tertiary teaching hospitals) either after giving birth or at follow up in the hospital clinics, 11 studies recruited their participants from community-based maternal and child health clinics (MCHCs) of primary health care centers (PHCCs). Lastly, 2 studies chose a combined hospital and MCHCs pool of participants and 1 study recruited mothers directly from the community by home visits. (See Table 2).

4.2. Study Design

All of the 25 studies were cross-sectional prevalence studies. Seven studies used a longitudinal panel approach by measuring depression in the same participants at multiple time-points during pregnancy and the postpartum period, thus tracking the changing rates of depression in relation to the different time points. A further 3 studies used a cross-sectional approach to estimate point prevalences and a case-control design to determine risk factors. The remaining 15 studies used point or period prevalence estimates on one occasion or during a specific period after delivery (Table 2).

4.3. Sample Size and Sampling Method

Only 4 studies reported a random sampling approach [10Mirza I, Jenkins R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. BMJ 2004; 328(7443): 794.
[http://dx.doi.org/10.1136/bmj.328.7443.794] [PMID: 15070634]
-14Khalifa DS, Glavin K, Bjertness E, Lien L. Postnatal depression among Sudanese women: prevalence and validation of the Edinburgh Postnatal Depression Scale at 3 months postpartum. Int J Womens Health 2015; 7: 677-84.
[http://dx.doi.org/10.2147/IJWH.S81401] [PMID: 26185471]
] and the remaining studies used convenience sampling and so their representativeness of the general population is doubtful. However, a number of studies aimed to be more representative by recruiting their sample from the entire available primary or secondary care units serving the target population [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 15Glasser S, Tanous M, Shihab S, Goldman N, Ziv A, Kaplan G. Perinatal depressive symptoms among Arab women in northern Israel. Matern Child Health J 2012; 16(6): 1197-205.
[http://dx.doi.org/10.1007/s10995-011-0845-2] [PMID: 21735141]
-18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
] rather than simply sampling the institution in which they worked. The small sample size in many studies hindered the generalization of the results.

4.4. Tools Used

The 25 studies used the Edinburgh Postnatal Depression Scale (EPDS) for the screening and investigation of PPD; however, different cut-off scores were sometimes used, making comparisons between studies more complicated in addition to the other methodological differences. The most used cut-off of EPDS score to screen positive for depression was ≤ 13 used by 7 studies, and a further 7 studies used a score of 10-12 to define moderate depression and ≤ 13 for severe depression. 6 studies used a cut-off of ≤ 12, 3 used ≤ 10, and one used ≤ 9. Hamdan and Tamim used both ≤ 10 and ≤ 12.

Four studies used The Mini-International Neuropsychiatric Interview (MINI) to establish PPD diagnosis after screening with EPDS [14Khalifa DS, Glavin K, Bjertness E, Lien L. Postnatal depression among Sudanese women: prevalence and validation of the Edinburgh Postnatal Depression Scale at 3 months postpartum. Int J Womens Health 2015; 7: 677-84.
[http://dx.doi.org/10.2147/IJWH.S81401] [PMID: 26185471]
, 16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
, 19Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Women Ment Health 2005; 8(1): 37-43.
[http://dx.doi.org/10.1007/s00737-005-0069-9] [PMID: 15868390]
, 20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
]. Other screening tools included the Beck depression inventory (BDI) [21Hassanein IM, Fathalla MM, Abdel Rahim T. The role of newborn gender in postpartum depressive symptoms among women in Upper Egypt. Int J Gynaecol Obstet 2014; 125(2): 138-40.
[http://dx.doi.org/10.1016/j.ijgo.2013.11.006] [PMID: 24572456]
], the Depression, Anxiety and Stress Scale (DASS) [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 22Bener A, Gerber LM, Sheikh J. Prevalence of psychiatric disorders and associated risk factors in women during their postpartum period: a major public health problem and global comparison. Int J Womens Health 2012; 4: 191-200.
[http://dx.doi.org/10.2147/IJWH.S29380] [PMID: 22654524]
], the Postpartum Depression Predictors Inventory (PDPI) [23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7.], the Structured Interview for DSM-IV Axis Disorders- Clinician Version (SCID-CV) [24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
], and the Present State Examination (PSE) diagnostic protocol [25Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997; 171: 65-8.
[http://dx.doi.org/10.1192/bjp.171.1.65] [PMID: 9328498]
]. Regardless of the tool used, PPD rates were high in general and many studies had a prevalence close to the average rate for other low and lower-middle-income countries [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G.].

5. PREVALENCE

Prevalence of postpartum depression varied widely due to the different tools and different cut-off points used, and also because of the difference in time-points at which depression was investigated (Table 2). Twelve studies concluded that 15-25% of mothers had or likely had postpartum depression. Seven studies reported prevalence rates less than 15% (with a minimum rate of 7%) and 6 studies reported rates> 25% (maximum 74%).

