Accepted Manuscript

Prevalence and incidence of postpartum depression among healthy mothers: A

systematic review and meta-analysis

Shefaly Shorey, Cornelia Chee Yin Ing, Esperanza Debby Ng, Chan Yiong Huak,
Wilson Tam Wai San, Chong Yap Seng

PII: S0022-3956(18)30492-8
DOI: 10.1016/j.jpsychires.2018.08.001
Reference: PIAT 3425

To appear in: Journal of Psychiatric Research

Received Date: 16 April 2018

Revised Date: 23 July 2018
Accepted Date: 1 August 2018

Please cite this article as: Shorey S, Yin Ing CC, Debby Ng E, Yiong Huak C, Wai San WT, Seng CY,
Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and
meta-analysis, Journal of Psychiatric Research (2018), doi: 10.1016/j.jpsychires.2018.08.001.

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 ACCEPTED MANUSCRIPT
TITLE: Prevalence and incidence of postpartum depression among healthy mothers: A

systematic review and meta-analysis

AUTHORS:

Shefaly SHOREYa, Cornelia CHEE Yin Ingb, Esperanza Debby NGa, CHAN Yiong Huakc,

Wilson TAM Wai Sana, CHONG Yap Sengd

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a
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National

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University of Singapore; Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive,

Singapore 117597

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b
Department of Psychological Medicine, 5 Lower Kent Ridge Road, National University
Hospital, Singapore 119074

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c
Biostatistics Unit, Yong Loo Lin School of Medicine, Block MD 1, 12 Science Drive 2,
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National University of Singapore, Singapore 117549
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Women’s Centre, 5 Lower Kent Ridge Road, National University Hospital, Singapore
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119074

CORRESPONDING AUTHOR:
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Dr. Shefaly Shorey, PhD, RN, RM

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Assistant Professor
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Alice Lee Centre for Nursing Studies

Yong Loo Lin School of Medicine

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National University of Singapore

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Level 2, Clinical Research Centre, Block MD11

10 Medical Drive, Singapore 117597

Tel: (65) 66011294; Fax: (65) 67767135

Email: nurssh@nus.edu.sg
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Abstract

This review aims to examine the prevalence and incidence of postpartum depression among

healthy mothers without prior history of depression including postpartum depression and who

gave birth to healthy full-term infants. A systematic search of ClinicalTrials.gov, CINAHL,

EMBASE, PsycINFO, and PubMed was performed for English articles from the inception of

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the database to November 2017, as well as a manual search of the reference lists of the

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included articles, and an expert panel was consulted. Across 15,895 articles, 58 articles

(N=37,294 women) were included in the review. The incidence of postpartum depression was

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12% [95% CI 0.04 - 0.20] while the overall prevalence of depression was 17% [95% CI 0.15

- 0.20] among healthy mothers without a prior history of depression. Prevalence was similar

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regardless of the type of diagnostic tool used; however, there were statistical differences in
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the prevalence between different geographical regions, with the Middle-East having the
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highest prevalence (26%, 95% CI 0.13 - 0.39) and Europe having the lowest (8%, 95% CI

0.05 - 0.11). There was no statistical difference in prevalence between different screening
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time points, but an increasing prevalence was observed beyond six months postpartum.
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Intervention studies often neglect healthy mothers. This review reports a similar prevalence

rate of postpartum depression among mothers without history of depression when compared
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to mothers with history of depression. Thus, future studies should place equal emphasis on
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this neglected group of mothers so that targeted interventions and follow-ups can be
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introduced at appropriate time points.

Keywords: Incidence; meta-analysis; mothers; postpartum depression; prevalence

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INTRODUCTION

The postpartum period is a challenging transition period for mothers, leaving them

highly susceptible to psychiatric disorders (Vesga-López et al., 2008). The likelihood of

depressive episodes can be twice as high as during other periods of a woman’s life (Cox et

al., 1993), and they often go undetected and untreated (Pearlstein et al., 2009), which can

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adversely affect the wellbeing of mothers, new born infants (Soe et al., 2016), and other

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family members (Letourneau et al., 2012). Mothers suffering from postpartum depression

often display hostility and negligence, have lower tolerance, and are less responsive to their

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infants’ needs (Murray et al., 1996; Stein et al., 2014). This not only disrupts mother-infant

bonding and reduces breastfeeding (Pope and Mazmanian, 2016) but also impairs the

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cognitive, behavioural, and social-emotional development and physical health of the child
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(Letourneau et al., 2012; Stein et al., 2014). Moreover, maternal postpartum depression
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(PPD) was found to be the strongest risk factor for paternal depression, affecting 24 to 50%

of all fathers (Goodman, Janice H., 2004). This leads to increased marital conflicts associated
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with communication breakdown, feelings of isolation and frustration, and limited interaction
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with the child (Davey et al., 2006). Therefore, the early diagnosis, management, and possible

prevention of maternal postpartum affective disorders are important in establishing an

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optimal and healthy family environment for the child’s upbringing.

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PPD refers to non-psychotic depressive episodes during the postpartum period that
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persist for more than two weeks, which has an estimated prevalence of 13% (O’Hara and

Swain, 1996). In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

(DSM-5, American Psychological Association, 2013), PPD shares the same diagnostic

criteria as major depressive disorder, with an additional postpartum onset specifier of four

weeks (American Psychological Association, 2013). PPD is commonly characterised by

transient mood lability, insomnia, disorganised behaviour, irritability, and agitation (Monzon
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et al., 2014). While studies have suggested a multifactorial aetiology of PPD, such as

psychosocial stressors (Beck, 2001; O’Hara and Swain, 1996) and biological factors

(Brummelte and Galea, 2016), the specific aetiology of PPD still remains unclear.

