Systematic Review and Meta-Analysis of the Prevalence of the Maternity Blues in the Postpartum Period

Full text

Systematic Review and Meta-Analysis
of the Prevalence of the Maternity Blues
in the Postpartum Period
Khadije Rezaie-Keikhaie, Mohammad Edris Arbabshastan, Hosein Rafiemanesh, Mehrbanoo Amirshahi,
Shokoufeh Mogharabi Ostadkelayeh, and Azizollah Arbabisarjou
ABSTRACT
Objective: To determine the prevalence of maternity blues among women in the postpartum period.
Data Sources: We conducted our systematic review and meta-analysis by searching the literature for relevant articles
published in three international databases, PubMed, Web of Science, and Scopus, from date of inception through
December 11, 2019, using the keywords prevalence,incidence,maternity blues, and baby blues.
Study Selection: From 336 articles initially screened, we included 26 articles in the systematic review and meta-
analysis.
Data Extraction: Two independent reviewers used a standardized form to extract data from eligible articles. We
evaluated the quality of individual studies and the overall evidence according to Hoy et al.’s risk of bias tool.
Data Synthesis: The prevalence of maternity blues in the 26 included studies was 13.7% to 76.0%. Based on the
results of the random effects model, the prevalence of maternity blues in 5,667 women was 39.0% (95% confidence
interval [32.3, 45.6]; I
2
¼96.6%). The prevalence of maternity blues among women in Africa was greatest at 49.6%.
Conclusion: Considering the great prevalence of maternity blues in women after childbirth, paying attention to the key
symptoms of maternity blues and implementing educational programs for health care providers and mothers after
childbirth are essential.
JOGNN, 49, 127–136; 2020. https://doi.org/10.1016/j.jogn.2020.01.001
Accepted January 2020
During the postpartum period, potential
complications can occur that have signifi-
cant effects on women and their neonates. The
lack of accurate and timely diagnosis and atten-
tion to physical and mental disorders, specifically
after birth, may result in irrecoverable emotional
and cognitive impairment for women and their
neonates (Norhayati, Hazlina, Asrenee, & Emilin,
2015). One such postpartum psychological dis-
order is maternity blues (Rai, Pathak, & Sharma,
2015), also referred to as mother’s blues or
third-,fourth-,ortenth-day blues. Maternity blues is
a transient physiologic and psychological disorder
with potential symptoms of depression, tearful-
ness, sorrow/weeping, unstable mood, insomnia,
anxiety, and confusion (Ntaouti et al., 2018).
Maternity blues may disrupt infant care and
increase the risk of symptoms of postpartum
depression (Zanardo et al., 2019), impair
maternal–infant interactions (Badr &
Zauszniewski, 2017; Bydlowski, Lalanne, Golse,
& Vaivre-Douret, 2013), and affect child devel-
opment (Mirhosseini et al., 2015). The exact
causes of maternity blues are unknown, but the
most probable cause is sudden hormonal
changes after childbirth; hence, women who are
more sensitive to hormonal changes have greater
incidence of maternity blues than women who are
not (Pop et al., 2015). Various researchers re-
ported that maternity blues is a definite and
important risk factor for postpartum depression
(Gerli et al., 2019; Meilina & Nasrudin, 2019).
Maternity blues may begin the first day after birth
and may continue for up to 10 days or several
weeks. The prevalence of maternity blues in in-
dividual studies was estimated to be 10% to
80% (O’Hara & McCabe, 2013). Although the
prevalence of maternity blues has been reported
in individual studies, to our knowledge, there is no
systematic review or meta-analysis about the
prevalence of maternity blues. Furthermore, the
The authors report no con-
flicts of interest or relevant
financial relationships.
Correspondence
Mohammad Edris
Arbabshastan, BSc, MSc,
Balouch St., Iranshahr
University of Medical
Sciences, Iranshahr, Iran
9916643535.
kanregeli@gmail.com
Keywords
maternity blues
meta-analysis
postpartum period
prevalence
Khadije Rezaie-Keikhaie,
MD, is an associate
professor, Department of
Obstetrics and Gynecology,
Zabol University of Medical
Sciences, Zabol, Iran.