When using an EPDS cut-off score ≥ 10 (EPDS maximum score is 30), the PPD prevalence ranged from 13.2% at 6 weeks postpartum in Tunisia [26Masmoudi J, Tabelsi S, Charfeddine F, Ben Ayed B, Guermazzi M, Jaoua A. [Study of the prevalence of postpartum depression among 213 Tunisian parturients]. Gynécol Obstét Fertil 2008; 36(7-8): 782-7.
[http://dx.doi.org/10.1016/j.gyobfe.2008.03.015] [PMID: 18650112]
] to 43% and 44.2% in Bedouin Palestinians of Southern Israel [27Glasser S, Stoski E, Kneler V, Magnezi R. Postpartum depression among Israeli Bedouin women. Arch Women Ment Health 2011; 14(3): 203-8.
[http://dx.doi.org/10.1007/s00737-011-0216-4] [PMID: 21479760]
] and in the Abu Dhabi hospital study [28Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physical factors. Psychol Health Med 2006; 11(4): 425-31.
[http://dx.doi.org/10.1080/13548500600678164] [PMID: 17129919]
] respectively. The rate was reported to be 73.7% in the city of kom-ombo in Egypt, but the sample size was small (57 mothers) and the time of measurement wide (2 weeks to one year postpartum) [29Mohamed HA, Spencerb SL, Al Swasyc AH, Swidand SE, Aboueleniene MS. A social and Biological Approach for Postpartum Depression in Egypt. Woman- Psychosom Gynaecol Obstet 2014; 1(1): 30-9.
[http://dx.doi.org/10.1016/j.woman.2014.10.002]
]. The use of this cut-off score results in high sensitivity, with a slight reduction in specificity [30Ghubash R, Abou-Saleh MT, Daradkeh TK. The validity of the Arabic Edinburgh Postnatal Depression Scale. Soc Psychiatry Psychiatr Epidemiol 1997; 32(8): 474-6.
[PMID: 9409163]
]. On the other hand, the use of the more accepted cut-off score of ≥12 resulted in depression rates ranging from 9.2% in Sudan [14Khalifa DS, Glavin K, Bjertness E, Lien L. Postnatal depression among Sudanese women: prevalence and validation of the Edinburgh Postnatal Depression Scale at 3 months postpartum. Int J Womens Health 2015; 7: 677-84.
[http://dx.doi.org/10.2147/IJWH.S81401] [PMID: 26185471]
], 16.8% in Sharjah in UAE [16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
] and 17.6% in Qatar [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
] to 20.1% and 21% in Morocc [19Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Women Ment Health 2005; 8(1): 37-43.
[http://dx.doi.org/10.1007/s00737-005-0069-9] [PMID: 15868390]
] and Lebanon [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
] respectively. Bahrain was an outlier with a prevalence of 37.1% with EPDS score ≥ 12 [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
]

The most recent studies used score ≤13 as a cut off for depression or used 2 cut-offs for moderate and severe depression (≤10 and ≤13). The prevalence ranged from 8-10% in Arab Palestinian mothers of Northern Israel, Saudi Arabia and Oman [15Glasser S, Tanous M, Shihab S, Goldman N, Ziv A, Kaplan G. Perinatal depressive symptoms among Arab women in northern Israel. Matern Child Health J 2012; 16(6): 1197-205.
[http://dx.doi.org/10.1007/s10995-011-0845-2] [PMID: 21735141]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 33Al Hinai FI, Al Hinai SS. Prospective study on prevalence and risk factors of postpartum depression in Al-dakhliya governorate in oman. Oman Med J 2014; 29(3): 198-202.
[http://dx.doi.org/10.5001/omj.2014.49] [PMID: 24936270]
] to 20-22% in Jordan, Egypt, Abu Dhabi and the Palestinian mothers of Naqab [12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
, 17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 28Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physical factors. Psychol Health Med 2006; 11(4): 425-31.
[http://dx.doi.org/10.1080/13548500600678164] [PMID: 17129919]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
]. The prevalence of depression assessed using diagnostic tools such as Mini-International Neuropsychiatric Interview (MINI) did not differ greatly from the results obtained by the EPDS screening tool.

6. RISK FACTORS

Risk factors for PPD were classified into five categories: socio-demographic factors, pregnancy and birth factors, infant-related factors, marital and family relationship factors, and psychosocial and psychological history factors. Table 3 summarizes the risk factors associated with PPD.

6.1. Socio-demographic Factors

The most prominent socio-demographic factor that was associated with PPD was low income or socio-economic status (SES) and it was reported to be significantly higher in depressed mothers in 7 studies. 2 studies reported an age less than 25 years as a risk factor for PPD [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 33Al Hinai FI, Al Hinai SS. Prospective study on prevalence and risk factors of postpartum depression in Al-dakhliya governorate in oman. Oman Med J 2014; 29(3): 198-202.
[http://dx.doi.org/10.5001/omj.2014.49] [PMID: 24936270]
], whilst one reported ages older than 35 years [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
] and another reported older ages at first marriage as risk factors [28Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physical factors. Psychol Health Med 2006; 11(4): 425-31.
[http://dx.doi.org/10.1080/13548500600678164] [PMID: 17129919]
]. Lower education levels were associated with PPD in 3 studies in Qatar and Naqab [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 27Glasser S, Stoski E, Kneler V, Magnezi R. Postpartum depression among Israeli Bedouin women. Arch Women Ment Health 2011; 14(3): 203-8.
[http://dx.doi.org/10.1007/s00737-011-0216-4] [PMID: 21479760]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
]. The rural residency was a risk factor in 2 studies in Lebanon and Egypt [24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
, 31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]. The role of employment in predicting PPD was unclear. Hamdan and Tamim reported mothers’ employment as a risk factor for PPD in UAE [16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
], and Abdel Wahid et al. reported unemployment as a risk factor in Egypt [13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
]. Al-Hinai reported difficulties at work rather than employment itself as a predisposing factor [33Al Hinai FI, Al Hinai SS. Prospective study on prevalence and risk factors of postpartum depression in Al-dakhliya governorate in oman. Oman Med J 2014; 29(3): 198-202.
[http://dx.doi.org/10.5001/omj.2014.49] [PMID: 24936270]
]

Table 3
Factors identified to be associated with postpartum depression.