Many studies have shown substantial interest in the prevalence of PPD and their

predictors, with most reporting the significance of history of psychiatric illnesses on the

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prevalence of PPD (O’Hara et al., 1991; Patel et al., 2012). In addition, women with a history

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of PPD have an increased risk of experiencing a recurrence in subsequent deliveries (Banti et

al., 2011; Cox et al., 1993; Rasmussen et al., 2017). Results from Rasmussen’s (2017) study

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reported a 15 to 21% recurrence risk of affective disorders in women who had no prior

psychiatric disorders but were diagnosed with PPD after their first childbirth. This recurrence

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risk is 27 to 46 times higher in women with history of PPD after first birth. Since having a
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history of depression is a high risk factor of PPD, many studies included and focused on the
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population of mothers with a history of depression, resulting in a negligence of mothers

without a prior history of depression (including PPD). In previous studies (Banti et al., 2011;
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Chee et al., 2005), women without a history of depression are shown to be as likely to have
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subsequent depressive episodes during the perinatal period as those with prior history. This

rate of depression was 7.7% in the postpartum period. As mothers without prior history of
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depression are at a similar risk of PPD, the effects of PPD are equally detrimental to them and
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their family; hence, knowing the prevalence of first onset of PPD among healthy mothers is
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vital in preventing further elevations of symptoms and reducing the recurrence risk.

Reviews specifically on depression in the postpartum period were largely available;

however, either meta-analysis or meta-regression was lacking in most of the reviews

(Andrews-Fike, 1999; Leahy-Warren and McCarthy, 2007; Patel et al., 2012) or focused on

specific countries (Jones and Coast, 2013; Ozcan et al., 2017; Upadhyay et al., 2017); hence,

a global prevalence of PPD and their moderating factors were hardly reported in those
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postpartum reviews. The most recent review by Hahn-Holbrook and colleagues (2018)

reported a pooled global prevalence of 17.7% for PPD from 291 studies, and identified

significant risk factors like maternal mortality, infant mortality, long working hours of

women at the childbearing age, and nations with high income inequality. However, the

review was limited in its inclusivity of using only the Edinburgh Postnatal Depression Scale

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(EPDS), and study samples of mothers who were less than one year postpartum were

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included. As self-reported measures tend to report higher PPD prevalence than clinical

interviews (O’Hara and Swain, 1996), this may have resulted in an overestimation of global

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prevalence. A postpartum review by Leahy-Warren (2007) reported a wide range of

prevalence estimates (4.4-73.7%) in the postpartum period and attributed it to the difference

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in sampling methods, measurement instruments, and sociodemographic variances across the
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studies. However, no meta-analysis and meta-regression have been conducted thus far to
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account for the heterogeneity of the studies statistically, and the moderators of heterogeneity

had been based on assumption.

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Other available reviews were mostly focused on perinatal depression or specific

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population groups (i.e. immigrants, ethnic minorities, mothers living in rural areas, first time

mothers)(Falah-Hassani et al., 2015; Jones and Coast, 2013; Ozcan et al., 2017; Upadhyay et
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al., 2017; Vigod et al., 2010; Villegas et al., 2011). To the best of our knowledge, no review
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has been done among mothers without prior psychiatric history and who had given birth to
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healthy infants during the postpartum period. As this period is a stressful transition period for

new mothers, it is important to see the development of depression among healthy mothers.

This group has been often neglected, and it has been shown that mothers with PPD influence

the future development of their healthy newborns (Ali et al., 2013; Letourneau et al., 2012;

Soe et al., 2016). Hence, this review aims to provide new insights on the prevalence and

incidence of PPD among healthy mothers, without prior history of mental illnesses, including
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PPD, with healthy infants during the stressful postpartum period so that appropriate

interventions can be planned for this specific group of mothers, which may benefit not only

mothers but also their newborn and family.

METHODS

Search Strategy

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The meta-analysis was conducted in accordance with Preferred Reporting Items for

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Systematic Review and Meta-Analyses (PRISMA) guidelines (Liberati et al., 2009)

(Appendix 1). A three-step strategy was used to identify relevant studies: (i) a systematic

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search of electronic databases, (ii) a manual search of the reference lists of the included

articles, and (iii) consultation with an expert panel. The electronic databases searched were

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ClinicalTrials.gov, CINAHL, EMBASE, PsycINFO, and PubMed. Grey literature was
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searched from MedNar. Only papers published in English were searched for from the
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inception of the databases to November 2017. The review was registered in PROSPERO

(CRD 42018081484). The key MeSH search terms used were: (“mothers” or “females” or
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“women”), with “postpartum period” and (“depressive disorders” or “depression”, or “PPD”

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or “puerperal disorders”), and (“incidence” or “prevalence” or “therapeutics”). There was no

restriction on study types during the preliminary search. Studies validating different versions
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of depression assessment tools while reporting the prevalence and/or incidence of PPD were
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included; however, studies on PPD treatment efficacy and clinical trials involving PPD
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interventions were excluded. Elaboration on search strategy and search keywords used for

each database can be found in supplementary files Appendix 2 and 3.

Inclusion and Exclusion Criteria

A list of inclusion and exclusion criteria was generated prior to identifying relevant

studies. Studies were only included if they had: (i) assessed a group of healthy mothers

without prior history of clinical or self-reported depression post-birth, (ii) analyzed the
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overall prevalence or incidence of depression, (iii) determined the prevalence or incidence of

depression using standardized validated instruments, self-reported questionnaires, or

clinically structured interviews, and (iv) provided sufficient information for the authors to

calculate the aggregated prevalence of depression in the selected group of mothers. To get an

overall view, studies on perinatal depression were also included, but only data on postnatal

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follow-ups were extracted.

