©INTERNATIONAL CENTRE FOR DIARRHOEAL
DISEASE RESEARCH, BANGLADESH
J HEALTH POPUL NUTR 2013 Sep;31(3):398-402
ISSN 1606-0997 | $ 5.00+0.20
Correspondence and reprint requests:
Dr. Azita Goshtasebi
Family Health Research Group
Health Metrics Research Center
Iranian Institute for Health Sciences Research
No. 23, Nazari St., South Palestine
St. Enghelab Ave.
contributing to PPD (6). Recently, the role of iron-
deficiency anaemia (IDA) has been considered.
Prevalence of IDA during pregnancy is around
7.5%, and recovery of iron stores in the postpartum
period is often delayed in women who experience
IDA during pregnancy (6,7). Behavioural symptoms
associated with anaemia in adults include changes
in cognition, emotions, irritability, apathy, fatigue,
depressive symptoms, and hypoactivity (7,8).
Alterations in thyroid hormone metabolism (6),
changes in the neurotransmitters function (9), and
reduction in some inflammatory cytokines, such as
interleukin 2 in iron deficiency, might be underly-
ing causes for the development of PPD (10-12).
There is a relative lack of information regarding the
influence of maternal anaemia on postpartum de-
pression. The aim of our study was to determine
the relationship between anaemia during pregnan-
cy and postpartum depression.
MATERIALS AND METHODS
For a significance level of 0.05 and to find a 10%
Association between Maternal Anaemia and
Postpartum Depression in an Urban Sample of
Pregnant Women in Iran
Azita Goshtasebi1, Mozhgan Alizadeh2, Samira Behboudi Gandevani3
1Family Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR,
Tehran, Iran; 2Imam Hospital, Sari, Iran; 3Reproductive Endocrinology Research Center, Research Institute for Endocrine
Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
The aim of this prospective study was to determine the relationship between anaemia during pregnancy
and postpartum depression. Two hundred eighty-one non-anaemic mothers with singleton and low-risk
pregnancy and no history of antidepressant-use were studied. Demographic and reproductive data at week
20 were obtained. Mothers were followed up and haemoglobin (Hb) was checked at delivery. Iranian ver-
sion of Edinburgh Postpartum Depression Scale (EPDS) was completed 4-6 weeks after delivery. Mean age
of the mothers was 26.6±4 years. The prevalence of postpartum depression according to EPDS was 5.5%.
Binary logistic regression analysis showed that Hb <11 g/dL at delivery would increase the chance of post-
partum depression (OR 4.64; 95% CI 1.33-16.08). The results show that diagnosis and treatment of physi-
ologic factors, especially anaemia, would reduce the risk of postpartum depression.
Key words: Anaemia; Edinburgh Postpartum Depression Scale; Haemoglobin; Postpartum depression; Iran
Postpartum depression (PPD) is a major episode
that most often emerges within 6 to 12 weeks after
delivery (1,2). The prevalence of postpartum de-
pression is about 10-15%, depending on the diag-
nostic criteria, timing of screening, and screening
instruments used (3). Apart from affecting mental
health of a mother, it also disturbs family relation-
ships and emotional and cognitive development of
a child (4,5).
A number of psychosocial risk factors have been
identified that entail the development of PPD but
few studies have recognized physiologic variables
Goshtasebi A et al. Maternal anaemia and postpartum depression
Volume 31 | Number 3 | September 2013
prevalence of postpartum depression, the number
of subjects required was 216. Two hundred eighty-
one healthy pregnant women were included in
the study from February to December 2009. The
study population consisted of primipara women
aged 18-35 years with normal BMI (19.8-26) with
singleton pregnancy. Women with iron-deficiency
anaemia (defined as Hb <10.5 g/dL), history of
chronic disease or other diseases known to interfere
with iron metabolism, history of antidepressant-use,
stressful life-events, consumption of alcohol, ciga-
rette smoking, or drug-abuse, were not recruited.
The participants were registered at prenatal clinic
of Imam Hospital at Sari, a coastal city located in
north of Iran.
