Journal of Affective Disorders 301 (2022) 345–351

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Risk factors associated with postpartum depressive symptoms: A

multinational study
Helen Bradshaw a, Julia N. Riddle a, Rodion Salimgaraev b, Liudmila Zhaunova b, Jennifer
L. Payne a, c, *
a
Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Women’s Mood Disorders Center, 550 North Broadway, Suite 305, Baltimore,
MD 21025, USA
b
Flo Health, Inc. 1013 Centre Road, Suite 403-B, Wilmington, DE, 19805, USA
c
Department of Psychiatry and Neurobehavioral Sciences, Reproductive Pschiatry Research Program, PO Box 800548, Charlottesville, VA 22908

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To evaluate the association between maternal age, parity, gestational number (singleton vs twin),
Postpartum depression newborn gender and self-reported postpartum depressive symptoms (PDS) in a large multinational sample using
Parity survey data from a digital telephone application.
Infant sex
Methods: Women using the Flo app answered a survey (available in 10 languages) from January 2018 to April
Gestational number
Maternal age
2020. A survey question asking about emotional state was used to determine the presence of PDS. Chi-squared
statistics were used to compare groups. A weighted mean prevalence was calculated based upon the socioeco­
nomic status and reproductive population of each country in 2020.
Results: Over a million women from 138 countries participated. Of all respondents, 9.4% endorsed PDS. The
weighted mean prevalence of PDS was 11%. We found that PDS decreased with advancing age. First-time
mothers reported higher rates of PDS. Twin births were associated with a higher symptom burden than
singleton births and mothers of twins in the oldest age group reported the greatest burden. We did not find a
clinically significant difference in rates of PDS between mothers of singleton girls and boys.
Conclusions: To our knowledge, this study is the first to examine risk factors for postpartum symptoms using the
same survey across a large international population. These results can further research and clinical aims to
identify and treat maternal depression more effectively.
Limitations: Data was aggregated, thereby limiting analysis of individual associations. The survey was self-report
and not diagnostic for postpartum depression. Generalizability of risks of postpartum depression should be
approached with caution.

1. Introduction psychotic disorders, than offspring of women without perinatal psy­

Postpartum depression is a common complication of childbirth, is a
source of significant disability around the world (Glavin and Leahy-­
Warren, 2013), and has a global prevalence of 7 to 25% (Gavin et al.,
2005; Guintivano et al., 2018; Gelaye et al., 2016; Villegas et al., 2011).
During the childbearing years, women are twice as likely as men to
experience depression (Salk et al., 2017) and the postpartum
time-period carries an elevated risk for the development of a major
depressive episode (Vesga-Lopez et al., 2008). Offspring of women that
experienced depression in the perinatal period are more likely to go on
to develop major depression and other psychiatric disorders, including
chiatric illness (Srinivasan et al., 2020). Further, postpartum depression
has been associated with a number of undesirable outcomes in exposed
children including lower IQ, slower language development, and adverse
childhood behaviors (Netsi et al., 2018; Sui et al., 2016). There is a
growing necessity to identify risk factors that place women at elevated
risk, prior to the onset of affective illness, during this vulnerable
time-period (Salk et al., 2017; Di Florio et al., 2017; Mahon et al., 2009)
so that preventative measures can be instituted.
Current understanding surrounding the biological and environ­
mental risk factors for postpartum depression remains limited (Di Florio
et al., 2017; Mahon et al., 2009) but there are several established risk

* Corresponding author.
E-mail address: jlp4n@virginia.edu (J.L. Payne).