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Studies were excluded if: (i) the study sample consisted solely of adolescent mothers

below 18 years old, (ii) the study sample consisted of mothers who delivered preterm,

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stillborn, or babies with congenital anomalies, (iii) the study sample consisted of mothers

who had a history or existing psychiatric illness and major medical conditions such as

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cardiovascular and cancer, (iv) the outcome interests were indistinguishable from women
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with maternity blues, bipolar disorder, or primary psychotic disorders, and/or (v) the study
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did not use a validated diagnostic tool. If the study sample was a subset of a previous study,

the sample demographics of the earlier study were screened for eligibility instead.
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Study Selection
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Two reviewers with expertise in PPD independently reviewed the shortlisted articles

against the inclusion criteria. In case of any discrepancies, a third reviewer was consulted. A
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PRISMA flowchart summarizing the search process and exclusion of the studies is presented
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in Figure 1. After the removal of duplicates, the search procedure yielded 12,387 articles. The
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abstracts and titles of these articles were reviewed for potential relevance; only 325 articles

were shortlisted for the screening of full-text and language. Two hundred and fourteen

articles were further reviewed for inclusion, and 58 studies were finalized.

Based on the PRISMA checklist (Moher, 2009), data were extracted and presented in

a table (Appendix 4). From each included study, features such as: (i) publication details

(primary author’s last name and year of publication), (ii) geographical region and country,
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(iii) number of participants, (iv) mean age/age range of the participants, (v) timepoints of

PPD screening, and (vi) description of the instruments used to assess depressive symptoms,

including cut-offs and diagnostic criteria, were extracted. In order to have a comprehensive

view, postpartum data were also extracted from 13 perinatal studies. Studies that reported

both prevalence and incidence of PPD were included in the analyses.

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For the analysis, standard error (SE) values were extracted from the studies, since

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they are more commonly reported than the 95% confidence interval (CI). When both SE and

95% CI were not provided, SE was calculated using the formula (SE = √P × (1 − P)/N),

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where P is the proportion of the cases reported and N is the denominator of the prevalence

estimate (Ferrari et al., 2013).

Statistical Analysis
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Depression was reported as a dichotomous variable (presence versus absence) in all
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studies. If studies used both a self-reported assessment and a clinical interview as the

diagnostic instrument to determine PPD, prevalence estimates derived from the clinical
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interviews were used in the analysis. For studies that reported prevalence of both minor
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depression and major depression, unless an overall prevalence estimate was provided, only

estimates for major depression were included in the analysis in order to adhere to DSM-5’s
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diagnostic criteria for PPD. For longitudinal studies, only the prevalence rate from the latest
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PPD screening was included in the analysis as our study would like to investigate the long-
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term prevalence of PPD.

Review Manager Version 5.3 was used to conduct the meta-analysis. The studies

included in the meta-analysis have been presented in Appendix 5. Prevalence rate was used

instead of log odds ratio as it was readily provided in all the studies. Quantitative

heterogeneity was explored using Cochran’s Q-test (Chi2) and I2 statistics. The I2 statistic

attributes the total percentage of variance among studies to heterogeneity rather than
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sampling chance (Higgins et al., 2003). The estimates of heterogeneity (I2) were considered

low at 25%, moderate at 50%, and high at 75% (Higgins et al., 2003). Cochran’s Q tests the

null hypothesis which claims that the prevalence estimates come from the same distribution;

a p-value of < 0.05 indicates that they are heterogeneous and do not come from the same

distribution. The random effects model was used to derive the overall prevalence estimate

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when heterogeneity was moderate or high (I2>50%). The random effects model was preferred

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over the fixed effects model because it took into consideration the variance in effect sizes

between studies and led to a greatly conservative null hypothesis (Han and Eskin, 2011). The

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results of the meta-analysis were represented in a forest plot, visually displaying the effect

size and 95% CI for each study. The combined estimates, 95% CI, Z-value, and heterogeneity

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test values (i.e. T2, Chi2, I2) were reported for each analysis.
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Stata 11.0 was used to perform random effects meta-regression to investigate the
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impact of moderator variables on study effect size when significant heterogeneity was

detected. Based on previous reviews (Leahy-Warren and McCarthy, 2007; O’Hara and
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Swain, 1996; Patel et al., 2012) and the clinical expertise of the authors, three study
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characteristics were assessed as potential moderators: (i) mean age of the mothers, (ii) parity,

and (iii) marital status or cohabiting status.

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Subgroup analyses were performed to investigate the effect of time of assessment and
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the method of assessment on the prevalence of PPD. Studies with assessment time points in a
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similar period were grouped together as such: (i) 0-3 months, (ii) 4-6 months, (iii) 7-12

months, and (iv) more than 12 months. Methods of assessment were stratified as: (i) clinical

interviews, and (ii) self-reported assessments. Subgroup analyses were also used to examine

the effect of geographic region by grouping studies based on the United Nations’ standard

geographic region classification (United Nations, 2013): (i) Asia, (ii) Africa, (iii) Australia,

(iv) Europe, (v) Middle Eastern, (vi) North America, and (vii) South America. Middle
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Eastern countries were differentiated from Asian countries based on differences in traditions

(Klainin and Arthur, 2009).

Quality of Assessment

The quality of the included studies was appraised by two reviewers using Downs and

Black’s instrument for observational studies (Downs and Black, 1998). It assesses the clarity

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and completeness of the articles and rates the external and internal validity of the study

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design. In order to adopt a holistic approach, all studies were included for meta-analyses

regardless of their quality scores. Detailed scoring of each included study can be found in

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Appendix 6.