During a longitudinal study, low-risk pregnant
mothers with parity ≤2 and singleton pregnancy
were enrolled in the first prenatal visit at 14-20
weeks of gestation. Demographic and obstetric
data and laboratory test results were collected. The
eligible mothers in their first prenatal visit were ex-
amined for iron-deficiency anaemia, and women
with Hb <11 g/dL and ferritin <15 mcg/dL were not
recruited. All mothers received routine prenatal
care (including standard vitamin and mineral sup-
plementation) and followed up during the prenatal
period till delivery. Maternal blood haemoglobin
and ferritin concentrations were determined at
birth. According to the CDC reference values for
haemoglobin (Hb <11 g/dL in the third trimester
for anaemia), the women were divided into anae-
mic and non-anaemic groups. They were followed
up till 4-6 weeks after delivery. Iranian version of
the Edinburgh Postpartum Depression Scale (EPDS)
was employed 4-6 weeks after delivery. The EPDS
score 13 was used as cutoff point for screening de-
pression in the mothers under study.
Two mothers were excluded (one with severe pre-
eclampsia and pregnancy termination before week
34, one having idiopathic thrombocytopenic pur-
pura), and 25 (10%) mothers were not accessible
and did not complete the EPDS. Demographic and
obstetric characteristics of these mothers did not
differ from the others.
Iranian version of the Edinburgh Postnatal Depres-
sion Scale (EPDS) was used as the screening tool for
postpartum depression. This scale was used success-
fully in previous studies on postnatal depression
in Iran (13,14). In general, the Iranian version of
the EPDS was found to be acceptable to almost all
women. Cronbach’s alpha coefficient was found to
be 0.77. Validity as performed using comparison
among known groups showed satisfactory results.
The questionnaire discriminated well between
subgroups of women differing in mode of delivery
in the expected direction. The factor analysis indi-
cated a three-factor structure that jointly accounted
for 58% of the variance. A cutoff score of 13 pro-
vided 95.3% sensitivity and 87.9% specificity for
clinical depression (13). Maternal Hb values were
determined by the cyanmethohaemoglobin meth-
od. A complete blood count was done using an au-
tomatic cell counter (T890, Coulter), and serum fer-
ritin was assessed by radioimmunoassay (Gamma
Counter System, Kontron).
Data were collected in the prenatal clinic and la-
bour ward of Imam Hospital in Sari, Iran. A venous
blood sample at the time of delivery was obtained
and was immediately assessed for anaemia. Then,
mothers were followed for 4-6 weeks after delivery.
A specific room in prenatal clinic (which is also the
postnatal care clinic) was allocated for this job, and
every mother was invited to the room and asked to
fill up the questionnaire. A trained midwife was in
charge of all data-collection process. She was pres-
ent in the room to help mothers who had difficulty
in reading or understanding the questionnaire.
The study was approved by review board of the
Iranian Institute for Health Sciences Research
(ACECR), Tehran, Iran. An informed consent for
scientific use of the data was obtained from each
All statistical analyses were performed using SPSS
(version 11.5) for Windows (SPSS Inc., Chicago,
IL). Based on Hb concentration at delivery, partici-
pants were divided into anaemic and non-anaemic
groups, and all comparisons were performed accord-
ingly. Mothers were grouped into three educational
levels based on the completed years of academic
education. The results were presented as mean±SD.
Comparisons between groups were performed using
unpaired t-test, χ2-test, and binary regression. Statis-
tical significance was set at the 95% level (p<0.05).
Goshtasebi A et al. Maternal anaemia and postpartum depression
Overall, 254 women were included in the final
analysis. There were no obstetric complications in
the final sample studied. The sociodemographic
and obstetric characteristics of the study women
are shown in Table 1.
