The Open Public Health Journal




ISSN: 1874-9445 ― Volume 13, 2020
SYSTEMATIC REVIEW

A Systematic Review and Meta-analysis of Depression in Postpartum Women in a Low-income Country; Ethiopia, 2020



Mogesie Necho1, *, Merid Abadisharew2, Yemiyamirew Getachew1
1 Department of Psychiatry, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
2 Department of Sociology, College of Social Science and Humanities, Wollo University, Dessie, Ethiopia

Abstract

Background:

Maternal mental health in the postpartum period is essential for the optimal development of the newborn. Despite this, a shortage of concrete evidence exists regarding it.

Methods:

PubMed, Scopus, and EMBASE were investigated with no time limitation. A manual search for a reference list of articles was also done. Relevant data were extracted using the Meta XL package and analysis was done using Stata-11 meta-prop package. Heterogeneity was checked with Cochran's Q-statistics and the Higgs I 2 test.

Results:

Sixteen studies were included. The average prevalence of postpartum depression was 21.9%. The pooled prevalence was found to be higher in studies assessed with SRQ-20, i.e 24.6% than studies assessed using PHQ-9, which was 18.9%. Moreover, the pooled prevalence was slightly higher in southern Ethiopia (22.6%) than Addis Ababa (21.2%). Poor marital relation (pooled aOR= 3.56) (95% CI: 2.50, 4.63), unplanned pregnancy (pooled aOR=3.48) (95% CI: 2.18, 4.79), previous history of depression (pooled aOR= 4.33) (95% CI: 2.26, 6.59), poor social support (pooled aOR= 4.5) (95% CI: 3.34, 5.56), and domestic violence were among the associated factors for postpartum depression.

Conclusion:

More than one in five women were found to have postpartum depression and factors such as poor marital relations, history of depression, poor social support, domestic violence, and unplanned pregnancy were observed to be associated with it. Therefore, maternal postnatal care services should integrate this essential health concern.

Keywords: Postpartum depression, A low-income country, Ethiopia, Poor social support, Heterogeneity, Risk groups.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 13
First Page: 595
Last Page: 610
Publisher Id: TOPHJ-13-595
DOI: 10.2174/1874944502013010595

Article History:

Received Date: 05/06/2020
Revision Received Date: 15/08/2020
Acceptance Date: 16/08/2020
Electronic publication date: 13/11/2020
Collection year: 2020

© 2020 Necho et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Department of Psychiatry, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia; E-mail: nechomoges2014@gmail.com





1. BACKGROUND

Women with depression in the postpartum period show manifestations like sleep disturbance, change in appetite patterns, feeling of sadness, recurrent guilty feeling, crying, low energy, and unease feelings of anxiety and suicidal ideas [1Coast E, Leone T, Hirose A, Jones E. Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries. Health Place 2012; 18(5): 1188-97.
[http://dx.doi.org/10.1016/j.healthplace.2012.05.004] [PMID: 22749341]
]. Nowadays, postpartum depression plays a major role in the burden of disease among women of 15 to 49 years of age [2Edition F. Diagnostic and statistical manual of mental disorders 2013.]. Globally,10-20% of postnatal women develop depression at one point in time [3Salem MN, Thabet MN, Fouly H, Abbas AM. Factors affecting the occurrence of postpartum depression among puerperal women in Sohag city, Egypt. Proceedings in Obstetrics and Gynecology 2017; 7(1): 1-10.
[http://dx.doi.org/10.17077/2154-4751.1328]
]. A survey by the World Health Organization (WHO) identified that 20-40% of childbearing women in the developing world sustained depression in the antepartum and postpartum period at a given time [4Khalifa DS, Glavin K, Bjertness E, Lien L. Postnatal depression among Sudanese women: prevalence and validation of the Edinburgh Postnatal Depression Scale at 3 months postpartum. Int J Womens Health 2015; 7: 677-84.
[http://dx.doi.org/10.2147/IJWH.S81401] [PMID: 26185471]
]. Besides, 19% of postnatal women in low and middle-income countries [5Parsons CE, Young KS, Rochat TJ, Kringelbach ML, Stein A. Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries. Br Med Bull 2012; 101(1): 57-79.
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[http://dx.doi.org/10.1111/j.1447-0349.2010.00671.x] [PMID: 20550644]
] develop postpartum depression.

Different studies across the world have reported different prevalence rates for postpartum depression.

A systematic review and meta-analysis study in 2018 by S Shorey et al. [8Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. J Psychiatr Res 2018; 104: 235-48.
[http://dx.doi.org/10.1016/j.jpsychires.2018.08.001] [PMID: 30114665]
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[http://dx.doi.org/10.1016/S2215-0366(16)30284-X] [PMID: 27650773]
] reported 19.2% of women as having postpartum depression. Another systematic review and meta-analysis study in India which assessed 38 studies reported a pooled prevalence of postpartum depression to be 22% [10Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
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[http://dx.doi.org/10.1016/j.midw.2011.05.001] [PMID: 21601966]
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[http://dx.doi.org/10.1111/j.1552-6909.2006.00007.x] [PMID: 16466357]
], intimate partner violence [22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
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, 56Mendonça MFSd. Depression and associated factors among women within their first postnatal year in Erzurum province in eastern Turkey. Women & health 2017; 41(2): 1-12.], poor education of the husband [45Rahman A, Creed F. Outcome of prenatal depression and risk factors associated with persistence in the first postnatal year: prospective study from Rawalpindi, Pakistan. J Affect Disord 2007; 100(1-3): 115-21.
[http://dx.doi.org/10.1016/j.jad.2006.10.004] [PMID: 17098291]
], husbands' unemployment [46Andajani-Sutjahjo S, Manderson L, Astbury J. Complex emotions, complex problems: understanding the experiences of perinatal depression among new mothers in urban Indonesia. Cult Med Psychiatry 2007; 31(1): 101-22.
[http://dx.doi.org/10.1007/s11013-006-9040-0] [PMID: 17205386]
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[http://dx.doi.org/10.1007/s001270200004] [PMID: 11990009]
] were among the associated factors for the development of postpartum depression. In the context of Ethiopia too, poor marital relation [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 29Kerie S, Menberu M, Niguse W. Prevalence and associated factors of postpartum depression in Southwest, Ethiopia, 2017: a cross-sectional study. BMC Res Notes 2018; 11(1): 623.
[http://dx.doi.org/10.1186/s13104-018-3730-x] [PMID: 30157909]
, 32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
, 35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
], unplanned pregnancy [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 29Kerie S, Menberu M, Niguse W. Prevalence and associated factors of postpartum depression in Southwest, Ethiopia, 2017: a cross-sectional study. BMC Res Notes 2018; 11(1): 623.
[http://dx.doi.org/10.1186/s13104-018-3730-x] [PMID: 30157909]
, 32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], previous history of depression [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27, 28, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], domestic violence [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22, 27, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], poor social support [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 32-35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
], and family history of mental illness [24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 28, 31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia ] were among the documented factors responsible for the development of Postpartum Depression (PPD).

