Beyond survival: Prioritizing the unmet mental health needs of pregnant and postpartum women and their caregivers

Mental disorders are among the most common morbidities of pregnancy and the postnatal period, and can have adverse effects on the mother, her child, and family. This Series paper summarises the evidence about epidemiology, risk factors, identification, and interventions for non-psychotic mental disorders. Although the phenomenology and risk factors for perinatal mental disorders are largely similar to those for the disorders at other times, treatment considerations differ during pregnancy and breastfeeding. Most randomised controlled trials have examined psychosocial and psychological interventions for postnatal depression, with evidence for effectiveness in treating and preventing the disorder. Few high-quality studies exist on the effectiveness or safety of pharmacological treatments in the perinatal period, despite quite high prescription rates. General principles of prescribing of drugs in the perinatal period are provided, but individual risk-benefit analyses are needed for decisions about treatment.

Introduction: Depression and anxiety affect one in seven women during the perinatal period, and are associated with increased risk of preterm delivery, reduced mother-infant bonding, and delays in cognitive/emotional development of the infant. With this survey we aimed to rapidly assess the influence of the COVID-19 pandemic and subsequent physical distancing/isolation measures on the mental health and physical activity of pregnant and postpartum women. Methods: Between April 14 and May 8, 2020, we recruited women who were pregnant or within the first year after delivery to participate in an online survey. This included questionnaires on self-reported levels of depression/depressive symptoms (Edinburgh Postnatal Depression Survey; EPDS), anxiety (State-Trait Anxiety Inventory; STAI-State), and physical activity. Current and pre-pandemic values were assessed for each. Results: Of 900 eligible women, 520 (58%) were pregnant and 380 (42%) were in the first year after delivery. Sixty-four percent of women reported reduced physical activity with the onset of isolation measures, while 15% increased, and 21% had no change to their physical activity. An EPDS score > 13 (indicative of depression) was self-identified in 15% of respondents pre-pandemic and in 40.7% currently (mean ± SD; 7.5 ± 4.9 vs. 11.2 ± 6.3, respectively; p < 0.01, moderate effect). Moderate to high anxiety (STAI-state score > 40) was identified in 29% of women before the pandemic (mean STAI = 34.5 ± 11.4) vs. 72% of women currently (mean STAI = 48.1 ± 13.6; p < 0.01, large effect). However, women engaging in at least 150 min of moderate intensity physical activity (meeting current guidelines) during the pandemic had significantly lower scores for both anxiety and depression than those who did not ( p < 0.01, large and small effect, respectively). Discussion: This rapid response survey identifies a substantial increase in the likelihood of maternal depression and anxiety during the COVID-19 pandemic. This highlights the strong need for heightened assessment and treatment of maternal mental health. However, these data also suggest that physical activity, which has previously been shown to reduce depression and depressive symptoms in pregnancy, may be associated with better mental health during the pandemic.

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.