The women in two groups were not significantly
different in terms of age, job, education, BMI, and
gestational age at delivery. The mean age of moth-
ers was 26.6±4.0 years, and the mean schooling of
formal education was 9.24±3.5 years. Most of the
study women were housewives (97.6%); 14 of 254
women (5.5%) had postpartum depression accord-
ing to EPDS. The incidence of anaemia (Hb <11 g/
dL) at delivery was 14% without hypoferritinae-
mia. Table 1 shows the probability of PPD at 4-6
weeks postpartum in anaemic and non-anaemic
mothers at delivery. The mean values of ferritin
were not different in anaemic and non-anaemic
mothers. Binary logistic regression analysis showed
that Hb <11 (OR 4.64; 95% CI 1.33-16.08) at de-
livery and secondary level of education (OR 6.76;
95% CI 1.10-41.16) would increase the chance of
postpartum depression (Table 2).
Anaemia, as a physiological cause of PPD, has re-
cently received attention from scholars in both
the fields. Findings of this study and other similar
works could provide evidence for this.
The aim of the study was to evaluate the effect of
iron-deficiency anaemia on postpartum depres-
sion. However, since the study sample was derived
from a low-risk population and according to na-
tional iron supplementation programme, all preg-
nant mothers should receive iron supplements dur-
ing pregnancy, regardless of ferritin or Hb levels; no
mothers at the time of delivery had iron-deficiency
anaemia (low haemoglobin and ferritin values).
Our study demonstrated 5.5% prevalence of post-
partum depression, which is much lower than the
figures described previously (2,3,14,15). This may
be due to the different tools and the cutoff points
used by others. In the present study, we used Irani-
an version of the EPDS because it has been proven
as an acceptable, reliable, and valid measure of
postnatal depression among women in Iran. Also,
we used a cutoff value of 13 to signify depression.
Table 1. Sociodemographic and obstetric characteristics of the study women
Age1: mean (SD)
Education2: mean (SD)
BMI3: mean (SD)
Gestational age at birth4:
Caesarean delivery: (%)
Pregnancy weight gain5:
Newborn sex (male): (%)
Hb6 at delivery: mean (SD)
Ferritin7 at delivery: mean (SD)
EPDS score <13: (%)
Anaemic Non-anaemicp value
25.50 (4.37) 26.11 ( 4.03)0.40*
1Years, 2Years of completed academic education, 3kg/m2, 4Days, 5kg, 6g/dL, 7mcg/dL, *t-test, **χ2-test,
Goshtasebi A et al.Maternal anaemia and postpartum depression
Volume 31 | Number 3 | September 2013
This cutoff has been shown to have high sensitivity
and specificity in Iran (14). Moreover, the selected
sample was very healthy and of low risk for any
complication, including postpartum depression.
Research suggests several psychosocial risk factors
for postpartum depression but few from cited stud-
ies examined the relationship between physiologi-
cal factors, specifically anaemia and postpartum
depression. This topic is a relatively new one in the
field. There is a large body of literature on postpar-
tum depression and its risk factors but these did not
focus on physiological factors, such as anaemia to
the desired extent.
There are some controversial studies in this field.
Wolf and colleagues (15) did not find an associa-
tion between maternal iron status and depression
symptoms at 1 year postpartum in a large sample
of mothers from Chile and Costa Rica. Corwin and
co-workers (6) demonstrated a significant relation-
ship between anaemia and depressive symptoms in
the postpartum period.
The results of our study suggest that Hb <11 g/dL
at delivery, but not iron deficiency, would increase
the chance of postpartum depression. The wide
confidence interval might be explained by small
sample-size or homogeneous low-risk mothers we
studied. Based on routine prenatal care at the na-
tional level, all mothers received iron supplement
during pregnancy, and we did not detect any
hypoferritinaemia in our samples. This suggests
that anaemia regardless of iron status might af-
fect emotions in postpartum period. Considering
the negative consequences of depression on the
mother, her offspring and whole family, diagnosis
and treatment of anaemia should be an essential
part of maternity care during pregnancy and after
This study is original in that it is one of the first
studies in Iran to report on the association between
anaemia and postpartum depression.
Our study had a few limitations that should be con-
sidered. As it can be seen from Table 1, the study
sample came from an urban population of low so-
cioeconomic status. We excluded all the mothers
who had stressful life-experiences, history of using
antidepressant drugs and mental or physical disor-
ders. There were no maternal or neonatal complica-
tions or birth of even LBW neonates. Most mothers
were young and had their first or second pregnancy.