https://doi.org/10.1016/j.jad.2021.12.121
Received 11 July 2021; Received in revised form 3 December 2021; Accepted 30 December 2021
Available online 31 December 2021
0165-0327/© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
H. Bradshaw et al.
factors. For example, one of the strongest known risk factors for post­
partum depression is a personal history of psychiatric illness, particu­
larly a history of a mood disorder including both major depression and
bipolar disorder (Guintivano et al., 2018, 2018; Viguera et al., 2011).
Another established risk factor is a family history of postpartum
depression, particularly in the setting of a family history of either major
depression or bipolar disorder. Two studies have found that a family
history of postpartum depressive episodes increases the chance that
women will experience a postpartum depressive episode (Forty et al.,
2006; Murphy-Eberenz et al., 2006). For example, Forty et al. compared
concordance of postpartum depression status between sisters (in fam­
ilies with major depression) and found that 42% with a family history
experienced depression following their first delivery, whereas only 15%
of women without a family history experienced depression following
first delivery (2006). Similarly, three studies have found that post­
partum depressive episodes demonstrate familiality in families with
bipolar disorder (Dean et al., 1989; Payne et al., 2008; Bauer et al.,
2018). Environment also plays a role and other known environmental
risk factors for postpartum depression include low socioeconomic status,
immigrant status, and low educational attainment (Guintivano et al.,
2018).
Other maternal and perinatal factors such as maternal age, parity,
gestational number, and sex of the infant have been studied as risk
factors for postpartum depression with conflicting or limited results. For
example, studies examining the relationship between maternal age and
postpartum depression have had results ranging from a protective effect
of advancing age (Savarimuthu et al., 2010; Viguera et al., 2011;
Guintivano et al., 2018; Wallenborn et al., 2018), to no correlation with
age (Sutan et al., 2010; Ghosh and Goswami, 2011; Cerulli et al., 2011).
Other studies have found a U-shaped curve, with an increased risk
among younger (age < 24 years) mothers (Viguara et al., 2011; Guin­
tivano et al., 2018), reduced risk in late 20 s and early to mid 30 s
(Rincón-Pabón et al., 2014), and a return to elevated risk in mothers
older than 35 (Guintivano et al., 2018).
The literature is sparse regarding the effects of parity on the risk for
postpartum depression (Di Florio et al., 2014). A 2018 meta-analysis by
Shorey et al. found that while prior individual studies indicated
vulnerability in older, primiparous women (Gavin et al., 2005), they
found no statistically significant difference based on parity. They
postulated that this finding was due to the inclusion of heterogeneous
studies with incomplete data. Some studies suggest that having prior
children may provide a protective effect against postpartum depression
(Blackmore et al., 2006; Iwata et al., 2016). However, other studies have
found no significant association between parity and the risk of post­
partum depression (Stewart et al., 2003; Ghosh and Goswami, 2011;
Cerulli et al., 2011; Shorey et al., 2018). The literature surrounding the
protective effects of parity has also largely been constrained to a few
specific countries (Savarimuthu et al., 2010; Rincón-Pabón et al., 2014;
Mori et al., 2017; Tsuchida et al., 2019) and it remains unclear if the
association between parity and postpartum depression varies by
country.
One might surmise that mothers of multiples experience added stress
during the perinatal period and are, in turn, at an increased risk for
postpartum depression. However, few studies offer a direct comparison
of the burden of depressive symptoms between mothers of singletons
and mothers of multiples (Leonard 1998; Fisher and Stocky, 2003). In a
1998 paper, Leonard postulated that mothers of multiples carry an
elevated risk but based this prediction on a review of a small number of
studies undertaken with small population sizes and emphasized the need
for ongoing research in this area. Other systematic reviews have also
found an increased risk of postpartum depression among mothers of
twins when compared to mothers of singletons (Fisher and Stocky, 2003;
