ArticlePDF Available
Postpartum Depression
In 2004, the World Health Organisation estimated
that over 150 million people were living with
depressive disorders, with about 10% of these being
in Africa (1). Depression is the third leading cause of
the global burden of disease as measured using the
Disability-Adjusted Life Years (DALYs), contributing
to upto 4.3% of the DALYs. In the high and middle-
income countries, it is the leading cause of the burden
of disease while in low income countries it is the 8th
leading cause. It is estimated that in 2030, depressive
disorders will be the leading cause of the global burden
of disease (1).
Among women in the reproductive age-group,
depressive disorders are the leading cause of the
global burden of disease (1). This is due to the greater
prevalence of depression among women compared to
men in the general population, and the chronic nature
of the illness. For various reasons, including the
reproductive cycle, it is highly probable that women
suffer a greater burden of depression than men.
The Diagnostic and Statistical Manual for Mental
Disorders, DSM IV TR (2) does not dene postpartum
depression as a distinct category of illness. However,
under the classication for major depressive disorders,
a specier for ‘postpartum onset’ is included. Although
the postpartum period in this case covers the period
upto four weeks postpartum, in most research and
clinical settings a period of upto one year is considered
The clinical presentation of postpartum depression
is the same as that of depression outside of this period,
although additional symptoms such as mood lability
and over-concern with the infant are commonly
reported (2). This disorder should be distinguished
from postpartum blues, a syndrome characterised by
mood symptoms that are common in the rst seven
to ten days after delivery and that usually resolve
within a few days without any intervention. Symptoms
include mood lability, irritability, interpersonal
hypersensitivity, insomnia, anxiety, tearfulness, and
sometimes elation (3).
Although there is no difference between the
prevalence rate of postpartum depression and that of
depression among women in the general population,
the incidence of depression within one month of
delivery rises to three times the average monthly
incidence in non-childbearing women (4). Many
studies suggest that the postpartum period carries a
higher risk of developing depression than any other
period during the reproductive life of a woman (5, 6).
Depending on the criteria used to diagnose postpartum
depression, prevalence rates range from 7% to 20% (3,
4) but can go as high as 63% as was found in a review
of Asian studies (7).
In this issue of the journal, Onwere et al (8) reports
the ndings of a study using the Edinburgh Postnatal
Depression Scale to determine the prevalence and
possible risk factors for postpartum depression in
Nigeria. This study yielded a relatively high prevalence
of screen-positive postpartum depression of 23.5%.
Comparable studies from African settings are few,
but the results are comparable to those reported by
Onwere et al(8) in this issue of the journal.
A 2005 study in Nigeria reported a postpartum
depression prevalence rate of 14.6% (9), while in a
Zimbabwean random sample of postpartum women
33% of them met the DSM IV criteria for depression
(10). A South African study similarly found a high
prevalence rate of 34.7% among mothers in a peri-
urban settlement (11). Obviously, then, postpartum
depression is a serious problem among women in
Africa, and it is possible that further research will
yield the true burden of this disabling disorder.
Among the identied risk factors for the
development of postpartum depression are: history of
any psychopathology (including history of previous
postpartum depression), low social support, poor
marital relationship, recent life events and unwanted
pregnancy (4,7). Studies from African countries
have identied further risk factors including hospital
admissions during the pregnancy, female sex of
the baby, preterm delivery, instrumental delivery,
Caesarean section and being single (9).
The importance of onwere et al’s(8) study lies in
two areas. Firstly, it adds to the small but growing body
of knowledge originating from Africa and other low-
income regions on postpartum depression and mental
disorders in general. In this regard, more cross-
Journal of Obstetrics and Gynaecology of
Eastern and Central Africa
JOGECA 2011; 23(1):1-3
disciplinary research of this nature is to be encouraged
due to the potential saving in costs and the benet of
pooling expertise.
Secondly, the study highlights the magnitude
of the problem, raising the need for screening and
treatment of depression during the postnatal clinic
visits. Due to the limited amount of research in this
area, it has remained difcult for policy-makers to
design interventions targeting depression and other
mental disorders among women in this category, and
one hopes that studies such as these will provide the
necessary evidence base for action.
Questions may be raised concerning the need
to screen for depression, and whether management
of postpartum depression has any public health
importance beyond relieving the patient’s symptoms.
The evidence overwhelmingly supports an aggressive
approach to management of this disorder in order
to reduce the risk of multiple socio-economic and
psychological complications.