RESULTS

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Thirty prospective cohort studies, 26 cross sectional studies, and two case-control
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studies covering a total of 37,294 women in the postpartum period were included in the
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analysis. This review included 17 studies that adopted clinical interviews to diagnose PPD

and 39 studies that used varied validated self-report measurement tools to determine the
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presence of PPD. When stratified according to time points of assessment for depression, 25
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studies reported prevalence in the first three months postpartum, 18 studies between the

fourth to sixth month, seven studies between the seventh to twelfth month, and only six
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studies reported beyond one year postpartum. When stratified according to region, 13 studies
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reported prevalence in Asia, six in Europe, nine in the Middle East, 13 in North America, five
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in South America, seven in Australia, and three in Africa. Only six out of 58 studies reported

the incidence of PPD. Varied instruments were used to measure PPD. The majority of the

studies (n = 27) used the EPDS with 16 studies using a cut-off score of 13. Other scales used

were the Beck’s Depression Inventory (BDI; n = 4), Center for Epidemiological Studies

Depression (CES-D; n = 3), Patient Health Questionnaire (PHQ; n = 2), Inventory to

Diagnose Depression (IDD; n = 1), Hamilton Depression Scale (HAM-D; n = 1), and
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Depression Anxiety Stress Scales (DASS; n = 1). Table 1 summarizes the major

characteristics of the included studies, which were sorted by alphabetical order of the authors’

name.

The global prevalence of PPD among mothers was 17% (95% CI 0.15 - 0.20; Z =

15.3, df = 55, T2 = 0.01, I2 = 98%) based on the random effects model. Figure 2 demonstrates

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the results of 56 studies that reported the prevalence of depression among healthy postpartum

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mothers.

Considering the substantial heterogeneity between the included studies, a meta-

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regression against mean age (p = 0.983), proportion of primiparous mothers (p = 0.099), and

proportion of single mothers was conducted, but none of the moderators were found to have a

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statistically significant effect (Table 2). Twenty-nine studies were excluded from the meta-
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regression due to insufficient data, leaving only 27 eligible studies for the meta-regression

analysis. The tau (T2) value of 0.673 suggests that there is little heterogeneity between the 27
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studies.
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Analyses conducted by assessment time point showed increasing prevalence beyond

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six months postpartum; however, there was no statistical difference between groups (p =

0.29). Prevalence was highest at 25% (95% CI 0.12 - 0.39) after one year postpartum, closely
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followed by 7 to 12 months postpartum at 20% (95% CI 0.11 - 0.29), 4 to 6 months

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postpartum (16%, 95% CI 0.13 - 0.19), then 0 to 3months (14%, 95% CI 0.11 - 0.17). The
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results are presented in a forest plot below (Figure 3.).

Prevalence estimates were statistically significant (p < 0.001) when stratified by

geographical regions, with the Middle East having the highest prevalence of 26% (95% CI

0.13 - 0.39), followed by Australia (21%, 95% CI 0.16 - 0.25), South America (19%, 95% CI

0.18 - 0.21), Asia (16%, 95% CI 0.13 - 0.20), North America (16%, 95% CI 0.11 - 0.20),
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Africa (11%, 95% CI 0.05 - 0.17), then Europe (8%, 95% CI 0.05 - 0.11). The results can be

seen in Figure 4 below.

Analyses conducted by method of assessment have shown no statistical differences (p

= 0.30), with slightly higher prevalence in self-reported assessment tools (19%, 95% CI 0.17

- 0.22) than clinical interviews (17%, 95% CI 0.05 - 0.11) (Figure 5).

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The incidence of PPD was 12% (95% CI 0.04 - 0.20; Z = 3.05, df = 5, tau2 = 0.01, I2

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= 97%) based on the random effects model. A forest plot of the six studies that reported the

incidence of PPD is shown in Figure 6. Meta-regression was not conducted due to the small

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number of studies.

A funnel plot (Figure 7) was generated using RevMan 5.3 to test for publication bias.

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According to the visual representation of the funnel plot, the slight asymmetry indicates
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possible publication bias.
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DISCUSSION

Results from the meta-analysis of 58 studies suggest that the overall prevalence of
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PPD is 17% (95% CI 0.15 - 0.20). This estimate falls within previously published estimates
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of 13% to 19.2% (Gavin et al., 2005; O’Hara and Swain, 1996) and is similar to Hanhn-

Holbrook’s (2018) finding of 17.7%. However, it is higher than the prevalence of 0.6%
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reported in Rasmussen’s (2017) study on postpartum affective disorders among 457,317

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primiparous mothers without prior psychiatric history. Unique to this review, the prevalence
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was generated based on time of assessment, methods of assessment, and geographical

regions, in contrast to previous reviews (Fisher et al., 2012; Gavin et al., 2005; Woody et al.,

2017) in which prevalence was generated based on the World Bank’s guidelines of income

level (Fisher et al., 2012; Woody et al., 2017), or as individual countries (Gavin et al., 2005).

Also, previous reviews did not investigate the effect of the time of assessment on the
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prevalence of PPD; therefore, this review has added further insights on PPD prevalence in

different regions of the world, and at different postpartum time periods.

All geographical regions were represented in this review, with the highest coverage in

Asia (n=13) and North America (n=13), moderate coverage for Australia (n=7), Europe

(n=7), and the Middle East (n=10), and the lowest coverage for South America (n=5) and

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Africa (n=3). Studies conducted in Africa were mostly unable to meet our sample inclusion

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criteria of healthy mothers and infants; hence, the prevalence data for Africa are

underrepresented in this review. In addition, epidemiologic data were also the most lacking in

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low- and middle- income countries (i.e. South America and Africa). This could be due to a

poorly educated, non-English speaking population, and a society which does not prioritize

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mental illnesses (Baxter et al., 2013). The lack of a representative global epidemiological data
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on mental illnesses can hinder the implementation of effective measures.
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Our review also found statistical significant differences between geographical regions,

however the differences in psychometric properties of the different language versions of

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assessment tools used in each region were not accounted for and could be responsible such
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effects. Europe had the lowest prevalence of 8% (95% CI 0.05 - 0.11), while the Middle East

had the highest prevalence of 26% (95% CI 0.13 - 0.39); and the rest of Asia had a
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prevalence of 16% (95%CI 0.13 - 0.20). This falls between the reported range of prevalence
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in Asia (including the Middle East) of 3.5% to 63.3% (Klainin and Arthur, 2009). Haque’s
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(2015) review also found that the Middle East had a higher prevalence of PPD compared to

other countries like the United States of America (12%), Sweden (13%), Australia (15%),

