Factors associated with postpartum depression symptoms among postpartum women in five countries during the COVID-19 pandemic: an online cross-sectional study

Coca et al. BMC Psychiatry (2023) 23:171 https://doi.org/10.1186/s12888-023-04607-0 BMC Psychiatry Open Access RESEARCH Factors associated with postpartum depression symptoms among postpartum women in five countries during the COVID-19 pandemic: an online cross-sectional study Kelly Pereira Coca1, Li-Yin Chien2, Eun Young Lee3, Ana Carolina de Prima Souza1, Seo Ah Hong4,6* and Yan-Shing Chang5 Abstract Background This study aimed to examine factors associated with postpartum depression (PPD) symptoms during the COVID-19 pandemic among postpartum women in five countries, a subject that has not been investigated thus far. Methods A multi-country, cross-sectional, online survey was conducted with a convenience sample of 3,523 postpartum women in Brazil, South Korea, Taiwan, Thailand, and the United Kingdom, from July to November 2021. Sociodemographic and obstetric data, food insecurity, COVID-19 positive status, COVID-19 vaccination, infant feeding, breastfeeding belief score, and social support were investigated. PPD and social support were measured using the Edinburgh Postnatal Depression Scale and Maternal Social Support Scale, respectively. Descriptive statistics, chisquared tests, and t-tests were used to identify associations with PPD symptoms. A binary logistic regression model was used to identify explanatory factors associated with PPD and adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated. Results Women in Taiwan (AOR = 0.5; 95%CI 0.34, 0.73) and Thailand (AOR = 0.68; 95%CI 0.46, 0.99) had a lower risk of PPD symptoms than those in Brazil. In addition, women with planned pregnancies had a lower risk of PPD (AOR = 0.74; 95%CI 0.60, 0.91). Younger women (AOR = 1.62; 95%CI 1.05, 2.51), health problems during pregnancy, delivery, or postpartum (AOR = 1.71; 95%CI 1.42, 2.06), and no change or worse food insecurity during COVID-19 (AOR = 1.66; 95%CI 1.21, 1.27 for no change and AOR = 1.68; 95%CI 1.27, 1.23, respectively) presented a higher likelihood of having PPD. Feeding babies with expressed human milk (AOR = 1.25; 95%CI 1.03, 1.50) and/or complementary food (AOR = 1.51; 95%CI 1.17, 1.94) were associated with PPD symptoms. Women who received low (AOR = 7.74; 95%CI 5.43, 11.03) or medium support (AOR = 3.25; 95%CI 2.71, 3.88) had higher likelihoods of PPD. Conclusion PPD symptoms during the pandemic were high in young women, particularly Brazilian women, with health problems in the puerperal pregnancy cycle who fed their babies expressed breast milk and/or complementary *Correspondence: Seo Ah Hong Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Coca et al. BMC Psychiatry (2023) 23:171 Page 2 of 10 food. Low social support also impacted PPD symptoms. This study highlights the need for the professional screening for PPD and provision of virtual or personal support. Keywords Postpartum depression, Food insecurity, Social support, Breastfeeding, SARS-CoV-2, Infant health, Mother health, Pregnancy Background The COVID-19 pandemic has affected mental health globally [1]. A survey conducted in the United Kingdom (UK) showed the effect of social isolation or social distancing on well-being. An increase in depression, anxiety, stress, and other negative feelings were identified, which may be related to individual, social, and population factors [2]. Specific populations, such as pregnant and breastfeeding women, have also been affected by the COVID-19 pandemic. A study conducted in Ireland, Norway, Switzerland, the Netherlands, and the UK showed that the prevalence of major depression symptoms (Edinburgh Depression Scale ≥ 13) was 15% in pregnant women and 13% in breastfeeding women up to three months postpartum. In addition, the authors identified moderate and severe generalized anxiety symptoms in 11% and 10% of the patients, respectively [3]. PPD is the most common psychological condition following delivery [4]. It can start at any time after childbirth within the first year, and continue for many years [4, 5]. The global prevalence of PPD is 17.2% with South America being 21.7%, Northern Europe 13.8%, Eastern Asia 17.4%, Southern Asia 19.8%, and South-Eastern Asia 13.5% [6]. The prevalence of PPD is very high in some countries and might be due to cross-cultural variables, biological vulnerability factors, and different socio-economic environments, such as levels of social support and stress [7]. Nations with a higher prevalence of PPD have a higher rates of income inequality, higher maternal mortality, infant mortality, or women of childbearing age working 40 h or more/week [8]. High levels of depressive symptoms and anxiety in pregnant and breastfeeding women during the COVID-19 pandemic were found to be associated with chronic mental illness, chronic postpartum somatic illness, and unplanned pregnancy [3]. Low social support was also a predictor of PPD [9]. Women with PPD are less sensitive to their infants and more negative about their infant experience. They can also present with disturbances in early mother-infant interactions and are associated with poorer infant cognitive outcomes at 18 months [10]. It may also have a negative impact on breastfeeding initiation and duration [11, 12]. Women in conflict with partners are associated with a higher risk of PPD [13]. Early life abuse, adult abuse, maternal low education, low socioeconomic status at the time of pregnancy, and lack of social support have been consistently identified as risk factors for PPD in low- and middle-income countries [14]. However, there is a lack of research on the association between breastfeeding and PPD, and the association between COVID-19 related factors and PPD. The lockdown periods and limited social contact and social support during the COVID-19 pandemic have been a major challenge for mothers, children, and families [15]. Investigating the factors causing PPD (...truncated)