Many studies have demonstrated a link between
postpartum depression and problems with child-rearing
and family dynamics, resulting in multiple negative
effects including slow infant growth and malnutrition,
multiple infections, poor family dynamics and
increased risk of current and future behavioural and
psychological problems in the child (11-15). Evidently,
then, it follows that proper management of postpartum
depression has the potential to improve not only the
mother’s overall health, but also that of the infant and
the family as a whole.
Based on these observations, it is evident that
postpartum depression is a global public health priority
that needs more research and interventions than is
currently the case. As in the paper by onwere et al (8)
in the current issue of the journal, it is recommended
that routine screening for depression be carried out
during visits by pregnant and postnatal women in order
to identify the problem early and institute corrective
In conclusion, there is little doubt that depression
among women of reproductive age, including
syndromes such as postpartum depression, is a
major public health issue and interventions should
be integrated into the routine care of women in
reproductive health services. It is my conviction that
this integration is the only approach that will have
signicant impact towards improving both maternal
and child health in Africa.
Dr. Lukoye Atwoli -
Lecturer, Department of Mental
Health, Moi University School of Medicine PO Box
1493 Eldoret 30100, Kenya. Email: Lukoye@gmail.
1. WHO. The global burden of disease: 2004 update.
Geneva: WHO: 2008.
2. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders.
Washington, DC: American Psychiatric
Association: 2000.
3. O’Hara M.W. Postpartum depression: what we
know. J. Clin. Psychol. 2009; 65:1258-1269.
4. Craig, M. and Howard, L. Postnatal depression.
Clin. Evid. (Online) 2009; 2009.
5. Eberhard-Gran, M., Eskild, A., Tambs, K.,
Samuelsen, S.O. and Opjordsmoen, S. Depression
in postpartum and non-postpartum women:
prevalence and risk factors. Acta Psychiatr. Scand.
2002; 106:426-433.
6. Vesga-Lopez, O., Blanco, C., Keyes, K., Olfson,
M., Grant, B.F. and Hasin, D.S. Psychiatric
disorders in pregnant and postpartum women
in the United States. Arch. Gen. Psych. 2008;
7. Klainin, P. and Arthur, D.G. Postpartum depression
in Asian cultures: a literature review. Int. J. Nurs.
Stud. 2009; 46:1355-1373.
8. Onwere, S., Chigbu, B., Kamanu, C. I., Okoro, O.,
Aluka, C. and Onwere, A. Use of the Edinburgh
Postnatal Depression Scale to identify postpartum
depression and its risk factors in South-Eastern
Nigeria. JOGECA. 2011; 23(1): 4-8
9. Adewuya, A.O., Fatoye, F.O., Ola, B.A., Ijaodola,
O.R. and Ibigbami, S.M. Sociodemographic and
obstetric risk factors for postpartum depressive
symptoms in Nigerian women. J. Psych. Pract.
2005; 11:353-358.
10. Chibanda, D., Mangezi, W., Tshimanga, M. et al.
Validation of the Edinburgh Postnatal Depression
Scale among women in a high HIV prevalence
area in urban Zimbabwe. Arch. Womens Ment.
Health. 13:201-206.
11. Cooper, P.J., Tomlinson, M., Swartz, L., Woolgar,
M., Murray, L. and Molteno, C. Post-partum
depression and the mother-infant relationship in a
South African peri-urban settlement. Br. J. Psych.
1999; 175:554-558.
12. Adewuya, A.O., Ola, B.O., Aloba, O.O., Mapayi,
B.M. and Okeniyi, J.A. Impact of postnatal
depression on infants’ growth in Nigeria. J. Affect.
Disord. 2008; 108:191-193.
13. Burke, L. The impact of maternal depression
on familial relationships. Int. Rev. Psych. 2003;
Journal of Obstetrics and Gynaecology of
Eastern and Central Africa
Atwoli L
14. Ndokera, R. and MacArthur, C. The relationship
between maternal depression and adverse infant
health outcomes in Zambia: a cross-sectional
feasibility study. Child Care Health Dev. 2010;
15. Parsons, C.E., Young, K.S., Rochat, T.J.,
Kringelbach, M.L. and Stein, A. Postnatal
depression and its effects on child development: a
review of evidence from low- and middle-income
countries. Br. Med. Bull. 2011; Epub (PMID
Journal of Obstetrics and Gynaecology of
Eastern and Central Africa
JOGECA 2011; 23(1):1-3
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
It is well established that postnatal depression (PND) is prevalent in high-income countries and is associated with negative personal, family and child developmental outcomes. Here, studies on the prevalence of maternal PND in low- and middle-income countries are reviewed and a geographical prevalence map is presented. The impact of PND upon child outcomes is also reviewed. The available evidence suggests that rates of PND are substantial, and in many regions, are higher than those reported for high-income countries. An association between PND and adverse child developmental outcomes was identified in many of the countries examined. Significant heterogeneity in prevalence rates and impact on child outcomes across studies means that the true extent of the disease burden is still unclear. Nonetheless, there is a compelling case for the implementation of interventions to reduce the impact of PND on the quality of the mother-infant relationship and improve child outcomes.