Mohammad Edris
Arbabshastan, BSc, MSc, is
a lecturer, Department of
Nursing, Iranshahr
University of Medical
Sciences, Iranshahr, Iran.
(Continued)
ª2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses.
Published by Elsevier Inc. All rights reserved.
http://jognn.org 127
REVIEW

precise estimation of the prevalence of maternity
blues may be helpful to provide timely and appro-
priate treatment for maternity blues. Therefore, the
aim of our systematic review and meta-analysis
was to determine the prevalence of maternity
blues among women in the postpartum period.
Methods
Search Strategy
We searched international databases PubMed,
Web of Science, and Scopus for relevant articles
published in English from the inception of the
databases through December 11, 2019. We
adapted the search strategy we used for MED-
LINE for the other databases. The specific search
strategy was created by a health sciences
librarian with expertise in systematic review
based on the Peer Review of Electronic Search
Strategies (PRESS) standard (McGowan et al.,
2016). Additionally, we used PROSPERO to
search for ongoing or recently completed sys-
tematic reviews. We used Boolean operators
(AND, OR, and NOT), medical subject headings,
truncation (*), and related words to search titles
and abstracts using the following keywords:
prevalence,incidence,occurrence,survey,fre-
quency,surveillance,maternity blues,baby
blues,postpartum blues, and maternal blues.
Eligibility Criteria
The methods adapted for this systematic review
were developed in accordance with the
Cochrane Handbook for Systematic Reviews
(Higgins & Green, 2011), and results are reported
using the Preferred Reporting Items for System-
atic Reviews and Meta-Analyses (PRISMA) tool
(Moher, Liberati, Tetzlaff, & Altman, 2009).
Descriptive cross-sectional, retrospective, and
prospective studies were included. We excluded
reviews, letters to the editor, correspondence,
case reports, and case series; articles published
in languages other than English; articles without
available full texts; studies with poor methodo-
logic quality based on Hoy et al.’s (2012) quality
assessment tool; and studies in which the tools
used to measure maternity blues were not spec-
ified accurately. We excluded randomized
controlled trials because our study aim was to
find observational studies on prevalence;
because the randomized controlled trials were
conducted with specific populations, prevalence
may have been erroneously estimated. The target
population consisted of women in the postpartum
period. The prevalence of maternity blues after
childbirth was calculated based on the available
standard instruments. The included studies were
conducted using prospective and retrospective
approaches.
Selection of Studies and Data Extraction
According to the study protocol, two researchers
(M.E.A. and M.A.) independently screened the
titles and abstracts based on the eligibility
criteria. After removal of the duplicate articles, the
full texts of the remaining articles were screened
based on the eligibility criteria, and the required
information was extracted. Disagreements be-
tween the two researchers were resolved by
consensus. We extracted the following data from
each article: first author information, year of
publication, country, sampling method, age of
participants, design, name of tool, day after birth
of measurement for maternity blues, income level
(defined based on the World Bank categories of
high income, high-middle income, low-middle
income, and low income), risk of bias, and prev-
alence of maternity blues.
Quality Assessment
To assess the methodologic quality and risk of
bias, we evaluated each observational study us-
ing Hoy et al.’s (2012) tool. This 10-item tool is
used to evaluate the quality of studies in two di-
mensions: external validity (Items 1–4: target
population, sampling frame, sampling method,
and nonresponse bias minimal) and internal val-
idity (Items 5–9: data collection method, case
definition, study instrument, and mode of data
collection). Item 10 assesses bias related to the
analysis. Two researchers (K.R.K. and M.E.A.)
independently evaluated risk of bias.
Data Synthesis
We recorded the frequency with percentage of
prevalence of maternity blues from each study.
We then tested for pooled effect size of preva-
lence and evaluated the heterogeneity of the
preliminary studies by I
2
, tau-square, and chi-
square tests. Because of great variability among
study results, we reported pooled prevalence
based on the random-effects model and used a
forest plot to present the results. We conducted
subgroup analyses to determine heterogeneity
based on the location of the studies and
instruments used to assess the prevalence of
maternity blues. We conducted univariate meta-
regression to assess the heterogeneity of studies
Hosein Rafiemanesh, BSc,
MSc, is a PhD candidate,
Student Research
Committee, Department of
Epidemiology, School of
Public Health and Safety,
Shahid Beheshti University
of Medical Sciences,
Tehran, Iran.
