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. 2020 Jan 10;15(1):e0227323. doi: 10.1371/journal.pone.0227323

Antenatal depression and its association with adverse birth outcomes in low and middle-income countries: A systematic review and meta-analysis

Abel Fekadu Dadi 1,2,*, Emma R Miller 2, Lillian Mwanri 2
Editor: Animut Alebel3
PMCID: PMC6953869  PMID: 31923245

Abstract

Background

Depression in pregnancy (antenatal depression) in many low and middle-income countries is not well documented and has not been given priority for intervention due to competing urgencies and the belief that it does not immediately cause fatalities, which mainly emanated from lack of comprehensive research on the area. To fill this research gap, this systematic review was conducted to investigate the burden of antenatal depression and its consequences on birth outcomes in low- and middle-income countries.

Methods

We systematically searched the databases: CINHAL, MEDLINE, EMCare, PubMed, PSyc Info, Psychiatry online, and Scopus for studies conducted in low and middle-income countries about antenatal depression and its association with adverse birth outcomes. We have included observational studies (case control, cross-sectional and cohort studies), written in English-language, scored in the range of “good quality” on the Newcastle Ottawa Scale (NOS), and were published between January 1, 2007 and December 31, 2017. Studies were excluded if a standardized approach was not used to measure main outcomes, they were conducted on restricted (high risk) populations, or had fair to poor quality score on NOS. We used Higgins and Egger’s to test for heterogeneity and publication bias. Primary estimates were pooled using a random effect meta-analysis. The study protocol was registered in PROSPERO with protocol number CRD42017082624.

Result

We included 64 studies (with 44, 035 women) on antenatal depression and nine studies (with 5,540 women) on adverse birth outcomes. Antenatal depression was higher in the lower-income countries (Pooled Prevalence (PP) = 34.0%; 95%CI: 33.1%-34.9%) compared to the middle-income countries (PP = 22.7%, 95%CI: 20.1%-25.2%) and increased over the three trimesters. Pregnant women with a history of economic difficulties, poor marital relationships, common mental disorders, poor social support, bad obstetric history, and exposure to violence were more likely to report antenatal depression. The risk of having preterm birth (2.41; 1.47–3.56) and low birth weight (1.66; 1.06–2.61) was higher in depressed mothers compared to mothers without depression.

Conclusions

Antenatal depression was higher in low-income countries than in middle-income countries and was found to be a risk factor for low birth weight and preterm births. The economic, maternal, and psychosocial risk factors were responsible for the occurrence of antenatal depression. While there could be competing priority agenda to juggle for health policymakers in low-income countries, interventions for antenatal depression should be reprioritized as vitally important in order to prevent the poor maternal and perinatal outcomes identified in this review.

Introduction

Depression is a common mental health disorder worldwide, which can manifest as a depressed mood, feeling of guilt, loss of interest, low self-esteem, difficulty in getting adequate sleep, and lack of concentration in everyday life [1]. Globally, more than 300 million peoples of all age suffer from depression [1] with much higher prevalence in the African (9%) and South-east Asian (27%) regions [2, 3]. By 2030, depression is predicted to be the second and third leading cause of disease burden in developing and low-income countries, respectively [4]. Depression prevalence is higher in pregnant populations relative to general female populations, often due to hormonal changes during pregnancy [5]. A systematic review of studies conducted in developed and low-income countries reported an antenatal depression prevalence in the range of 5% to 30% [6–8] and 15.6% to 31.1%) [9–11], respectively. These estimates varied according to ethnicity, history of miscarriage, medically assisted pregnancy, ambivalent attitude about the current pregnancy, and socioeconomic condition of the women [6–8].

Maternal depression could affect household income, productivity, child development [12], and quality of life [13]. Pregnant women with depression can produce a high level of stress hormones such as cortisol that can subsequently affect fetal growth [14] and brain development [15, 16]. Depression during pregnancy has been reported as a risk factor for low birth weight [17] and preterm births [18–22] and may also affect the child stress coping ability in later life [23]. In contrast, some other studies have reported a lack of association between antenatal depression and adverse birth outcomes [24–28].

Depression manifests in different ways during pregnancy and the postnatal period [29], which could challenge its identification and treatment. One study reported a triadic pattern of depression during pregnancy including an increase during the first few weeks of pregnancy, a decrease mid-way during the pregnancy and another increase again after the final weeks of pregnancy [30]. A number of systematic reviews have been conducted on maternal mental health and its effect on birth outcomes. However, these were not specific to depression [9, 31, 32], did not focus on low and middle-income countries (where the problem is thought to be high) [7], and did not evaluate if there is any relationship between antenatal depression and risk of adverse birth outcomes [33]. Therefore, the current systematic review and meta-analysis was conducted to explore the burden of antenatal depression, its risk factors and its association with adverse birth outcomes in low and middle-income countries.

Methods

Search strategy

CINHAL, MEDLINE, EMCare, PubMed, Psych INFO and, Psychiatry online, and Scopus data bases were systematically searched for the following key terms: Pregnan*, antenat*, depression, clinical depression, depressed mood, major depressive disorder, depressive symptom, adverse birth outcomes, stillbirth, preterm birth, and low birth weight. Example of full electronic search strategy in PubMed.

Search ((((((Pregnant mothers*) OR (antenatal mothers*) OR (pregnant women*) OR (antenatal period*) OR pregnancy* OR (antepartum women*)) AND ((depression* OR (clinical depression*) OR (depressed mood*) OR(major depressive disorder*) OR (depressive symptom*) OR (psychological morbidity*) OR (major depression*) OR (unipolar depression*)) AND((exposure* OR (risk factor*) OR correlates* OR (associated factors*) OR predictors*) AND (((cross sectional*) OR (crosssectional*) OR survey* OR(case control*) OR (nested case control*)) Sort by: Publication Date Filters: Publication date from 2007/01/01 to 2017/12/31; Humans; English; MEDLINE; Field: Title/Abstract

Eligibility criteria

We included observational studies (case-control, cross-sectional, and follow up studies) that were conducted in low and middle-income countries, written in the English language and published between January 1, 2007 and December 31, 2017. The following were the other criteria for studies to be selected for the review: depression was measured using validated screening tools; low birth weight was measured and classified as birth weight less than 2500grams; preterm birth was studied and defined as birth occurring before 37 complete weeks of gestation. Studies were excluded if a standardized approach was not used to measure main outcomes, conducted on restricted (high risk) populations such as studies conducted in refugee camps, conducted following certain disasters, conducted on mothers living with HIV/TB, restricted studies such as those exclusively conducted on first time mothers, women with high complication during pregnancy, grey literatures or had fair to poor quality score on NOS. The study inclusion, exclusion and reason for exclusion is presented in Fig 1 and page 11 of the S1 File.

Fig 1. Flow chart of study inclusion for systematic review and meta-analysis of antenatal depression and its effect on birth outcomes.

Fig 1

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Study quality assessment

Identified studies were exported to Endnote version 7 and duplicates were removed. Two independent reviewers (AFD & BAD) conducted a full-text quality review. Disagreement between the two reviewers was found to be very low (1.5%) and they resolved this through discussion. The Newcastle-Ottawa Scale (NOS) [34, 35] for observational studies was used to assess the quality and risk of bias in included studies. The NOS includes 3 categorical criteria with a maximum score of 10 points: “selection” which accounts a maximum of 5 points, “comparability” which accounts a maximum of 2 points, and “outcome” which accounts a maximum of 3 points. The quality of each study was rated using the following scoring algorithm: ≥7 points was considered as “good” quality study, 2 to 6 points was considered as “fair” quality study, and ≤ 1 point was considered as “poor” quality study. Only studies of good quality (NOS score ≥7 points) were included in this systematic review and meta-analysis. The scoring of each quality assessment component for each study was presented in a table. (See in S1 File) This systematic review and meta-analysis was based on the Meta-analysis Of Observational Studies in Epidemiology (MOOSE)[36] statement.

Data extraction

The following data from studies with good quality [NOS score ≥7 points] was extracted using a structured data extraction form and summarized in table format: Name of authors, year of publication, name of country in which the study was conducted, country income category, study design, sample size, type of screening tool used to identify depression and its cut of value, and the estimates (prevalences of antenatal depression with their confidence intervals and odds ratios with their confidence intervals for risk factors). (Tables 1 and 4)

Table 1. Summary of studies conducted on antenatal depression in low and middle-income countries, (N = 64, in the year 2007–2017).

