Review
Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms

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Abstract

Background

The prevalence of postpartum depression (PPD) is currently considered to be 10–15%. Most studies were performed with a brief unidimensional instruments (mostly the Edinburgh Postnatal Depression Scale—EPDS) with focus on depression and not on other symptoms and disorders. Most cited studies were conducted in Western economically developed countries.

Methods

We reviewed the literature on prevalence of postpartum depression and depressive symptoms in a wide range of countries.

Results

143 studies were identified reporting prevalence in 40 countries. It is demonstrated that there is a wide range of reported prevalence of PPD ranging from almost 0% to almost 60%. In some countries like Singapore, Malta, Malaysia, Austria and Denmark there are very few reports of PPD or postpartum depressive symptoms, whereas in other countries (e.g. Brazil, Guyana, Costa Rica, Italy, Chile, South Africa, Taiwan and Korea) reported postpartum depressive symptoms are very prevalent.

Conclusions

We believe that the widely cited mean prevalence of PPD—10–15% is not representative of the actual global prevalence and magnitude of the problem, due to the wide range of reports.

The variability in reported PPD might be due to cross-cultural variables, reporting style, differences in perception of mental health and its stigma, differences in socio-economic environments (e.g. poverty, levels of social support or its perception, nutrition, stress), and biological vulnerability factors. The elucidation of the underlying processes of this variability as well as the diversity of postpartum normal versus abnormal expressions of symptoms may contribute to better understanding of the diversified ante, peri- and postpartum phenomena.

Introduction

Pregnancy and the postpartum period are associated with profound physical and emotional changes. They are also associated with mental symptoms and disorders ranging in severity from very mild to psychotic (e.g. Brockington, 2004, Geller, 2004).

The DSM IV-TR (APA, 2000) indicates that postpartum disorders are distinguished not by their phenomena but by their timing—within first 4 weeks postpartum. There are several forms of postpartum disorders—from the transient experience of “postpartum blues”, to the severe postpartum psychosis. “Postpartum blues”, or “Maternity blues” typically occurs for a short period of few hours or days, 4–7 days following delivery. It includes symptoms such as irritability, restlessness, despondency, mild confusion and/or hypochondriasis (Morsbach et al., 1983). Postpartum depression (PPD) which is a later, more prolonged and serious condition (APA, 2000) generally occurs within 4–6 weeks after childbirth (Patel et al., 2002) and includes symptoms such as low mood, anhedonia, forgetfulness, irritability, anxiety, sleep disturbance and poor functioning (Stuchbery et al., 1998). Description, symptoms, course, and outcome of PPD are similar to clinically significant major depressive disorder (MDD) with the time specifier (American Psychiatric Association, 2000, Wickberg and Hwang, 1997). Postpartum psychosis, the gravest form of the group, is rare, occurring in 1–2 per 1000 deliveries. It is characterized by acute psychotic state of confusion, delirium, delusions, hallucinations and insomnia (Rahim and al-Sabiae, 1991).

PPD is of concern to primary and mental health care professionals because it may severely affect the health of the mother as well as the health and development of her baby (Leiferman, 2002, Hobfoll et al., 1995, Wickberg and Hwang, 1997, Wolf et al., 2002). It has been reported that depressed mothers tend to express behaviors that have a negative impact on their children, including being intrusive or withdrawn, disengaged, not interacting with their babies (Hart et al., 1998, Weinberg and Tronick, 1998, Wolf et al., 2002) and being less sensitively attuned to their infants (Murray, 1992, Cooper et al., 1999). Since children are particularly dependent on caregivers during the critical imprinting period of infancy, young infants may be most vulnerable to the unresponsive or rejecting care associated with PPD (Campbell and Cohn, 1991). Infants may have adverse cognitive, behavioral and emotional outcomes, as well as long-term developmental disturbances as a result of poor mother–child interactions (Bernazzani et al., 1997, Cryan et al., 2001, Lee et al., 2001, Kelly et al., 1999, Rahman et al., 2003, Cooper et al., 1999, Murray et al., 1996). Furthermore, evidence from developing countries suggests that poor maternal mental health is associated with malnutrition and poor physical health in their infants (Rahman et al., 2003). The new mother's depression influences her entire family, since it has been demonstrated that partners of postnatally depressed women are more likely to become clinically depressed (Stuchbery et al., 1998) and the marital relationship can be strained.

PPD also has a negative long-term effect on mental health since it may increase the risk for continuing or recurrent depression (Nielsen Forman et al., 2000, Wolf et al., 2002).

Postpartum depression is often undetected and underdiagnosed and women at risk are rarely recognized during pregnancy or at the delivery ward (Nielsen Forman et al., 2000, Halbreich et al., submitted for publication). This is especially the case in developing countries where mental health in general is relatively ignored (Reichenheim and Harpham, 1991). It has been suggested that up to 80% of women with PPD do not report it and are not diagnosed by their physicians (Kelly et al., 2001, Whitton et al., 1996, Yonkers et al., 2001).