6.2. Pregnancy and Birth-related Factors

The most common pregnancy and birth variable reported to be associated with PPD was an unplanned or unwanted pregnancy, as reported by 7 studies [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
, 25Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997; 171: 65-8.
[http://dx.doi.org/10.1192/bjp.171.1.65] [PMID: 9328498]
, 27Glasser S, Stoski E, Kneler V, Magnezi R. Postpartum depression among Israeli Bedouin women. Arch Women Ment Health 2011; 14(3): 203-8.
[http://dx.doi.org/10.1007/s00737-011-0216-4] [PMID: 21479760]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
]. Primiparity was associated with PPD in 2 studies [25Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997; 171: 65-8.
[http://dx.doi.org/10.1192/bjp.171.1.65] [PMID: 9328498]
, 28Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physical factors. Psychol Health Med 2006; 11(4): 425-31.
[http://dx.doi.org/10.1080/13548500600678164] [PMID: 17129919]
] whilst higher parity was associated with PPD in 2 studies [16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
]. Four studies reported complications of pregnancy or delivery such as bleeding and threatened abortion to be associated with PPD [12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
-20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
] and another 4 studies reported chronic medical illnesses during pregnancy to be associated with PPD [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
, 35El-Hachem C, Rohayem J, Bou Khalil 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; 14: 242.
[http://dx.doi.org/10.1186/s12888-014-0242-7] [PMID: 25193322]
, 36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
]. Lastly, the association of delivery mode with PPD was inconsistent. Whilst Bener reported higher PPD in mothers undergoing Caesarean sections [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
], Abdelwahid reported higher PPD among those undergoing vaginal deliveries [13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
]. Chaaya et al. reported higher PPD in urban mothers undergoing vaginal deliveries and in rural mothers undergoing Caesarean sections [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]. Bener et al. investigated the relationship of PPD with either history of abortion or stillbirth and history of infertility and reported both to be unassociated [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
].

6.3. Infant Factors

Infants who were ill or of low weight predisposed their mothers to PPD in 7 studies [12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 19Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Women Ment Health 2005; 8(1): 37-43.
[http://dx.doi.org/10.1007/s00737-005-0069-9] [PMID: 15868390]
, 20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
, 25Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997; 171: 65-8.
[http://dx.doi.org/10.1192/bjp.171.1.65] [PMID: 9328498]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
] and two other studies found associations with premature births.(18, 36) Whilst formula feeding was higher among depressed mothers in 3 studies [16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
] breastfeeding was associated with PPD in the study by Abdelwahid et al. in Egypt [13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
]. Interestingly, having a female baby was associated with PPD in 3 Egyptian and 1 Jordanian study [13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
, 17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 21Hassanein IM, Fathalla MM, Abdel Rahim T. The role of newborn gender in postpartum depressive symptoms among women in Upper Egypt. Int J Gynaecol Obstet 2014; 125(2): 138-40.
[http://dx.doi.org/10.1016/j.ijgo.2013.11.006] [PMID: 24572456]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
]

6.4. Marital and Family Relationship Factors

A poor marital relationship and marital conflict, including physical or verbal violence and a poor or unsatisfying marital and sex life, were strongly associated with PPD in 11 studies [13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
-20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
-26Masmoudi J, Tabelsi S, Charfeddine F, Ben Ayed B, Guermazzi M, Jaoua A. [Study of the prevalence of postpartum depression among 213 Tunisian parturients]. Gynécol Obstét Fertil 2008; 36(7-8): 782-7.
[http://dx.doi.org/10.1016/j.gyobfe.2008.03.015] [PMID: 18650112]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
-34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
, 36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
]. Moreover, PPD was associated with poor support or practical help from the husband in 6 studies [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
] Conflict with the mother-in-law predisposed mothers to PPD in 4 studies [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 28Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physical factors. Psychol Health Med 2006; 11(4): 425-31.
[http://dx.doi.org/10.1080/13548500600678164] [PMID: 17129919]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
] whereas the absence of one’s own mothers support or conflict with her were not associated with PPD (2 studies) [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 28Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physical factors. Psychol Health Med 2006; 11(4): 425-31.
[http://dx.doi.org/10.1080/13548500600678164] [PMID: 17129919]
].

6.5. Psychosocial Factors and Psychological History Factors

The most consistent predictor of PPD was a personal history of depression or mental illness, reported in 11 studies [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7.-26Masmoudi J, Tabelsi S, Charfeddine F, Ben Ayed B, Guermazzi M, Jaoua A. [Study of the prevalence of postpartum depression among 213 Tunisian parturients]. Gynécol Obstét Fertil 2008; 36(7-8): 782-7.
[http://dx.doi.org/10.1016/j.gyobfe.2008.03.015] [PMID: 18650112]
, 31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
-36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
] Stressful life events in the past year or during pregnancy were associated with higher rates of PPD in 8 studies [19Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Women Ment Health 2005; 8(1): 37-43.
[http://dx.doi.org/10.1007/s00737-005-0069-9] [PMID: 15868390]
, 20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
, 23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7.-25Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997; 171: 65-8.
[http://dx.doi.org/10.1192/bjp.171.1.65] [PMID: 9328498]
, 31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
]. Moreover, poor social and family support and major financial problems or difficulty managing with income were associated with PPD in 5 [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7., 31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
, 36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
] and 3 studies, respectively [12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 20Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health 2006; 9(6): 343-6.
[http://dx.doi.org/10.1007/s00737-006-0154-8] [PMID: 17033739]
].