Author, P. year Country by income Study setting Study design Sample size Trimester screened Tool used for screening Prevalence
1. Adewuya, A. O. et al 2007[44] Middle HI cross sectional 180 3 DSM-IV 8.3%
2. Esimai, O. et al 2008[45] Middle HI cross sectional 195 1,2,3 HADS 10.8%
3. Gausia k et al, 2009[46] Middle Community cross sectional 361 3 EPDS 33%
4. Luna Matos M.L et al, 2009[47] Middle HI cross sectional 222 1,2,3 EPDS 40.1%
5. Mitsuhiro SS et al 2009[48] Middle HI cross sectional 1000 1,2,3 CESD-10 12.9%
6. Pereira PK et al 2009[49] Middle HI cross sectional 331 3 CESD-10 14.2%
7. Pottinger AM et al 2009[50] Middle HI Longitudinal 452 1,2,3 EPDS 25%
8. Golbasi Z et al 2009[51] Middle Community cross sectional 258 1,2,3 EPDS 27.5%
9. Silva RA et al 2010[52] Middle HI cross sectional 1264 1,2,3 EPDS 21.1%
10. Kaaya SF et al 2010[53] Low HI cross sectional 560 2 HSC 39.5%
11. Mohammad KI et al, 2011[54] Low HI cross sectional 353 1,2,3 EPDS 67.2%
12. Nasreen HE et al, 2011[55] Low Community cross sectional 720 3 EPDS 18.3%
13. Li J et al, 2011[13] Middle HI cross sectional 454 1,2,3 EPDS 39.0%
14. Lau Y et al 2011[56] Middle HI cross sectional 1609 2 EPDS 35.9%
15. Senturk V et al 2011[57] Middle HI cross sectional 971 3 EPDS 33.1%
16. Faisal-Cury A et al 2012[58] Middle HI cross sectional 312 2 BDI 21.1%
17. Melo Jr et al 2012[59] Middle HI cross sectional 600 3 EPDS 24.3%
18. Hartley M et al, 2011[60] Middle Community cross sectional 1062 1,2,3 EPDS 39.0%
19. Rochat TG et al, 2011[61] Middle HI cross sectional 109 2 DSM-IV 47%
20. Ajinkya s et al, 2012[62] Middle HI cross sectional 185 1,2,3 BDI 9.2%
21. Fisher J et al, 2012[63] Middle Community Longitudinal 419 1 EPDS 22.4%
22. Fisher J et al, 2012[63] Middle Community Longitudinal 419 3 EPDS 10.7%
23. Fisher J et al, 2012[63] Middle Community Longitudinal 419 1,2,3 EPDS 17.4%
24. Silva R et al, 2012[64] Middle Community cross sectional 1264 1,2,3 EPDS 20.5%
25. Lara MA et al, 2012[65] Middle Community cross sectional 250 1,2,3 CESD-10 16.2%
26. Manikkam L et al, 2012[66] Middle HI cross sectional 387 3 EPDS 38.5%
27. Fadzil A et al, 2013[67] Middle HI cross sectional 175 1,2,3 HADS 10.3%
28. Jeong H et al, 2013[68] Middle Community cross sectional 1262 1,2,3 EPDS 20.2%
29. Bindt C et al 2013[69] Middle HI Longitudinal 719 3 PHQ 28.9%
30. Dibaba Y et al 2013[70] Low Community cross sectional 627 3 EPDS 19.9%
31. Gemta A et al 2013[71] Low HI cross sectional 660 1,2,3 EPDS 25.6%
32. Guo N et al 2013[72] Middle, cot devoir HI Longitudinal 654 3 PHQ 26.3%
33. Guo N et al 2013 Middle, Ghana HI Longitudinal 654 3 PHQ 28.3%
34. Dmitrovic BK et al, 2014[73] Middle HI cross sectional 212 3 EPDS 21.7%
35. Abujilban SA et al 2014[74] Low HI cross sectional 218 3 EPDS 57%
36. Actas S et al 2014[75] Middle HI cross sectional 266 1,2,3 BDI 18.8%
37. Stewart RS et al, 2014[76] Low HI cross sectional 583 2 SRQ 21.1%
38. Weobong B et al 2014[77] Middle Community Longitudinal 2086 1 SRQ 9.9%
39. Waqas A et al 2015[78] Middle HI cross sectional 289 3 HADS 31.8%
40. Barrios Y et al 2015[79] Middle HI Longitudinal 1521 1 PHQ 29.1%
41. de Oliveira F et al 2015[80] Middle HI cross sectional 358 3 EPDS 28.2%
42. Abdelhai R et al 2015[81] Middle HI cross sectional 376 1,2,3 HADS 10.4%
43. Mahenge B et al 2015[82] Low HI cross sectional 1180 1,2,3 HSC 78.2%
44. Rwakarema M et al; 2015[83] Low HI cross sectional 397 1,2,3 EPDS 33.8%
45. Heyningen T et al 2015[84] Middle HI cross sectional 376 1,2,3 CIS-R 22.0%
46. Biratu A et al 2015[85] Low HI cross sectional 393 1,2,3 EPDS 24.9%
47. Bavle A et al 2016[86] Middle HI cross sectional 318 1,2,3 EPDS 12.3%
48. George C et al 2016[87] Middle Community cross sectional 202 1,2,3 CIS-R 16.3%
49. Moshki et al 2016[88] Middle HI cross sectional 208 3 EPDS 37.0%
50. Padmapriya N et al 2016[89] Middle Community Longitudinal 1144 1 EPDS 7.3%
51. Alvarado-EC et al 2016[90] Middle HI cross sectional 270 1,2,3 EPDS 37.4%
52. de Jesus Silva M et al 2016[91] Middle HI cross sectional 209 1,2,3 HADS 14.8%
53. de Moraes EV et al 2016[92] Middle HI cross sectional 375 1,2,3 HADS 40.8%
54. Malqvist M et al 2016[93] Middle Community cross sectional 1038 3 EPDS 22.7%
55. Thompson O et al 2016[94] Middle HI cross sectional 314 1,2,3 EPDS 24.5%
56. Ayele TA et al 2016[95] Low HI cross sectional 388 1,2,3 BDI 23.0%
57. Bisetegn TA et al 2016[96] Low Community cross sectional 527 1,2,3 EPDS 11.8%
58. Bitew T et al 2016[97] Low Community cross sectional 1311 2 PHQ 29.5%
59. Gelaye B et al 2017[98] Middle HI cross sectional 1298 2 PHQ 10.3%
60. Huanging H et al 2017[99] Middle HI cross sectional 4210 1,2,3 HADS 12.5%
61. Shidhaye P et al 2017[100] Middle HI cross sectional 302 1,2,3 EPDS 16.9%
62. Coll CVDN et al 2017[101] Middle Community Longitudinal 4130 2 EPDS 16.0%
63. Mossie Tb et al 2017[102] Low HI cross sectional 196 1,2,3 BDI 31.1%
64. Sahile MA et al 2017[103] Low HI cross sectional 233 3 BDI 31.2%
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HSC: Hopkins Symptom Checklist CIS-R: Clinical Interview Schedule–Revise HI: Health Institution BDI: Beck Depression Inventory

EPDS: Edinburgh Postnatal Depression scale HADS: Hospital Anxiety and Depression Scale CIS-R: Clinical Interview Schedule Revised

SRQ: Self Reporting Questionnaire CESD-10: Center for Epidemiological Studies Depression Scale DSM-V: Diagnostic and Stastical Manual of

Mental Disorder PHQ: Patient Health Questionnaire

Table 4. Summary of studies conducted on the association of antenatal depression with adverse birth outcomes in the low and middle-income countries, (N = 9, in the year 2007–2017).

Author, Year Country, income Study setting Study design Sample size Follow up start time Tool used for screening LBW (<2500gm) Estimate (RR/OR) PB(<37weeks), Estimate (OR)
Rahman A et al, 2007[104] Pakistan, Low Community Prospective cohort 290 3rd ICD-10 1.9;1.3–2.9)
Nasreen HE et al 2010[105] Bangladesh, Middle Community Prospective cohort 720 2nd and 3rd EPDS> = 10 2.24, 1.37–3.68
Niemi M et al, 2013[106] Vietnam, Middle Community Prospective cohort 334 3rd EPDS > = 3 2.40;1.09–5.25 2.07, 1.2–3.56
Sanchez SE et al, 2013[107] Peru, Middle HI Case control 959 3rd PHQ-9> = 10 3.67, 2.09–6.46
Chang HY et al, 2014[26] Korea, Low HI Prospective cohort 691 3rd CESD-10> = 10 1.66; 0.55–5.02
Husain N et al, 2014[27] Pakistan, Low Community Prospective cohort 763 3rd EPDS > = 12 0.88; 0.73–1.06
Rao D et al, 2015[108] India, Middle HI Prospective cohort 150 2nd & 3rd PHQ-9> = 5 3.3, 0.99–11.17
Bindt C et al 2013[69] Ghana, Middle HI Longitudinal, birth cohort 719 3rd PHQ-9 > = 10 β = 52.2; 18.2–122.6 2.1, 0.8–5.6
Wado WD et al 2014[109] Ethiopia, Low Community Longitudinal, birth cohort 537 2nd & 3rd EPDS> = 13 1.77; 1.03–3.04
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LBW: Low Birth weight HI: Health Institutions ICD-10: International classification of Disease 10th EPDS: Edinburgh Postnatal Depression Scale SRQ: Self Reporting Questionnaire CESD-10: Center for Epidemiological Studies Depression Scale DSM-V: Diagnostic and Stastical Manual of Mental Disorder PHQ: Patient Health Questionnaire

Data synthesis

The data synthesis was separately conducted for antenatal depression and birth outcomes. Meta-analysis of proportions for antenatal depression, odds ratios for factors associated with antenatal depression, and relative risks for reporting adverse birth outcomes were calculated after log-transforming the estimates from primary studies. If multiple outcomes were reported in a single study, each outcome was analysed independently.

Risk of bias and adjustment

Funnel plot and Egger’s regression test were conducted to check for the presence of potential publication bias [37, 38]. In the presence of publication bias, an estimate from Trim and Fill analysis was reported [39]. Galbraith plot [40] and Higgins test [41] were used to explore the presence of heterogeneity. Sub-analyses was conducted according to the identified sources of heterogeneity and the effect size from the random effect models was calculated [42]. Sensitivity analyses was also been conducted. All analysis was conducted in Stata 14 [43].

Protocol registration

This review was registered in PROSPERO with a protocol number CRD42017082624. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017082624.

Results

Our search strategy identified 313 records for antenatal depression and 156 records for the effect of antenatal depression on birth outcomes. After duplicates were removed and preliminary screening of the titles and abstracts, 83 articles fulfilled a criterion for full-text review and quality assessment. Finally, 73 articles were assessed as good quality and included in the systematic review and meta-analysis. From these articles, 64 were conducted on antenatal depression and 9 articles were conducted to investigate the effect of antenatal depression on birth outcomes. (Fig 1)

Antenatal depression prevalence and its associated factors

Among 64 articles conducted on antenatal depression, 49 (77%) were conducted in middle-income countries, 15 (23%) studies were conducted in low-income countries, and 46 (72%) were health institutional based studies. Half of the studies (32) investigated antenatal depression at all stages of pregnancy while 20 (31%) of the studies investigated antenatal depression during the last trimester of pregnancy. A relatively large number of studies, 20 (31%), were published in the year 2015–2016 and the majority of the studies, 34 (53%), used Edinburgh Postnatal Depression Scale (EPDS) for screening antenatal depression. (Table 1)

Because of a high heterogeneity index (I2 = 96.7%, P<0.001) among included antenatal depression studies, we were unable to pool all the estimates but we conducted a sub-analysis based on the following characteristics: year of publication, country income category, study setting, sample size, tools used for screening, and time of pregnancy at which the screening has been conducted. As the Egger’s test for publication bias was significant (P<0.001), Tweedie’s and Duval’s trim and fill analysis was used to report the final effect size under the random effect model. The pooled odds ratio was not affected when individual studies were omitted during the sensitivity analysis. (See in S1 File)

High prevalence of antenatal depression was estimated in the year 2011–2012, (pooled prevalence (PP), 95%CI: 28.6%; 22.3%-34.8%), followed by the year 2015–2016, (PP = 26.8%, 95%CI: 17.8%-35.8%). The antenatal depression was higher in low-income countries (PP = 34.1%, 95%CI: 22.7%-45.6%) and in health institution-based studies (PP = 27.6%, 95%CI: 23%-32.3%) as compared to high-income countries and community-based studies, respectively. Antenatal depression increased over the three trimesters; 17.1% (95%CI: 7.7%-26.5%) in the first trimester, 27.1% (95%CI: 19.7%-34.6%) in the second trimester, and 28.9% (95%CI: 23.7%-34.1%) in the third trimester. The antenatal depression prevalence was estimated to be higher among the studies with sample less than 600 participants (PP = 25.7%; 95%CI: 22.1%- 29.5%) and those that used the Hopkins Symptom Checklist for screening depression (PP = 58.9%, 95%CI; 21%-96.8%). (Table 2)

Table 2. Sub-analysis of antenatal depression prevalence in the low- and middle-income countries (N = 64, 2007–2017), (random effect model).