Canada (8%), and Norway (10%). These statistics correspond with Affonso and colleagues’

(2000) results from a cohort study, which showed that the prevalence of PPD and anxiety was

generally higher in Asia than Western countries. Differences in cultural practices may

contribute to this difference. In the Middle East and developing countries in Asia, girls are
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known to marry as young as 16 years old (Dixon, 1971), which has been shown to be a

significant predictor of PPD (O’Hara et al., 2007). Other key differences between Asian and

Western societies include religiosity (Hamdan and Tamim, 2011; Klainin and Arthur, 2009),

relationship with mother-in-law (Green et al., 2006; Haque et al., 2015), and practice of the

confinement period (Chang et al., 2014; Murray et al., 2015; Rahman et al., 2003).

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Westerners have more individualistic postpartum practices while Asian cultures are more

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reliant on others for social support during the postpartum period (Klainin and Arthur, 2009).

Therefore, the Asian practice of the confinement period, which involves special dietary

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preparations and infant care by the mother or mother-in-law, serves as a protective factor of

PPD (Chang et al., 2014; Murray et al., 2015). However, in the United Arab Emirates (UAE),

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Muslims were found to have a higher risk of PPD than non-Muslims (Hamdan and Tamim,
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2011). Also, Middle Eastern women traditionally reside with their husband’s family after
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marriage, this involves living with the mothers-in law who are usually highly involved in the

son’s and daughter-in-law’s life (Green et al., 2006). Hence, having a negative relationship
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with one’s mother-in-law has been shown to lead to marital conflict, which in turn increases
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the risk of PPD (Green et al., 2006; Holroyd et al., 2011). Compared to a Western society

with a non-Muslim majority and an individualistic culture, these variances may be plausible
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reasons accounting for the difference in prevalence. In this review, most of the studies
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(Astbury et al., 1994; Gotlib et al., 1989; Iwata et al., 2016; Leung et al., 2005) only
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investigated the sociodemographic risk factors of PPD and neglected cultural factors; this

suggests a need for more holistic future research on the predictors of PPD, including cultural

influence to improve an early detection of PPD in specific regions.

From our meta-analysis on the type of diagnostic tool used in each study, no

statistically significant differences were found. Our prevalence findings of 17% (95% CI 0.12

- 0.21) for clinical interviews and 18% (95% CI 0.15 - 0.20) for self-reported measures were
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largely similar as those reported in previous reviews (O’Hara et al., 2007; Woody et al.,

2017). Studies that adopted self-reported methods had varying time scales ranging from one

day to four years post childbirth, and varying score cut-offs ranging from 9 to 13. The

majority of the studies used different instruments to measure PPD, highlighting the

importance of the standardization of screening tools to provide a more accurate measure for

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PPD.

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In our meta-analysis, no significant difference was found between assessment time

points; however, an observable trend of increasing prevalence was noted from few days

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postpartum to more than 1 year postpartum. There were only a few studies (n=6) that

investigated prevalence after one year, compared to 24 studies that investigated prevalence in

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the first 3 months postpartum. Previous published reports have suggested that the first three
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months postpartum is a high-risk timeframe for the onset of PPD (Cooper et al., 1988;
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O’Hara et al., 1984). This could be the reason that many individual studies investigated the

prevalence of PPD and depressive symptoms only in the early postpartum period (first three
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months) (Andrews-Fike, 1999; Cooper et al., 1988; Cox et al., 1993). However, there are a
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few longitudinal studies that reported persistence in depressive symptoms even after two

years (Chang et al., 2014; Small et al., 2003; Woolhouse et al., 2015). It was reported that
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women with no prior history of depression but who were depressed at eight months were
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found to remain depressed even after their child turned two years old. In a study by Horowitz
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and Goodman (2004), women with elevated depressive symptoms between two to four weeks

postpartum remained depressed up to two years post childbirth. In Beeghly et al.’s study

(2003), depression scores peaked at two months postpartum, but there was no significant

change in depression scores at two months and three to 12 months postpartum. A review by

Goodman (2004) examining the course and incidence of PPD further reaffirmed the

persistence and high prevalence of depressive symptoms in the late postpartum period; the
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author also suggested possible differences in factors associated with persistent depressive

symptoms compared to depressive symptoms in the early postpartum period. This signifies

the importance of depression screening in the late postpartum period, extending beyond one

year post childbirth, and that appropriate follow-up treatment should be introduced.

In this review, the incidence of PPD was found to be 12% and it ranged from 3.4% to

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34% based on the six studies (Abbasi et al., 2014; Abdollahi et al., 2016; Gotlib et al., 1989;

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Lara et al., 2015; Sood and Sood, 2003; Stuart et al., 1998). Two studies reported incidence at

one month postpartum, three months postpartum, and six months postpartum respectively,

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with the peak incidence at three months (Abbasi et al., 2014). Congruent to this review, a

previous study (Stuart et al., 1998) found an incidence of 7.48% between 3 to 7 months

U
postpartum, which suggests a significant number of PPD onset during this period of time.
AN
However, as half of the included studies in this review were conducted in North America, the
M

results are not representative of global incidence and the small number of available studies

reduces the statistical power of the review and increases the margin of error. This is
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supported by Baxter’s (2013) review on global epidemiology of mental health, which found
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that most incidence studies were done in Western Europe and North America, with almost

nonexistent incidence data available on other regions. This highlights the need for more
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incidence studies to be conducted globally, especially in the Middle East, Africa, and
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developing countries in Asia, in order to identify the peak period for the new onset of PPD so
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that treatment can be administered effectively.