Interestingly, having anxiety, stress or depression during pregnancy was associated with the occurrence of PPD in 6 studies [16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
, 17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7., 31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
] and the occurrence of ‘1st week maternity blues’ was associated with subsequent PPD in 2 studies [23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7., 35El-Hachem C, Rohayem J, Bou Khalil 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; 14: 242.
[http://dx.doi.org/10.1186/s12888-014-0242-7] [PMID: 25193322]
]. Other factors such as perceived low parenting knowledge [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
] perceived low self-efficacy [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
] and dissatisfaction with overall care during pregnancy and birth were associated with PPD only in the study by Mohammad et al. [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
]. A family history of depression was associated with higher rates of PPD in 3 studiesn [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 35El-Hachem C, Rohayem J, Bou Khalil 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; 14: 242.
[http://dx.doi.org/10.1186/s12888-014-0242-7] [PMID: 25193322]
].

6.6. Maternity Care-related Factors

Mohammad et al. investigated factors related to the maternity care of the mother during labor and birth and their associations with PPD [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
]. Factors found to be significantly associated with PPD at 6-8 weeks postpartum were: duration of labor of more than 11 hours; more than 8 vaginal exams; lying in lithotomy position during labor; episiotomy or requiring sutures; very painful suturing; labor more painful than expected; dissatisfaction with pain relief during labor; postpartum hemorrhage; overall poor quality of care; unhelpful doctors; mother’s desire to talk more about birth; mother not always kept informed; decisions were made without taking mother’s wishes into account; mother felt pressured to have baby quickly; mother felt labor was taken over by strangers and/or machines; doctors and midwives not encouraging nor reassuring; attendance of other mothers; mothers wanted more information during labor; mothers wanted more information about why induction was necessary; mother felt worried, anxious or frightened when labor began; mother did not feel confident in labor; mother felt out of control, frightened or helplessness.

6.7. Effect Size of Each Risk Factor

The earlier studies before 2012 discussed the significance of the risk factors associations with PPD based on hypothesis testing and p-values and gave no information regarding the magnitude of this association, except for the study of Chaayaet al. in 2002 [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]. From 2012, the authors gave more attention to the magnitude of associations by reporting odds ratios (OR). Eight of the 15 studies published in 2012 or later reported the OR of risk factors [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
-13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
-34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
, 36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
, 37Alharbi AA, Abdulghani HM. Risk factors associated with postpartum depression in the Saudi population. Neuropsychiatr Dis Treat 2014; 10: 311-6.
[PMID: 24570584]
], in contrast to only one [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]among 10 studies published prior to 2012. This review calculated the odds ratios of the risk factors and their 95% confidence intervals (CI), where this was possible based on the 2×2 tables presented in the reviewed papers.

Low income was the socio-demographic factor associated with the highest ORs for PPD (OR: 3.06-3.56) [12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 27Glasser S, Stoski E, Kneler V, Magnezi R. Postpartum depression among Israeli Bedouin women. Arch Women Ment Health 2011; 14(3): 203-8.
[http://dx.doi.org/10.1007/s00737-011-0216-4] [PMID: 21479760]
]. Low socio-economic status was strongly associated with PPD (OR=23.8, 95% CI [2.29-245.6]) in one study [26Masmoudi J, Tabelsi S, Charfeddine F, Ben Ayed B, Guermazzi M, Jaoua A. [Study of the prevalence of postpartum depression among 213 Tunisian parturients]. Gynécol Obstét Fertil 2008; 36(7-8): 782-7.
[http://dx.doi.org/10.1016/j.gyobfe.2008.03.015] [PMID: 18650112]
] and mothers who perceived their income as low were 1.5 times more likely to be depressed as reported by Al-fayoumi-Zeadna et al. [34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
]. Other socio-demographic factors such as age, residency, mother’s employment and education had odds ratios ranging from 1.3-2.5. Pregnancy and birth-related factors were reported to have odds ratios in the region 1.5-6.5. Ill or low weight infants and premature infants were 2.1-14.5 times and 1.6-3.6 times higher in their association with PPD, respectively. Similarly, formula-feeding mothers were at 1.9-5.8 higher PPD risk [16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
]. Lastly, mothers with female babies had 2-4 times higher PPD risk compared to those having male babies in 4 studies [13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
, 17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 21Hassanein IM, Fathalla MM, Abdel Rahim T. The role of newborn gender in postpartum depressive symptoms among women in Upper Egypt. Int J Gynaecol Obstet 2014; 125(2): 138-40.
[http://dx.doi.org/10.1016/j.ijgo.2013.11.006] [PMID: 24572456]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
]