However, we did not assess the social support to the
study mothers. Several studies showed that the lack
of social support can increase the incidence of PPD.
Therefore, we tried to remove as many as possible
factors influencing the level of stress and receiving
support from the family and society.
Hb concentrations at delivery were used as an indi-
cator of maternal anaemia during early postpartum
period. While some studies showed that the con-
current Hb values might be more practical, others
showed that anaemia at delivery usually continues
during postpartum period. Although the sample-
size was relatively small, the relationship between
anaemia and PPD was evident in the present study.
This study was funded by Iranian Institute for
Health Sciences Research (ACECR). We would like
to thank all the mothers who participated in this
study. We also wish to express our gratitude to staff
of maternity care clinic in Imam Hospital.
Table 2. Results of logistic regression analysis
with the odds ratios of postpartum de-
pression for each risk factor adjusted for
other variables in the model
Type of delivery
Gestational age at
Hb at delivery5
1Years; 2Normal vaginal delivery; 3Caesarean sec-
tion; 4Weeks, 5g/dL; ٭p<0.05; **Distribution of
sample in each category
Goshtasebi A et al. Maternal anaemia and postpartum depression Download full-text
1. Doucet S, Dennis C-L, Letourneau N, Blackmore ER.
Differentiation and clinical implications of postpar-
tum depression and postpartum psychosis. J Obstet
Gynecol Neonatal Nurs 2009;38:269-79.
2. Leung BMY, Kaplan BJ. Perinatal depression: preva-
lence, risks, and the nutrition link—a review of the
literature. J Am Diet Assoc 2009;109:1566-75.
3. Marcus SM. Depression during pregnancy: rates, risks
and consequences. Can J Clin Pharmacol 2009;16:e15-
4. Gjerdingen DK, Yawn BP. Postpartum depression
screening: importance, methods, barriers, and reco-
mmendations for practice. J Am Board Fam Med
5. Wójcik J, Dudek D, Schlegel-Zawadzka M, Grabowska
M, Marcinek A, Florek E et al. Antepartum/postpar-
tum depressive symptoms and serum zinc and mag-
nesium levels. Pharmacol Rep 2006;58:571-6.
6. Corwin EJ, Murray-Kolb LE, Beard JL. Low hemoglo-
bin level is a risk factor for postpartum depression. J
7. Murray-Kolb LE, Beard JL. Iron deficiency and child
and maternal health. Am J Clin Nutr 2009;89:946S-50S.
8. Ludwig H, Strasser K. Symptomatology of anemia.
Semin Oncol 2001;28(Suppl 8):7-14.
9. Shariatpanaahi MV, Shariatpanaahi ZV, Moshtaaghi
M, Shahbaazi SH, Abadi A. The relationship between
depression and serum ferritin level. Eur J Clin Nutr
10. Bergman M, Bessler H, Salman H, Siomin D, Strauss-
berg R, Djaldetti M. In vitro cytokine production in
patients with iron deficiency anemia. Clin Immunol
11. Bodnar LM, Siega-Riz AM, Miller WC, Cogswell ME,
McDonald T. Who should be screened for postpar-
tum anemia? An evaluation of current recommenda-
tions. Am J Epidemiol 2002;156:903-12.
12. Myint A-M, Leonard BE, Steinbusch HWM, Kim Y-K.
Th1, Th2, and Th3 cytokine alterations in major de-
pression. J Affect Disord 2005;88:167-73.
13. Montazeri A, Torkan B, Omidvari S. The Edinburgh
Postnatal Depression Scale (EPDS): translation and
validation study of the Iranian version. BMC Psychia-
14. Mazhari S, Nakhaee N. Validation of the Edinburgh
Postnatal Depression Scale in an Iranian sample. Arch
Womens Ment Health 2007;10:293-7.
15. Wolf AW, De Andraca I, Lozoff B. Maternal depres-
sion in three Latin American samples. Soc Psychiatry
Psychiatr Epidemiol 2002;37:169-76.