Variables of sub-analysis Number of studies (%) Sample size Pooled prevalence; 95%CI
Year of publication
 2007–2008 2(3.13) 375 9.46 (6.5–12.5)
 2009–2010 8(12.50) 4,448 26.4(19.5–33.4)
 2011–2012 16(25.00) 9,533 28.6(22.3–34.8)
 2013–2014 12(18.75) 8,116 23.8(18.3–29.3)
 2015–2016 20(31.25) 11,194 26.8(17.8–35.8)
 2017 6(9.38) 10,369 18.2(14.6–21.8)
Income of the country
 Low income 15(23.44) 8346 34.1(22.7–45.6)
 Middle income 49(76.56) 35,689 22.7(20.1–25.2)
Study setting
 Health institution 46(71.88) 26536 27.6(22.9–32.3)
 Community based 18(28.13) 17499 19.8(16.1–23.5)
Time of screening
 First trimester 4(6.25) 5170 17.1 (7.7–26.5)
 Second trimester 8(12.50) 9912 27.1(19.7–34.6)
 Third trimester 20(31.25) 9532 28.9(23.7–34.1)
 All trimester 32(50.00) 19421 23.9(18.2–29.5)
Median sample size
 < = 600 42(65.62) 13290 25.7(22.0–29.5)
 >600 22(34.38) 30745 24.8(18.9–30.6)
Tool used for screening depression
 EPDS 34(53.13) 23,612 27.2(23.5–30.8)
 CIS-R 2(3.13) 578 19.3(13.8–24.9)
 PHQ-9 6(9.38) 6157 25.4(17.3–33.4)
 SRQ-20 2(3.13) 2669 15.4(4.4–26.4)
 Hopkins symptom checklist 2(3.13) 1740 58.9(20.9–96.8)
 BDI 6(9.38) 1580 22.2(15.7–28.6)
 HADS 7(10.94) 5829 18.6(11.8–25.4)
 DSM-IV 2(3.13) 289 27.4(10.5–65.3)
 CESD-10 3(4.69) 1581 13.6(11.9–15.3)
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BDI: Beck Depression Inventory EPDS: Edinburgh Postnatal Depression scale HADS: Hospital Anxiety and Depression Scale CIS-R: Clinical Interview Schedule Revised SRQ: Self Reporting Questionnaire CESD-10: Center for Epidemiological Studies Depression Scale DSM-V: Diagnostic and Stastical Manual of Mental Disorder

We have also summarized and pooled the effect size for reported risk factors under relatively homogeneous groups. Accordingly, bad obstetric history (Pooled Odds Ratio (POR) = 2.01; 95%CI: 1.67, 2.42) in 16 studies and economic difficulties in 14 studies (POR = 2.03; 95%CI: 1.63, 2.53) were significantly associated with increased risk of antenatal depression. Similarly, having poor social support (POR = 1.77; 95%CI: 1.49, 2.10) and history of common mental disorders (POR = 3.27; 95%CI: 2.47, 4.33) were increased the risk of antenatal depression in 13 studies. Moreover, having a history of violence in 11 studies (POR = 2.99; 95%CI: 2.20, 4.07), unsatisfied with relationship in 9 studies (POR = 2.18; 95%CI: 1.64, 2.90), and male gender preference in four studies (POR = 1.41; 95%CI: 2.97; 6.26) were the other factors associated with an increased risk of antenatal depression. (Table 3)

Table 3. Risk factors associated with antenatal depression, a meta-analysis of studies in the low- and middle-income countries (N = 64, 2007–2017), (estimate from random effect model after trim and fill analysis).

Variable of sub-analysis Number of studies Sample size POR, 95%CI I2, p-value
Poor obstetric history (history of adverse birth outcome, unwanted pregnancy, obstetric complications) 16 13450 2.01(1.67,2.42) 81.7%, p = 0.137
Economic difficulties 14 11207 2.03(1.63,2.53) 74.3%, p = 0.001
Poor social support 13 7372 1.77(1.49,2.10) 85.7%, p = 0.001
History of CMD(depression, anxiety, stressful life events) 13 11799 3.27(2.47,4.33) 89.9%, p = 0.001
History of all forms of violence 11 7428 2.99(2.20, 4.07) 71.7%, p = 0.001
Unsatisfied marital condition (Unmarried, divorced, separated, shorter marital duration, polygamous) 9 7533 2.18(1.64,2.90) 73.0%, p = 0.001
Male gender preference (the family preferred male than girl) 4 1135 2.97(1.41,6.26) 88.2%, p = 0.001
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Association of antenatal depression with adverse birth outcomes

From nine studies conducted to investigate the association of antenatal depression with adverse birth outcomes, six were from middle-income countries and community-based studies while half of them used the EPDS as a screening tool to measure depression. Almost all, 8 (90%) of the studies were prospective studies with a total sample of 5,540. The low birth weight was reported in seven studies but was found to be significantly associated with antenatal depression in five of the studies. Similarly, two of four studies reported a significant association between antenatal depression and risk of preterm birth. (Table 4)

The risk of adverse birth outcomes (low birth weight or preterm birth) was 1. 59 times (95%CI: 1.34–2.92) higher among pregnant mothers who had signs of depression as relative to those did not. (Fig 2). Compared to LBW, the risk of PB was significantly higher among pregnant mothers with signs of depression (Pooled Relative Risk (PRR) = 2.41; 95%CI: 1.47–3.56). As the test for heterogeneity (I2; 81.1%, p = 0.0) and small study effect were significant (P<0.001), the final effect size was reported from Tweedie’s and Duval’s trim and fill analysis in the random effect model. (Figs 3 and 4) We did not find any influential study in our sensitivity analysis. (Fig 5)

Fig 2. Association between antenatal depression and adverse birth outcomes (N = 9, 2007–2017).

Fig 2

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Fig 3. Funnel plot before Tweedie’s and Duval’s trim and fill analysis.

Fig 3

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Fig 4. Funnel plot after Tweedie’s and Duval’s trim and fill analysis (Filled by four studies).

Fig 4

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Fig 5. Sensitivity analysis for studies on antenatal depression and its effect on adverse birth outcomes (N = 9, 2007–2017).

Fig 5

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In the sub-analyses, relative to high income countries, the risk of adverse birth outcomes was significantly higher among mothers from middle-income countries (PRR = 2.51; 95%CI: 1.92–3.28), in health institution-based studies (PRR = 2.92; 95%CI: 1.92–4.43), and when depression commenced in the second trimester (PRR = 2.47; 95%CI: 1.76–3.46). The association between antenatal depression and adverse birth outcomes did not differ between studies in which pregnant mothers were clinically diagnosed with depression and were identified based on a self-reported scale of depression symptom. (Table 5)

Table 5. Sub-analysis of the association of antenatal depression with adverse birth outcomes in the low- and middle-income countries (N = 9, in the year 2007–2017), (random effect model).

Variable of sub-analysis Number of studies (%) Sample size Pooled RR; 95%CI I2, p-value
Income of the country
 Low income 4 2324 1.42(0.85,2.38) 81.3%, p = 0.029
 Middle income 5 3216 2.51(1.92,3.28) 0.0%, p = 0.736
Study setting
 Health institution 4 2519 2.92(1.92,4.43) 0.0%, p = 0.607
 Community based 5 3021 1.72(1.11,2.67) 83.6%, p = 0.002
Time follow up started
 2nd and 3rd trimester 3 2366 2.47(1.76, 3.46) 19.3%, p = 0.454
 Third trimester 6 3174 1.66(1.04,2.66) 78.9%%, p = 0.026
Tool used for depression screening
 EPDS 4 2688 1.70(1.01,2.83) 84.1%, p = 0.01
 PHQ-9 3 1828 3.20(2.04,5.04) 0.0%, p = 0.633
 CESD-10/ICD-10 2 1024 1.87(1.28,2.73) 0.0%, p = 0.843
Type of adverse birth outcome
 Low birth weight 6 3712 1.66(1.06,2.61) 81.5%%, p = 0.008
 Preterm birth 4 2496 2.41(1.47,3.56) 0.0%, p = 0.620
Sample size
 <350 3 1151 2.07(1.55,2.77) 0.0%, p = 0.83
 > = 350 6 4389 1.84(1.05,3.25) 85.9%, p = 0.001
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Discussion

This review has provided strong evidence for the burden of antenatal depression and its association with adverse birth outcomes in low and middle-income countries. To our knowledge, this review represents the first attempt to quantify this information and provides valuable impetus for the development of interventions aimed at addressing issue which has so far been neglected in the countries with greatest antenatal depression prevalence.

We found the prevalence of antenatal depression in the low-income countries was higher than that of middle-income countries and has increased from 9.5% in 2007 to 18.2% in 2017. The increase in prevalence over time might be attributed to the increase in number of studies on the topic as a result of the problem got more attention by researchers or the prevalence has been increasing overtime because of low attention has been given for the problem by different countries. This could be also exemplified in the sub-analysis table in the result section of this article. The increase does, however, support the prediction that depression will become the third leading cause of disease burden in the low-income countries by 2030 [110, 111]. Consistent with previous reviews [10, 112], we found significantly higher antenatal depression prevalence in low-income countries relative to middle-income countries. This might be because depression has not previously been prioritized as an area for intervention relative to other problems during pregnancy [112]. It is also likely that risk factors associated with mental health disorders are more common in low-income countries [10].