Wenze et al., 2015).
The literature is also mixed regarding the impact of infant sex on
depressive symptoms. Some studies have demonstrated a trend toward
elevated rates of depressive symptoms among mothers of male infants as
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Journal of Affective Disorders 301 (2022) 345–351
compared to mothers of female infants (Sorg et al., 2019; de Tychey
et al., 2008; Myers and Johns, 2019) and have postulated that a male
fetus may trigger an inflammatory immune response that increases the
risk for depression (Myers and Johns, 2019; Cowell et al., 2021). In a
2011 longitudinal study conducted in Sweden, Sylvén et al. found an
increased risk of postpartum blues among mothers of boys, as compared
to mothers of girls. However, there was no difference in the rate of
postpartum depression at six weeks or six months postpartum. In
contrast, a 2020 metanalysis of cohort and case-control studies
demonstrated a significantly increased risk of postpartum depression
among mothers of girls (Ye et al., 2020). In countries where there is a
preference toward male babies (such as India, China, Azerbaijan, and
Vietnam) (United Nations Population Fund, https://www.unfpa.or
g/gender-biased-sex-selection), higher rates of postpartum depression
have been reported among mothers of female babies (Savarimuthu et al.,
2010; Upadhyay et al., 2017; Xie et al., 2019). Other studies, conducted
in Western societies, have demonstrated no difference in postpartum
depressive symptoms based upon infant sex (Robertson et al., 2004;
Sidor et al., 2011). It remains unclear whether the sex of the infant in­
fluences the onset of postpartum depression.
Overall, most prior studies that examine maternal and infant risk
factors for postpartum depression are small, country-specific, or are
reviews and metanalyses based upon a collection of smaller studies
employing inconsistent assessments of postpartum depression (Savar­
imuthu et al., 2010; Sutan et al., 2010; Ghosh and Goswami, 2011;
Glavin and Leahy-Warren, 2013; Rincón-Pabón et al., 2014). Our cur­
rent study aimed to identify factors, including maternal age, parity,
gestational number, and sex of the infant that correlate with postpartum
depressive symptoms across a large and cross-cultural population of
women. We hypothesized that, in a large sample from many countries,
we would be able to clarify the role these factors do or do not play in the
development of postpartum depressive symptoms.
2. Methods
2.1. Data source
Data was collected by the private outside party, Flo Health, Inc. via
the phone application (“app”), Flo (https://flo.health). The Flo app
provides a tool to chart mood, attitudes, and physical symptoms, and to
concurrently track menstrual cycle, fertility windows, pregnancy,
motherhood, and menopause. Users can select a goal that configures Flo
to their current circumstances and needs, such as to track their men­
strual cycle, conceive, or to track the course of a pregnancy. At the time
of data collection for this study, the Flo phone application had an esti­
mated 26 million active users residing in 150 countries. The app is
available for download on both Google Play and the Apple App Store
and thus the study included both Android and iOS phone owners.
2.2. Data extraction
Data was self-reported by app users via the “After Childbirth Survey.”
The survey was developed in collaboration with an obstetrician gyne­
cologist and then reviewed by a second obstetrician gynecologist. To
identify potential issues with the survey, it was pretested on 10% of Flo
users that logged childbirth in the app prior to full-scale administration.
The survey was released in 10 languages (English, Russian, Spanish,
German, French, Italian, Portuguese, Polish, Japanese, and Chinese) and
was available for a duration of 6 months to all Flo app users who logged
“childbirth" in the app. The survey was pushed within the app with only
one response per user account permitted, therefore preventing duplicate
submissions. If a user failed to respond to all survey questions during
their first passage, they were able to access the survey again through the
“Feed” functionality within the app to complete missing questions. A
response to the survey was optional. Data collected between January
2018 and April 2020 were included. The geographical location of the
H. Bradshaw et al. Journal of Affective Disorders 301 (2022) 345–351