Poor marital relationships, including marital conflict, physical or verbal violence and unsatisfying marital and sex life, were associated with 1.5-11.7 times higher odds of depression. Poor husband support was associated with2.4-7.1 higher odds of depression in 5 studies [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
]. Conflict with mother-in-law was associated with PPD in 4 studies, but only 2 reported the size of this association (OR=1.8; 2.7), respectively [32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 38Abou-Saleh MT, Ghubash R. The prevalence of early postpartum psychiatric morbidity in Dubai: a transcultural perspective. Acta Psychiatr Scand 1997; 95(5): 428-32.
[http://dx.doi.org/10.1111/j.1600-0447.1997.tb09657.x] [PMID: 9197909]
]. Psychosocial variables were the most important group of PPD risk factors. Personal history of depression or mental illness led to 2 to 23 times higher odds of depression in 11 studies [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 12Mohammed ES, Mosalem FA, Mahfouz EM, Abd ElHameed MA. Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study. Public Health 2014; 128(9): 817-24.
[http://dx.doi.org/10.1016/j.puhe.2014.06.006] [PMID: 25213100]
, 23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7.-26Masmoudi J, Tabelsi S, Charfeddine F, Ben Ayed B, Guermazzi M, Jaoua A. [Study of the prevalence of postpartum depression among 213 Tunisian parturients]. Gynécol Obstét Fertil 2008; 36(7-8): 782-7.
[http://dx.doi.org/10.1016/j.gyobfe.2008.03.015] [PMID: 18650112]
, 31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
, 32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 34Alfayumi-Zeadna S, Kaufman-Shriqui V, Zeadna A, Lauden A, Shoham-Vardi I. The association between sociodemographic characteristics and postpartum depression symptoms among Arab-Bedouin women in Southern Israel. Depress Anxiety 2015; 32(2): 120-8.
[http://dx.doi.org/10.1002/da.22290] [PMID: 25044129]
-36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
], but the Qatari study which had the largest sample size (about 1400) found no association (OR=0.9) [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
] Family history of depression or mental illness was 2.8 to 7.8 times higher odds of depression whilst a history of depression, anxiety or stress during the index pregnancy were associated with ORs of 2.3-14. Depressed mothers reported experiencing stressful life events in the previous pregnancy (e.g., loss of a dear person or financial difficulties), with the most reported event being financial problems and difficulty managing with income.

7. DISCUSSION

To the best of our knowledge, this review is the largest and most comprehensive review of the prevalence and associated risk factors of postpartum depression, specifically among Arab mothers in the Arab regions. It included 25 studies from 1997 to 2015. Only studies that were conducted in Arab countries were included as Arab people in the Diaspora are likely to have different risk profiles since they experience a different cultural context.

Some studies among Arab mothers were included in previous multi-national and regional reviews. For example, Halbreich and Karkun [39Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006; 91(2-3): 97-111.
[http://dx.doi.org/10.1016/j.jad.2005.12.051] [PMID: 16466664]
] mentioned 3 Arab studies out of 143 studies worldwide, Sawyer et al. [8Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010; 123(1-3): 17-29.
[http://dx.doi.org/10.1016/j.jad.2009.06.027] [PMID: 19635636]
] mentioned 2 studies in their review of 35 African studies and Fisher et al. mentioned only one study in their review of 47 studies in low-income countries. In 2015, Haque et al [40Haque A, Namavar A, Breene K-A. Prevalence and Risk Factors of Postpartum Depression in Middle Eastern/Arab Women. J Muslim Ment Health 2015; 9(1): 20.
[http://dx.doi.org/10.3998/jmmh.10381607.0009.104]
]. published a review about prevalence and risk factors of PPD in the Middle East and Arab countries, and it included 15 Arab studies among 22 studies from the Middle East. Lastly, the most recent and comprehensive review was published by Alhasanat and Fry-McComish [41Alhasanat D, Fry-McComish J. Postpartum Depression Among Immigrant and Arabic Women: Literature Review. Journal of immigrant and minority health / Center for Minority Public Health 2015; 17(6): 1882-94.] in 2015 about the prevalence and risk factors for PPD among Arab women in their homelands and immigrant women in industrialized countries, regardless of their origin. The review included studies until the start of 2013 and it compared two non-homogenous populations of immigrants and non-immigrants, and concluded that the prevalence of PPD in Arab countries ranged from 10-37% and the most important risk factors were lack of social support, stressful events, partner violence and low income.

In our review, all of the included studies were cross-sectional or panel longitudinal studies. Although these types of studies are useful for reporting prevalence, causation of risk factors is less clear. In fact, 3 studies [24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
, 35El-Hachem C, Rohayem J, Bou Khalil 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; 14: 242.
[http://dx.doi.org/10.1186/s12888-014-0242-7] [PMID: 25193322]
, 37Alharbi AA, Abdulghani HM. Risk factors associated with postpartum depression in the Saudi population. Neuropsychiatr Dis Treat 2014; 10: 311-6.
[PMID: 24570584]
] used a case-control approach and recruited control mothers to compare risk factors for PPD. Moreover, most of these studies used convenience sampling techniques with small sample sizes, but more recent studies tended to address this by using probability sampling and reporting of sample size calculations.

