Coronavirus disease 2019 (COVID-19) emerged as a global pandemic in March 2020 and caused a big crisis, especially the health crisis. Pregnant and postpartum women experienced significant physical, social, and mental changes that put them at higher risk for several conditions during the pandemic. This study aimed to report the prevalence of depression in pregnant and postpartum women during the COVID-19 pandemic. Eligible studies were identified using several databases. Prevalence analysis was conducted using MedCalc ver. 19.5.1. This systematic review and meta-analysis was registered in PROSPERO on July 12, 2021 with registration number CRD42021266976. We included 54 studies with 95.326 participants. The overall prevalence of depression was 32.60% among pregnant and postpartum women during the COVID-19 pandemic. The rate was higher among pregnant women (31.49%) compared to postpartum women (27.64%). The prevalence of depression among pregnant and postpartum women increased during the COVID-19 pandemic.
Coronavirus disease 2019 (COVID-19), a novel infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a global pandemic by the World Health Organization (WHO) on March 11, 2020 [
The incidence of depression during pregnancy and the postpartum period is 20.7% and 17%, respectively [
Understanding the implications of the COVID-19 pandemic on psychological changes in pregnant and postpartum women is essential to avoid its negative impacts and secondary consequences [
The literature search was limited to retrospective and prospective studies published in English or Indonesian. Eligible studies had to meet all of the following inclusion criteria: 1) participants were pregnant or delivery women; 2) participants met the clinical cut-off point for depression, assessed through validated questionnaire/healthcare professional diagnosis; 3) data were obtained during the COVID-19 pandemic; 4) empirical or original research studies; and 5) studies that reported the prevalence rates of depression among pregnant and postpartum women during the COVID-19 pandemic.
Single case reports, editorials, commentaries, letters, nonfull-texts, and unpublished or non-peer-reviewed articles were excluded from our review. Single case reports were excluded because they tend to report only severe or unique cases and have the lowest evidence quality. Studies that reported only patients with severe features were also excluded from this review.
A systematic search of studies was conducted electronically on several databases, including PubMed, EBSCO, and ProQuest, until June 30, 2021. MeSH terms, keywords, and word variants for “COVID-19,” “SARS-CoV-2,” and “pregnancy” were used. References of relevant articles or reviews were searched for additional studies.
To perform a systematic review and meta-analysis of studies evaluating depression in pregnant and postpartum women, we used the retrieval expressions: “pregnant women or pregnancy or perinatal or postpartum;” “SARS-CoV-2 or COVID-19 or coronavirus;” and “stress or psychological or mental or depression or depressive or psychology.”
The articles used in this systematic review and meta-analysis were assessed independently by two authors (NA and JC) for study quality using the Newcastle-Ottawa Scale et al. [
Meta-analysis of proportions was used to combine all the data; logit transformations were conducted before meta-analysis, and the reported pooled proportions of depression were calculated using a random-effects model. All meta-analyses were performed using MedCalc, version 19.5.1 (MedCalc Software Ltd, Ostend, Belgium). [
Publication bias was assessed for each pooled study group using Egger’s linear regression test. As a supplementary approach, Begg’s rank correlation was also applied to assess potential publication bias; when P was >0.05, there was no publication bias in the study.