Mehrbanoo Amirshahi, BSc,
MSc, is a lecturer,
Department of Midwifery,
School of Nursing and
Midwifery, Zabol University
of Medical Sciences, Zabol,
Iran.
Shokoufeh Mogharabi
Ostadkelayeh, BSc, MSc, is
an instructor, Faculty of
Nursing, Iranshahr Branch,
Islamic Azad University,
Iranshahr, Iran.
Azizollah Arbabisarjou,
BSc, MSc, PhD, is an
associate professor, Health
Promotion Research Center,
Zahedan University of
Medical Sciences, Zahedan,
Iran.
Maternity blues is one of the most common complications
in the postpartum period.
Prevalence of the Maternity Blues in the Postpartum PeriodREVIEW
128 JOGNN, 49, 127–136; 2020.https://doi.org/10.1016/j.jogn.2020.01.001 http://jognn.org

and the proportion of between-study variance
explained by covariates using regression coeffi-
cient with 95% confidence interval (CI) and
adjusted R
2
. We performed meta-analysis using
Stata (Version 14; StataCorp, College Station, TX).
Results
We retrieved 336 articles from the initial search in
the three electronic databases. Among the 231
nonduplicated articles, we excluded 188 after
review of abstracts. Of the 43 articles that
remained, 26 met the eligibility criteria. Of the 17
excluded articles, six were reviews, three were
published in languages other than English, six
did not have full text, one had an unrelated tool,
and one did not meet the minimum quality
requirements for inclusion (see Figure 1).
Study Characteristics
The 26 eligible studies included a total of 5,667
participants whose ages ranged from 18 to 39
years. Most studies were conducted in Asia
(n¼10) and Europe (n¼12); only one study was
conducted in the United States (n¼1). Most of
the Asian studies were conducted in Japan
(n¼7). Most of the studies were descriptive
cross-sectional (n¼21), and convenience sam-
pling was used for data collection. The instrument
used to measure maternity blues in most studies
(n¼13) was the Stein scale (Stein, 1980). The
sample size of the included studies that used the
Stein scale was 2,623 participants. All of the
included studies had suitable quality in terms of
methods and a low risk of bias. In most studies
(n¼16), researchers assessed maternity blues
during the first week postpartum. Moreover, anx-
iety and postpartum depression, considered to
be associated disorders, were reported in one
and seven studies, respectively (see
Supplemental Table S1).
Tools
The most commonly used tools in the 26 studies
were the Stein scale (n¼13) and the Kennerley
and Gath Blues Scale (n¼8). Other tools
included the Pitt scale (Pop et al., 1995), Zung
Self-Rating Depression Scale (ZSDS; Nagata
et al., 2000), Middlesex Hospital Questionnaire
Figure 1. Preferred ReportingItems for SystematicReviews andMeta-Analyses (PRISMA) flow diagram of study selection process.
Rezaie-Keikhaie, K. et al. REVIEW
JOGNN 2020; Vol. 49, Issue 2 129

(MHQ; Harris, 1981), Edinburgh Postnatal
Depression Scale (EPDS; Cox, Holden, &
Sagovsky, 1987), and Maternity Blues Scale
(MBS; Pop et al., 2015). All of the tools were
validated. The number of items and scoring sys-
tem based on the type of tool were as follows: Pitt
(12 items, score range ¼1–26), Stein (24 items,
score range ¼1–48), Kennerley and Gath Blues
Scale (28 items, score range ¼1–28), MHQ (48
items, score range ¼1–8), ZSDS (20 items, score
range ¼1–100), EPDS (10 items, score range ¼
1–30), and MBS (16 items, score range ¼1–100).
Prevalence of Maternity Blues
The prevalence of maternity blues reported in the
26 studies was 13.7% to 76.0%. Based on the
results of the random-effects model, the overall
prevalence of maternity blues in 5,667 women
was 39.0% (95% CI [32.3, 45.6], I
2
¼96.6%).