Overall, published studies about postpartum depression in the Arab world are scarce and there were no identified articles in the searched databases from big Arab countries such as Algeria. The studies in other Arab countries such as Egypt and Saudi Arabia were recent (after 2010). Nevertheless, the prevalence of this problem is substantial, ranging from 8 to 40%. Most studies (12 studies) reported prevalence of 15 to 25% and 7 and 4 studies reported prevalences from 8-14% and from 26-40%, respectively. Another 2 Egyptian studies reported very high rates of 52% [23Mohamed NA, Mahmoud GA, Said NA, Abdelhafez HA, Maklof AMA. Postpartum Depression: Prevalence and Predictors among Women at El Eman’s Specialized Hospital. J Am Sci 2011; 7(12): 7.] and 74% [29Mohamed HA, Spencerb SL, Al Swasyc AH, Swidand SE, Aboueleniene MS. A social and Biological Approach for Postpartum Depression in Egypt. Woman- Psychosom Gynaecol Obstet 2014; 1(1): 30-9.
[http://dx.doi.org/10.1016/j.woman.2014.10.002]
], but both studies investigated small non-representative samples in a wide period of postpartum time that may include those with ‘maternity blues’ in the first 2 weeks.

The large variation in postpartum depression rates can be explained by the use of different methods and timing in the assessment of the problem (see Table 2). Previous systematic reviews noted that the use of self-report tools results in significantly higher depression rates than interview-based assessments [5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
]. Moreover, higher rates in the first week after birth may be an exaggeration due to the occurrence of temporary ‘maternity blues’ in the first week postpartum [42Robertson E, Celasun N, Stewart D. Risk factors for postpartum depression.Postpartum depression: Literature review of risk factors and interventions 2003.]. Higher rates may also be due to reporting or publication bias towards higher rates and the exclusion of unpublished research reporting lower prevalence or non-significant associations. In order to overcome this obstacle, we translated a French article that met our review criteria. Nevertheless, the prevalence of postpartum depression in the Arab world seems to be higher than in the Western world [5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
, 43Wisner KL, Chambers C, Sit DK. Postpartum depression: a major public health problem. JAMA 2006; 296(21): 2616-8.
[http://dx.doi.org/10.1001/jama.296.21.2616] [PMID: 17148727]
], and closer rates found in other low- and lower-middle-income countries [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G.]. This high prevalence was also reported in Arab countries of high income like Gulf countries. Nine of 25 studies were done in high-income countries like UAE, Saudi Arabia, Qatar, Bahrain and Oman and 5 out of 9 studies reported prevalences of 15.8% to 37.1% [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
, 25Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997; 171: 65-8.
[http://dx.doi.org/10.1192/bjp.171.1.65] [PMID: 9328498]
, 28Green K, Broome H, Mirabella J. Postnatal depression among mothers in the United Arab Emirates: socio-cultural and physical factors. Psychol Health Med 2006; 11(4): 425-31.
[http://dx.doi.org/10.1080/13548500600678164] [PMID: 17129919]
, 37Alharbi AA, Abdulghani HM. Risk factors associated with postpartum depression in the Saudi population. Neuropsychiatr Dis Treat 2014; 10: 311-6.
[PMID: 24570584]
]. Three of the remaining studies were conducted in Saudi Arabia and adapted a higher cut of for EPDS ≥ 13, so prevalences were 8% (32), 10.6% (33) and 13.7% [36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
].

The strongest socio-demographic risk factor for PPD was low income or low socioeconomic status(OR 1.6-23.8). The effect sizes of related factors such as mother’s age, education, rural residency and mothers employment were around 2. Fisher et al. found that younger mother's age, lower education, low income and SES, mother's unemployment and rural or crowded areas were associated with at least a doubled PPD rate in low and lower-middle-income countries [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G.], whereas only low income was a significant predictor of PPD in high-income countries [5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
]

The presence of obstetric complications during pregnancy, such as bleeding, preeclampsia or gestational diabetes; the presence of more than one chronic disease, and unwanted pregnancies were all highly associated with higher rates of PPD, as is the case in other low-income countries [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G., 8Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010; 123(1-3): 17-29.
[http://dx.doi.org/10.1016/j.jad.2009.06.027] [PMID: 19635636]
]. This could be due to the increased stress and poor mood caused by these factors. On the other hand, the mode of delivery, whether vaginal or Cesarean Section (CS) delivery, had limited associations with PPD. Although CS delivery was associated with higher PPD rates in low-income countries [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G., 8Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010; 123(1-3): 17-29.
[http://dx.doi.org/10.1016/j.jad.2009.06.027] [PMID: 19635636]
], it seems that this association is based on the mother's perspective of the delivery mode [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]. This was shown in Chaaya’s et al. study of the differences between rural and urban postpartum depressed Lebanese women, as rural women who were delivered by CS had higher PPD rates, whilst the contrary was true among their urban counterparts [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]. The explanation given is that rural women were afraid of CS delivery and considered it as a complication of normal vaginal delivery failure [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]. This concept was emphasized in previous qualitative studies. Cesarean delivery also could be associated with longer hospital admission and subsequent separation from the family which may put further stress on rural women who usually live in proximity of their extended families compared to their big-city resident counterparts [31Chaaya M, Campbell OM, El Kak F, Shaar D, Harb H, Kaddour A. Postpartum depression: prevalence and determinants in Lebanon. Arch Women Ment Health 2002; 5(2): 65-72.
[http://dx.doi.org/10.1007/s00737-002-0140-8] [PMID: 12510201]
]