Postpartum depression in women has a great impact on the health of both the mother and her baby. Early discontinuation of breastfeeding [60Field T. Postpartum depression effects on early interactions, parenting, and safety practices: a review. Infant Behav Dev 2010; 33(1): 1-6.
[http://dx.doi.org/10.1016/j.infbeh.2009.10.005] [PMID: 19962196]
], negative emotion and poor health care utilization [61Feldman R, Granat A, Pariente C, Kanety H, Kuint J, Gilboa-Schechtman E. Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity. J Am Acad Child Adolesc Psychiatry 2009; 48(9): 919-27.
[http://dx.doi.org/10.1097/CHI.0b013e3181b21651] [PMID: 19625979]
], cognitive impairment, and behavioral defects [62Grace SL, Evindar A, Stewart DE. The effect of postpartum depression on child cognitive development and behavior: a review and critical analysis of the literature. Arch Women Ment Health 2003; 6(4): 263-74.
[http://dx.doi.org/10.1007/s00737-003-0024-6] [PMID: 14628179]
], poor mother-infant bonding resulting in rejection of the infant [63Brockington IF, Aucamp HM, Fraser C. Severe disorders of the mother-infant relationship: definitions and frequency. Arch Women Ment Health 2006; 9(5): 243-51.
[http://dx.doi.org/10.1007/s00737-006-0133-0] [PMID: 16699838]
], and suicidal behaviors [64Caparros-Gonzalez RA, Romero-Gonzalez B, Strivens-Vilchez H, Gonzalez-Perez R, Martinez-Augustin O, Peralta-Ramirez MI. Hair cortisol levels, psychological stress and psychopathological symptoms as predictors of postpartum depression. PLoS One 2017; 12(8)e0182817
[http://dx.doi.org/10.1371/journal.pone.0182817] [PMID: 28846691]
] are common complications leading to postpartum depression. Furthermore, a community-based cross-sectional study in Ethiopia [23Anato A, Baye K, Tafese Z, Stoecker BJ. Maternal depression is associated with child undernutrition: A cross-sectional study in Ethiopia. Matern Child Nutr 2020; 16(3)e12934
[http://dx.doi.org/10.1111/mcn.12934] [PMID: 31833231]
] revealed that maternal postnatal depression strongly affects a child's nutritional status leading to stunting and underweight as well as inappropriate complementary feeding practices of infants.

Even though maternal mental health problems in the postpartum period are much more prominent in poorly developed nations including Ethiopia, there still exists a gap in the pooled magnitude of postpartum depression and the associated factors. The objective of the present meta-analysis was, therefore [1Coast E, Leone T, Hirose A, Jones E. Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries. Health Place 2012; 18(5): 1188-97.
[http://dx.doi.org/10.1016/j.healthplace.2012.05.004] [PMID: 22749341]
] to determine the pooled estimated prevalence of postpartum depression among women in the postnatal period in Ethiopia and [2Edition F. Diagnostic and statistical manual of mental disorders 2013.]: to determine the pooled odds ratio of the associated factors for postpartum depression in Ethiopia.

2. MATERIALS AND METHODS

2.1. Search Strategy

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [65Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4(1): 1.
[http://dx.doi.org/10.1186/2046-4053-4-1] [PMID: 25554246]
], we performed both an electronic and manual search of eligible articles. Our search of electronic libraries in Scopus, PubMed, and EMBASE and manual exploration of the reference list of articles was the backbone of the current meta-analysis. For searching articles on postpartum depression among women in the postnatal period using the PubMed database, we used the following search terms: (Prevalence OR Epidemiology OR magnitude AND depression OR PPD OR “depressive disorder” AND mothers OR females OR women AND postpartum period AND factor OR “risk factor” OR determinant AND Ethiopia). Besides, the search for literature in EMBASE and Scopus was done according to database-specific searching guidelines. Furthermore, the reference list of included studies was made and there was no specification for studies based on the study period.