We found that antenatal depression prevalence increases from the first to the third trimester of pregnancy, which contrast with the quadratic pattern (increase during the first trimester, drop in the second, and increase during the third trimester) noted elsewhere [30]. This might associate with the number of included studies during different trimesters, the pooled prevalence was high where large number of studies included and low where small studies were included as adjustment was not made on the number of studies. Consistent with our findings, one study reported an increased pattern of depression from the first to the second trimester due to increases in a range of risk factors during the three trimesters of pregnancy [113]. Further study could assist in prevention planning in identifying the appropriate timing and frequency of screening and intervention. Further investigation could also help to identify risk factors that might change in the level of influence over the pregnancy, which could better target interventions across the three trimesters.

However, there are some methodological issues that might cause variation in estimations. For instance, we noted that institutional based studies reported higher prevalence relative to community-based studies and studies with smaller sample sizes reported higher prevalence relative to larger studies and these are mainly explained by the inherence limitations of cross-sectional studies. Estimate size also varied according to the tools used to measure depression. While the estimates from EPDS were the most consistent one with previous similar reviews, there was greater variation among estimates from studies using other tools [10, 114, 115].

We found that previous medical conditions (bad obstetric history and history of the previous episode of common mental disorders) and social or cultural factors (poor social support, financial difficulties, exposure to all forms of violence during pregnancy or childhood, unfavorable marital conditions, and male gender preference) were an important risk factors for antenatal depression.

Bad obstetric histories such as unwanted pregnancy, multiparity, history of miscarriage, still and preterm birth, and other un specified complications were reported in 15 studies. Having greater numbers of children might have considerable economic impact and stress and could be further exacerbated by an additional unwanted pregnancy [112]. History of miscarriage, still- and preterm birth (defined here as a negative obstetric history) may be associated with trauma and fear in relation to the current pregnancy outcome [9]. Other pregnancy complications such as hyperemesis gravidarum, hypertension, and diabetes mellitus could also pose additional stress on mothers [116].

Maternal or familial history of common mental disorders (such as depression, anxiety, stressful life event, and any other psychiatric issue) predicted the current depression episodes in 13 studies. This provides support for the familial and recurrent nature of depression and other mental health morbidities as pointed out by Shyn and Hamilton [117]. Concomitant exposure to stressful life events could also trigger the occurrence of depression by playing an additive role in the causal process [10, 118, 119].

Good social support [120] could positively affect the mother’s stress coping ability by playing a buffering role in the causal model [10, 120, 121] means social support significantly reduces the risk of antenatal depression. Moreover, studies have shown a preventive effect of balanced nutritional interventions [122, 123] during pregnancy on antenatal depression. However, mothers in low income countries are living in economic pressure which also indirectly affect their adherence to proper nutrition during pregnancy. Exposure to sexual, physical, and emotional violence before or during pregnancy or history of childhood abuse was associated with an increased risk of antenatal depression. This is associated with disruption of neurobiological and stress response system through changing of brain structure and function [124–126] and the prevalence of such forms of violence in low and middle-income countries is known to be high [127].

Reduced relationship satisfaction with partners was reported as a risk factor for having depression symptoms. The risk of depression was also higher when the pregnant mothers are from a family that prefers male than a girl in the current pregnancy. This gender preference could directly affect maternal support and combined with a problem with partner relationship could brought maternal distress, loneliness and, ultimately, depression throughout the pregnancy [10, 119].

After accounting for publication bias, an exposure history of antenatal depression was associated with a 59% higher risk of adverse birth outcomes. In the sub-analysis according to a type of adverse birth outcomes, the risk of preterm birth was higher compared to the risk of low birth weight. A significant association between antenatal depression and low birth was also reported in two systematic reviews [33, 128], however, Kathleen et al reported absence of association between antenatal depression and adverse birth outcomes [129].

An increased preterm birth risk (1.4) among mothers with depression history was consistent with a meta-analysis published by Grigoriadis et al [130]. Similarly, a 1.2 times risk of preterm birth and 1.3 times risk of low birth weight was reported in a meta-analysis conducted by Grote, which is also in line with our finding [131]. More importantly, this review found that the association of antenatal depression on adverse birth outcomes was similar among studies that used clinical investigation and studies that used self-reported screening tool to identify pregnant mothers with depression.

The causal mechanisms between antenatal depression and adverse birth outcomes could be explained in multiple ways: (1) Depression may exert an influence on adverse birth outcomes via dysregulation of the Hypothalamic-Pituitary-Adrenocortical Axis [132] that stimulates the release of stress hormone such as cortisol, which could prevents adequate oxygen and nutrient flow to the fetus [129, 133]; (2) Antenatal depression might also disrupt immune system dysfunction that leads the mothers to develop different type of infections and, potentially, affects fetal growth [131]; (3) Depressed mothers may be more likely to smoke and drink while being less likely to attend medical care [134–136] and have poor appetite all of which can lead to malnourishment and impact on fetal development [137].

Limitations

We included all available high-quality studies on antenatal depression and its effect on adverse birth outcomes, however, our estimation may still have been subject to measurement bias due to variation in diagnostic approaches among studies. Moreover, language restrictions might also introduce the risk of publication bias. Nonetheless, our analytical approach addressed heterogeneity and publication bias and provides some confidence in our estimates of the burden and consequences of antenatal depression in low and middle-income countries.

Conclusion

We found that antenatal depression is highly prevalent and increases over the duration of pregnancy. We also noted increases in prevalence over the last ten years. Antenatal depression prevalence was found to be higher in low-income countries relative to middle-income countries. The current review has identified risk factors for pregnant mothers at higher risk of developing antenatal depression such as; bad obstetric history, previous episode of common mental disorders, poor social support and financial difficulties. Similarly, women reporting a history of exposure to violence (during pregnancy or earlier) and unsatisfactory relationships were more at risk of developing depression. A strong association between antenatal depression and adverse birth outcomes, which was not affected by method of depression identification in pregnant mothers, was also noted in the current review. While there could be competing priority agenda to juggle for health policymakers in low-income countries, interventions for antenatal depression should be reprioritized as vitally important in order to prevent the poor maternal and perinatal outcomes identified in this review.

Supporting information

S1 File

(DOCX)

Click here for additional data file. (1.1MB, docx)

Acknowledgments

Our heartfelt gratitude will go to Mr. Berihun Assefa Dachew for his contribution in quality assessment of the included studies.