user was estimated based on their IP address. All participants in the
study agreed to the use of their de-identified and aggregated data for
research purposes.
Data were de-identified and sent in aggregate to the Johns Hopkins
research team. Provided data came from just over 1 million users, sub­
divided by age, parity, and country. Age was divided into the following
groups: 18 to 24-year-olds, 25 to 29-year-olds, 30 to 34-year-olds, 35 to
39-year-olds, and participants 40 and older. The Johns Hopkins Insti­
tutional Review Boards (IRBs) approved the protocol and acknowledged
the application as a minimal risk secondary research protocol.
2.3. Survey and definition of postpartum depressive symptoms (PDS)
Within 90 days of a user reporting delivery of her infant(s), a survey,
entitled “After Childbirth Survey,” was sent to the user via the Flo
application. The survey asked mothers to report whether the user
delivered twins or a single baby, the sex of their recently delivered child
(ren), the number of previously delivered children, and asked them to
complete a brief characterization of their mood state following delivery
based on six options. This question specifically read, “How would you
describe your emotional state after giving birth?” The six choices were as
follows: (1) “I am in high spirits;” (2) “I can characterize my condition as
emotionally stable;” (3) “I am experiencing mood swings;” (4) “I am
experiencing anxiety, irritability, dissatisfaction;” (5) “I feel sad, hope­
less, helpless, useless, I am scared for my child, I have feelings of guilt
and shame;” and (6) “No emotions at all, I feel disconnected, emotion­
ally exhausted with no energy to take proper care of my child.” The de-
identified data were presented broken down by maternal age (grouped)
and by country of residence. We considered endorsement of option 4, 5,
or 6 as a positive screen for postpartum depressive symptoms (PDS).
Those that selected either “I am in high spirits” or “I can characterize my
condition as emotionally stable” were categorized as being without
depressive symptoms. Those endorsing the selection “I am experiencing
mood swings” were not considered in analyses of PDS as this answer was
judged to be nonspecific.
2.4. Analyses
We exported the aggregate data to Excel and MATLAB for analyses.
The Chi squared statistic was calculated for differences between groups,
categorized by variables of interest. To calculate a weighted mean
prevalence, data was sorted by 2020 World Bank income group and each
prevalence was weighted by the proportion of the global population of
reproductive women residing within each income group based on World
Health Organization data from 2020. Survey responses without a
country of residence were excluded from the calculation of the weighted
mean prevalence.
of births among 18–24-year-olds, 2.1% among 25–29-year-olds, 2.7%
among 30–34-year-olds, 3.3% among 35–39-year-olds, and 4.3% among
women aged 40 and older. Table 1 describes study participants by age
group and pregnancy status. Among all respondents, 9.39% endorsed
PDS. Table 2 depicts prevalence rates by World Bank income groups. A
weighted mean prevalence was found to be 11.03%, weighted by the
World Bank income group for each country and World Health Organi­
zation data on number of women of reproductive age (15–49 years)
residing in each country in 2020 (World Health Organization, 2020).
3.2. Maternal age
In general, the rate of PDS decreased with advancing age group,
except for the 40 and older age group (See Fig. 1). The rates of reported
PDS by age groups were as follows: 10% among 18–24-year-olds, 8.5%
among 25–29-year-olds, 7.1% among 30–34-year-olds, 6.5% among
35–39-year-olds, and 6.9% among women 40 and older. The rates of
PDS by age group were statistically significantly different (p < 0.05)
between all age groups, except for between the 30–34-year-olds and the
40 and older age groups (p = 0.139).
3.3. Parity
The rates of PDS were assessed among women with and without prior
children in each age group (See Fig. 2). Women with prior children re­
ported significantly lower PDS than primiparas across all age groups (p
= 3.4E-290). Within each age group, multiparous women were less
likely to report depressive symptoms than were first-time mothers (p <
0.0001).
3.4. Twin versus singleton births
Mothers of twins endorsed a significantly higher burden of PDS than
mothers of singletons, with 11.3% (twins) and 8.3% (singletons) of the
whole sample, respectively reporting PDS (p = 1.8E-96) (See Fig. 3).
This was true across all age groups (p < 0.05).
There was no difference in the rate of reported PDS between 35 and
39-year-old and 40 plus year-old mothers of a singleton birth (p = 0.3).
However, mothers of twins in the oldest age group (40 plus) reported a
higher burden of PDS than their slightly younger counterparts (35–39-
year-olds) (p = 2.2E-6); 15% of mothers of twins in the most advanced
age group endorsed PDS, as compared to 9.6% of mothers of twins aged
35–39 years-old. Further, only 6.6% of mothers of singletons in the most
advanced aged group endorsed PDS.
3.5. Biological sex of infant(s)