2.2. Eligibility Criteria

Data refining was done according to the inclusion and exclusion criteria. Articles were eligible for inclusion if [1Coast E, Leone T, Hirose A, Jones E. Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries. Health Place 2012; 18(5): 1188-97.
[http://dx.doi.org/10.1016/j.healthplace.2012.05.004] [PMID: 22749341]
] they assessed the outcome of interest among women in the postpartum period, [2Edition F. Diagnostic and statistical manual of mental disorders 2013.] their primary outcome of interest was the prevalence of postpartum depression and its associated factors, [3Salem MN, Thabet MN, Fouly H, Abbas AM. Factors affecting the occurrence of postpartum depression among puerperal women in Sohag city, Egypt. Proceedings in Obstetrics and Gynecology 2017; 7(1): 1-10.
[http://dx.doi.org/10.17077/2154-4751.1328]
] the design of the study was community and institution-based cross-sectional, case-control and cohort study design, [3Salem MN, Thabet MN, Fouly H, Abbas AM. Factors affecting the occurrence of postpartum depression among puerperal women in Sohag city, Egypt. Proceedings in Obstetrics and Gynecology 2017; 7(1): 1-10.
[http://dx.doi.org/10.17077/2154-4751.1328]
] and [4Khalifa DS, Glavin K, Bjertness E, Lien L. Postnatal depression among Sudanese women: prevalence and validation of the Edinburgh Postnatal Depression Scale at 3 months postpartum. Int J Womens Health 2015; 7: 677-84.
[http://dx.doi.org/10.2147/IJWH.S81401] [PMID: 26185471]
] the study has been piloted in Ethiopia. Previously studied reviews, studies on women with an already known psychiatric problem, studies on animals, editorials, and studies reporting depression solely during pregnancy were excluded. MN and YG screened the topics and abstracts of searched articles stored in an endnote reference manager depending on the primary and pre-specified eligibility criteria independently. After that, the next stage was a detailed exploration of the screened articles in the first step by the two review authors stated above. Any disagreement between the two authors regarding the eligibility of articles was settled through discussion in line with available logical evidence.

2.3. Methods for Data Extraction and Quality Assessment

The two authors (MN and MA) extracted the relevant data from the articles included in the final analysis autonomously using a standardized data extracted template. The included studies were extracted and summarized in the form of a table. Information that was extracted and has been summarized in the table includes the author's name, publication year, study setting, study population, sample size, study design, and the assessment instrument for postpartum depression. Data from incorporated studies was extracted based on a template structured as suggested by PRISMA guidelines [65Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4(1): 1.
[http://dx.doi.org/10.1186/2046-4053-4-1] [PMID: 25554246]
].

The modified Newcastle-Ottawa Scale (NOS) [66Stang 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.
[http://dx.doi.org/10.1007/s10654-010-9491-z] [PMID: 20652370]
] was employed for the evaluation of the quality of studies. The domains of the NOS scale for assessing the quality of studies include comparability between participants, representativeness of sample and sample size, statistical quality as well as ascertainment of cases.

2.4. Data Synthesis and Analysis

In this study, we employed a random-effect model to evaluate the aggregate prevalence of postpartum depression and the associated factors for postpartum depression with their 95% CIs [67Doi SA, Thalib L. A quality-effects model for meta-analysis. Epidemiology 2008; 19(1): 94-100.
[http://dx.doi.org/10.1097/EDE.0b013e31815c24e7] [PMID: 18090860]
]. Meta-XL version 5.3 [68Barendregt JJ, Doi SA. MetaXL user guide. Version 2016; 4: 2011-6.] was employed to extract relevant data from included studies and the STATA11 Meta-prop package [69Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health 2014; 72(1): 39.
[http://dx.doi.org/10.1186/2049-3258-72-39] [PMID: 25810908]
] was implemented to estimate the pooled prevalence of postpartum depression and pooled odds ratio of the associated factors for Postpartum depression. Cochran Q-statistics and Higgs I2 statistics [70Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21(11): 1539-58.
[http://dx.doi.org/10.1002/sim.1186] [PMID: 12111919]
] were also used to diagnose heterogeneity. The I2 statistical values of zero, 25, 50, and 75% connote absence, little, moderate, and great heterogeneity, respectively [70Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21(11): 1539-58.
[http://dx.doi.org/10.1002/sim.1186] [PMID: 12111919]
]. Furthermore, subgroup analysis and sensitivity analysis tests were also done to explore the source of heterogeneity between the included studies. A funnel plot test [71Liu JL. The role of the funnel plot in detecting publication and related biases in meta-analysis. Evid Based Dent 2011; 12(4): 121-2.
[http://dx.doi.org/10.1038/sj.ebd.6400831] [PMID: 22193659]
] and eggers publication bias test were used to detect publication bias.

3. RESULTS

3.1. Identification of Studies

Our search with the pre-specified search strategies resulted in an overall of 845 articles. Besides, 5 articles were obtained from the reference list of included articles making the total number of retrieved articles to be 850. Of this, we removed 24 duplicated studies before further screening. In the next stage, we excluded 789 of the articles simply by observing their titles. Therefore the leftover 37 articles had been completely inspected for eligibility to be included in the current systematic review and meta-analysis study; nevertheless, only 16 articles were tailored in the final meta-analysis since the rest 21 articles were also excluded due to various methodological and technical flaws (Fig. 1).