Abbreviations

CES-D 20

Center for Epidemiologic Studies depression scale 20

DM

Diabetic Mellitus

DSM-IV

Diagnostic and Statistical Manual of mental disorders version 4

EPDS

Edinburgh Postnatal Depression Scale

HIV

Human Immune Deficiency

IPV

Intimate Partner Violence

LAMICS

Low and Middle Income Countries

NOS

New Castle Ottawa Scale

OR

Odds Ratio

PDQ

Pitt Depression Questionnaire

PHQ-9

Patient Health Questiner-9

PND

Postnatal Depression

POR

Pooled Odds Ratio

PRISMA

Preferred Reporting Items for Systematic Review and Meta-analysis

RCT

Randomized Control Trial

RR

Relative Risk

SRQ-20

Self Reporting Questioner

WHO

World Health Organization

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

Not funded

References

  • 1.WHO. Depression and other common mental disorders: global health estimates. World Health Organization; 2017.
  • 2.Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, Carter A, et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. 2016;388(10053):1459–544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Vos T, Allen C, Arora M, Barber RM, Bhutta ZA, Brown A, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. 2016;388(10053):1545–602. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.GBD. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. The lancet. 2015(388):1459–544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Sunday EM, Okoli PC, Dinwoke VO. Level of awareness and treatment of anxiety and depression during pregnancy in southeast Nigeria. S Afr J Psychiatr. 2018;24:1192 10.4102/sajpsychiatry.v24i0.1192 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Mukherjee S, Trepka M, Pierre-Victor D, Bahelah R, Avent T. Racial/Ethnic Disparities in Antenatal Depression in the United States: A Systematic Review. Maternal & Child Health Journal. 2016;20(9):1780–97. [DOI] [PubMed] [Google Scholar]
  • 7.Chatillon O, Even C. [Antepartum depression: prevalence, diagnosis and treatment]. Encephale. 2010;36(6):443–51. 10.1016/j.encep.2010.02.004 [DOI] [PubMed] [Google Scholar]
  • 8.Mitchell-Jones N, Gallos I, Farren J, Tobias A, Bottomley C, Bourne T. Psychological morbidity associated with hyperemesis gravidarum: a systematic review and meta-analysis: BJOG: An International Journal of Obstetrics and Gynaecology. 124(1) (pp 20–30), 2017. [DOI] [PubMed] [Google Scholar]
  • 9.Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety and depression: A systematic review. Journal of Affective Disorders. 2016;191:62–77. 10.1016/j.jad.2015.11.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. The Lancet Psychiatry. 2016;3(10):973–82. 10.1016/S2215-0366(16)30284-X [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Woody CA, Ferrari AJ, Siskind DJ, Whiteford HA, Harris MG. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord. 2017;219:86–92. 10.1016/j.jad.2017.05.003 [DOI] [PubMed] [Google Scholar]
  • 12.Slomian J, Honvo G, Emonts P, Reginster J-Y, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond). 2019;15:1745506519844044. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Li J, Mao J, Du Y, Morris JL, Gong G, Xiong X. Health-related quality of life among pregnant women with and without depression in Hubei, China. Matern Child Health J. 2012;16(7):1355–63. 10.1007/s10995-011-0900-z [DOI] [PubMed] [Google Scholar]
  • 14.Franke K, Bergh Bvd, de Rooij SR, Roseboom TJ, Nathanielsz PW, Witte OW, et al. Effects of Prenatal Stress on Structural Brain Development and Aging in Humans. bioRxiv. 2017. January 1:148916. [Google Scholar]
  • 15.Sikander S, Ahmad I, Bates LM, Gallis J, Hagaman A, O'Donnell K, et al. Cohort Profile: Perinatal depression and child socioemotional development; the Bachpan cohort study from rural Pakistan. BMJ Open. 2019;9(5). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Wen DJ, Poh JS, Ni SN, Chong YS, Chen H, Kwek K, et al. Influences of prenatal and postnatal maternal depression on amygdala volume and microstructure in young children. Translational Psychiatry. 2017;7(4). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Latendresse G, Wong B, Dyer J, Wilson B, Baksh L, Hogue C. Duration of Maternal Stress and Depression. Nursing Research. 2015;64(5):331–41. 10.1097/NNR.0000000000000117 [DOI] [PubMed] [Google Scholar]
  • 18.Diego MA, Field T, Hernandez-Reif M, Schanberg S, Kuhn C, Gonzalez-Quintero VH. Prenatal depression restricts fetal growth. Early Human Development. 2009;85(1):65–70. 10.1016/j.earlhumdev.2008.07.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Field T, Diego M, Hernandez-rief M, Figueiredo B, Schanberg. Kuhn C, et al. Chronic prenatal depression and neonatal outcome. International Journal of Neuroscience. 2008;118(1):95–103. 10.1080/00207450601042144 [DOI] [PubMed] [Google Scholar]
  • 20.Stringer E, Johnson J, Jackson C, Meltzer-Brody S. 646: Antenatal depression in an urban population of pregnant adolescents and young adults may contribute to preterm birth. American Journal of Obstetrics & Gynecology. 2016;214(1):S344. [Google Scholar]
  • 21.Kim DR, Sockol LE, Sammel MD, Kelly C, Moseley M, Epperson C. Elevated risk of adverse obstetric outcomes in pregnant women with depression. Archives of Women's Mental Health. 2013;16(6):475–82. 10.1007/s00737-013-0371-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Feinberg ME, Jones DE, Roettger ME, Hostetler ML, Sakuma KL, Paul IM, et al. Preventive Effects on Birth Outcomes: Buffering Impact of Maternal Stress, Depression, and Anxiety. Matern Child Health J. 2016;20(1):56–65. 10.1007/s10995-015-1801-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Raisanen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Risk factors for and perinatal outcomes of major depression during pregnancy: a population-based analysis during 2002–2010 in Finland. BMJ Open. 2014;4(11) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Quispel C, Bangma M, Kazemier BM, Steegers EAP, Hoogendijk WJG, Papatsonis DNM, et al. The role of depressive symptoms in the pathway of demographic and psychosocial risks to preterm birth and small for gestational age. Midwifery. 2014;30(8):919–25. 10.1016/j.midw.2014.03.008 [DOI] [PubMed] [Google Scholar]
  • 25.Szegda K, Bertone-Johnson ER, Pekow P, Powers S, Markenson G, Dole N, et al. Depression during pregnancy and adverse birth outcomes among predominantly puerto rican women. Maternal and child health journal. 2017. April 1;21(4):942–52. 10.1007/s10995-016-2195-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Chang HY, Keyes KM, Lee KS, Choi IA, Kim SJ, Kim KW, et al. Prenatal maternal depression is associated with low birth weight through shorter gestational age in term infants in Korea. Early Human Development. 2014;90(1):15–20. 10.1016/j.earlhumdev.2013.11.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Husain N, Munshi T, Jafri F, Husain M, Parveen A, Saeed Q, et al. Antenatal depression is not associated with low birth weight: A study from urban Pakistan. Frontiers in psychiatry. 2014. December 10;5:175 10.3389/fpsyt.2014.00175 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Saeed A, Raana T, Saeed AM, Humayun A. Effect of antenatal depression on maternal dietary intake and neonatal outcome: a prospective cohort. Nutrition Journal. 2016;15(1):64 10.1186/s12937-016-0184-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Stewart DE. Depression during Pregnancy. New England Journal of Medicine. 2011;365(17):1605–11. 10.1056/NEJMcp1102730 [DOI] [PubMed] [Google Scholar]
  • 30.Amiel Castro RT, Pinard Anderman C, Glover V, O’Connor TG, Ehlert U, Kammerer M. Associated symptoms of depression: patterns of change during pregnancy. Archives of Women's Mental Health. 2017;20(1):123–8. 10.1007/s00737-016-0685-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Araujo DM, Vilarim MM, Sabroza AR, Nardi AE. [Depression during pregnancy and low birth weight: a systematic literature review]. Cad Saude Publica. 2010;26(2):219–27. 10.1590/s0102-311x2010000200002 [DOI] [PubMed] [Google Scholar]
  • 32.Hanlon C, Medhin G, Alem A, Tesfaye F, Lakew Z, Worku B, et al. Impact of antenatal common mental disorders upon perinatal outcomes in Ethiopia: The P-MaMiE population-based cohort study. Tropical Medicine and International Health. 2009;14(2):156–66. 10.1111/j.1365-3156.2008.02198.x [DOI] [PubMed] [Google Scholar]
  • 33.Gelaye B, Rondon M, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. The lancet Psychiatry. 2016;3(10):973–82. 10.1016/S2215-0366(16)30284-X [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Bae J-M. A suggestion for quality assessment in systematic reviews of observational studies in nutritional epidemiology. Epidemiology and Health. 2016;38. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5. 10.1007/s10654-010-9491-z [DOI] [PubMed] [Google Scholar]
  • 36.Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12. 10.1001/jama.283.15.2008 [DOI] [PubMed] [Google Scholar]
  • 37.Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. Bmj. 1997;315(7109):629–34. 10.1136/bmj.315.7109.629 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Loannidis JP. Interpretation of tests of heterogeneity and bias in meta-analysis. Journal of evaluation in clinical practice. 2008;14(5):951–7. 10.1111/j.1365-2753.2008.00986.x [DOI] [PubMed] [Google Scholar]
  • 39.Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455–63. 10.1111/j.0006-341x.2000.00455.x [DOI] [PubMed] [Google Scholar]
  • 40.Galbraith RF. Graphical display of estimates having differing standard errors. Technometrics. 1988;30(3):271–81. [Google Scholar]
  • 41.Higgins J, Thompson S, Deeks J, Altman D. Statistical heterogeneity in systematic reviews of clinical trials: a critical appraisal of guidelines and practice. Journal of health services research & policy. 2002;7(1):51–61. [DOI] [PubMed] [Google Scholar]
  • 42.Fletcher J. What is heterogeneity and is it important? BMJ: British Medical Journal. 2007;334(7584):94–6. 10.1136/bmj.39057.406644.68 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Stata A. Stata Base Reference Manual Release 14. 2015.
  • 44.Adewuya AO, Ola BA, Aloba OO, Dada AO, Fasoto OO. Prevalence and correlates of depression in late pregnancy among Nigerian women. Depression & Anxiety. 2007;24(1):15–21. [DOI] [PubMed] [Google Scholar]
  • 45.Esimai O, Fatoye F, Quiah A, Vidal O, Momoh R. Antepartum anxiety and depressive symptoms: a study of Nigerian women during the three trimesters of pregnancy. J Obstet Gynaecol. 2008;28. [DOI] [PubMed] [Google Scholar]
  • 46.Gausia K, Fisher C, Ali M, Oosthuizen J. Antenatal depression and suicidal ideation among rural Bangladeshi women: a community-based study. Archives of Women's Mental Health. 2009;12(5):351–8. 10.1007/s00737-009-0080-7 [DOI] [PubMed] [Google Scholar]
  • 47.Luna Matos ML, Salinas Pielago J, Luna Figueroa A. [Major depression in pregnant women served by the National Materno-Perinatal Institute in Lima, Peru]. Pan American Journal of Public Health. 2009;26(4):310–4. 10.1590/s1020-49892009001000004 [DOI] [PubMed] [Google Scholar]
  • 48.Mitsuhiro SS, Chalem E, Moraes Barros MC, Guinsburg R, Laranjeira R. Brief report: Prevalence of psychiatric disorders in pregnant teenagers. Journal of Adolescence. 2009;32(3):747–52. 10.1016/j.adolescence.2008.12.001 [DOI] [PubMed] [Google Scholar]
  • 49.Pereira PK, Lovisi GM, Pilowsky DL, Lima LA, Legay LF. Depression during pregnancy: prevalence and risk factors among women attending a public health clinic in Rio de Janeiro, Brazil. Cadernos de Saude Publica. 2009;25(12):2725–36. 10.1590/s0102-311x2009001200019 [DOI] [PubMed] [Google Scholar]
