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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 2  |  Page : 55-60

Burden of antenatal depression and its risk factors in Indian settings: A systematic review


Department of Food and Nutrition, Institute of Home Economics, Delhi University, New Delhi, India

Date of Submission10-Dec-2018
Date of Decision04-Feb-2019
Date of Acceptance19-Feb-2019
Date of Web Publication10-Apr-2019

Correspondence Address:
Dr. Bani Tamber Aeri
Department of Food and Nutrition, Institute of Home Economics, Delhi University F-4, Hauz Khas Enclave, New Delhi - 110 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_36_18

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  Abstract 


According to the National Mental Health Survey-2016, one in every ten persons in India suffers from depression and anxiety, and 20% of these depressed Indians are pregnant women and new mothers. This systematic review was conducted to assess the burden of depression and risk factors associated with it among the Indian pregnant women. Electronic database (PubMed and Google Scholar) was used to identify any retrospective/prospective observational research studies published in English language which specifically examined antenatal depression (AD) among Indian women using a validated scale. A total of 995 citations were retrieved, out of which only eight studies were included. The prevalence of AD was found to be ranging from 9.18% to 65.0% in northern, western, and southern part of India. However, there is a lack of research on AD from the eastern part of country. The factors such as unplanned pregnancy, multigravidity, history of abortion, advancing pregnancy and age, lower/lower-middle socioeconomic status, poor education status of women, unemployment, bad relations with in-laws, male gender preference, and demand for dowry were significant predictors for AD. Therefore, it is necessary to provide the health-care professionals and women with the knowledge about these factors for early prediction of women at high risk of AD, which might help them to get timely intervention and reduce the burden of depression. Furthermore, the results from this review implicate that more research is needed in future in this field to further validate the findings of the present review.

Keywords: Antenatal, depression, India, pregnant women, prevalence


How to cite this article:
Arora P, Aeri BT. Burden of antenatal depression and its risk factors in Indian settings: A systematic review. Indian J Med Spec 2019;10:55-60

How to cite this URL:
Arora P, Aeri BT. Burden of antenatal depression and its risk factors in Indian settings: A systematic review. Indian J Med Spec [serial online] 2019 [cited 2019 Jun 26];10:55-60. Available from: http://www.ijms.in/text.asp?2019/10/2/55/255798




  Introduction Top


Mental health is increasingly recognized as a core component which needs to be integrated with other dimensions of health to achieve the Millennium Development Goals, especially three of eight goals relating to women and child health.[1] The World Health Organization (WHO) defines maternal mental health as “a state of well-being in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her community.“[2],[3],[4] Among the mental/neurological disorders, depression contributes the maximum share among the women of reproductive years.[5] Maternal depression (from conception to 12 months' postpartum) forms the second leading cause of global morbidity in women.[1],[6] According to the National Mental Health Survey (NMHS)-2016, one in every ten persons in India suffers from depression and anxiety, and 20% of these depressed Indians are pregnant women and new mothers.[7] Antenatal depression (AD), generally defined as the onset of depressive symptoms during pregnancy, can occur at any time during the pregnancy.[8] The prevalence of depression was found to be 15.5% in early and mid-pregnancy, 11.1% in the third trimester, and 8.7% in the postpartum period,[9] whereas a meta-analysis on the prevalence of AD in middle- and low-income countries reported a mean prevalence of 15.6%.[10]

Several risk factors predispose to depression during pregnancy. Some of them are poor antenatal care; poor nutrition; stressful life events such as economic deprivation, gender-based violence and polygamy, previous history of psychiatric disorders, and previous puerperal complications; events during pregnancy such as previous abortions; and modes of previous delivery such as past instrumental or operative delivery. In addition to these, other factors associated with AD include age, marital status, gravidity, whether pregnancy was planned or not, previous history of stillbirth, previous history of prolonged labor, and level of social support.[11],[12],[13],[14],[15],[16],[17],[18] Thus, AD has been reported with dangerous practices, including poor nutrition and hygiene and lack of motivation to obtain prenatal care or to follow medical recommendations all of which adversely affect pregnancy outcomes.[19] These have resulted in immediate effects, including low birth weight, intrauterine growth restriction, and preterm birth to long-term implications such as malnutrition, inadequate child growth, and impaired behavioral, emotional, and cognitive abilities and poor mental health in future.[1],[20],[21],[22] AD is found to be associated with postnatal depression.[23] It can predispose to chronic or recurrent depression, which further may affect the mother-infant relationship and child growth and development.[24],[25],[26],[27] A meta-analysis in developing countries showed that the children of mothers with postpartum depression are at greater risk of being underweight and stunted.[27] Moreover, mothers who are depressed are more likely not to breastfeed their babies and not seek health care appropriately.[26]