3.2. Characteristics of Included Studies

In this meta-analysis, a total of sixteen studies that assessed the prevalence of postpartum depression [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
-36Azale T, Fekadu A, Medhin G, Hanlon C. Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study. BMC Psychiatry 2018; 18(1): 41.
[http://dx.doi.org/10.1186/s12888-018-1624-z] [PMID: 29422037]
] and fourteen studies that assessed the associated factors [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 26Bitew T, Hanlon C, Kebede E, Honikman S, Fekadu A. Antenatal depressive symptoms and perinatal complications: a prospective study in rural Ethiopia. BMC Psychiatry 2017; 17(1): 301.
[http://dx.doi.org/10.1186/s12888-017-1462-4] [PMID: 28830395]
-35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] had been analyzed. A total of 11400 postpartum women had participated in this analysis. Region-wise, six [26Bitew T, Hanlon C, Kebede E, Honikman S, Fekadu A. Antenatal depressive symptoms and perinatal complications: a prospective study in rural Ethiopia. BMC Psychiatry 2017; 17(1): 301.
[http://dx.doi.org/10.1186/s12888-017-1462-4] [PMID: 28830395]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 29Kerie S, Menberu M, Niguse W. Prevalence and associated factors of postpartum depression in Southwest, Ethiopia, 2017: a cross-sectional study. BMC Res Notes 2018; 11(1): 623.
[http://dx.doi.org/10.1186/s13104-018-3730-x] [PMID: 30157909]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
, 36Azale T, Fekadu A, Medhin G, Hanlon C. Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study. BMC Psychiatry 2018; 18(1): 41.
[http://dx.doi.org/10.1186/s12888-018-1624-z] [PMID: 29422037]
, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
], six [22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
-25Baumgartner JN, Parcesepe A, Mekuria YG, et al. Maternal mental health in Amhara region, Ethiopia: a cross-sectional survey. Glob Health Sci Pract 2014; 2(4): 482-6.
[http://dx.doi.org/10.9745/GHSP-D-14-00119] [PMID: 25611481]
, 32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
, 35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
], three [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia , 33Tefera TB, Erena AN, Kuti KA, Hussen MA. Perinatal depression and associated factors among reproductive aged group women at Goba and Robe Town of Bale Zone, Oromia Region, South East Ethiopia. Matern Health Neonatol Perinatol 2015; 1(1): 12.
[http://dx.doi.org/10.1186/s40748-015-0013-6] [PMID: 27057329]
], one [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
] and one [30Mariam D, Dessalegn B, Tadesse Z, Siyoum D. Assessment of prevalence and associated factors of postpartum depression among postpartum mothers in Eastern zone of Tigray. Eur J Pharm Med Res 2016; 10(3): 54-60.] of the studies were from the southern part of Ethiopia, Amhara region, Oromia region, Addis Ababa and Tigray, respectively. Of included studies, three [26Bitew T, Hanlon C, Kebede E, Honikman S, Fekadu A. Antenatal depressive symptoms and perinatal complications: a prospective study in rural Ethiopia. BMC Psychiatry 2017; 17(1): 301.
[http://dx.doi.org/10.1186/s12888-017-1462-4] [PMID: 28830395]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
, 36Azale T, Fekadu A, Medhin G, Hanlon C. Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study. BMC Psychiatry 2018; 18(1): 41.
[http://dx.doi.org/10.1186/s12888-018-1624-z] [PMID: 29422037]
], ten [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
-24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 29Kerie S, Menberu M, Niguse W. Prevalence and associated factors of postpartum depression in Southwest, Ethiopia, 2017: a cross-sectional study. BMC Res Notes 2018; 11(1): 623.
[http://dx.doi.org/10.1186/s13104-018-3730-x] [PMID: 30157909]
-32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
, 35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
], and another three [25Baumgartner JN, Parcesepe A, Mekuria YG, et al. Maternal mental health in Amhara region, Ethiopia: a cross-sectional survey. Glob Health Sci Pract 2014; 2(4): 482-6.
[http://dx.doi.org/10.9745/GHSP-D-14-00119] [PMID: 25611481]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 33Tefera TB, Erena AN, Kuti KA, Hussen MA. Perinatal depression and associated factors among reproductive aged group women at Goba and Robe Town of Bale Zone, Oromia Region, South East Ethiopia. Matern Health Neonatol Perinatol 2015; 1(1): 12.
[http://dx.doi.org/10.1186/s40748-015-0013-6] [PMID: 27057329]
] utilized PHQ-9, EPDS, and SRQ-20 to assess depression in the postnatal women. Besides regarding the design of the study, eight [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 23Anato A, Baye K, Tafese Z, Stoecker BJ. Maternal depression is associated with child undernutrition: A cross-sectional study in Ethiopia. Matern Child Nutr 2020; 16(3)e12934
[http://dx.doi.org/10.1111/mcn.12934] [PMID: 31833231]
, 25Baumgartner JN, Parcesepe A, Mekuria YG, et al. Maternal mental health in Amhara region, Ethiopia: a cross-sectional survey. Glob Health Sci Pract 2014; 2(4): 482-6.
[http://dx.doi.org/10.9745/GHSP-D-14-00119] [PMID: 25611481]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
-34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
, 36Azale T, Fekadu A, Medhin G, Hanlon C. Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study. BMC Psychiatry 2018; 18(1): 41.
[http://dx.doi.org/10.1186/s12888-018-1624-z] [PMID: 29422037]
], seven [22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 29Kerie S, Menberu M, Niguse W. Prevalence and associated factors of postpartum depression in Southwest, Ethiopia, 2017: a cross-sectional study. BMC Res Notes 2018; 11(1): 623.
[http://dx.doi.org/10.1186/s13104-018-3730-x] [PMID: 30157909]
-31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia , 35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
] and one [26Bitew T, Hanlon C, Kebede E, Honikman S, Fekadu A. Antenatal depressive symptoms and perinatal complications: a prospective study in rural Ethiopia. BMC Psychiatry 2017; 17(1): 301.
[http://dx.doi.org/10.1186/s12888-017-1462-4] [PMID: 28830395]
] were community-based cross-sectional, institution-based cross-sectional and cohort studies in their respective order. Besides, six of the studies [23Anato A, Baye K, Tafese Z, Stoecker BJ. Maternal depression is associated with child undernutrition: A cross-sectional study in Ethiopia. Matern Child Nutr 2020; 16(3)e12934
[http://dx.doi.org/10.1111/mcn.12934] [PMID: 31833231]
, 25Baumgartner JN, Parcesepe A, Mekuria YG, et al. Maternal mental health in Amhara region, Ethiopia: a cross-sectional survey. Glob Health Sci Pract 2014; 2(4): 482-6.
[http://dx.doi.org/10.9745/GHSP-D-14-00119] [PMID: 25611481]
, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 30Mariam D, Dessalegn B, Tadesse Z, Siyoum D. Assessment of prevalence and associated factors of postpartum depression among postpartum mothers in Eastern zone of Tigray. Eur J Pharm Med Res 2016; 10(3): 54-60., 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
] employed a multi-stage sampling method during data collection. All of the studies have reported a response rate for the study (Table 1) [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
-36Azale T, Fekadu A, Medhin G, Hanlon C. Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study. BMC Psychiatry 2018; 18(1): 41.
[http://dx.doi.org/10.1186/s12888-018-1624-z] [PMID: 29422037]
].