Subgroup analysis for the diagnosis of hetero-
geneity was performed based on the instrument
used for maternity blues assessment and the
country where the study was conducted. Mater-
nity blues had a lesser pooled prevalence with
the Stein scale (33.6%) and Kennerley and Gath
Blues Scale (40.1%) than with the other
instruments (50.9%). The prevalence of maternity
blues when measured with the other instruments
was 76.1% with the MHQ, 40.6% with the Pitt,
66.7% with the ZSDS, 29.4% with the EPDS, and
43.1% with the MBS (see Figure 2). The preva-
lence of maternity blues in Africa was greater
than in other continents. Among women in Africa
and Asia, the prevalence of maternity blues was
49.6% (95% CI [31.7, 67.5]) and 33.1% (95% CI
[20.1, 46.0]), respectively (see Figure 3).
One study was conducted in a low-income
country, four studies were conducted in middle-
income countries, and 21 studies were conduct-
ed in high-income countries. Subgroup analysis
based on income status showed that the preva-
lence of maternity blues was greater in low- and
middle-income countries than in high-income
countries. Hence, the pooled prevalence of ma-
ternity blues was 76.0% (95% CI [61.8, 86.9]),
40.8% (95% CI [28.4, 53.3]; I
2
¼95.3%), and
38.4% (95% CI [30.0, 46.7]; I
2
¼97.0%) in low-,
middle-, and high-income countries, respectively.
Prevalence of Maternity Blues by Tools
The pooled prevalence of maternity blues based
on the random-effects model for the two main
measurement tools (Stein scale and Kennerley
and Gath Blues Scale) in 21 studies with 4,597
Heterogeneity between groups: p = 0.174
Overall (I^2 = 96.634%, p = 0.000);
Stein, G.
Henshaw, C.
Ishikawa, N.
Takahashi, Y.
Edhborg, M.
Faisal-Cury, A.
Ehlert, U.
Okano, T.
Subtotal (I^2 = 96.746%, p = 0.000)
Bruno, A.
Watanabe, M.
Reck, C.
Harris, B.
Doornbos, B.
kariman, N.
Moslemi, L.
* Kennerley & Gath Blues Scale
Gonidakis, F.
Subtotal (I^2 = 95.779%, p = 0.000)
Glangeaud-Freudenthal, N.M.C.
Hau, F.W.L.
Nagata, M.
Murata, A.
Sakumoto, K.
Zanardo, V.
First
Gerli, S.
Pop, V. J.
Subtotal (I^2 = 94.808%, p = 0.000)
Adewuya, A.O.
author
* Stein scale
Sutter, A.
* Other instruments
1980
2004
2011
2014
2008
2008
1990
1992
2018
2008
2009
1981
2008
2016
2012
2007
1999
2002
2000
1998
2002
2019
2019
1995
2005
Year
1997
United kingdom
United kingdom
Japan
Japan
Sweden
Brazil
Germany
Japan
Italy
Japan
Germany
East africa
Netherland
Iran
Iran
Greece
France
Hong Kong
Japan
Japan
Japan
Italy
Italy
Netherland
Nigeria
Country
France
0.390 (0.323, 0.456)
0.757 (0.588, 0.882)
0.500 (0.430, 0.570)
0.215 (0.177, 0.257)
0.150 (0.086, 0.235)
0.374 (0.302, 0.451)
0.321 (0.236, 0.416)
0.414 (0.298, 0.538)
0.255 (0.139, 0.403)
0.509 (0.343, 0.675)
0.355 (0.266, 0.451)
0.153 (0.110, 0.206)
0.552 (0.518, 0.586)
0.760 (0.618, 0.869)
0.308 (0.143, 0.518)
0.442 (0.381, 0.504)
0.551 (0.504, 0.598)
0.445 (0.396, 0.495)
0.336 (0.252, 0.421)
0.137 (0.077, 0.220)
0.443 (0.337, 0.553)
0.667 (0.619, 0.712)
0.153 (0.092, 0.234)
0.271 (0.207, 0.342)
0.431 (0.339, 0.526)
0.294 (0.231, 0.363)
0.406 (0.349, 0.465)
0.401 (0.299, 0.503)
0.313 (0.272, 0.355)
ES (95% CI)
0.510 (0.410, 0.609)
100.00
3.48
3.92
4.03
3.91
3.90
3.83
3.64
3.58
19.36
3.81
4.01
4.05
3.62
3.17
3.96
4.01
4.00
50.08
3.93
3.72
4.01
3.93
3.94
3.81
%
3.94
3.97
30.56
4.03
Weight
3.77
0.390 (0.323, 0.456)
0.757 (0.588, 0.882)
0.500 (0.430, 0.570)
0.215 (0.177, 0.257)
0.150 (0.086, 0.235)
0.374 (0.302, 0.451)