However, the support required for AD among the disadvantaged population in India at large is not available despite the emphasis that antenatal and postnatal psychological disorders are considered as one of the most important maternal and child health priorities.[22] Thus, it is essential to determine the true estimates of the prevalence of AD and the factors leading to such depression, which further can be utilized as evidence by the researchers and policymakers to develop strategies for detection and management of maternal depression.[5]

Objective

The present review was performed to assess the burden of depression and risk factors associated with it among the Indian pregnant women.


  Materials and Methods Top


Literature information sources and search strategy

Two electronic databases (Google Scholar and PubMed) were searched during August and September 2017 using combinations of the following text and MeSH terms: “Maternal depression,” “depression during pregnancy,” “antenatal depression,” “risk factors,” and “India.” The articles published from January 2000 to July 2017 were taken into consideration, and the final search was done on September 30, 2017. The reference lists of all the review articles related to AD were also searched for identifying potentially eligible research articles.

Inclusion and exclusion criteria

Inclusion

Any retrospective/prospective observational studies assessing the depression among the Indian pregnant women irrespective of their age at the time of conception, medical condition, comorbidity, gestational age, and socioeconomic status using a validated tool/scale were included. The articles published only in English language were taken into consideration.

Exclusion criteria

The research articles which assessed any mental disorder such as anxiety, stress during pregnancy, or recruited the women shortly after the delivery to assess the postpartum depression were excluded. The studies which have recruited Indian women residing in a country other than India were not considered. In addition to this, the research articles for which full text was not available were also excluded.

Study selection and data extraction

A total of 995 studies were screened by the authors. After the screening of titles and abstracts, the full text was read to identify the articles which fulfilled the predefined inclusion criteria for the final analysis. The study details (author, publication year, study design, sample size, subjects' characteristics, and scale used for the assessment of AD) were aggregated in Microsoft Office Excel 2010 for summary and analyses. Mean, median, range, and percentage were used to represent and summarize the data. This review is reported in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.[28]


  Results Top


Study selection

The flow diagram [Figure 1] outlines the process of identification and selection of studies. The search yielded 995 citations, of which 987 were excluded for the reasons shown in [Figure 1]. Accordingly, eight studies met the inclusion criteria and were included in the review.
Figure 1: Flow diagram of study selection process

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Study characteristics

Among eight selected articles, three studies each were from northern[29],[30],[31] and southern regions[5],[32],[33] and two from the western region of India[34],[35] whereas none of them belong to eastern part of India. It indicates the paucity of research on AD in the eastern region of India. The research design of majority of included studies was cross-sectional,[5],[31],[32],[33],[34],[35] whereas one was cohort[29] and another one was longitudinal study.[30] In addition to it, none of these studies were retrospective. A total of 1570 pregnant women (mean 196 and median 200) participated with an age range of 15–45 years in all eight included studies. A summary table was designed to gather the study characteristics of interest which is presented in [Table 1].
Table 1: Study Characteristics of Included Studies*

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After the analysis of all included studies, it was concluded that there was a difference in recruitment criteria of participants. For instance in recent studies,[31],[33] women with poor obstetric history, obstetric complications in present pregnancy, women with known psychological disorders, women using antiepileptic neurogenic drugs, antidepressants, or central nervous system stimulants were excluded from the study. Similarly, there was a study[5] in which pregnant women with any mental or physical challenge were not included in the study. Pregnant women consuming psychotropic medications were also not permitted to participate in the study.[34] In another study, it was observed that pregnant women who were not available at home for two visits in spite of prior notice were no longer considered for follow-up.[29] Another study[30] included women who have already reached the third trimester of pregnancy. Besides this, language barrier was another factor which influences the recruitment criteria of participants. This was clearly evident by one of the south[32] and western[35] Indian studies in which women who did not know either of the language – English/Kannada and Marathi, respectively, were not included in the study.