3. Results Mothers of female singletons reported slightly lower rates of PDS,

than mothers of singleton males, 9.1% and 9.4%, respectively (p =
3.1. Descriptive statistics 1.08E-8) (Data not shown).

Collectively 1.135 million women from 138 countries responded to 4. Discussion

the "After Childbirth Survey” during the data collection period. The
countries with the highest number of respondents were the United States Given our large and international study population, this cross-
(n = 177,451) representing 17.6% of the sample, Russia (n = 163,611) sectional study speaks more definitively to an array of longstanding,
representing 10.9% of the sample, and Brazil (n = 64,754) representing
6.4% of the sample. Respondents ranged in age from 18 to 40 plus years Table 1
old. The youngest participants (18–24 years) accounted for 27.5% of the Study participants by age group and pregnancy status.
study population, 25–29-year-olds accounted for 34.7%, 30–34-year- Age Total Primigravid Singleton Twin
olds accounted for 26.1%, 35–39-year-olds accounted for 10%, and group pregnancies (%) births births
women aged 40 and above represented 1.6% of the study population. 18–24 317,119 80.31 311,673 5446
Two percent of women reported delivery of twins. Among singleton 25–29 396,321 67.29 387,993 8328
births, 51.3% were male and 48.7% were female. Among twin births, 30–34 292,149 55.51 284,310 7839
31.3% were both male, 32.8% were both female, and 35.9% gave birth 35–39 111,209 41.69 107,565 3644
40 plus 18,300 34.87 17,518 782
to one boy and one girl. The rate of twin births increased with age: 1.7%

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H. Bradshaw et al. Journal of Affective Disorders 301 (2022) 345–351

Table 2 reliability.
Prevalence of postpartum depressive symptoms by world bank income groups.
World Bank income group Endorsed Total PDS 4.1. Maternal age
(2020) PDS Respondents Prevalence

High 35,445 479,809 7.39% Our results provide clarity surrounding the relationship between age
Upper Middle 39,248 374,530 10.48% and depressive symptoms during the perinatal period. Reported
Lower Middle 20,148 155,061 12.99% depressive symptoms were highest among women ages 18–24, followed
Low 453 5293 8.56% by a stepwise decline in reported rates among the 25–29-year-old group,
and the 30–34-year-old group. Among mothers of singletons, there was
though previously inadequately addressed, questions surrounding risk further significant (though slight) reduction of symptoms from age
factors for postpartum depression. We report rates of PDS consistent 30–34 to the 35–39-year-olds, with subsequent leveling off among
with current worldwide estimates of postpartum depression. This sug­ mothers aged 40 and older. We did not find a U-shaped relationship, but
gests external validity of our survey assessment of depressive symptoms rather a flattening of reported PDS with advancing age among mothers
in evaluating rates of PDS and the potential generalizability of the cur­ of singletons. In contrast, among mothers of twins, we found a marked
rent study. Furthermore, given that all participants completed the same increase in symptom burden among women aged 40 and older,
survey questions across the 138 countries, we can expect strong internal demonstrating a U-shaped curve, as described in other studies. Consis­
tent with prior research, we found that advancing age is correlated with

Fig. 1. Maternal age and postpartum depressive symptoms.

Fig. 2. Postpartum depressive symptoms by maternal age and parity.