The meta-regression analysis of 27 studies in this review did not show any population

characteristics that significantly contributed to the prevalence of PPD. Prevalence of PPD

was found to be similar across age, parity, and marital status. This is inconsistent with many

individual studies that reported demographic predictors such as age (Gotlib et al., 1989;

Green et al., 2006; Iwata et al., 2016; Katon et al., 2014), marital status (Beeghly et al., 2003;
 16
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Faria Pereira et al., 2015; Hobfoll et al., 1995), parity (Faria Pereira et al., 2015; Green et al.,

2006; Iwata et al., 2016), and societal economic status (Beeghly et al., 2003; Campbell and

Cohn, 1991; Moraes et al., 2006) to be the predictors for PPD. Gavin’s (2009) findings stated

that primiparous mothers aged 36 years and above have a higher prevalence of PPD. A study

by Hobfall and colleagues (1995) found that single mothers and those without a cohabiting

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partner were at heightened risk for PPD compared to married and cohabiting mothers. The

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current review does not show any statistically significant differences among demographic

variables, probably due to the heterogeneity of the studies and the incomplete data presented

SC
in the included studies. Apart from sociodemographic predictors, studies have shown other

significant psychosocial predictors such as the availability of social support (Beck, 2001;

U
Leahy-Warren et al., 2012; Shorey et al., 2015), parenting self-efficacy(Leahy-Warren et al.,
AN
2012; Shorey et al., 2015), and self-esteem (Beck, 2001; Green et al., 2006; Tsao et al.,
M

2015). However, investigating the effects of these predictors on the prevalence of PPD was

beyond the scope of our review, which should be further examined in future reviews instead.
D

A major limitation of this review is that the included studies were published only in
TE

English and highly diversified, and had varying sampling methods that were adopted and

screening methods that were not standardized, which results in high heterogeneity between
EP

the studies. Also, the studies of non-representative populations were included in this review;
C

hence, this may not be reflective of the general population. Furthermore, the lack of available
AC

studies for certain subgroups (i.e. Africa) resulted in the analysis of a small study size, which

likely affected the overall results. Prevalence was found to be lower in Africa than Western

countries, but this was based on the analysis of only three studies; therefore, comparisons

may not be accurate. Lastly, due to the lack of significant findings from our meta-regression,

the results were unadjusted, and heterogeneity was not accounted for. However, the inclusion

of healthy mothers without prior history of psychiatric illnesses and who gave birth to healthy
 17
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full-term infants provided greater insights about this specific group of neglected mothers. As

such, this review can be a stepping stone for future research in examining PPD and

supportive interventions for this specific group of mothers.

This review has provided valuable insights on the incidence of depression among

healthy mothers. Healthcare professionals should acknowledge the stressfulness of the

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postpartum period and assess each mother for depression beyond one year irrespective of

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their psychiatry history. The review also highlights the importance of cultural relevance in

supporting mothers during this stressful transition period. Especially with the globalization of

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medical care, it is very important that healthcare professionals recognize the importance of

providing culturally congruent care to new mothers.

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Future research should fill in the gaps highlighted in this review, including the limited
AN
data on PPD incidence, the under representation of Africa, and long-term PPD follow-ups
M

beyond one year postpartum. Future papers should also consider comparing both groups of

mothers (with versus without a history of depression) using the same analytical criteria such
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that a more accurate comparison of observed prevalence will be available. Even though they
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are not examined in this review, other significant predictors, like social support (Shorey et al.,

2015) and household income (Beeghly et al., 2003), and risk factors such as living conditions,
EP

events during pregnancy, and birth complications, can be taken into account for sub-group
C

analysis in future reviews. Due to the inconsistent indicators of received social support across
AC

studies, as well as the difference in currency used to measure household income, we were

unable to include these variables in our review. As such, consistent definitions and

measurements of social support and household income as well as standard tools to measure

PPD should be considered when planning research globally so that future reviews can

compare homogeneous studies to provide more concrete evidence.

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CONCLUSION

The findings from this review presented the prevalence and incidence of PPD for a

specific group of healthy mothers without prior history of mental illnesses including PPD.

This group is often neglected in previous research; however, given that the PPD prevalence

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among this group of mothers is similar to those with a history of psychiatric illnesses, equal

RI
emphasis should be placed on them. Despite the lack of significant common predictors like

age, parity, and marital status on PPD prevalence, our review showed that Middle Eastern

SC
and Asian mothers have heightened risks of PPD, especially beyond six months postpartum.

Overall, this review sets the stage for future practice and research to focus on healthy mothers

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during the postpartum period. This can potentially lead to the development of a more targeted
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treatment or an intervention method to prevent PPD in this specific group of mothers, and add
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implications that healthcare professionals should be mindful of when providing culturally

congruent care.
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Declaration of Interest

None
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ACKNOWLEDGMENTS:
The authors would like to thank the National University Health System, Medical Publications

Support Unit, for assistance in the language editing of this manuscript.

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Figure Captions
Figure 1. PRISMA flowchart of the systematic review literature search illustrating the
identification of included studies.
Figure 2. Forest plot of 56 studies assessing the prevalence of postpartum depression among
mothers (n = 35,943). The size of the shaded square box indicates the weight of each study.
Horizontal lines show the 95% confidence intervals (CI). SE, standard error.
Figure 3. Forest plot assessing the prevalence of postpartum depression among mothers at

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different assessment time periods. The size of the shaded square box indicates the weight of
each study. Horizontal lines show the 95% confidence intervals (CI). SE, standard error.
Figure 4. Forest plot assessing the prevalence of postpartum depression among mothers in

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different geographical regions. The size of the shaded square box indicates the weight of each
study. Horizontal lines show the 95% confidence intervals (CI). SE, standard error.

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Figure 5. Forest plot assessing the prevalence of postpartum depression among mothers
according to method of assessment. The size of the shaded square box indicates the weight of
each study. Horizontal lines show the 95% confidence intervals (CI). SE, standard error.