0.321 (0.236, 0.416)
0.414 (0.298, 0.538)
0.255 (0.139, 0.403)
0.509 (0.343, 0.675)
0.355 (0.266, 0.451)
0.153 (0.110, 0.206)
0.552 (0.518, 0.586)
0.760 (0.618, 0.869)
0.308 (0.143, 0.518)
0.442 (0.381, 0.504)
0.551 (0.504, 0.598)
0.445 (0.396, 0.495)
0.336 (0.252, 0.421)
0.137 (0.077, 0.220)
0.443 (0.337, 0.553)
0.667 (0.619, 0.712)
0.153 (0.092, 0.234)
0.271 (0.207, 0.342)
0.431 (0.339, 0.526)
0.294 (0.231, 0.363)
0.406 (0.349, 0.465)
0.401 (0.299, 0.503)
0.313 (0.272, 0.355)
ES (95% CI)
0.510 (0.410, 0.609)
100.00
3.48
3.92
4.03
3.91
3.90
3.83
3.64
3.58
19.36
3.81
4.01
4.05
3.62
3.17
3.96
4.01
4.00
50.08
3.93
3.72
4.01
3.93
3.94
3.81
%
3.94
3.97
30.56
4.03
Weight
3.77
0.25 .5 .75 1
Figure 2. Pooled analyses and subgroup analyses by type of instrument for estimation of maternity blues prevalence in the
world. CI ¼confidence interval; ES ¼effect size.
Across studies, the prevalence of maternity blues was
39%.
Prevalence of the Maternity Blues in the Postpartum PeriodREVIEW
130 JOGNN, 49, 127–136; 2020.https://doi.org/10.1016/j.jogn.2020.01.001 http://jognn.org

participants was 36.1% (95% CI [29.1, 43.1];
I
2
¼96.2%). Based on these two main measure-
ment tools, the prevalence of maternity blues in
Europe was greater than on other continents.
Moreover, the prevalence of maternity blues in
middle-income countries was greater than in
high-income countries (see Table 1).
Three studies based on other instruments were
conducted in The Netherlands (Pitt), Japan (ZSDS),
Tanzania (MHQ), and Italy (EPDS and MBS). Sub-
group prevalence of maternity blues based on
these tools showed greater pooled prevalence than
prevalence determined with the other instruments
(MHQ, Pitt, ZSDS, EPDS, and MBS) and for the
Kennerley and Gath Blues Scale. Hence, we
repeated the meta-analysis and subgroup analyses
separately based on the tools used.
Metaregression
The results of the univariate random-effects met-
aregression analyses showed that the publication
year significantly contributed to the heterogeneity
of prevalence, with coefficients of –0.66%
(95% CI [–1.3, -0.01]) and R
2
of 11.3%. The in-
struments used to measure maternity blues did
not significantly explain variation in prevalence
(p¼.060). Moreover, income status was not
significantly associated with the prevalence of
maternity blues (p¼.685). Although the mean
age of participants had an indirect association
with maternity blues prevalence, the effect size
variation was not significant (p¼.131; see
Table 2 and Figure 4).
Discussion
We conducted a systematic review and meta-
analysis to investigate the prevalence of mater-
nity blues. Maternity blues is considered the most
common psychological disorder in the early
weeks after childbirth. We included 26 studies
published between 1980 and 2019 involving
5,667 participants in our meta-analysis. The
prevalence of maternity blues across these
studies was 39.0% (13.7%–76%). We also found
that the prevalence of maternity blues was
greater in African and European countries than in
Asian countries and the United States.
Additionally, the prevalence of maternity blues
was greater in low- and middle-income countries
than in high-income countries. This finding was
consistent with those of previous studies that
women with poor economic status experienced
greater levels of postpartum depression and
Heterogeneity between groups: p = 0.198
Overall (I^2 = 96.634%, p = 0.000);
Subtotal (I^2 = .%, p = .)