The initial articles identified from the electronic database yielded 1,112 studies. After screening the titles and abstracts, 73 articles were identified. Finally, 54 studies were included in this meta-analysis. The search flowchart and selection methods used in this study are summarized in
Fifty-four studies were included in this systematic review and meta-analysis (
A random-effects meta-analysis of 54 studies revealed a pooled event rate of 0.326 (95% confidence interval [CI], 0.284–0.369), which suggested that the prevalence of depression was 32.6% across the study. This meta-analysis found no evidence of publication bias, which was confirmed statistically by the Begg’s test and Egger’s test of intercept. There was significant between-study heterogeneity (Q=9778.38,
In this meta-analysis, we found significantly elevated rates of depression among pregnant and postpartum women during the COVID-19 pandemic compared with the global prevalence of depression before the COVID-19 pandemic, which ranged from 17–20.7% [
Since its recognition in December 2019, COVID-19 has spread rapidly worldwide, with serious health, social, and financial consequences. The COVID-19 pandemic has caused significant public health emergencies and resulted in increased fear, anxiety, and uncertainty, especially among pregnant women who are more susceptible to respiratory pathogens and are at an increased risk of severe pneumonia due to the immunological and physiological changes that occur during pregnancy [
During the COVID-19 pandemic, meeting the mental health needs of pregnant and postpartum women was a considerable challenge. Prenatal and postnatal psychiatric problems have substantial long-term adverse effects on mothers, fetuses, and children. The negative consequences include complications during pregnancy and childbirth (pre-eclampsia, miscarriage, preterm birth, gestational hypertension, low infant birth weight, and stillbirth) [
Several factors increased the risk of depression in pregnant women during the COVID-19 pandemic, including COVID-19-related worries (fear of infection, worry about the baby’s safety during pregnancy, and the health of family members) [
Similar to other mental disorders, biopsychosocial factors are implicated in the etiology of postpartum depression. The possibility of getting infected by SARS-CoV-2 became a new stressor for postpartum women during the pandemic. The uncertainty and unpredictability of the pandemic, which caused fluctuations in regulations, could have played a role [
We included all available high-quality studies and updated the literature on depression among pregnant and postpartum women. Our study also highlighted the vulnerable groups among the study population.
This study has some limitations. First, there was high heterogeneity between the included studies; however, the funnel plot was symmetrical. The primary cause of heterogeneity is thought to be the various scales and cut-offs used for its analysis (EPDS, PHQ-9, PHQ-2, HADS, EDS, DASS, PHQ-4, K-10, SDS, and CES-D-10), with only one study conducted by professional health diagnosis. Samples were collected at different times and in different countries in each study. Hence, the challenge faced during the COVID-19 pandemic that served as a stressor differed in every study. Furthermore, the use of self-reported questionnaires may indicate the presence of biases such as social desirability bias, such that pregnant women may have underreported or overreported their data. Second, most of the included studies collected data through online surveys, resulting in a selection bias [