The effect of the characteristics of the new baby on mother's PPD varied. Whilst infant's ill-health, low birth weight and prematurity were associated with higher PPD rates [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
, 19Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Women Ment Health 2005; 8(1): 37-43.
[http://dx.doi.org/10.1007/s00737-005-0069-9] [PMID: 15868390]
, 25Ghubash R, Abou-Saleh MT. Postpartum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997; 171: 65-8.
[http://dx.doi.org/10.1192/bjp.171.1.65] [PMID: 9328498]
], the birth of a female baby was only associated with PPD in Jordanian and Egyptian mothers [13Abdelwahid HAE, Mansour NM, Ismail MA. Postpartum depression among women in a rural community, Ismailia, Egypt. Suez Canal University Medical Journal SCU-MJ 2012; 15(1): 8.
[http://dx.doi.org/10.21608/scumj.2012.54673]
, 17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
, 21Hassanein IM, Fathalla MM, Abdel Rahim T. The role of newborn gender in postpartum depressive symptoms among women in Upper Egypt. Int J Gynaecol Obstet 2014; 125(2): 138-40.
[http://dx.doi.org/10.1016/j.ijgo.2013.11.006] [PMID: 24572456]
, 24Saleh S, El-Bahei W, Del El-Hadidy MA, Zayed A. Predictors of postpartum depression in a sample of Egyptian women. Neuropsychiatr Dis Treat 2013; 9: 15-24.
[PMID: 23293523]
]. Although those factors predicted higher PPD rates in low-income countries(4), the birth of a female baby or a baby contrary to the desired gender were counter-intuitively not associated with PPD in Morocco [19Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Women Ment Health 2005; 8(1): 37-43.
[http://dx.doi.org/10.1007/s00737-005-0069-9] [PMID: 15868390]
] Bahrain [11Al Dallal FH, Grant IN. Postnatal depression among Bahraini women: prevalence of symptoms and psychosocial risk factors. East Mediterr Health J 2012; 18(5): 439-45.
[http://dx.doi.org/10.26719/2012.18.5.432] [PMID: 22764429]
] Qatar [18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
] Saudi Arabia [32Alasoom LI, Koura MR. Predictors of postpartum depression in the eastern province capital of saudi arabia. J Family Med Prim Care 2014; 3(2): 146-50.
[http://dx.doi.org/10.4103/2249-4863.137654] [PMID: 25161973]
, 36Al-Modayfer O, Alatiq Y, Khair O, Abdelkawi S. Postpartum depression and related risk factors among Saudi females. Int J Cult Ment Health 2015; 8(3): 9.
[http://dx.doi.org/10.1080/17542863.2014.999691]
, 37Alharbi AA, Abdulghani HM. Risk factors associated with postpartum depression in the Saudi population. Neuropsychiatr Dis Treat 2014; 10: 311-6.
[PMID: 24570584]
] and Oman [33Al Hinai FI, Al Hinai SS. Prospective study on prevalence and risk factors of postpartum depression in Al-dakhliya governorate in oman. Oman Med J 2014; 29(3): 198-202.
[http://dx.doi.org/10.5001/omj.2014.49] [PMID: 24936270]
]. These results are encouraging since Arab societies are predominantly male-biased societies. Breastfeeding was investigated as a protective factor against PPD and the results were equivocal (see Table 3), whilst formula feeding was associated with higher PPD rates [16Hamdan A, Tamim H. Psychosocial risk and protective factors for postpartum depression in the United Arab Emirates. Arch Women Ment Health 2011; 14(2): 125-33.
[http://dx.doi.org/10.1007/s00737-010-0189-8] [PMID: 21063891]
, 18Bener A, Burgut FT, Ghuloum S, Sheikh J. A study of postpartum depression in a fast developing country: prevalence and related factors. Int J Psychiatry Med 2012; 43(4): 325-37.
[http://dx.doi.org/10.2190/PM.43.4.c] [PMID: 23094465]
]. This may be a manifestation of the inability of depressed mothers to fulfill their mothering role and to breastfeed their infants [44Logsdon MC, Wisner KL, Pinto-Foltz MD. The impact of postpartum depression on mothering. J Obstet Gynecol Neonatal Nurs 2006; 35(5): 652-8.
[http://dx.doi.org/10.1111/j.1552-6909.2006.00087.x] [PMID: 16958723]
]