Full-text available
Postpartum depression (PPD) is a serious mental health problem. It is prevalent, and offspring are at risk for disturbances in development. Major risk factors include past depression, stressful life events, poor marital relationship, and social support. Public health efforts to detect PPD have been increasing. Standard treatments (e.g., Interpersonal Psychotherapy) and more tailored treatments have been found effective for PPD. Prevention efforts have been less consistently successful. Future research should include studies of epidemiological risk factors and prevalence, interventions aimed at the parenting of PPD mothers, specific diathesis for a subset of PPD, effectiveness trials of psychological interventions, and prevention interventions aimed at addressing mental health issues in pregnant women.
Full-text available
Unlabelled: Despite the significant burden of common mental disorders (CMD) among women in sub Saharan Africa, data on postnatal depression (PND) is very limited, especially in settings with a high HIV prevalence. The Edinburgh Postnatal Depression Scale (EPDS), a widely used screening test for PND has been validated in many countries, but not in Zimbabwe. We assessed the validity of the EPDS scale among postpartum women compared with Diagnostic Manual of Mental Disorders (DSM-IV) criteria for major depression. Six trained community counselors administered the Shona version of the EPDS to a random sample of 210 postpartum HIV-infected and uninfected women attending two primary care clinics in Chitungwiza. All women were subsequently subjected to mental status examination using DSM IV criteria for major depression by 2 psychiatrists, who were blinded to the subject's EPDS scores. Data were analyzed using receiver operating characteristic (ROC) curve analysis. Of the 210 postpartum mothers enrolled, 64 (33%) met DSM IV criteria for depression. Using a cut-off score of 11/12 on the Shona version of the EPDS for depression, the sensitivity was 88%, and specificity was 87%, with a positive predictive value of 74%, a negative predictive value of 94%, and an area under the curve of 0.82. Cronbach's alpha coefficient for the whole scale was 0.87. Conclusion: The Shona version of the EPDS is a reliable and valid tool to screen for PND among HIV-infected and un-infected women in Zimbabwe. Screening for PND should be integrated into routine antenatal and postnatal care in areas with high HIV prevalence.
Full-text available
The differentiation between postnatal depression and other types of depression is often unclear, but there are treatment issues in nursing mothers that do not apply in other situations. Overall, the prevalence of depression in postpartum women is the same as the prevalence in women generally, at about 12-13%. Suicide is a major cause of maternal mortality in resource-rich countries, but rates are lower in women postpartum than in women who have not had a baby. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, and of non-drug treatments, for postnatal depression? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We found 34 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. In this systematic review we present information relating to the effectiveness and safety of the following interventions: group cognitive behavioural therapy, hormones, individual cognitive behavioural therapy (CBT), infant massage by mother, interpersonal psychotherapy, light therapy, mother-infant interaction coaching, non-directive counselling, other antidepressants, physical exercise, psychodynamic therapy, psychoeducation with partner, selective serotonin reuptake inhibitors (SSRIs), St John's Wort, telephone-based peer support.
Full-text available
Postpartum depression (PPD), a major health concern, produces insidious effects on new mothers, their infant, and family. This literature review aims to explore risk factors for postpartum depression among women in Asian cultures, which has not been fully elaborated. A literature search was undertaken by using various electronic research databases. Studies were eligible for this review if they (a) examined risk factors for PPD, (b) were conducted in Asian countries using quantitative or qualitative methodologies, and (c) were published in English in peer-reviewed journals between 1998 and 2008. A total of 64 studies from 17 countries were reviewed, summarised, and synthesised. The prevalence of postpartum depression in Asian countries ranged from 3.5% to 63.3% where Malaysia and Pakistan had the lowest and highest, respectively. Risk factors for postpartum depression were clustered into five major groups: biological/physical (e.g., riboflavin consumption), psychological (e.g., antenatal depression), obstetric/paediatric (e.g., unwanted pregnancy), socio-demographic (e.g., poverty), and cultural factors (e.g., preference of infants' gender). Traditional postpartum rituals were not found to provide substantial psychological benefits for the new mothers. This review informs a current state of knowledge regarding risk factors for postpartum depression and has implications for clinical practice. Health care professionals should be aware that the phenomenon is as prevalent in Asian cultures as in European cultures. Women should be screened for potential risk factors and depressive symptoms during pregnancy and postpartum periods so that appropriate interventions, if needed, can be initiated in a timely fashion.