348
H. Bradshaw et al.
Fig. 3. Postpartum depressive symptoms by maternal age and gestational number.
a decrease in PDS for both singleton pregnancies and twin pregnancies
until women reach 40 years of age, at which point the PDS rate leveled
(for mothers of singletons) or increased (for mothers of twins). Many
individual and societal factors may contribute to this observation.
Women may become more stable in their careers, finances, relation­
ships, and personal mental health with advancing age. Our study did not
include questions surrounding fertility treatments and history of spon­
taneous abortions, both of which might contribute to elevated symptom
rates in the subset of older women reporting twin births, especially given
that twin pregnancies may be an indicator of utilization of fertility
technologies. The finding that women aged 40 and older with twin
pregnancies reported significantly higher rates of PDS compared to
younger women with twins as well as mothers of singletons aged 40 and
older is an important finding and indicates a need for heightened
awareness and screening in this population.
4.2. Parity
Given that advancing age might serve as a confounder of the pro­
posed protective effects of maternal experience, groups were addition­
ally analyzed based upon parity. We observed a generally stepwise
decline in PDS with advancing age, as noted above, which was preserved
when groups were separated based upon parity (i.e., presence or absence
of prior children). First-time mothers demonstrated an increased risk in
each age group, when compared to counterparts with another child or
children.
4.3. Gestational number
Our data demonstrate a highly statistically significant increase in
PDS among mothers of twins. This offers support for previous work
which postulated an increased risk but was not definitive due to small
sample sizes (Fisher 2003; Leonard 1998; Wenze 2015). The increased
risk was notably highest among mothers of twins in the oldest age group.
4.4. Sex of infant
While more mothers of boys (9.4%) reported depressive symptoms
than mothers of girls (9.1%), the difference is of questionable clinical
significance. Though statistically significant (p = 1.08E-8), the differ­
ence of 0.3% was evaluated to be clinically insignificant and likely a
result of this highly powered study rather than a true difference in
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Journal of Affective Disorders 301 (2022) 345–351
individual experiences. Further, based on standard rules for rounding,
both reported rates of PDS would round to 9% making them equivalent.
Although Myers and Johns (2019) proposed a link between the intra­
uterine immune environment and elevated risk among mothers of male
infants, there is little additional research surrounding the possible bio­
logical etiology of elevated depressive symptoms among mothers of
boys. Our findings do not support a relationship between infant sex and
burden of PDS in this large international sample.
5. Limitations
Our current study has several limitations that future research might
serve to address. As data were aggregated to preserve the anonymity of
participants, we were unable to consider all responses associated with a
given participant. Pooling of data constrained the research questions
that we were able to address with the current data set. For example, we
were unable to run regression analyses to consider the contributions of
multiple variables, such as the effect of a prior history of postpartum
depression in previous pregnancies and a family history of postpartum
depression. Although a strength of our study is that the same survey
instrument was used to assess PDS for all participants, the survey itself is
not a standardized scale and responses are self-reported. Therefore, our
results do not reflect rates of postpartum depression diagnoses and
further research is necessary to assess rates of baby blues versus
depression versus other perinatal mental health conditions. Another
limitation of our study is that our data does not include any information
on the temporality of symptoms. Women may have been struggling with
depressive symptoms prior to the postpartum period, however, the
survey did not assess the onset or course of symptoms. Risk factors that
contribute to prenatal mood symptoms may differ from those involved
in postpartum onset. Further research is warranted to investigate
possible differences between the risk factors for prenatal and postpartum
mood symptoms.
Smartphone ownership is increasing throughout the world; however,
access varies widely within and between nations. An estimated 5 billion
people own mobile devices globally, with smartphones accounting for
more than half of these mobile devices. Developing countries report
lower rates of smartphone ownership than developed countries (Taylor
and Silver, 2019), in addition to higher rates of perinatal depression
(Guintivano et al., 2018). The requirement of smartphone ownership for
participation in the current study likely selects for a disproportionate
representation of women of higher socioeconomic status both within
H. Bradshaw et al.
and between countries. Women of low socioeconomic status are more
likely to be without access to smartphones and at higher risk for post­