The high rate of depression in mothers of young children represents a compounded public health hazard and highlights the need for further research in order to improve treatment and prevention. Early identification and intervention during pregnancy and early postpartum periods may lead to a decrease in the long-term negative effects on child development, as well as a decrease in the debilitating effect on new mothers (Montgomery, 2001, Cooper et al., 1999), though evidence on the effectiveness of screening all pregnant women and providing a preventative intervention to those scoring at high risk has not been systematically investigated and evaluated (Gaynes et al., 2003).

Surveys and epidemiological studies have reported increasingly high rates of postpartum depression in diverse cultures across the world (Rahman et al., 2003). The determination of prevalence of PPD and its social and biological correlates across different populations and cultures is of importance in order to determine if this problem is specific to particular cultural contexts or is significantly influenced by them (Wolf et al., 2002).

Most reviews, meta-analyses and opinions published thus far focus on postpartum depression and estimate that in Western countries it affects 10–15% of women (Beck, 2001, O'Hara and Swain, 1996). A recent commissioned report that aimed at being a systematic, evidence-based review (Gaynes et al., 2005) demonstrates the very focused approach of many established investigators in the field. It was limited to reports from developed countries “to increase the likelihood of it being generalized to the US population”, it required structured clinical interviews for diagnosis of major and minor depression though the time period was 12 months postpartum and excluded self-reports (as the Edinburgh Postnatal Depression Scale—EPDS) (Cox et al., 1987). The point prevalence for minor and major depression at 1 month postpartum (7 studies) was 8.8% and the period prevalence for the 1st month (1 study) was 13.6%.

A closer assessment of the USA reports demonstrates a considerable variability. Most (but not all) reports of high prevalence of postpartum depressive symptoms included a large number of inner-city women with diversified ethnicity—mostly Hispanics, but also Asians (Hobfoll et al., 1995, Morris-Rush et al., 2003, Affonso et al., 2000, Heilemann et al., 2004). Single women with low socio-economic status (SES) have been overrepresented in these samples (Zlotnick et al., 2001). Even though earlier reviews suggest that socio-economic and ethnic variables do not necessarily influence the prevalence of PPD, more recent reports suggest that low SES and poverty, as well as being a single mother, are positively associated with PPD. Since many inner-city poor women are African American or Hispanic, the overlap between these factors still needs to be untangled.

Since most reports focus on prevalence of PPD (postpartum depression) in industrialized countries, there is a need to evaluate the global diversified cross-cultural prevalence and incidence of PPDs (postpartum disorders) and their culturally-sensitive correlates. Once cultural and biological factors of the disorders are identified, preventative measures and treatment procedures may be developed and integrated in order to enhance women's well being. Before this large scale endeavor is undertaken there is a need to document the cross-cultural diversity of rates of PPD as it has been assessed by structured interviews as well as by the widely accepted and widely applied Edinburgh Postnatal Depression Scale (EPDS). The current report is a review of the literature on rates of PPD as well as depressive symptoms as they are measured by relevant questionnaires.

Section snippets

Methods

We conducted a literature search using MEDLINE, PSYCHINFO, CINAHL, EMBASE databases from 1980 to 2005. Additional articles were identified by being cited in retrieved articles. Keywords used were “postpartum depression”, “postnatal depression”, “depression”, “postnatal, “postpartum”, “incidence”, “prevalence” etc. Keywords were also combined and used to identify as many articles as possible on the topic of postpartum depression. Most papers reported on rates of depression in women at follow up

Results

Details of results are presented in Table 1a, Table 1b (other countries). It is clearly demonstrated that the prevalence of PPD as it is estimated by the EPDS varies among countries from almost 0% to almost 60%. In some countries like Singapore (Kok et al., 1994), Malta (Felice et al., 2004), Denmark (Nielsen Forman et al., 2000) and Malaysia (Kit et al., 1997) there are almost no reports of PPD (0.5–9%), whereas in other countries e.g. Guyana (Affonso et al., 2000), Costa Rica (Wolf et al.,

Discussion

We believe that the widely cited prevalence rate of PPD as being 10–15% is not representative of the actual global prevalence and magnitude of the problem. This assertion is mostly based on two observations: First, the wide range of reported prevalence, ranging from almost 0% to over 60% of women. This across-countries range does not even fully take into account the within-country cross-cultural and diversified socio-economic factors, deeming the overall mean meaningless.

Second, the majority of

Culturally sensitive methodological factors effecting diversity of rates of PPD

Differences in research procedures and their context among countries are common and greatly influence prevalence results (Wickberg and Hwang, 1997, Huang and Mathers, 2001). One of the main problems in studying PPD across cultures is differences in symptom definition and expression (Reichenheim and Harpham, 1991, Wolf et al., 2002). The use of standardized “Western” methods and diagnostic classification systems, even by local-but-Westernized Investigators, may be culturally insensitive and

Conclusion and future directions

It may be assumed that an information trove of about 140 reports on the prevalence of postpartum depression would provide a definitive determination of that issue. However, we believe that this should not be taken for granted. To the contrary, many reports reveal the complexity of the issues at focus and the need to examine their multiple dimensions.

The need for re-evaluation is on several levels:

  • a)

    Conceptual: According to the DSM IV the nature of and criteria for postpartum disorders are the

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