Despite the importance of the aforementioned factors, psychosocial factors and family relationships have a deeper influence on the occurrence of PPD [8Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010; 123(1-3): 17-29.
[http://dx.doi.org/10.1016/j.jad.2009.06.027] [PMID: 19635636]
]. Poor marital relationships and marital conflict, absence of the husband, family and social support and physical and verbal abuse were predictors of higher PPD rates despite variation in assessment of these factors by either direct questions or standardized tools. These factors are recognized as PPD predictors in both high and low-income settings [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G., 5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
, 8Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: a systematic review. J Affect Disord 2010; 123(1-3): 17-29.
[http://dx.doi.org/10.1016/j.jad.2009.06.027] [PMID: 19635636]
]. Similar to other less industrialized countries, the role of the extended family is still important as conflicts with the mother-in-law can lead to a higher incidence of PPD [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G.]. Although there were big differences in measuring stressful life events during pregnancy, such as the death of a dear person or major financial problems and problems of adjustment, these stresses were significantly associated with higher PPD rates. This supports the notion that PPD is mainly a psychosocial problem [3Wisner KL, Parry BL, Piontek CM. Clinical practice. Postpartum depression. N Engl J Med 2002; 347(3): 194-9.
[http://dx.doi.org/10.1056/NEJMcp011542] [PMID: 12124409]
, 5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
, 45Brockington I. Postpartum psychiatric disorders. Lancet 2004; 363(9405): 303-10.
[http://dx.doi.org/10.1016/S0140-6736(03)15390-1] [PMID: 14751705]
] In addition, the personal history of depression or mental illness or depression during the index pregnancy increased the risk of PPD occurrence. Although the Bahraini study found antepartum depression to be unassociated with PPD, it did not indicate how depression was measured during pregnancy. It seems that participants were only asked if they had a history of depression during pregnancy as the study is performed at two months postpartum. Those who found a relationship between antepartum and postpartum depression measured depression in a standardized way during pregnancy, hence their results are more informative and correspond more with international studies [4Fisher J. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. BullWorld Health Organ 2012; 90(2): 139G-49G., 5O’Hara M, Swain A. Rates and risk of postpartum depression - a meta-analysis. Int Rev Psychiatry 1996; 8: 37-54.
[http://dx.doi.org/10.3109/09540269609037816]
].

Mohammad et al. found a significant association between the quality and satisfaction of the maternity care offered during delivery and subsequent development of PPD. The conclusion was that PPD is associated with negative experiences of the mother during giving birth, such as feeling out of control, lacking appropriate knowledge, being uninformed about obstetric decisions and more invasive obstetric interventions [17Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011; 27(6): e238-45.
[http://dx.doi.org/10.1016/j.midw.2010.10.008] [PMID: 21130548]
]. Since there was no objective assessment of maternity services, it is difficult to determine whether negative birth experiences may predispose to psychological problems, or alternatively, whether it is the depression that causes mothers to recall birth experiences badly.

In addition to the difference in investigation time and tools, the variation in PPD prevalence and reported risk factors could be explained in the context of the new studies calling to consider PPD as a heterogeneous condition with more than one characteristic subtype that differs in the time of presentation, severity and associated risk factors [6Kettunen P, Koistinen E, Hintikka J. Is postpartum depression a homogenous disorder: time of onset, severity, symptoms and hopelessness in relation to the course of depression. BMC Pregnancy Childbirth 2014; 14: 402.
[http://dx.doi.org/10.1186/s12884-014-0402-2] [PMID: 25491477]
, 7Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium. Heterogeneity of postpartum depression: a latent class analysis. Lancet Psychiatry 2015; 2(1): 59-67.
[http://dx.doi.org/10.1016/S2215-0366(14)00055-8] [PMID: 26359613]
]. There could be different subtypes of PPD among Arab women, but this needs more in-depth, robustly designed studies rather than simple cross-sectional assessments.

From the available evidence, it seems that low income and socio-economic status; obstetric complication during pregnancy; unwanted or unplanned pregnancy; ill newborn; formula feeding; poor marital relationships and low social support; personal or family history of depression or mental illness; antepartum depression; and stressful life events during pregnancy are the main predictors of PPD in the Arab people. The high prevalence of postpartum depression in the Arab Countries should raise concerns about screening efforts during pregnancy and postpartum periods using simple but valuable tools like EPDS. More focus should be centered on those at higher risk of developing PPD, including those with antepartum depression and poor marital and social support, lower-income and those with a history of depression. Maternal and Child Health clinic staff should work closely with mothers to identify high-risk mothers and to provide the needed support and education as an integral part of the provided health care.

The limitations of this study include the lack of complete information in some studies despite the authors’ efforts to contact the study authors, with some not replying and others no longer possessing the data. This made the calculation of many odds ratios and meta-analysis of odds ratios problematic. Moreover, the difference in timing and tools used to assess prevalence precluded a good meta-analytical approach to determine overall PPD rates.

CONCLUSION

In conclusion, published research on PPD in the Arab world is still scarce, despite the fact that PPD is high among Arab women and is likely to affect at least 1 in 5 mothers. In order to avoid “maternity blues”, it is recommended to screen for PPD after the first week of giving birth. Furthermore, health care services should start to introduce psychological support in the treatment plan for women who present with obstetric complications during pregnancy. It is crucial for researchers and policymakers to target this area with appropriate tools and approaches in order to avoid the deleterious effects PPD can have on mothers, children, families, and societies.

LIST OF ABBREVIATIONS

PPD  = Postpartum Depression.
MDE  = Major Depressive Episode.
APA  = American Psychiatric Association
MCHC  = Maternal and Child Health Clinic.
PHCH  = Primary Health Care Clinic.
EPDS  = Edinburgh Postnatal Depression Scale
BDI  = Beck Depression Inventory.
DASS  = Depression, Anxiety and Stress Scale
MINI  = Mini International Neuropsychiatric Interview.
PSE  = Present State Examination
SES  = Socio-economic Status
CS  = Caesarean Section.
OR  = Odds Ration
CI  = Confidence Interval.

AUTHORS’ CONTRIBUTION

K.A. and A.S. put the study design and retrieved the articles and assessed their quality. K.A. and S.H. did the data analysis. K.A. wrote the manuscript and A.S. and S.H. critically revised and modified it. The 3 authors approved the final manuscript for submission.

CONSENT FOR PUBLICATION

Not applicable.

STANDARDS FOR REPORTING

PRISMA guideline have been followed.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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