Assessment of antenatal depression among Indian women

Data indicated that in a recent study which was conducted over 6 months to assess the mental health status of pregnant women attending antenatal clinic of tertiary care hospital, Srinagar, it was found that 14.28% of the second trimester women and 32.30% of the third trimester women scored above 10 on Edinburg Postnatal Depression Scale (EPDS), which indicates possible depression among these women.[31] Similar trend was noticed among the women attending urban health center of Bangalore, and it was found that 17.1% of the first trimester, 23% of the second trimester, and 30.11% of the third trimester women were positive for EPDS. Thus, nearly one-fourth of the pregnant women had depression.[33] In contrary to this, another study[32] conducted in the obstetric outpatient department of hospital at Mangalore revealed that majority of women of the first (55%) and second (48.4%) trimester whereas least women (26.1%) from third trimester had depression (with EPDS cutoff 13). A precise picture of AD was highlighted in another study,[5] which reflects that the thought of harming oneself was reported by 24% of the women and more than half of them (56%) found themselves to be anxious or worried without any reason during pregnancy. Thirty-six per cent of women also reported that they were not able to cope up with things while 47% of them reported sleeplessness. Thus, the overall majority (65%) of women had scored 13 or higher on EPDS, indicating high likelihood of depression. In another observational study[34] conducted among the women under the Indian Council Medical Research Short-term Research Studentship (STS-2011) Program, it was seen that after administering Beck Depression Inventory (BDI), 10.25% of the first trimester, 8.4% of the second trimester, and 11.11% of the third trimester women were depressed. A cohort study[29] was undertaken at Chhainsa village under the Intensive Field Practice Area of Comprehensive Rural Health Services Project, Ballabhgarh Centre for Community Medicine, All India Institute of Medical Science, New Delhi. Two tools, namely, BDI and International Classification of Diseases-10 (ICD-10), were administered to assess the mental status among the women during the third trimester. Antepartum screening using BDI was positive for depression in 20 women (10%), which was further confirmed by the administration of ICD-10 criteria as the same 20 women were found to be diagnosed with depression. Of these 20 women, 70% were mildly depressed whereas 30% were moderately depressed.

Another study[30] was conducted to compare depression level during the third trimester and postpartum period using Zung Self-rating Depression Scale among women. It was observed that mean depression score during the third trimester (39.75) was higher than the postpartum period. A cross-sectional study was conducted among the pregnant women from rural Maharashtra. The outcome of interest was a probable diagnosis of depression in antenatal women which was measured using EPDS. Mean EPDS score was found to be 6.9 (standard deviation: 5.4), and the overall range was from 0 to 25. In addition to this, 25.5% of the first trimester women, 21.2% of the second trimester women, and 11.2% of the third trimester women were diagnosed with AD.[35]

Risk factors associated with antenatal depression

When the risk factors associated with AD were analyzed from these eight studies, the following results were obtained. According to a recent study finding, 15% of multigravidas, 19% of women who had unplanned pregnancy, 60% of women with current obstetric complications, 66.66% of women with a history of obstetric complications, and half of the women with the history of previous abortions were found to be depressed during pregnancy. There was a significant association between these obstetric factors and AD.[34] Another study which focused on obstetric factors and other than these factors found that 20% of women <20 years of age, 25% of women who were either illiterate/completed their primary school, 17.5% of unemployed women, 27.1% of women who belonged to backward classes other than scheduled caste/scheduled tribe (SC/ST), 33.3% of women who were reportedly victim of intimate partner violence, 21.7% of women with unplanned pregnancy, 18.7% women who had one or more child, 19.4% women with a history of spontaneous abortions, and 18.2% of women with a history of medical termination of pregnancy were diagnosed with AD. In addition to these, feeling pressurized to deliver a male child, unsatisfactory reactions of in-laws to dowry, and difficult relationship with in-laws were significantly associated with AD.[35] Similar trend was seen in other study[33] which reported that although the majority of women enjoyed good relation with their in-laws, there was statistically significant presence of depression among them who had bad relations with in-laws. Depression was found to be significantly increasing with advancing pregnancy. Furthermore, socioeconomic status, educational status of women, and the women with a history of abortion were found to be statistically significant. In addition to these factors, AD was also found to be significantly increasing with advancing age as well.[31]