Sakumoto, K.
Glangeaud-Freudenthal, N.M.C.
author
Reck, C.
Subtotal (I^2 = 93.814%, p = 0.000)
Doornbos, B.
kariman, N.
Gerli, S.
Hau, F.W.L.
* America
Subtotal (I^2 = 98.053%, p = 0.000)
Bruno, A.
Harris, B.
Okano, T.
Murata, A.
Nagata, M.
Adewuya, A.O.
Pop, V. J.
Watanabe, M.
Sutter, A.
* Africa
Takahashi, Y.
* Asia
Ehlert, U.
Faisal-Cury, A.
Ishikawa, N.
Henshaw, C.
Edhborg, M.
Gonidakis, F.
Stein, G.
Moslemi, L.
Zanardo, V.
* Europe
First
2002
1999
Year
2009
2008
2016
2019
2002
2018
1981
1992
1998
2000
2005
1995
2008
1997
2014
1990
2008
2011
2004
2008
2007
1980
2012
2019
Japan
France
Country
Germany
Netherland
Iran
Italy
Hong Kong
Italy
East africa
Japan
Japan
Japan
Nigeria
Netherland
Japan
France
Japan
Germany
Brazil
Japan
United kingdom
Sweden
Greece
United kingdom
Iran
Italy
0.390 (0.323, 0.456)
0.496 (0.317, 0.675)
0.271 (0.207, 0.342)
0.137 (0.077, 0.220)
ES (95% CI)
0.552 (0.518, 0.586)
0.418 (0.333, 0.503)
0.308 (0.143, 0.518)
0.442 (0.381, 0.504)
0.294 (0.231, 0.363)
0.443 (0.337, 0.553)
0.331 (0.201, 0.460)
0.355 (0.266, 0.451)
0.760 (0.618, 0.869)
0.255 (0.139, 0.403)
0.153 (0.092, 0.234)
0.667 (0.619, 0.712)
0.313 (0.272, 0.355)
0.406 (0.349, 0.465)
0.153 (0.110, 0.206)
0.510 (0.410, 0.609)
0.150 (0.086, 0.235)
0.414 (0.298, 0.538)
0.321 (0.236, 0.416)
0.215 (0.177, 0.257)
0.500 (0.430, 0.570)
0.374 (0.302, 0.451)
0.445 (0.396, 0.495)
0.757 (0.588, 0.882)
0.551 (0.504, 0.598)
0.431 (0.339, 0.526)
100.00
11.66
3.94
3.93
Weight
4.05
45.40
3.17
3.96
3.94
3.72
39.12
3.81
3.62
3.58
3.93
4.01
4.03
3.97
4.01
3.77
3.91
3.64
3.83
4.03
3.92
3.90
4.00
3.48
4.01
3.81
%
0.390 (0.323, 0.456)
0.496 (0.317, 0.675)
0.271 (0.207, 0.342)
0.137 (0.077, 0.220)
ES (95% CI)
0.552 (0.518, 0.586)
0.418 (0.333, 0.503)
0.308 (0.143, 0.518)
0.442 (0.381, 0.504)
0.294 (0.231, 0.363)
0.443 (0.337, 0.553)
0.331 (0.201, 0.460)
0.355 (0.266, 0.451)
0.760 (0.618, 0.869)
0.255 (0.139, 0.403)
0.153 (0.092, 0.234)
0.667 (0.619, 0.712)
0.313 (0.272, 0.355)
0.406 (0.349, 0.465)
0.153 (0.110, 0.206)
0.510 (0.410, 0.609)
0.150 (0.086, 0.235)
0.414 (0.298, 0.538)
0.321 (0.236, 0.416)
0.215 (0.177, 0.257)
0.500 (0.430, 0.570)
0.374 (0.302, 0.451)
0.445 (0.396, 0.495)
0.757 (0.588, 0.882)
0.551 (0.504, 0.598)
0.431 (0.339, 0.526)
100.00
11.66
3.94
3.93
Weight
4.05
45.40
3.17
3.96
3.94
3.72
39.12
3.81
3.62
3.58
3.93
4.01
4.03
3.97
4.01
3.77
3.91
3.64
3.83
4.03
3.92
3.90
4.00
3.48
4.01
3.81
%
0.25 .5 .75 1
Figure 3. Pooled analyses and subgroup analyses by continent of study conducted for estimation the maternity blues
prevalence in the world. CI ¼confidence interval; ES ¼effect size.