  • 50.Pottinger AM, Trotman-Edwards H, Younger N. Detecting depression during pregnancy and associated lifestyle practices and concerns among women in a hospital-based obstetric clinic in Jamaica. General Hospital Psychiatry. 2009;31(3):254–61. 10.1016/j.genhosppsych.2009.02.002 [DOI] [PubMed] [Google Scholar]
  • 51.Golbasi Z, Kelleci M, Kisacik G, Cetin A. Prevalence and Correlates of Depression in Pregnancy Among Turkish Women. Maternal and Child Health Journal. 2010;14(4):485–91. 10.1007/s10995-009-0459-0 [DOI] [PubMed] [Google Scholar]
  • 52.Silva RA, Jansen K, Souza LD, Moraes IG, Tomasi E, Silva GD, et al. Depression during pregnancy in the Brazilian public health care system. Brazilian Journal of Psychiatry. 2010. June;32(2):139–44 10.1590/s1516-44462010000200008 [DOI] [PubMed] [Google Scholar]
  • 53.Kaaya SF, Mbwambo JK, Kilonzo GP, Van Den Borne H, Leshabari MT, Fawzi MC, et al. Socio-economic and partner relationship factors associated with antenatal depressive morbidity among pregnant women in Dar es Salaam, Tanzania. Tanzania journal of health research. 2010;12(1):23–35. 10.4314/thrb.v12i1.56276 [DOI] [PubMed] [Google Scholar]
  • 54.Mohammad KI, Gamble J, Creedy DK. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery. 2011;27(6) [DOI] [PubMed] [Google Scholar]
  • 55.Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Prevalence and associated factors of depressive and anxiety symptoms during pregnancy: a population based study in rural Bangladesh. BMC Womens Health. 2011;11:22 10.1186/1472-6874-11-22 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Lau Y, Yin L, Wang Y. Antenatal Depressive Symptomatology, Family Conflict and Social Support Among Chengdu Chinese Women. Maternal & Child Health Journal. 2011;15(8):1416–26. [DOI] [PubMed] [Google Scholar]
  • 57.Senturk V, Abas M, Berksun O, Stewart R. Social support and antenatal depression in extended and nuclear family environments in Turkey: a cross-sectional survey. BMC Psychiatry. 2011;11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Faisal-Cury A, Savoia MG, Menezes PR. Coping style and depressive symptomatology during pregnancy in a private setting sample. The Spanish journal of psychology. 2012;15(1):295–305. 10.5209/rev_sjop.2012.v15.n1.37336 [DOI] [PubMed] [Google Scholar]
  • 59.Melo EF Jr, Cecatti JG, Pacagnella RC, Leite DFB, Vulcani DE, Makuch MY. The prevalence of perinatal depression and its associated factors in two different settings in Brazil. Journal of Affective Disorders. 2012;136(3):1204–8. 10.1016/j.jad.2011.11.023 [DOI] [PubMed] [Google Scholar]
  • 60.Hartley M, Tomlinson M, Greco E, Comulada WS, Stewart J, le Roux I, et al. Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements. Reproductive Health. 2011;8(1):9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Rochat TJ, Tomlinson M, Barnighausen T, Newell ML, Stein A. The prevalence and clinical presentation of antenatal depression in rural South Africa. Journal of Affective Disorders. 2011;135(1–3):362–73. 10.1016/j.jad.2011.08.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Ajinkya S, Jadhav PR, Srivastava NN. Depression during pregnancy: Prevalence and obstetric risk factors among pregnant women attending a tertiary care hospital in Navi Mumbai. Industrial Psychiatry Journal. 2013;22(1):37–40. 10.4103/0972-6748.123615 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Fisher J, Tran T, Duc Tran T, Dwyer T, Nguyen T, Casey GJ, et al. Prevalence and risk factors for symptoms of common mental disorders in early and late pregnancy in Vietnamese women: A prospective population-based study. Journal of Affective Disorders. 2013;146(2):213–9. 10.1016/j.jad.2012.09.007 [DOI] [PubMed] [Google Scholar]
  • 64.Silva R, Jansen K, Souza L, Quevedo L, Barbosa L, Moraes I, et al. Sociodemographic risk factors of perinatal depression: a cohort study in the public health care system. Revista Brasileira de Psiquiatria. 2012;34(2):143–8. 10.1590/s1516-44462012000200005 [DOI] [PubMed] [Google Scholar]
  • 65.Lara MA, Natera-Rey G, Berenzon S, Juarez-Garcia F, Villatoro-Velazquez JA, Nieto L, et al. Intimate partner violence and depressive symptoms in pregnant Mexican women: national survey results. Revista de investigacion clinica; organo del Hospital de Enfermedades de la Nutricion. 2014;66(5):431–8. [PubMed] [Google Scholar]
  • 66.Manikkam L, Burns JK. Antenatal depression and its risk factors: an urban prevalence study in KwaZulu-Natal. S Afr Med J. 2012;102. [DOI] [PubMed] [Google Scholar]
  • 67.Fadzil A, Balakrishnan K, Razali R, Sidi H, Malapan T, Japaraj RP, et al. Risk factors for depression and anxiety among pregnant women in Hospital Tuanku Bainun, Ipoh, Malaysia: Asia-Pacific Psychiatry. 5 (pp 7–13), 2013. 10.1111/appy.12036 [DOI] [PubMed] [Google Scholar]
  • 68.Jeong H-G, Lim J-S, Lee M-S, Kim S-H, Jung I-K, Joe S-H. The association of psychosocial factors and obstetric history with depression in pregnant women: Focus on the role of emotional support. General Hospital Psychiatry. 2013;35(4):354–8. 10.1016/j.genhosppsych.2013.02.009 [DOI] [PubMed] [Google Scholar]
  • 69.Bindt C, Guo N, Bonle MT, Appiah-Poku J, Hinz R, Barthel D, et al. No association between antenatal common mental disorders in low-obstetric risk women and adverse birth outcomes in their offspring: results from the CDS study in Ghana and Cote D'Ivoire. PLoS One. 2013;8(11). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 70.Dibaba Y, Fantahun M, Hindin MJ. The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia. BMC pregnancy and childbirth. 2013;13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 71.Assefa Gemta W. Prevalence and factors associated with antenatal depression among women following antenatal care at Shashemane health facilities, South Ethiopia. Annals of Global Health. 2015;81(1):90. [Google Scholar]
  • 72.Guo N, Bindt C, Te Bonle M, Appiah-Poku J, Hinz R, Barthel D, et al. Association of antepartum and postpartum depression in Ghanaian and Ivorian women with febrile illness in their offspring: a prospective birth cohort study. Am J Epidemiol. 2013;178(9):1394–402. 10.1093/aje/kwt142 [DOI] [PubMed] [Google Scholar]
  • 73.Dmitrovic BK, Dugalić MG, Balkoski GN, Dmitrovic A, Soldatovic I. Frequency of perinatal depression in Serbia and associated risk factors. International Journal of Social Psychiatry. 2013;60(6):528–32. 10.1177/0020764013511067 [DOI] [PubMed] [Google Scholar]
  • 74.Abujilban SK, Abuidhail J, Al-Modallal H, Hamaideh S, Mosemli O. Predictors of Antenatal Depression Among Jordanian Pregnant Women in Their Third Trimester. Health Care for Women International. 2014;35(2):200–15. 10.1080/07399332.2013.817411 [DOI] [PubMed] [Google Scholar]
  • 75.Aktas S, Yesilcicek Calik K. Factors Affecting Depression During Pregnancy and the Correlation Between Social Support and Pregnancy Depression. Iranian Red Crescent Medical Journal. 2015;17(9). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76.Stewart RC, Umar E, Tomenson B, Creed F. A cross-sectional study of antenatal depression and associated factors in Malawi. Archives of Women's Mental Health. 2014;17(2):145–54. 10.1007/s00737-013-0387-2 [DOI] [PubMed] [Google Scholar]
  • 77.Weobong B, Soremekun S, Ten Asbroek AH, Amenga-Etego S, Danso S, Owusu-Agyei S, et al. Prevalence and determinants of antenatal depression among pregnant women in a predominantly rural population in Ghana: The DON population-based study. Journal of Affective Disorders. 2014;165:1–7. 10.1016/j.jad.2014.04.009 [DOI] [PubMed] [Google Scholar]
  • 78.Waqas A, Raza N, Lodhi HW, Muhammad Z, Jamal M, Rehman A. Psychosocial factors of antenatal anxiety and depression in Pakistan: is social support a mediator? PLoS ONE; 2015;10(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 79.Barrios YV, Gelaye B, Zhong Q, Nicolaidis C, Rondon MB, Garcia PJ, et al. Association of childhood physical and sexual abuse with intimate partner violence, poor general health and depressive symptoms among pregnant women.[Erratum appears in PLoS One. 2015;10(3) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 80.De Oliveira Fonseca-Machado M, Alves LC, dos Santos Monteiro JC, Stefanello J, Nakano AMS, Haas VJ, et al. Depressive disorder in pregnant Latin women: Does intimate partner violence matter? Journal of Clinical Nursing. 2015;24(9–10):1289–99. 10.1111/jocn.12728 [DOI] [PubMed] [Google Scholar]
  • 81.Abdelhai R, Mosleh H. Screening for antepartum anxiety and depression and their association with domestic violence among Egyptian pregnant women. Journal of the Egyptian Public Health Association. 2015;90(3):101–8. 10.1097/01.EPX.0000471670.64665.8f [DOI] [PubMed] [Google Scholar]
  • 82.Mahenge B, Stockl H, Likindikoki S, Kaaya S, Mbwambo J. The prevalence of mental health morbidity and its associated factors among women attending a prenatal clinic in Tanzania. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2015;130(3):261–5. [DOI] [PubMed] [Google Scholar]
  • 83.Rwakarema M, Premji SS, Nyanza EC, Riziki P, Palacios-Derflingher L. Antenatal depression is associated with pregnancy-related anxiety, partner relations, and wealth in women in Northern Tanzania: a cross-sectional study. BMC Women's Health. 2015;15:68 10.1186/s12905-015-0225-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 84.Heyningen TV, Myer L, Onah M, Tomlinson M, Field S, Honikman S. Antenatal depression and adversity in urban South Africa. Journal of Affective Disorders. 2016;203:121–9. 10.1016/j.jad.2016.05.052 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 85.Biratu A, Haile D. Prevalence of antenatal depression and associated factors among pregnant women in Addis Ababa, Ethiopia: a cross-sectional study. Reprod Health. 2015;12:99 10.1186/s12978-015-0092-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 86.Bavle AD, Chandahalli AS, Phatak AS, Rangaiah N, Kuthandahalli SM, Nagendra PN. Antenatal Depression in a Tertiary Care Hospital. Indian Journal of Psychological Medicine. 2016;38(1):31–5. 10.4103/0253-7176.175101 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 87.George C, Lalitha AR, Antony A, Kumar AV, Jacob KS. Antenatal depression in coastal South India: Prevalence and risk factors in the community. International Journal of Social Psychiatry. 2016;62(2):141–7. 10.1177/0020764015607919 [DOI] [PubMed] [Google Scholar]
  • 88.Moshki M, Cheravi K. Relationships among depression during pregnancy, social support and health locus of control among Iranian pregnant women. International Journal of Social Psychiatry. 2016;62(2):148–55. 10.1177/0020764015612119 [DOI] [PubMed] [Google Scholar]
  • 89.Padmapriya N, Bernard JY, Liang S, Loy SL, Shen Z, Kwek K, et al. Association of physical activity and sedentary behavior with depression and anxiety symptoms during pregnancy in a multiethnic cohort of Asian women. Archives of Women's Mental Health. 2016;19(6):1119–28. 10.1007/s00737-016-0664-y [DOI] [PubMed] [Google Scholar]
  • 90.Alvarado-Esquivel C, Sifuentes-Alvarez A, Salas-Martinez C. Unhappiness with the fetal gender is associated with depression in adult pregnant women attending prenatal care in a public hospital in Durango, Mexico. International Journal of Biomedical Science. 2016;12(1):36–41. [PMC free article] [PubMed] [Google Scholar]