Fig. (1)
PRISMA flow chart for the review search process.


Table 1
Characteristics of studies on postpartum depression which are incorporated in this meta-analysis according to author first name, year of publication, setting of study, design, sample size, assessment instrument, study population and magnitude of postpartum depression and sampling metho1Coast E, Leone T, Hirose A, Jones E. Poverty and postnatal depression: a systematic mapping of the evidence from low and lower middle income countries. Health Place 2012; 18(5): 1188-97.
[http://dx.doi.org/10.1016/j.healthplace.2012.05.004] [PMID: 22749341]
ds, response rate.



3.3. Quality of Included Studies

For assessing the quality of included studies, we used the modified Newcastle Ottawa quality assessment as a gold standard. The quality of the studies varied from 7 to 10, implying that none of the studies were of poor quality. One of the studies was of moderate quality [31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia ] and the remaining fifteen were of good quality (Table 2).

Table 2
Quality assessment result of the studies included in this meta-analysis.


3.4. The Pooled Prevalence of Postpartum Depression in this Study

Sixteen studies [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
-36Azale T, Fekadu A, Medhin G, Hanlon C. Coping strategies of women with postpartum depression symptoms in rural Ethiopia: a cross-sectional community study. BMC Psychiatry 2018; 18(1): 41.
[http://dx.doi.org/10.1186/s12888-018-1624-z] [PMID: 29422037]
] were incorporated to yield the pooled estimated effect size of postpartum depression. The reported magnitude of postpartum depression among the included studies ranged from 12.2%(36) to 33.8% (29). The average estimated prevalence of postpartum depression using the random effect model was 21.9% (95% CI: 18.98, 24.77). This average prevalence of postpartum depression was found to differ(I2 = 98%, p-value =0.000) from the included studies (Fig. 2).

3.5. Subgroup Analysis of the Prevalence of Postpartum Depression by the Tools used to Measure Postpartum Depression.

Since the average prevalence of postpartum depression was significantly influenced by the difference between the included studies, it was mandatory to conduct a subgroup analysis. Therefore, we used the measurement tools for postpartum depression to perform subgroup analysis. The subgroup analysis by assessment instrument yields that measurement with SRQ-20 provided significantly higher result, 24.6%% (95% CI: 18.42, 30.84) with (I2 =98%, p < 0.001) than the result with PHQ-9 which was 18.9% (95% CI: 11.52, 26.28) (I2 =99%, p < 0.001) (Fig. 3).

3.6. Sub-group Analysis of the Prevalence of Postpartum Depression taking into Account the Setting of the Study.

Although a subgroup analysis was done based on the setting where the study was done, there was no significant difference in the pooled prevalence of postpartum depression between community-based studies (22%) and institution-based studies (21.7%).

3.7. Sub-group Analysis of the Prevalence of Postpartum Depression with Regard to the Regional Location of the Study.

The pooled prevalence of post-partum depression was slightly higher in studies from the southern part of Ethiopia (22.6%) than the central region (Addis Ababa) (21.2%) and this difference was also significant statistically (p =0.001).

3.8. Sensitivity Analysis

We performed a leave one out sensitivity analysis to detect the source of heterogeneity. However, our result showed that the average prevalence of postpartum depression when each study was left out from the analysis ranged from 21.08% (18.47, 23.68) to 22.52% (20.34, 24.69). Therefore, the result was not outweighed by the influence of a single study (Table 3).

Fig. (2)
A forest plot for the prevalence of postpartum depression in Ethiopia.


Table 3
A sensitivity analysis of the prevalence of postpartum depression in women at postnatal period when each indicated studies are removed at a time with its 95% confidence interval.


Fig. (3)
A forest plot for the sub-group analysis of the prevalence of postpartum depression by measurement tool used.


3.9. Publication Bias

A scatter plot of the logit event rate of postpartum depression on the X-axis and its standard error on the Y-axis was done, which showed that there was a publication bias since the graph was slightly asymmetrical (Fig. 4). However, the eggers publication bias test revealed that there was no significant publication bias (B=71.2, SE = 44 and P-value = 0.13).

Fig. (4)
A funnel plot for the pooled adjusted odds ratio of poor marital relationship.


3.10. Associated Factors for Postpartum Depression in Ethiopian Women

As stated previously, fourteen studies [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 26Bitew T, Hanlon C, Kebede E, Honikman S, Fekadu A. Antenatal depressive symptoms and perinatal complications: a prospective study in rural Ethiopia. BMC Psychiatry 2017; 17(1): 301.
[http://dx.doi.org/10.1186/s12888-017-1462-4] [PMID: 28830395]
-35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] had reported one or more factors related to the development of depression in postnatal women. Our narrative synthesis revealed that poor marital relation [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 29Kerie S, Menberu M, Niguse W. Prevalence and associated factors of postpartum depression in Southwest, Ethiopia, 2017: a cross-sectional study. BMC Res Notes 2018; 11(1): 623.
[http://dx.doi.org/10.1186/s13104-018-3730-x] [PMID: 30157909]
, 32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
, 35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
], unplanned pregnancy [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 29Kerie S, Menberu M, Niguse W. Prevalence and associated factors of postpartum depression in Southwest, Ethiopia, 2017: a cross-sectional study. BMC Res Notes 2018; 11(1): 623.
[http://dx.doi.org/10.1186/s13104-018-3730-x] [PMID: 30157909]
, 32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], previous history of depression [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], domestic violence [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], poor social support [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 32Shitu S, Geda B, Dheresa M. Postpartum depression and associated factors among mothers who gave birth in the last twelve months in Ankesha district, Awi zone, North West Ethiopia. BMC Pregnancy Childbirth 2019; 19(1): 435.
[http://dx.doi.org/10.1186/s12884-019-2594-y] [PMID: 31752760]
-35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
], family history of mental illness [34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia ], use of substance [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
] and low income [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] were among the most commonly reported factors contributing to development of postpartum depression in postnatal women (Table 4).