Rezaie-Keikhaie, K. et al. REVIEW
JOGNN 2020; Vol. 49, Issue 2 131

maternity blues (Hahn-Holbrook, Cornwell-
Hinrichs, & Anaya, 2018; Manjunath, Giriyappa,
& Rajanna, 2011; Shivalli & Gururaj, 2015).
Because it was observed by researchers that
mothers with newborn daughters experience
more maternity blues (Manjunath et al., 2011),
factors that may contribute to the increased
prevalence of maternity blues in less-developed
countries include the lesser importance associ-
ated with female newborns in these countries and
the lack of emotional and social support
(Alvarado-Esquivel, Sifuentes-Alvarez, Salas-
Martinez, & Martı
´nez-Garcı
´a, 2006; Goyal, Gay, &
Lee, 2010; Manjunath et al., 2011). Moreover, in
terms of policy making, the lack of necessary
infrastructure to better manage maternity blues
and provide support for women until it resolves,
such as shortage of health care personnel,
insufficient mental health screening services for
mothers, and low awareness about use of social
support services in countries with low income
levels, is the primary factor affecting the resolu-
tion of maternity blues (Gelaye, Rondon, Araya, &
Williams, 2016; Patel et al., 2007; World Health
Organization, 2008). Moreover, this difference in
the prevalence of maternity blues among
countries might be related to differences in cul-
tural backgrounds and their lifestyles (Alves,
Fonseca, Canavarro, & Pereira, 2018; Fiala,

Svancara, Kla
´nova
´,&Ka

spa
´rek, 2017; Shi, Ren,
Li, & Dai, 2018).
The most commonly used tools to measure ma-
ternity blues were the Stein scale and the Ken-
nerley and Gath Blues Scale, which were used in
13 and 8 studies, respectively. A greater preva-
lence in maternity blues was found using the
Kennerley and Gath Blues Scale than the Stein
scale. This difference may arise from the different
symptoms measured by the two tools. Because
maternity blues causes a variety of emotional and
psychological symptoms and each tool may
examine a slightly different domain of symptoms,
there may be variations in the prevalence of ma-
ternity blues depending on the measurement tool
(Manjunath et al., 2011). This difference can also
be caused by the study population, demographic
characteristics (residence, educational attain-
ment, and age), and time elapsed between data
collection and when the participants gave birth.
Implications
Timely detection and treatment of the symptoms
of maternity blues can help reduce the burden of
these symptoms. Untreated symptoms of mater-
nity blues can have negative consequences on
the health of women and their infants, including
Table 1: Pooled Prevalence of Maternity Blues in Continents and Income Status
Subgroups by Tools
Characteristic
Stein Scale Kennerley–Gath Blues Scale Two Main Tools
a
n
Effect Size, %
[95% CI] I
2
n
Effect Size
(95% CI) I
2
n
Effect Size, %
(95% CI) I
2
Continent
Asia 9 29.2 [18.4, 40.1] 96.6 0 — — 9 29.2 [18.4, 40.1] 96.6
America 1 32.1 [23.6, 41.6] NA 0 — — 1 32.1 [23.6, 41.6] NA
Europe 2 55.5 [46.6, 64.4] NA 7 39.3 [26.7, 52.0] 95.5 9 43.3 [32.1, 54.5] 94.8
Africa 1 31.3 [27.2, 35.5] NA 1 44.5 [39.6, 49.5] NA 2 36.7 [33.6, 39.8] NA
Income status
Middle 4 40.8 [28.4, 53.3] 95.3 0 — — 4 40.8 [28.4, 53.3] 95.3
High 9 29.9 [21.4, 38.5] 92.4 8 40.1 [29.9, 50.3] 94.8 17 35.0 [26.5, 43.4] 96.4
Overall pooled
effect size
13 33.6 [25.2, 42.1] 95.8 8 40.1 [29.9, 50.3] 94.8 21 36.1 [29.1, 43.1] 96.2
Note. CI ¼confidence interval; I
2
index ¼degree of heterogeneity; NA ¼not applicable.
a
The two main tools are the Stein scale and Kennerley–Gath Blues scale.