  • 91.de Jesus Silva MM, Carvalho Leite EPR, Nogueira DA, Clapis MJ. Depression in pregnancy. Prevalence and associated factors. Investigacion & Educacion en Enfermeria. 2016;34(2):342–50. [DOI] [PubMed] [Google Scholar]
  • 92.de Moraes EV, Campos RN, Avelino MM. Depressive symptoms in pregnancy: The influence of social, psychological and obstetric aspects. Revista Brasileira de Ginecologia e Obstetricia. 2016;38(6):293–300. 10.1055/s-0036-1585072 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 93.Målqvist M, Clarke K, Matsebula T, Bergman M, Tomlinson M. Screening for Antepartum Depression Through Community Health Outreach in Swaziland. Journal of Community Health. 2016;41(5):946–52. 10.1007/s10900-016-0175-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 94.Thompson O, Ajayi I. Prevalence of Antenatal Depression and Associated Risk Factors among Pregnant Women Attending Antenatal Clinics in Abeokuta North Local Government Area, Nigeria. Depression Research and Treatment. 2016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 95.Ayele TA, Azale T, Alemu K, Abdissa Z, Mulat H, Fekadu A. Prevalence and Associated Factors of Antenatal Depression among Women Attending Antenatal Care Service at Gondar University Hospital, Northwest Ethiopia. PLOS ONE. 2016;11(5) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 96.Bisetegn TA, Mihretie G, Muche T. Prevalence and predictors of depression among pregnant women in debretabor town, northwest Ethiopia. PLoS ONE. 2016;11(9). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 97.Bitew T, Hanlon C, Kebede E, Medhin G, Fekadu A. Antenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in Ethiopia. BMC Pregnancy & Childbirth. 2016;16(1):301. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 98.Gelaye B, Addae G, Neway B, Larrabure-Torrealva GT, Qiu C, Stoner L, et al. Poor sleep quality, antepartum depression and suicidal ideation among pregnant women. Journal of Affective Disorders. 2017;209:195–200. 10.1016/j.jad.2016.11.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 99.Hu HQ, Zhang J, Zhao W, Tian T, Huang AQ, Wang LL. [The occurrence and determinants of anxiety and depression symptoms in women of six counties/ districts in China during pregnancy]. Chung-Hua Yu Fang i Hsueh Tsa Chih [Chinese Journal of Preventive Medicine]. 2017;51(1):47–52. 10.3760/cma.j.issn.0253-9624.2017.01.010 [DOI] [PubMed] [Google Scholar]
  • 100.Shidhaye P, Shidhaye R, Phalke V. Association of gender disadvantage factors and gender preference with antenatal depression in women: a cross-sectional study from rural Maharashtra. Social Psychiatry & Psychiatric Epidemiology. 2017;09:09. [DOI] [PubMed] [Google Scholar]
  • 101.Coll CD, da Silveira MF, Bassani DG, Netsi E, Wehrmeister FC, Barros FC, et al. Antenatal depressive symptoms among pregnant women: Evidence from a Southern Brazilian population-based cohort study. Journal of Affective Disorders. 2017;209:140–6. 10.1016/j.jad.2016.11.031 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 102.Mossie TB, Sibhatu AK, Dargie A, Ayele AD. Prevalence of Antenatal Depressive Symptoms and Associated Factors among Pregnant Women in Maichew, North Ethiopia: An Institution Based Study. Ethiopian Journal of Health Sciences. 2017;27(1):59–66. 10.4314/ejhs.v27i1.8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 103.Sahile MA, Segni MT, Awoke T, Bekele D. Prevalence and predictors of antenatal depressive symptoms among women attending Adama Hospital Antenatal Clinic, Adama, Ethiopia. International Journal of Nursing and Midwifery. 2017;9(5):58–64. [Google Scholar]
  • 104.Rahman A, Bunn J, Lovel H, Creed F. Association between antenatal depression and low birthweight in a developing country. Acta Psychiatrica Scandinavica. 2007;115(6):481–6. 10.1111/j.1600-0447.2006.00950.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 105.Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Low birth weight in offspring of women with depressive and anxiety symptoms during pregnancy: Results from a population based study in Bangladesh. BMC Public Health. 2010;10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 106.Niemi M, Falkenberg T, Petzold M, Chuc NT, Patel V. Symptoms of antenatal common mental disorders, preterm birth and low birthweight: a prospective cohort study in a semi-rural district of Vietnam. Tropical Medicine & International Health. 2013;18(6):687–95. [DOI] [PubMed] [Google Scholar]
  • 107.Sanchez SE, Puente GC, Atencio G, Qiu C, Yanez D, Gelaye B, et al. Risk of spontaneous preterm birth in relation to maternal depressive, anxiety, and stress symptoms. Journal of Reproductive Medicine. 2013;58(1–2):25–33. [PMC free article] [PubMed] [Google Scholar]
  • 108.Rao D, Kumar S, Mohanraj R, Frey S, Manhart LE, L. Kaysen D. The impact of domestic violence and depressive symptoms on preterm birth in South India. Social Psychiatry and Psychiatric Epidemiology. 2016;51(2):225–32. 10.1007/s00127-015-1167-2 [DOI] [PubMed] [Google Scholar]
  • 109.Wado YD, Afework MF, Hindin MJ. Effects of maternal pregnancy intention, depressive symptoms and social support on risk of low birth weight: A prospective study from Southwestern Ethiopia. PLoS ONE. 2014;9(5). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 110.Mathers C. The global burden of disease: 2004 update: World Health Organization; 2008.
  • 111.Mathers CD, Loncar D. Projections of Global Mortality and Burden of Disease from 2002 to 2030. PLoS medicine. 2006;3(11):e442 10.1371/journal.pmed.0030442 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 112.Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization. 2012;90(2):139–49H. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 113.Truijens SEM, Spek V, van Son MJM, Guid Oei S, Pop VJM. Different patterns of depressive symptoms during pregnancy. Archives of Women's Mental Health. 2017;20(4):539–46. 10.1007/s00737-017-0738-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 114.Bergink V, Kooistra L, Lambregtse-van den Berg MP, Wijnen H, Bunevicius R, van Baar A, et al. Validation of the Edinburgh Depression Scale during pregnancy. Journal of Psychosomatic Research. 2011;70(4):385–9. 10.1016/j.jpsychores.2010.07.008 [DOI] [PubMed] [Google Scholar]
  • 115.Chorwe-Sungani G, Chipps J. A systematic review of screening instruments for depression for use in antenatal services in low resource settings. BMC Psychiatry. 2017;17(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 116.Chou F-H, Kuo S-H, Wang R-H. A Longitudinal Study of Nausea and Vomiting, Fatigue and Perceived Stress in, and Social Support for, Pregnant Women Through the Three Trimesters. The Kaohsiung Journal of Medical Sciences.24(6):306–14. 10.1016/S1607-551X(08)70157-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 117.Shyn SI, Hamilton SP. The genetics of major depression: Moving beyond the monoamine hypothesis. The Psychiatric clinics of North America. 2010;33(1):125–40. 10.1016/j.psc.2009.10.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 118.Underwood L, Waldie K, D’Souza S, Peterson ER, Morton S. A review of longitudinal studies on antenatal and postnatal depression. Archives of Women's Mental Health. 2016;19(5):711–20. 10.1007/s00737-016-0629-1 [DOI] [PubMed] [Google Scholar]
  • 119.Roomruangwong C, Epperson CN. Perinatal depression in Asian women: Prevalence, associated factors, and cultural aspects. Asian Biomedicine. 2011;5(2):179–93. [Google Scholar]
  • 120.Stuart-Parrigon K, Stuart S. Perinatal Depression: An Update and Overview. Current Psychiatry Reports. 2014;16(9):468 10.1007/s11920-014-0468-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 121.Sparling TM, Henschke N, Nesbitt RC, Gabrysch S. The role of diet and nutritional supplementation in perinatal depression: a systematic review. Maternal & Child Nutrition. 2017;13(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 122.Rechenberg K, Humphries D. Nutritional interventions in depression and perinatal depression. The Yale journal of biology and medicine. 2013;86(2):127–37. [PMC free article] [PubMed] [Google Scholar]
  • 123.Kaplan BJ, Crawford SG, Field CJ, Simpson JS. Vitamins, minerals, and mood. Psychological bulletin. 2007;133(5):747–60. 10.1037/0033-2909.133.5.747 [DOI] [PubMed] [Google Scholar]
  • 124.Hart C, de Vet R, Moran P, Hatch SL, Dean K. A UK population-based study of the relationship between mental disorder and victimisation. Soc Psychiatry Psychiatr Epidemiol. 2012;47(10):1581–90. 10.1007/s00127-011-0464-7 [DOI] [PubMed] [Google Scholar]
  • 125.Teicher MH, Samson JA, Polcari A, McGreenery CE. Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment. Am J Psychiatry. 2006;163(6):993–1000. 10.1176/ajp.2006.163.6.993 [DOI] [PubMed] [Google Scholar]
  • 126.Teicher MH, Samson JA. Annual Research Review: Enduring neurobiological effects of childhood abuse and neglect. Journal of child psychology and psychiatry, and allied disciplines. 2016;57(3):241–66. 10.1111/jcpp.12507 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 127.World Helath Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and nonpartner sexual violence. 2013.
  • 128.Accortt EE, Cheadle ACD, Dunkel Schetter C. Prenatal Depression and Adverse Birth Outcomes: An Updated Systematic Review. Maternal and Child Health Journal. 2015;19(6):1306–37. 10.1007/s10995-014-1637-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 129.Szegda Kathleen, Markenson Glenn, Bertone-Johnson Elizabeth R., Chasan-Taber Lisa. Depression during pregnancy: a risk factor for adverse neonatal outcomes? A critical review of the literature. The Journal of Maternal-Fetal & Neonatal Medicine. 2014;27(9):960–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 130.Grigoriadis S, VonderPorten EH, Mamisashvili L, Tomlinson G, Dennis CL, Koren G, et al. The impact of maternal depression during pregnancy on perinatal outcomes: A systematic review and meta-analysis. Journal of Clinical Psychiatry. 2013;74(4):e321–e41. 10.4088/JCP.12r07968 [DOI] [PubMed] [Google Scholar]
  • 131.Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 132.Wadhwa PD, Glynn L, Hobel CJ, Garite TJ, Porto M, Chicz-DeMet A, et al. Behavioral perinatology: biobehavioral processes in human fetal development. Regulatory peptides. 2002;108(2–3):149–57. 10.1016/s0167-0115(02)00102-7 [DOI] [PubMed] [Google Scholar]
  • 133.Wadhwa PD, Entringer S, Buss C, Lu MC. The contribution of maternal stress to preterm birth: issues and considerations. Clin Perinatol. 2011;38(3):351–84. 10.1016/j.clp.2011.06.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 134.Azale T, Fekadu A, Hanlon C. Treatment gap and help-seeking for postpartum depression in a rural African setting. BMC Psychiatry. 2016;16(1):196. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 135.Neggers Y, Goldenberg R, Cliver S, Hauth J. The relationship between psychosocial profile, health practices, and pregnancy outcomes. Acta Obstet Gynecol Scand. 2006;85(3):277–85. 10.1080/00016340600566121 [DOI] [PubMed] [Google Scholar]
  • 136.Kelly RH, Russo J, Holt VL, Danielsen BH, Zatzick DF, Walker E, et al. Psychiatric and substance use disorders as risk factors for low birth weight and preterm delivery. Obstet Gynecol. 2002;100(2):297–304. 10.1016/s0029-7844(02)02014-8 [DOI] [PubMed] [Google Scholar]
  • 137.Borders AE, Grobman WA, Amsden LB, Holl JL. Chronic stress and low birth weight neonates in a low-income population of women. Obstet Gynecol. 2007;109(2 Pt 1):331–8. 10.1097/01.AOG.0000250535.97920.b5 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Animut Alebel