Full-text available
Post-partum depression in the developing world has received little research attention, and its association with disturbances in the mother-infant relationship is unknown. To determine the prevalence of post-partum depression and associated disturbances in the mother-infant relationship in Khayelitsha, a South African peri-urban settlement. The mental state of 147 women who had delivered two months previously was assessed, and the quality of their engagement with their infants was determined. The point prevalence of DSM-IV major depression was found to be 34.7%. Maternal depression was associated with poor emotional and practical support from the partner. It was also associated with insensitive engagement with the infants. The rate of post-partum depression in Khayelitsha was around three times that found in British post-partum samples, and these depressions were strongly associated with disturbances in the mother-infant relationship.
Post-partum depression affects many new mothers. In the developing world, there may be an association between post-partum depression and adverse mortality-related infant health. Such associations have been found in South Asia; however, findings are inconsistent in Africa. This study aimed to investigate the feasibility of such research in rural Zambia, and investigate associations between maternal depression and adverse infant health outcomes. A cross-sectional study was undertaken in a rural district of Zambia. Consecutive women with infants between 2 and 12 months were recruited from under five clinics in three locations. Depression was assessed using the Self-reporting Questionnaire. Outcomes of infant size (actual weight and length, and as ≤ 5th percentile) and infant health (serious illness, diarrhoeal episodes, incomplete vaccination) were obtained. Relative risk, step-wise logistic regression and linear regression were used to analyse the data. Two hundred seventy-eight of 286 women agreed to take part (97.1%). The proportion with a high risk of depression was 9.7%. Adverse infant health outcomes were all proportionally greater in infants of 'depressed' mothers, and the associations with adjusted mean difference in weight (0.58 kg, CI 0.09-1.08) and length (1.95 cm, CI 0.49-3.50) were statistically significant. Other independent associations with episodes of diarrhoea (maternal education, older infant age, supplementary feeding) and incomplete vaccination (location, older infant age) were identified. It is feasible to conduct a study on this subject in a rural area of Zambia. The results show that reduced infant weight and length were significantly associated with maternal 'depression'. Other adverse outcomes may be and need investigating in an appropriately powered study.
The aim of the study was to assess the prevalence of depression in postpartum women as compared with non-postpartum women, and to identify risk factors of depression in both groups. A population based questionnaire study was performed among women 18-40 years in two municipalities in Norway in 1998-1999. A total of 2,730 women were included, of whom 416 were in the postpartum period. The prevalence of depression was higher in non-postpartum as compared with postpartum women. High scores on the life event scale, a history of depression and a poor relationship to the partner were associated with depression in both postpartum and non-postpartum women. When controlling for the identified risk factors of depression the odds-ratio for depression in the postpartum period was 1.6 (95% CI: 1.0-2.6). The risk for depression was increased in the postpartum period, when controlling for the uneven distribution of risk factors.
Depression is one of the most prevalent psychiatric illnesses. It is particularly common in women of childbearing age. It is recurrent and tends to have a chronic course and is often comorbid in nature. It is important to view depression within its social context, as it is a disease, which impacts not only the individual but also the wider community. Evidence abounds as to the negative impact of maternal depression on children, husbands/partners, and family. Children of depressed women show deficits in social, psychological, and cognitive domains and are at increased risk for depression themselves and other psychiatric illness such as conduct disorder. They are also at an increased risk for child abuse. The mechanisms by which maternal depression may lead to child psychopathology including genetics, poor parenting, modelling, and environment are explored. Many children with depressed mothers cope well and escape negative effects; consequently the concept of resilience is elucidated. Research shows that a significant percentage of men become depressed when their wives/partners are depressed particularly if they have postnatal depression. There is an increase in marital discord and conflict within families of depressed women, all of which can have a deleterious effect on children. Children with two depressed parents are at an elevated risk of a negative outcome as compared to those with only one depressed parent. Finally the various interventions, management, and recommendations are examined.