The pooled odds ratio of the poor marital relationship among the above-mentioned studies was 3.56 (95% CI: 2.50, 4.63) (Fig. 5). This implied that women with poor marital relationships were 3.56 times at higher risk of developing PPD than women with good marital relationships. Also, the pooled odds ratio for unplanned pregnancy for the nine studies reported above was found to be 3.48 (95% CI: 2.18, 4.79) (Fig. 6). This showed that women who gave birth from an unplanned pregnancy were 3.5 times more likely to be depressed than women with a planned pregnancy. The previous history of depression was also an associated factor for the development of PPD with a pooled estimate odds ratio of 4.33 (95% CI: 2.26, 6.59); [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
]. Besides, domestic violence and poor social support were also found to have a significant association with the development of PPD with the estimated pooled odds ratio of 3.77 (95% CI:2.62, 4.92) [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22, 27, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], 4.5 (95% CI: 3.34, 5.56) [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 32-35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
], respectively.

Furthermore, the pooled odds ratio of family history of mental illness [24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 28, 31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia ], use of substance [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
] and low income [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 28, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
], stressful life event[22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] and perinatal complications [28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] was 4 (95% CI:1.56, 6.56), 4.67(95% CI:4.00, 5.34), 2.87 (95% CI: 1.59, 4.14), 3.5 (95% CI: 1.39, 5.87) and 3.8 (95% CI: 1.45, 6.15), respectively (Table 5).

Table 4
Characteristics of associated factors for postpartum depression in Ethiopia by their Odds ratio, Confidence interval, association strength, author and year of publication.


Fig. (5)
A forest plot for the pooled adjusted odds ratio of poor marital relationship.


Fig. (6)
A forest plot for the pooled adjusted odds ratio of unplanned pregnancy.


Table 5
Pooled estimate of the associated factors for postpartum depression in Ethiopia.


4. DISCUSSION

To date, this review and meta-analysis on depression and the related factors in women in the postnatal period are the first of its kind in the context of Ethiopia. Therefore, the pooled effect size of postpartum depression and related factors would be an added advantage for the scientific community and other diverse stakeholders who intend to intervene in this significant public health issue. We gathered data from a total of 11400 postpartum women and a total of sixteen studies from both institutional and community settings and the estimated pooled prevalence of postpartum depression was found to be 21.9% (95% CI: 18.98, 24.77).

The result of the pooled estimated prevalence of postpartum depression in this study (21.9%) was in line with a systematic review and meta-analysis on depression in the postpartum period in India (22%) which analyzed 38 studies and 20043 women [10Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
[http://dx.doi.org/10.2471/BLT.17.192237] [PMID: 29147043]
]. It was also consistent with the result of a systematic review and meta-analysis study on women from low and middle-income countries which assessed 34 studies and 19.8% of them were found to have a postpartum common mental disorder [9Fisher J. 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: 139-49.]. Furthermore, another study that incorporated 38412 women and 23 studies from low and middle-income countries [6Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016; 3(10): 973-82.
[http://dx.doi.org/10.1016/S2215-0366(16)30284-X] [PMID: 27650773]
] reported 19.2% of women as having postpartum depression, which was also supportive of the current finding.

However, the result of the pooled estimated prevalence of postpartum depression in Ethiopia exceeds the worldwide estimated prevalence of postpartum depression, such as 17% reported in 2018 by S Shorey et al. [8Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. J Psychiatr Res 2018; 104: 235-48.
[http://dx.doi.org/10.1016/j.jpsychires.2018.08.001] [PMID: 30114665]
]. The possible reason for the higher estimated prevalence in the earlier study as compared to our study could be due to the inclusion of a larger number of studies and participants in the analysis (26 cross-sectional, 30 prospective cohort and 2 case-control studies with an overall 58 studies and 37294 participants); however, only 16 studies were included in our study. Moreover, women in the previous study were healthy subjects having no history of depression previously but our study found that a previous history of depression was among the factors responsible for the increased prevalence of postpartum depression. Moreover, the rate of prevalence in our study was higher than the result of a systematic review and meta-analysis in 11 high-income countries reported in 2005, in which the pooled estimated prevalence of postpartum depression was 12.9% [72Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 2005; 106(5 Pt 1): 1071-83.
[http://dx.doi.org/10.1097/01.AOG.0000183597.31630.db] [PMID: 16260528]
].

Possible grounds for the difference could be due to a long time gap between the previous study and the present study. The difference in the time point for the assessment of postpartum depression could also be a reason. The previous study included studies that screened PPD only in the three months of the postpartum period but in the present study, assessment period was far beyond this. Moreover, a socio-economic and cultural difference between high-income study subjects of the earlier study and low-income study subjects of the present study could be a root cause for the variation.

Contrary to the subgroup analysis result of a worldwide meta-analysis study [8Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. J Psychiatr Res 2018; 104: 235-48.
[http://dx.doi.org/10.1016/j.jpsychires.2018.08.001] [PMID: 30114665]
] that observed the pooled estimated prevalence of postpartum depression to be similar across the different measurement tools for PPD, the present study revealed that pooled prevalence of postpartum depression was higher in studies as measured with SRQ-20 (24.6%%) (95% CI: 18.42, 30.84) than the result with PHQ-9 (18.9%) (95% CI: 11.52, 26.28). This could be because most studies that utilized SRQ-20 delineated a lower cut-off point (SRQ-20 score ≥ 6), which might result in an overestimation of postpartum depression.

In line with the result of an earlier meta-analysis study [8Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis. J Psychiatr Res 2018; 104: 235-48.
[http://dx.doi.org/10.1016/j.jpsychires.2018.08.001] [PMID: 30114665]
], the pooled estimated size of postpartum depression showed a geographical difference. The pooled estimated post-partum depression was slightly higher in studies from the southern part of Ethiopia (22.6%) than the central region (Addis Ababa) (21.2%), which could be due to the relatively improved socio-economic and cultural advances in the central region of Ethiopia. This was, however, in contrast to the result of a meta-analysis conducted in India [10Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
[http://dx.doi.org/10.2471/BLT.17.192237] [PMID: 29147043]
].