7 Oct 2019

PONE-D-19-25076

Prenatal Depression and its Effect on Birth Outcomes in Low and Middle-income Countries: A Systematic Review and Meta-analysis

PLOS ONE

Dear Mr Fekadu,

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Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Thank you for the opportunity to review this interesting and informative piece. I found, at times, there were minor edits required especially in the abstract. Overall I found the paper well considered, referenced, and articulated. I strongly recommend the authors follow a standard format for their reference list - it is a mixture of different formats which is distracting and indicates an editing issue.

Personally i would appreciate a visual (such as a flow chart) of article identification, fit with criteria, etc.

Again, I appreciate the quality of your contribution.

Reviewer #2: Manuscript Number: PONE-D-19-25076

Prenatal Depression and its Effect on Birth Outcomes in Low and Middle-income Countries: A Systematic Review and Meta-analysis

Thank you very much for the chance you gave me to review the manuscript detailed above.

The authors have rigorously conducted a systematic review and met analysis that estimates the pooled prevalence of prenatal depression and also indicates its effect on birth outcome in low and middle income countries. In addition, the authors comes to address one of the top priority public health challenges. Maternal and their birth outcome one of the most important indicators that indicates the health status of a given countries.

Overall it is of good quality and relevant especially to the considered study setting.

However the authors need to revise the manuscript to suit and satisfy the reader, scientific communities like typos,

Thanks for the work. My detailed comments are given below

Abstract

The authors loosely described the gap of the research. The authors also need to describe the statistical issues in this section.

Methods:

The authors did not follow the PRISMA checklist for this systematic review. I recommend them to revise based on this systematic review is based on the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) checklist guidelines to ensure scientific rigor. This systematic review lacks format especially in the method section. The authors also did not mention several subtitled for what they are mentioned in the method section. (Information sources); Authors did not include other major databases such Hinari?

Authors did not report anything about the grey literature that also needs to be explained here.

Newcastle-Ottawa Scale is over simplified, and authors should also consider NIH scale for observational studies as it is more detailed one to assess quality.

Result section

Throughout the manuscript the authors need to use the journal preparation guideline while citing the figures.

Page 5, paragraph 2 and 1 line, two independent reviewers … the authors need to mention who these authors are? Apply this comment also throughout the manuscript. On the same paragraph, line the authors considered good quality articles according to Newcastle Ottawa Scale greater than 7. What is your reference to use 7 as a cut-off point?

Page 6, the authors described that 46% of the included studies were health institutional based studies while the rest are community. So, why authors merge the two different setting studies? Are they similar population? How do you see the PICO criteria?

The authors described that they performed a subgroup analysis based on the publication year. 1) What is the advantage of reporting subgroup analysis based on publication year? I recommend the authors to report study period than publication year. Some articles published within one year of its done while others last 2/3/4/5 and more year that means a study conducted in 2010 may be published in 2013. Similarly what about publication between 2012 to 2014? 2) What is the base for categorizing publication year as 2011-2012 and 2015-2016? I need strong justification on this.

Discussion

Generally the authors need to improve more this section. All the articles that present the results of an investigation have to end in a section of discussion of results and conclusions. Therefore better discussion sounds reader and increase the quality of the study. These sections of the article should not be confused as they answer three clear questions, what was found? For the Results section, what is the meaning of what I found? When we are referring to the Discussion section and what are the most important findings of our work?

Specifically

Page #9, the authors mentioned that one of the reason for the increased postnatal depression is number of studies conducted in the setting. How could this be a reason for the increment?

Page #9, first line of last paragraph, the authors reported that prenatal depression prevalence increases from the first to the third trimester of pregnancy which also contradict with previous study reports. What did the authors think for potential justification for this increment?

The authors also did not mention any possible reason, justification for their findings. I strongly recommend also the authors to state the possible justification for each contradicting findings and also the implication of the findings.

Page #10, last paragraph, I am not clear about this paragraph. The paragraphs describe about evidences taken from other source. The authors did not mentioned what happened on their review about social support. Did the authors assessed the effects of social support on prenatal depression? If so what was the relationship? On the same paragraphs last statement has no source?

Limitation

The author described somewhere else in the method section that they included articles that assessed prenatal depression using standard measured or standardized approach using validated screening tools. However, the authors mentioned measurement bias as a limitation. How could this go together? What did the authors did to overcome this limitation?

Reference

The authors describe somewhere else in the method section that they managed the reference using EndNote software. However, most references listed under the referral list is not correct and does not fulfill the journal requirement. Therefore, I strongly recommend the authors to revise the EndNote library and also correct the reference list. Example: look reference #2, consider others also.

Figure

Figure 2, delete the weight of individual /primary studies. What is PRR mean in the figure?

In forest plots; only surname of authors will be enough, and studies should be either in alphabetic order or in year of publication order. Revise all.

**********

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Reviewer #1: Yes: Pammla Petrucka

Reviewer #2: Yes: Cheru Tesema Leshargie

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Decision Letter 1

Animut Alebel

11 Nov 2019

PONE-D-19-25076R1

Antenatal depression and its Effect on Birth Outcomes in Low and Middle-income Countries: A Systematic Review and Meta-analysis

PLOS ONE

Dear Mr Fekadu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Animut Alebel, BSc, MSc

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Editor’s comments

Title “Antenatal depression and its Effect on Birth Outcomes in Low and Middle-income Countries: A Systematic Review and Meta-analysis”

• Thank you for submitting your revised version of your manuscript. Most of the reviewers comments were addressed, but before going further steps, please address the following concerns.

Introduction

• Please update all old references used in the introduction section. For example, in 2015, the global prevalence of depression was estimated to be 4.4%.

Methods

• On your data sources (searching engine), why you did not search from EMBASE, which is a large database. Besides, you systematic review focused on depression. So, why not you searched from PsycINFO?

• Why you restricted your period from January 1, 2007 and December 31, 2017?

• I saw your search strategy from additional files, but I am not happy because it was not detail and compressive.

• Who are high risk?

• Could you attached your NOS tool because as far I know NOS has 10 maximum points?

• How you decided the category of quality scores as good, fair and poor?

• You reported a meta-analysis of proportions for antenatal depression. Therefore, for proportion or prevalence meta-analysis, the appropriate command is metaprop instead of metan command. Metan command is used to estimate the effect. Could you revise your analysis based on the above suggested command?

• For publication biases, objective tests (Egger's and Begg's tests). Therefore, please remove funnel plot.

• All the method components of PRIMA checklist are not reflected in the method section your review. Please include all the components listed in the method section of the PRISMA.

• Please include data extraction your method section.

• Risk of bias or quality score for each study should be assessed by two reviewers. Please say something about this. Moreover. If there were any disagreement during quality assessment, how this was resolved it? If quality assessment was done by two reviewers, and if there were any disagreements, please do KAPA test?

• Results

• The I2 value =96.7%, but in systematic review and meta-analysis, if the I2 > 75% it is better to report as a systematic review rather than merging heterogeneous results as a meta-analysis. How do you see this result?

• What is “the tooled” means?

• You tried to see the trend of depression over a time by dividing publication year. If you are interested to see the time trend in meta-analysis, I recommend you to do cumulative meta-analysis. Besides, to assess trend I recommend you to use study period rather than publication year.

• You included case control study to assess effect of antenatal depression on adverse birth outcomes. Can we assess effect using case control study?

• Discussion

• Please remove sub-headings from discussion.

• “This might associate with the number of included studies during different trimesters, the pooled prevalence was high where large number of studies included and low where small studies were included as adjustment was not made on the number of studies”. This is the limitation of this review rather than your justification.

• “We found that antenatal depression prevalence increases from the first to the third trimester of pregnancy”. Any association between antenatal depression and physiological changes during pregnancy?

• “We noted that institutional based studies reported higher prevalence relative to community-based studies. So, how do you justify this result?

• Limitations

• Only studies reported in the English language were included in your review. This is one limitation.

• What was your rational to exclude low quality papers?

• Conclusion

• Be consistent and conclude according to your result. Besides, the conclusion part of your abstract is not in line with the conclusion part of in the main document.

• Finally, I recommend you to edit the paper again there are some spelling and grammar problems.

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Decision Letter 2

Animut Alebel

18 Dec 2019

Antenatal depression and its Association with Adverse Birth Outcomes in Low and Middle-income Countries: A Systematic Review and Meta-analysis

PONE-D-19-25076R2

Dear Dr. Fekadu,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Animut Alebel, MSc, PhD student

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Animut Alebel

20 Dec 2019

PONE-D-19-25076R2

Antenatal depression and its Association with Adverse Birth Outcomes in Low and Middle-income Countries: A Systematic Review and Meta-analysis

Dear Dr. Fekadu:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Mr. Animut Alebel

Academic Editor

PLOS ONE

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