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Figure 6. Forest plot of six studies assessing the incidence of postpartum depression among
mothers (n = 1,351). The size of the shaded square box indicates the weight of each study.
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Horizontal lines show the 95% confidence intervals (CI). SE, standard error.
Figure 7. Funnel plot assessing the heterogeneity of the 56 studies on prevalence of
postpartum depression. Each plotted point represents the standard error (SE) and prevalence
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for a single study. The vertical line represents average prevalence of 0.17 in the meta-analysis.
The slight asymmetry suggests possible publication bias.
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Table 1
Major characteristics of the studies for the prevalence and incidence of postnatal depression

Author, Year Region, Country Sample Time Points of Diagnostic Diagnostic

Size, n Screening Tool (cutoff) Criteria
Incidence Studies
Abbasi et al., Europe, England 513 1st Trimester; EPDS (> 13)
2014 2nd Trimester;
3rd Trimester;

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3rd month PP
Abdollahi et Middle East, Iran 838 3rd month PP EPDS (≥ 13)
al., 2016

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Prevalence Studies
Affonso et al., North America, 202 10 - 14 weeks SADS RDC
1990 USA pregnant;

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30 - 32 weeks
pregnant;
1 - 2 weeks PP;
4 weeks PP

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Agoub et al., Africa, Morocco 144 2 weeks PP; MINI DSM-IV
2005 6 weeks PP;
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6 months PP;
9 months PP
Al Hinai et al., Middle East, 282 2 weeks PP; EPDS (≥ 13)
2014 Oman 8 weeks PP
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Astbury et al., Australia 771 8 months PP EPDS (≥ 13)

1994
Bakare et al., Africa, Nigeria 408 Mean 3.56 MINI; DSM-IV
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2014 months PP EPDS (≥ 9)

Beck et al., North America, 903 Mean 12.1 PHQ-2 (≥ 3)
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2011 USA months PP

Beeghly et al., North America, 163 2 months PP; CES-D (≥
2003 USA 3 months PP; 16)
6 months PP;
EP

12 months PP;
18 months PP
Bugdayci et al, Middle East, 1447 0 - 2 months EPDS (≥ 13)
C

2004 Turkey PP; 3 - 6months

PP;
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7 - 12months
PP;
> 12 months PP
Campbell and North America, 1033 6-8 weeks PP SADS; RDC
Cohn, 1991 USA CES-D (≥
16)
Chang et al., Asia, Taiwan 111 6 - 24 months CES-D (≥
2014 PP; 25 - 48 16)
months PP
Chen, 1994 Asia, Taiwan 129 6 weeks PP BDI (≥ 10)
Chien et al., Asia, Taiwan 166 1month PP; CES-D (≥
2009 1 year PP 15)
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Cooper et al., Africa, South 98 2 months PP; SCID DSM-IV
2005 Africa 18 months PP
Corrêa, 2016 South America, 3060 1 - 3 months PP EPDS (≥ 11)
Brazil
Cox et al., Europe, England 232 6 months PP SPI; RDC
1993 EDPS (≥ 9)
Dennis et al., North America, 1125 1 week PP; EPDS (≥ 10)
2016 Canada 16 weeks PP

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Edhborg, 2010 Europe, Sweden 238 2 months PP; EPDS (≥ 12)
1 year PP
Faisal-Cury, South America, 113 10 days PP BDI (≥ 16)
2004 Brazil

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Faria, 2015 South America, 86 1 month PP; EPDS (≥ 12)
Brazil 2 months PP;

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4 months PP
Garcia-Esteve Europe, Spain 1123 6 weeks PP SCID-NP; DSM-IV
et al., 2003 EPDS (≥ 9)

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Glasser et al., Middle East, Israel 104 < 3 months PP EPDS (≥ 13)
2011
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Glavin et al., Europe, Norway 2227 6 weeks PP EPDS (≥ 12)
2009
Gotlib et al., North America, 295 Mean 23.8 SADS; RDC
1989 Canada weeks pregnant; BDI (≥ 10)
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mean 35.9
weeks pregnant;
mean 4.2 weeks
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PP
Green et al., Middle East, UAE 56 3 months PP; EPDS (≥ 13)
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2006 6 months PP
Hamdan et al., Middle East, UAE 137 2nd trimester; MINI; DSM-IV
2010 3rd trimester; EPDS (≥ 10)
2 months PP
EP

Hobfoll et al., North America, 192 2nd trimester; SADS RDC

1995 USA 3rd trimester;
7 - 9 weeks PP
C

Ho-Yen et al., Asia, Nepal 426 5 - 10weeks PP EPDS (≥ 13)

2006
Huang and Asia, Taiwan 106 3 - 6 months PP EPDS (≥ 13)
AC

Mathers, 2008
Husain et al., Middle East, 149 Mean 12 weeks EPDS (≥ 12)
2006 Pakistan PP
Iwata et al., Asia, Japan 2709 1, 2, 4, and 6 EPDS (≥ 9)
2016 months PP
Josefsson et Europe, Sweden 1558 1 - 5days PP; EPDS (≥ 10)
al., 2001 6 - 8 weeks PP;
6 months PP
Khalifa et al., Middle East, 236 3 months PP EPDS (≥ 12)
2015 Sudan
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Kitamura et al., Asia, Japan 111 1st trimester; SADS RDC
1994 3rd trimester;
1 day PP;
1 month PP
Lara et al., North America, 210 3rd trimester; SCID DSM-IV
2014 Mexico 6 weeks PP;
6 months PP
Leung et al., Asia, Hong Kong 269 6 weeks PP EPDS (≥ 13)
2005

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McMahon et Australia 100 4 months PP; CIDI DSM-IV
al., 2005 12 months PP
Moraes et al., South America, 410 30 - 45 days PP HAM-D (≥