However, no significant variation in the magnitude of PPD was noticed between the community and institutional settings of the studies. This was consistent with a review and meta-analysis study in India [10Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
[http://dx.doi.org/10.2471/BLT.17.192237] [PMID: 29147043]
] in which little but insignificant variation was observed across the community and institutional setting studies. Even though heterogeneity was a problem in the present study, the 95% confidence interval of the average prevalence of postpartum depression was narrow. This might be due to the small standard error in the included studies, a large number of included studies with a large number of participants.

Regarding the associated factors of postpartum depression, fourteen studies [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22, 24, 26-35, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] had reported different factors and poor marital relation [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 29, 32, 34, 35, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
], unplanned pregnancy [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22, 24, 27, 29, 32, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], previous history of depression [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27, 28, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], domestic violence [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22, 27, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
], poor social support [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 32-35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
], family history of mental illness [24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 28, 31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia ], use of substance [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
] and low income [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 28, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] were among the most commonly reported factors.

The pooled odds ratio of the poor marital relationship among the above-mentioned studies was 3.56 that implies women with poor marital relationships were 3.56 times at higher risk of developing PPD than women with good marital relationships. A meta-analysis study in India showed a similar conclusion supporting this [10Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
[http://dx.doi.org/10.2471/BLT.17.192237] [PMID: 29147043]
]. The possible reason for this could be poor marital relationship increasing the burden of psychosocial responsibility of child care and other household responsibility in the postpartum period as compared to the shared psychosocial responsibility of women with good marital relation.

Besides, the pooled odds ratio for unplanned pregnancy for the nine studies reported above was found to be 3.48. This showed that women who gave birth from an unplanned pregnancy were 3.5 times more likely to be depressed than women with a planned pregnancy. A consistent finding was reported in studies conducted in Turkey [17Turkcapar AF, Kadıoğlu N, Aslan E, Tunc S, Zayıfoğlu M, Mollamahmutoğlu L. Sociodemographic and clinical features of postpartum depression among Turkish women: a prospective study. BMC Pregnancy Childbirth 2015; 15(1): 108.
[http://dx.doi.org/10.1186/s12884-015-0532-1] [PMID: 25935726]
], Qatar [14Bener A, Gerber LM, Sheikh J. Prevalence of psychiatric disorders and associated risk factors in women during their postpartum period: a major public health problem and global comparison. Int J Womens Health 2012; 4: 191-200.
[http://dx.doi.org/10.2147/IJWH.S29380] [PMID: 22654524]
], northwestern Brazil [73Alves SV, Ludermir AB, AraA�jo TVBd. Postpartum depression among women with an unintended pregnancy. Rev Saude Publica 2015; 49: 33.], and Iran [74Kheirabadi G-R, Maracy M-R, Barekatain M, et al. Risk factors of postpartum depression in rural areas of Isfahan Province, Iran. Arch Iran Med 2009; 12(5): 461-7.
[PMID: 19722767]
]. This might be due to the common factor involved in the development of PPD in Ethiopia too.

Another additional possible reason for this could be the absence of psychological readiness in mothers with unplanned pregnancy predisposing them to be vulnerable to physiological, psychosocial challenges of pregnancy and the postpartum period.

The previous history of depression [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27, 28, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
] and stressful life events [22Abebe A, Tesfaw G, Mulat H, Hibdye G, Yohannes K. Postpartum depression and associated factors among mothers in Bahir Dar Town, Northwest Ethiopia. Ann Gen Psychiatry 2019; 18(1): 19.
[http://dx.doi.org/10.1186/s12991-019-0244-4] [PMID: 31523264]
, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] was also an associated factor for the development of PPD with a pooled estimate odds ratio of 4.33 and 3.5, respectively. A consistent finding was observed in an Indian meta-analysis study[10Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
[http://dx.doi.org/10.2471/BLT.17.192237] [PMID: 29147043]
]. Furthermore, other several studies [6Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry 2016; 3(10): 973-82.
[http://dx.doi.org/10.1016/S2215-0366(16)30284-X] [PMID: 27650773]
, 75, 76Manikkam L, Burns JK. Antenatal depression and its risk factors: an urban prevalence study in KwaZulu-Natal. S Afr Med J 2012; 102(12): 940-4.
[http://dx.doi.org/10.7196/SAMJ.6009] [PMID: 23498042]
] reported the presence of depression during pregnancy, facing stressful life events during pregnancy, and prior history of depression as related to postpartum depression, which was also in line with the current study.

Besides domestic violence was also found to have a significant association with the development of PPD with the estimated pooled odds ratio of 3.77 [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 22, 27, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
]. A report by the World Health Organization in 2013 [77Organization WH. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence 2013.] suggested a similar conclusion in terms of intimate partner violence in women predisposed to various mental health problems in the postpartum period.