Results indicate that attention to symptoms of maternity
blues after childbirth is crucial in combination with
physical care.
Prevalence of the Maternity Blues in the Postpartum PeriodREVIEW
132 JOGNN, 49, 127–136; 2020.https://doi.org/10.1016/j.jogn.2020.01.001 http://jognn.org

the children’s cognitive growth (Kieviet, Dolman,
& Honig, 2013). Disagreement among special-
ists about approaches to the diagnosis of mater-
nity blues is an important barrier to
comprehensive management of maternity blues,
and this led to the great heterogeneity in preva-
lence in our study (Gonidakis, Rabavilas, Varsou,
Kreatsas, & Christodoulou, 2007; Ntaouti et al.,
2018). This can be attributed to the lack of a
specific definition of maternity blues based on
international standards. Although instances of
maternity blues present with postpartum changes
in mood, no specific diagnostic criteria have been
established (Gonidakis et al., 2007; Ntaouti et al.,
2018). Additionally, some rare medical disorders
such as frontotemporal dementia, frontal lobe
tuberculoma, and Sheehan syndrome may be
associated with some symptoms similar to those
of maternity blues (Dell & Halford, 2002; Gautam,
Bhatia, Rathi, & Kaur, 2014; Stavrou & Sgouros,
2002). Despite the variety of maternity blues
assessment tools, Vitale et al. (2016) found that
the use of mood-affecting drugs and antide-
pressants, along with appropriate precautions,
such as family support, can help in the treatment
of the symptoms of maternity blues.
Table 2: Univariate Metaregression for Prevalence of Maternity Blues
Variable Coefficient, % Standard Error 95% CI for Coefficient pAdjusted R
2
Mean age –2.1 1.3 [–4.9, 0.68] .131 7.0
Publication year –0.66 0.32 [–1.3, –0.01] .047 11.3
Type of instrument
a
8.2 4.2 [–0.36, 16.8] .060 12.1
Income status
b
–2.7 6.7 [–16.8, 11.2] .685 3.7
Note. CI ¼confidence interval.
a
Type of instrument: 1 ¼Stein scale, 2 ¼Kennerley–Gath Blues Scale, 3 ¼other tools.
b
Income status: 1 ¼low, 2 ¼middle, 3 ¼high.
Figure 4. Metaregression of the prevalence of maternity blues based on four variables: (a) publication year of study, (b)
instruments, (c) income status, and (d) mean age in years.
Rezaie-Keikhaie, K. et al. REVIEW
JOGNN 2020; Vol. 49, Issue 2 133

Limitations
There were several limitations to our review.
Among the most important challenges was that
the time at which the symptoms of maternity blues
were measured was diverse across the studies,
resulting in the inability to determine the preva-
lence of maternity blues based on time since
childbirth. The use of different maternity blues
measurement tools in various studies was another
important limitation that led to a broad range of
prevalence rates and substantially increased the
heterogeneity. To decrease the heterogeneity, we
assessed the prevalence of maternity blues
based on subgroups, including the type of scale
used and the continents where the studies were
conducted. Finally, all studies were cross-
sectional observational designs, and the esti-
mated prevalence in the United States was
determined based on one study.
Conclusion
Our findings suggest a relatively high prevalence
of maternity blues among women during the
postpartum period. Our findings also indicate that
attention to symptoms of maternity blues after
childbirth is crucial in combination with physical
care. The attention paid to psychological di-
mensions of the postpartum period can be
improved through educational programs
designed for women and their families before and
after childbirth. Furthermore, our results suggest
that health care professionals, including mid-
wives, nurses, and physicians, play a vital role in
identifying the occurrence and severity of mater-
nity blues through essential psychosocial care
and mental health support.
Supplementary Material
Note: To access the supplementary material that
accompanies this article, visit the online version
of the Journal of Obstetric, Gynecologic, &
Neonatal Nursing at http://jognn.org and at
https://doi.org/10.1016/j.jogn.2020.01.001.
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