In conclusion, we demonstrated that the prevalence of depression among pregnant and postpartum women during the COVID-19 pandemic was higher than that before the COVID-19 pandemic. The rate of depression is higher in pregnant women than in postpartum women.
There is no conflict of interest in this research.
No ethical approval was required because this review analyzed published data.
No patient consent was needed for this research.
None.
The Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram. The diagram summarizes the search strategy and selection process applied to include articles eligible for this meta-analysis.
Forest plot of 54 studies assessing the prevalence of depression in pregnant and postpartum women.
Forest plot of 36 studies assessing the prevalence of depression in pregnant women.
Forest plot of 19 studies assessing depression prevalence among postpartum women.
Characteristics of studies included
Study | Country | Study design | Mean MA (years) | Mean GA (weeks) | Depression scale | Depression (%) | Sample size | ||
---|---|---|---|---|---|---|---|---|---|
Pregnant (%) | Postpartum (%) | Total (%) | |||||||
Ahlers-Schmidt et al. [ |
USA | Cohort | 25.3 | - | Diagnosis (58-item electronic survey) | - | - | 9 (7.9) | 114 |
An et al. [ |
China | Cross-sectional | 30.39 | - | EPDS (≥10) | 0 | 119 (56.9) | 119 (56.9) | 209 |
Basu et al. [ |
64 countries | Cross-sectional | 31.3 | PHQ-4 (≥6) | 1,775 (31) | 363 (30.7) | 2,138 (31.0) | 6,894 | |
Berthelot et al. [ |
Canada | Cohort | 29.27 | 24.8 | K10 (≥30) | 30 (2.38) | - | 30 (2.38) | 1,258 |
Brik et al. [ |
Spain | Cohort | 32.3 | - | EPDS (≥10) | 62 (38) | - | 62 (38) | 164 |
Ceulemans et al. [ |
Ireland, Norway, Switzerland, the Netherlands, and UK | Cross-sectional | - | - | EDS (≥13) | 533 | 592 | 1,125 | 8,087 |
Chrzan-Dętkoś et al. [ |
Poland | Cross-sectional | 31.74 | 38.88 | EPDS (≥10) | 0 | 65 (83.32) | 65 (83.32) | 78 |
Dong et al. [ |
China | Cross-sectional | - | - | SDS (>50) | 79 (50.6) | 0 | 79 (50.6) | 156 |
Durankuş et al. [ |
Turkey | Cross-sectional | 29.56 | 7.04 | EPDS (≥13) | 92 (35.4) | 0 | 92 (35.4) | 260 |
Fallon et al. [ |
UK | Cross-sectional | 30.9 | - | EPDS (≥13) | 0 | 264 (43) | 264 (43) | 614 |
Farewell et al. [ |
USA | Mixed-method pilot | - | - | PHQ-2 (≥3) | - | - | 3 (12) | 27 |
Farrell et al. [ |
Qatar | Cross-sectional | 30.5 | 26.1 | PHQ-9 (≥5) | - | - | 113 (39.2) | 288 |
Gur et al. [ |
USA | Cross-sectional | 32.45 | 24.86 | PHQ-2 (>2) | 78 (9.9) | 0 | 78 (9.9) | 787 |
Hiiragi et al. [ |
Japan | Retrospective cohort | - | - | EPDS (≥9) | 0 | 38 (14) | 38 (14) | 279 |
Hui et al. [ |
Hong Kong | Retrospective cohort | 33.1 | - | EPDS (≥10) | 0 | 133 (14.4) | 133 (14.4) | 954 |
Janevic et al. [ |
USA | Cross-sectional | - | - | PHQ-2 (3–6) | 0 | 13 (5.83) | 13 (5.83) | 223 |
Jiang et al. [ |
China | Cross-sectional | 29 | - | EDS (≥10) | 859 (45.9) | 0 | 859 (45.9) | 1,873 |
Khamees et al. [ |
Egypt | Cross-sectional | 25.08 | 6.58 | EPDS (≥14) | 53 (44.2) | 0 | 53 (44.2) | 120 |
King et al. [ |
USA | Cohort | 33.69 | 26.79 | EPDS (≥11) | 144 (42) | 0 | 144 (42) | 343 |
Lebel et al. [ |
Canada | Cross-sectional | 32.4 | 22.5 | EPDS (≥13) | 653 (37) | 0 | 653 (37) | 1,764 |
Li et al. [ |
China | Cross-sectional | 30.19 | - | PHQ-9 (≥5) | - | - | 778 (35.34) | 2,201 |
Li et al. [ |
China | Cross-sectional | - | - | PHQ-9 (≥5) | 29 (64.4) | 0 | 29 (64.4) | 45 |
Liang et al. [ |
China | Cross-sectional | - | - | EPDS (≥10) | 0 | 253 (30) | 253 (30) | 845 |
Lin et al. [ |
China | Cross-sectional | 30.51 | - | PHQ-9 (≥5) | 266 (35.4) | 0 | 266 (35.4) | 751 |