Pregnant women of joint families (73%) had shown higher frequency of depression than pregnant women (58%) from nuclear families, but this difference was statistically insignificant. Similarly, there was no significant difference among primigravida and multigravida.[5] The factors which were found to be associated with reduced likelihood of AD were support from family and husband, being satisfied with pregnancy, and being employed during pregnancy.[32]


  Discussion Top


Summary of evidence

This review aimed at assessing the burden of depression and risk factors associated with it among the Indian pregnant women. Overall, the prevalence of depression among pregnant women was found to be significantly high ranging from 9.18% to 65.0% in northern, western, and southern part of India. However, there is a lack of research on AD from the eastern part of country. According to available literature, a mixed trend was observed in the prevalence of depression during all three trimesters among the pregnant women ranging from 10.25% to 55% (1st trimester), 8.4% to 48.4% (2nd trimester), and 11.11% to 30.11% (3rd trimester). It should be noted that inconsistency in the prevalence rate of AD might be due to inclusion of participants from different socioeconomic classes and different scales used in different studies. The analysis also suggests that there is no specific period of gestation during which the likelihood of AD among women is high or vice versa. However, there were several common risk factors attributable for the development of AD among the women. The factors, which were found to be associated with increased likelihood of AD, were unplanned pregnancy,[32],[34],[35] multigravidity,[34] history of abortion,[33],[34],[35] current obstetric complications,[34] and advancing pregnancy.[31],[33] Besides these obstetric factors, the other factors which were reportedly attributed to AD were advancing age,[31] women with SC/ST,[35] lower/lower-middle socioeconomic status,[31],[33] poor education status of women,[33],[35] unemployment,[32],[35] joint family,[5] and bad relations with in-laws.[31],[33],[35] It was not surprising that the issues such as male gender preference and dowry still persist in India, and it was clearly evident by the presence of higher proportion of antenatal women who were either pressurized to deliver a male child or struggled to attain the satisfied reactions from in-laws toward their dowry demand. These issues appear to be among the other risk factors for the development of AD among the Indian women.[32],[35] On the contrary, only one study highlighted the factors found to be associated with reduced likelihood of AD which comprises support from the family and husband, being satisfied with pregnancy, and being employed during pregnancy.[32]

Strength and limitations

The strength of the present review was the comprehensive search strategy adopted using two different databases. Another strength was the inclusion of studies performed in different parts of country (rural/urban settings), which enhanced the external validity of the review. The present review subjects to few limitations. First, it does not include any unpublished studies or articles reported in the grey literature. Second, it does not include any article published in language other than English.


  Conclusion Top


AD is highly prevalent among Indian women during all three trimesters. The factors such as unplanned pregnancy, multigravidity, history of abortion, advancing pregnancy and age, lower/lower-middle socioeconomic status, poor education status of women, unemployment, bad relations with in-laws, male gender preference, and demand for dowry were significant predictors for depression among the pregnant women. On the other hand, factors such as support from the family and husband, being satisfied with pregnancy, and being employed can be effective in reducing the depression among the women. Thus, it is necessary to provide the health-care professionals, psychiatrists, and the women themselves with the knowledge about these factors for the early prediction of women at high risk of AD, which might help them to get the timely intervention and reduce the burden of depression. Depression during pregnancy is an important health risk factor which needs to be addressed to ensure a positive pregnancy outcome. However, more research is needed in future in this field to further validate the findings of the present review.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
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