RI
2006 Brazil 18)
Motzfeldt, Europe, Greenland 174 3 months PP EPDS (≥ 13)
2013

SC
Murray et al., Asia, Vietnam 431 1 - 6 months PP EPDS (≥ 13)
2015
O’Hara et al., North America, 4332 Mean 4.6 IDD DSM-IV

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2007 USA months PP
Pawar et al., North America, 361 1 - 2 days PP PHQ-9 (≥
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2011 USA 10)
Rahaman and Middle East, 541 3rd trimester; SCAN ICD-10
Harrington, Pakistan 10 - 12weeks
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2003 PP
Rahman and Middle East, 129 3rd trimester; SCAN ICD-10
Creed, 2007 Pakistan 3 months PP;
6 months PP;
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12 months PP
Shafiei et al., Australia 39 4 months PP EPDS (≥ 13)
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2015
Small, R. et al., Australia 318 6 - 9 months PP EPDS (≥ 13)
2003
EP

Sood and Asia, India 84 3rd trimester; BDI (≥ 16)

Sood, 2003 1 - 3 days PP;
4 - 8 weeks PP
C

Stamp et al., Australia 235 6 weeks PP; EPDS (≥ 13)

1994 6 months PP
AC

Stuart et al., North America, 107 14 weeks PP; BDI (≥ 10)

1998 USA 30 weeks PP

Tannous et al., South America, 271 Mean 7.1 weeks EPDS (≥ 13)
2008 Brazil PP
Tsao et al., Asia, Taiwan 162 4th trimester; EPDS (≥ 13)
2015 6 weeks PP

Wan et al., Asia, Malaysia 174 6 - 8 weeks PP CIS ICD-10

2002
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Whiffen et al., North America, 115 6 - 8 weeks PP SADS RDC
1988 Canada (mean 52 days
PP)
Woolhouse, et Australia 1507 3 months PP; EPDS (> 13)
al., 2014 6 months PP;
12 months PP;
18 months PP;
4 years PP
Yelland et al., Australia 4366 6 months PP DASS-21 (≥
2010 10)

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Yusuff et al., Asia, Malaysia 1362 1 months PP; EPDS (≥ 12)
2015 3 months PP;
6 months PP

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Zelkowitz et North America, 106 during EPDS (≥ 12)
al., 2008 Canada pregnancy;
2 months PP

SC
Note. BDI = Beck’s Depression Inventory; CES-D = Center for Epidemiologic Studies Depression
Scale; CIDI = Composite International Diagnostic Interview; CIS = Clinical Interview
Schedule; DASS-21 = Depression Anxiety Stress Scales; DSM-IV = Diagnostic and Statistical
Manual of Mental Disorders IV; EPDS = Edinburgh Postnatal Depression Scale; HAM-D = Hamilton

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Depression Scale; ICD-10 = International Classification of Diseases, Tenth Revision; IDD =
Inventory to Diagnose Depression; MINI = Mini-International Neuropsychiatric Interview PHQ =
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Patient Health Questionnaire; PP = postpartum period; RDC = Research Diagnostic Criteria; SADS =
Social Avoidance and Distress Scale; SCAN = Schedules for Clinical Assessment in Neuropsychiatry;
SCID = Structured Clinical Interview for DSM-IV; SCID-NP = Structured Clinical Interview for
DSM-IV- Non Patient; SPI = Standardised Psychiatric Interview.
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Table 2
Results of the random effects meta-regression of demographic moderators for the prevalence
of postpartum depression among women with categorical moderators
Moderator Coefficient Standard Z-value p-value 95% CI
error
Age of mothers, mean -0.002 0.092 0.02 0.983 -0.17 – 0.18
Proportion of primiparous -0.013 0.008 -1.65 0.099 -0.27 – 0.00
mothers
Proportion of single -0.002 0.014 -0.13 0.899 -0.03 – 0.03

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mothers
Note. 95% CI = 95% confidence interval.

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Table 3
Results of the subgroup analyses of the prevalence of depression among postpartum women
with categorical moderators
Subgroup Comparison Studies, n Prevalence 95% CI
Assessment time period
0 - 3 months 24 0.14 0.11 - 0.17
4 - 6 months 18 0.16 0.13 - 0.19
7 - 12 months 7 0.20 0.11 - 0.29
More than 12 months 6 0.25 0.12 - 0.39

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Method of assessment
Clinical interviews 17 0.17 0.12 - 0.20
Self-report questionnaires 39 0.18 0.15 - 0.20

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Region
Asia 13 0.16 0.13 - 0.20
Africa 3 0.11 0.05 - 0.17

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Australia 5 0.19 0.18 - 0.21
Europe 6 0.08 0.05 - 0.11
Middle East 9 0.26 0.13 - 0.39

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South America 5 0.19 0.18 - 0.21
North America 13 0.16 0.11 - 0.20
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Note. 95% CI = 95% confidence interval.
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Records identified through database Additional records identified through

searching other sources/grey literature
(n = 15,895) (n = 61)

Duplicates

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removed
(n = 3,569)
Records screened for title and abstract
(n = 12,387)

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Records removed

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due to inaccessible
Records screened for full-text and language full text (non-
(n = 325) response from the
original authors

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when contacted)
or unavailable
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English text.
(n = 111)
Records screened for eligibility
(n = 214)
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studies, lack of
overall prevalence,
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irrelevant content
Studies eligible for inclusion
(i.e. antenatal,
(n = 58)
psychiatric
Studies Studies Studies disorders), invalid
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included for included for included for instruments, and

meta- meta-analysis meta-analysis insufficient
analysis of of incidence of both information for
prevalence (n = 2) prevalence analysis.
C

(n = 52) and incidence (n = 152)

(n = 4)
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Highlights
• Postpartum depression prevalence of 17% amongst healthy mothers
• Highest prevalence in Middle East and Asia compared to Western countries
• Increasing prevalence in time point assessments beyond three months
• No difference in prevalence through self-reports or clinical interviews

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