Liu et al. [ |
USA | Cross-sectional | - | - | EPDS (>13) | 260 (36.4) | 0 | 260 (36.4) | 715 |
Lubián López et al. [ |
Spain | Cross-sectional | - | - | EPDS (>10) | 182 (35.4) | 0 | 182 (35.4) | 514 |
Matsushima and Horiguchi [ |
Japan | Cross-sectional | - | - | EPDS (≥13) | 303 (17) | 0 | 303 (17) | 1,777 |
Medina-Jimenez et al. [ |
Mexico | Cross-sectional | 28.1 | 27.9 | EPDS (≥14) | 88 (17.5) | 0 | 88 (17.5) | 503 |
Mo et al. [ |
China | Cross-sectional | - | - | PHQ-9 (≥5) | 1,989 (48.7) | 0 | 1,989 (48.7) | 4,087 |
Molgora et al. [ |
Italy | Cross-sectional | - | - | EPDS (≥13) | 133 | 49 | 182 (31.65) | 575 |
Ng et al. [ |
Singapore | Cross-sectional | 31.8 | - | DASS-21 (>9) | 59 (18.4) | 0 | 59 (18.4) | 324 |
Nodoushan et al. [ |
Iran | Cross-sectional | - | 39.4 | DASS | 220 (39.2) | 0 | 220 (39.2) | 560 |
Obata et al. [ |
Japan | Cross-sectional | - | 23.3 | EPDS (≥9) | 1,608 (31.83) | 867 | 2,475 (31.83) | 7,775 |
Oskovi-Kaplan et al. [ |
Turkey | Cross-sectional | 26 | - | EPDS (≥13) | 0 | 33 (14.79) | 33 (14.79) | 223 |
Ostacoli et al. [ |
Italy | Cross-sectional | 34.77 | - | EPDS (≥11) | 0 | 72 (44.2) | 72 (44.2) | 163 |
Pariente et al. [ |
Israel | Cohort | 29.1 | - | EPDS (≥10) | 0 | 38 (23.5) | 52 (23.5) | 223 |
Perzow et al. [ |
USA | Prospective cohort | 31.81 | - | EPDS (≥10) | - | - | 45 (33.3) | 135 |
Racine et al. [ |
Canada | Prospective cohort | - | - | CES-D-10 (≥10) | 458 (35.21) | - | 458 (35.21) | 1,301 |
Sade et al. [ |
Israel | Cross-sectional | - | - | EPDS (≥10) | 84 (25) | - | 21 (25) | 84 |
Silverman et al. [ |
New York, USA | Cohort | 27 | 27.3 | EPDS (≥9) | - | 97 (18.8) | 97 (18.8) | 516 |
Suárez-Rico et al. [ |
Mexico | Cross-sectional | 29.9 | EPDS (≥13) | - | 115 (39.2) | 115 (39.2) | 293 | |
Sun et al. [ |
Wuhan, China | Cross-sectional | - | - | EPDS | 234 (31.7) | 714 (34.1) | 972 (33.71) | 2,830 |
Kahyaoglu Sut and Kucukkaya [ |
Turkey | Cross-sectional | 28.2 | - | HADS-D (≥8) | 227 (56.3) | - | 227 (56.3) | 403 |
Thayer et al. [ |
USA | Cross-sectional | - | - | EPDS (≥15) | 496 (23.6) | - | 496 (23.6) | 2,099 |
Tsakiridis et al. [ |
Greece | Cross-sectional | - | 25.4 | EPDS (≥13) | 68 (13.5) | - | 68 (13.5) | 505 |
Wang et al. [ |
China | Cross-sectional | - | - | PHQ-9 (>5) | 6,723 (43.6) | - | 6,723 (43.6) | 15,328 |
Wu et al. [ |
China | Cross-sectional | - | 39.41 | EPDS (≥10) | 381 (29.6) | - | 381 (29.6) | 1,285 |
Xu et al. [ |
China | Cross-sectional | 30.4 | - | EPDS (≥10) | 44 (16.1) | - | 44 (16.1) | 274 |
Yang et al. [ |
China | Cross-sectional | - | - | PHQ-9 (≥5) | 8,712 (44.6) | - | 8,712 (44.6) | 19,515 |
Zanardo et al. [ |
Northeastern Italy | Case–control | 33.73 | - | EPDS (>12) | - | 26 (28.6) | 26 (28.6) | 91 |
Zeng et al. [ |
China | Cross-sectional | 29.2 | - | EPDS | 109 (21.12) | 11 (10.1) | 625 (19.2) | 625 |
Zhang et al. [ |
China | Cross-sectional | 28.9 | - | EPDS (≥10) | 1,094 (58) | - | 1,094 (58) | 1,901 |
Zhou et al. [ |
China | Cross-sectional | 29.95 | - | PHQ-9 | 527 (41.63) | - | 527 (41.63) | 1,266 |
Zilver et al. [ |
The Netherlands | Cohort | 32.02 | - | HADS-D (≥8) | 145 (13.2) | - | 145 (13.2) | 1,102 |
MA, maternal age; GA, gestational age; EPDS, edinburgh postnatal depression scale; PHQ, patient health questionnaire; K-10, kessler psychological distress scale; EDS, Edinburgh depression scale; SDS, self-depression rating scale; DASS, depression anxiety and stress scale; CES-D-10, the 10 item center for epidemiologic studies depression scale; HADS, hospital anxiety and depression scale-depression.