Poor social support with a pooled odds ratio of 4.5 [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 32-35Wubetu AD, Engidaw NA, Gizachew KD. Prevalence of postpartum depression and associated factors among postnatal care attendees in Debre Berhan, Ethiopia, 2018. BMC Pregnancy Childbirth 2020; 20(1): 189.
[http://dx.doi.org/10.1186/s12884-020-02873-4] [PMID: 32228500]
] also increases the vulnerability to postpartum depression. This also supports the findings of the Indian review study [10Upadhyay RP, Chowdhury R, Aslyeh Salehi , et al. Postpartum depression in India: a systematic review and meta-analysis. Bull World Health Organ 2017; 95(10): 706-717C.
[http://dx.doi.org/10.2471/BLT.17.192237] [PMID: 29147043]
]. Multiple earlier studies have also reported that good interpersonal relationships across the social support networks increase flexibility to stress and subsidize enormously women from developing postpartum depression [78Ozbay F, Johnson DC, Dimoulas E, Morgan CA III, Charney D, Southwick S. Social support and resilience to stress: from neurobiology to clinical practice. Psychiatry (Edgmont Pa) 2007; 4(5): 35-40.
[PMID: 20806028]
-81Patel V, Rodrigues M, DeSouza N. Gender, poverty, and postnatal depression: a study of mothers in Goa, India. Am J Psychiatry 2002; 159(1): 43-7.
[http://dx.doi.org/10.1176/appi.ajp.159.1.43] [PMID: 11772688]
], hence decreasing the risk of postpartum depression. A study in Ghana on interventions for women with postpartum depression revealed that psychosocial support interventions are the most effective treatments implying an underling psychosocial deficit in this target population[82Anokye R, Acheampong E, Budu-Ainooson A, Obeng EI, Akwasi AG. Prevalence of postpartum depression and interventions utilized for its management. Ann Gen Psychiatry 2018; 17(1): 18.
[http://dx.doi.org/10.1186/s12991-018-0188-0] [PMID: 29760762]
].

Furthermore, the pooled odds ratio of family history of mental illness [24Asaye MM, Muche HA, Zelalem ED. Prevalence and Predictors of Postpartum Depression: Northwest Ethiopia. Psychiatry Journal 2020; 2020, 28, 31Shewangzaw1a A, Tadesse B, Ashani T, Misgana T, Shewasinad S. Prevalence of Postpartum Depression and Associated Factors among Postnatal Women Attending At Hiwot Fana Specialized University Hospital, Harar, East Ethiopia ], use of a substance [21Abadiga M. Magnitude and associated factors of postpartum depression among women in Nekemte town, East Wollega zone, west Ethiopia, 2019: A community-based study. PLoS One 2019; 14(11)e0224792
[http://dx.doi.org/10.1371/journal.pone.0224792] [PMID: 31721808]
, 27, 34Toru T, Chemir F, Anand S. Magnitude of postpartum depression and associated factors among women in Mizan Aman town, Bench Maji zone, Southwest Ethiopia. BMC Pregnancy Childbirth 2018; 18(1): 442.
[http://dx.doi.org/10.1186/s12884-018-2072-y] [PMID: 30428843]
] and low income [27Fantahun A, Cherie A, Deribe L. Prevalence and Factors Associated with Postpartum Depression Among Mothers Attending Public Health Centers of Addis Ababa, Ethiopia, 2016. Clin Pract Epidemiol Ment Health 2018; 14: 196-206.
[http://dx.doi.org/10.2174/1745017901814010196] [PMID: 30258485]
, 28, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] and perinatal complications [28Gebremichael G, Yihune M, Ajema D, Haftu D, Gedamu G. Perinatal Depression and Associated Factors among Mothers in Southern Ethiopia: Evidence from Arba Minch Zuria Health and Demographic Surveillance Site. Psychiatry journal 2018; 2018, 59Azale T, Fekadu A, Hanlon C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 2018; 12(1): 42.
[http://dx.doi.org/10.1186/s13033-018-0219-x] [PMID: 30069229]
] was 4, 4.67, 2.87, 3.5 and 3.8, respectively. A systematic review and meta-analysis study in which 17 articles were reviewed and postpartum depression between 3 and 52 weeks postpartum periods was assessed [83Ross LE, Dennis C-L. The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: a systematic review. J Womens Health (Larchmt) 2009; 18(4): 475-86.
[http://dx.doi.org/10.1089/jwh.2008.0953] [PMID: 19361314]
] reported substance use as a contributing factor for postpartum depression, being in line with the current study.

5. STRENGTHS AND LIMITATIONS

Regarding strength, this study utilized a pre-specified search strategy through the mentioned libraries that are intended to reduce the assessor's bias. The subsequent strength was that the independent extraction of data and quality assessment of the included studies by two autonomous reviewers also lessened the reviewer's bias. Furthermore, the employment of subgroup analysis and sensitivity analysis to distinguish the foundation of heterogeneity was also a strength. On the contrary, the limits of this meta-analysis study emanate from the presence of a high difference between the included studies that might disrupt the deduction of the study results. Besides, the use of two or three studies in the sub-group analysis might diminish the accuracy of the estimates.

CONCLUSION

This review and meta-analysis study obtained a high pooled estimated prevalence of postpartum depression (21.9%), suggesting that more than one in five women experience postpartum depression. The pooled estimate of postpartum depression was higher in studies that used SRQ-20 (24.6%) than studies that used PHQ-9 (18.9%. Moreover, the pooled prevalence of postpartum depression was slightly higher in the southern part of Ethiopia (22.6%) than Addis Ababa (21.2%). However, no significant difference in pooled prevalence was noticed across study settings (community versus institutional). Poor marital relations, unplanned pregnancy, previous history of depression, poor social support, domestic violence, family history of mental illness, use of the substance, low income, stressful life event, and perinatal complications were among the associated factors for postpartum depression. Therefore, postnatal antenatal care services should consider this significant mental health problem of women and its associated factors basically by delivering integrated postnatal care services for women.

LIST OF ABBREVIATIONS

AOR  = Adjusted Odds Ratio
CI  = Confidence Interval
CS  = Cross-Sectional
EPDS  = Edinburgh Postnatal Depression Scale
OR  = Odds Ratio
PHQ-9  = Patient Health Questionnaire-9
PPD  = Postpartum depression
PRISMA-P  = Preferred Reporting Items for Systematic Reviews and Meta-analysis
SRQ-20  = Self Reporting Questionnaire-20

CONSENT FOR PUBLICATION

Not applicable

FUNDING

None.

CONFLICT OF INTEREST

We authors have no competing interests regarding this meta-analysis study.

ACKNOWLEDGEMENTS

We acknowledge the authors of the included studies for their original contribution.

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