partum depression. Therefore, the current study likely under-samples
from women of lower socioeconomic status and underreports the
global burden of PDS, with countries and individuals of higher risk
particularly susceptible to exclusion. In an effort to account for the
sampling bias of women residing in countries of higher socioeconomic
status, we calculated a weighted mean prevalence. However, the
calculated mean prevalence does not account for the selection bias of
women of a higher socioeconomic status within each country. Our
finding of a higher prevalence of PDS among lower middle income
countries (12.99%), as compared to low income countries (8.56%),
likely results from this sampling bias for women of higher socioeco­
nomic status within a given country.
While one of the strengths of our study is that all users received the
same survey, societal differences may have resulted in disparate in­
terpretations of the questions and responses, and therefore, accurate
cross-cultural interpretation may limit this study.
6. Conclusion
With more than a million participants from 138 countries, the cur­
rent study is the most robust to date to examine relationships between
risk factors during the perinatal period and depressive symptoms. To our
knowledge, our study is the first to examine risk factors for postpartum
symptoms using the same survey across a large international population.
This global study reinforces the already well-established understanding
that depressive symptoms affect at least 1 in 10 women during the
postpartum period and indeed our study found an overall prevalence
rate of 9.39% among all women. A mean prevalence was calculated to be
11.03%, weighted by the World Bank Income Group and number of
reproductive age women residing in each country in 2020. The weighted
mean prevalence likely better estimates the global burden of PDS, as it
accounts for underreporting among women residing in lower income
countries.
The following factors were associated with elevated risk: age less
than 25 years, primiparity, and delivery of twins. Notably, mothers of
twins aged greater than 40 years were at markedly high risk. Our study
did not find significant differences in the rates of PDS in mothers of boy
versus girl infants.
Despite being relatively small (n = 782), the group composed of
mothers aged 40 years and older who had twins reported a markedly
disproportionate burden of depressive symptoms, with 15% of women
endorsing symptoms. Clinicians might take special consideration in
caring for women in this group, given their markedly elevated risk. In
the US, the mean age at first birth increased from 21.4 years old in 1970
to 26.9 years in 2018 (National Center for Health Statistics; Matthews
and Hamilton, 2009). With concurrent delay of motherhood and
increasing availability of reproductive technologies, we are likely to see
a growing number of this particularly high-risk group of older first-time
mothers with twins. Further research is necessary to understand the
possible causes of the elevated risk among older mothers of multiples.
In summary, our work identifies several maternal and perinatal
factors associated with the development of PDS including younger
maternal age, having twins, being primiparous, and having twins at an
older maternal age. This study also demonstrates in a large international
sample that mothers of male infants do not have clinically significant
elevated rates of PDS compared to mothers of girl infants. Given the high
burden of disability associated with maternal psychiatric illness during
the perinatal period (Glavin et al., 2013), and the long-term negative
outcomes found in exposed children, these results can be used by indi­
vidual clinicians as well as intervention programs aimed at the early
identification and prevention of postpartum depression.
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Journal of Affective Disorders 301 (2022) 345–351
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial or not-for-profit sectors. No funding
was given or received for this research and/or preparation of the
manuscript.
CRediT authorship contribution statement
Helen Bradshaw: Investigation, Data curation, Formal analysis,
Writing – original draft, Writing – review & editing. Julia N. Riddle:
Conceptualization, Writing – original draft, Formal analysis, Writing –
review & editing. Rodion Salimgaraev: Investigation, Data curation,
Writing – original draft, Writing – review & editing. Liudmila Zhau­
nova: Investigation, Data curation, Writing – original draft, Writing –
review & editing. Jennifer L. Payne: Conceptualization, Investigation,
Supervision, Writing – original draft, Writing – review & editing.
Declaration of Competing Interest
Dr. R. Salimgaraev and Dr. L. Zhaunova are salaried employees of Flo
Health. Dr. J. Payne owns a patent entitled “Epigenetic Biomarkers of
Postpartum Depression.” Dr. J. Payne has also provided consulation
services to SAGE Therapeutics, Brii Biosciences and Pure Tech LYT
Incorporated. All other authors declare no other conflicts of interest.
Acknowledgments
The authors wish to thank Flo Health for their collaboration on this
project.
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