Criteria of the new Ottawa scale scoring
Score | |
---|---|
1. Validated measure | |
Was the measure of depression or anxiety clearly defined, valid, reliable, and implemented consistently across all study participants? | 0=no, 1=yes |
2. Peer review | |
Was the study published in a journal (i.e., peer reviewed) | 0=no (unpublished), 1=yes |
3. Response rate | |
Was the participation rate of eligible persons at least 50%? |
0=no, 1=yes |
4. Objectivity of measure | |
Does the study rely on self-report of depression or anxiety symptoms, or does it use an objective measure (i.e., diagnostic interview)? | 0=self-report, 1=diagnostic interview |
5. Exposure time | |
Was the measurement time frame of anxiety or depression sufficient so that one could reasonably expect to see an association between COVID-19 and any symptoms if they existed (i.e., at least one week since the onset of COVID-19 in the country in which the study was conducted)? | 0=no, 1=yes |
6. Representativeness of the sample | |
Was the sample truly representative of the target population? | 0=no, 1=yes |
Adapted from the National Institutes of Health (NIH) assessment tool for observational cohort and cross-sectional studies and the Newcastle-Ottawa quality assessment scale for cross-sectional studies.
New Ottawa scale of the studies included in this review
Study | Validated measure | Published | Response rate | Measure objectivity | Sufficient exposure | Representative Sample | Total |
---|---|---|---|---|---|---|---|
Ahlers-Schmidt et al. [ |
Yes | Yes | Yes | Yes | Yes | No | 5 |
An et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Basu et al. [ |
Yes | Yes | No | No | Yes | No | 3 |
Berthelot et al. [ |
Yes | Yes | Yes | No | Yes | Yes | 5 |
Brik et al. [ |
Yes | Yes | Yes | No | Yes | Yes | 5 |
Ceulemans et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Chrzan-Dętkoś et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Dong et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Durankuş et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Fallon et al. [ |
Yes | Yes | Unknown | No | Yes | Unknown | 3 |
Farewell et al. [ |
Yes | Yes | Yes | No | Yes | No | 3 |
Farrell et al. [ |
Yes | Yes | Unknown | No | Yes | Yes | 4 |
Gur et al. [ |
Yes | Yes | No | No | Yes | Yes | 4 |
Hiiragi et al. [ |
Yes | Yes | Yes | No | Yes | No | 3 |
Hui et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Janevic et al. [ |
Yes | Yes | No | No | Yes | Unknown | 3 |
Jiang et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Khamees et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
King et al. [ |
Yes | Yes | No | No | Yes | No | 3 |
Lebel et al. [ |
Yes | Yes | Unknown | No | Yes | No | 4 |
Li et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Li et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Liang et al. [ |
Yes | Yes | Yes | No | Yes | No | 3 |
Lin et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Liu et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Lubián López et al. [ |
Yes | Yes | Unknown | No | Yes | Unknown | 3 |
Matsushima and Horiguchi [ |
Yes | Yes | No | No | Yes | No | 3 |
Medina-Jimenez et al. [ |
Yes | Yes | Yes | No | Yes | Yes | 5 |
Mo et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Molgora et al. [ |
Yes | Yes | Yes | No | Yes | Unknown | 4 |
Ng et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Nodoushan et al. [ |
Yes | Yes | Unknown | No | Yes | Yes | 4 |
Obata et al. [ |
Yes | Yes | Yes | No | Yes | Yes | 5 |
Oskovi-Kaplan et al. [ |
Yes | Yes | No | No | Yes | No | 3 |
Ostacoli et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Pariente et al. [ |
Yes | Yes | Yes | No | Yes | Unknown | 4 |
Perzow et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Racine et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Sade et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Silverman et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Suárez-Rico et al. [ |
Yes | Yes | Yes | No | Yes | Yes | 5 |
Sun et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Kahyaoglu Sut and Kucukkaya [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Thayer et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Tsakiridis et al. [ |
Yes | Yes | Yes | No | Yes | Unknown | 4 |
Wang et al. [ |
Yes | Yes | Unknown | No | Yes | Yes | 4 |
Wu et al. [ |
Yes | Yes | Unknown | No | Yes | Yes | 4 |
Xu et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Yang et al. [ |
Yes | Yes | Yes | No | Yes | Yes | 5 |
Zanardo et al. [ |
Yes | Yes | Yes | No | Yes | No | 4 |
Zeng et al. [ |
Yes | Yes | Yes | No | Yes | Yes | 5 |
Zhang et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Zhou et al. [ |
Yes | Yes | Unknown | No | Yes | No | 3 |
Zilver et al. [ |
Yes | Yes | Unknown | No | Yes | Yes | 4 |