Review articlePrevalence of perinatal depression and its determinants in Mainland China: A systematic review and meta-analysis
Introduction
Perinatal depression is an episode of depression experienced by women during pregnancy and up till one year after giving birth (Gaynes et al., 2005). Initiation into pregnancy, with its incumbent social role of motherhood accompanied by potential physical stresses, places females at an increased risk of depressive disorder, particularly in low- and middle-income (LAMICs) countries (Fisher et al., 2012). Anxiety, depression and distress during the perinatal period are associated with several harmful consequences including poor diet and social support, increased risk of preeclampsia, pregnancy and labor complications for the mother (Beijers et al., 2010; Bergman et al., 2007). In infants and newborns, its effects may include preterm birth, low birth weight, poor breastfeeding practices, high rates of diarrheal and infectious illnesses and poor cognitive development (Rahman et al., 2007; Sanchez et al., 2013). Despite these intergenerational concerns, depression remains under detected and under-treated during the perinatal period in most LAMICs.
The prevalence of perinatal depression has been reported to range from 15 to 20% in China (Mu et al., 2019). As per 2017 pregnancy and birth records, this translates into around 5 million to 7 million Chinese women with perinatal depression – the largest numbers for any single country (National Bureau of Statistics of China, 2018). China's rate of hospital delivery has been 99% since last 6 years (Xinhua News, 2019). Several factors peculiar to China would offer a unique platform to study perinatal depression. The first generation post-family planning policies has reached childbearing age in the last decade, and most of them embraced motherhood for the first time (Ding, 2015). Primiparas may be at an increased risk of perinatal anxiety and depression and some studies from China indicate approximately 50–70% of them may experience a period of unstable mood and accompanying varying degrees of physical symptoms and may require more effective preventive strategies (Cui, 2013). Furthermore, China has seen remarkable social and economical development in recent decades. This has meant rapid urbanization and potentially an erosion of traditional support structures for many people (Gong et al., 2012; Lee et al., 2004). On the other hand, economic development has improved the lives of a vast number of people so they enjoy a better quality of life. The impact of these changes on the psychological well being of women in the perinatal period needs to be examined in the current historical context of China.
To the best of our knowledge, till date, there is no review of prevalence of perinatal depression that includes both Chinese and English language studies. Mainland China is the region of China excluding Taiwan, Hong Kong and Macau with total population of 1.4 billion including 51.9% male while 48.1% female population (United Nations Department of Economic and Social Affairs, Population Division, 2019). We did a systematic review and meta-analysis of the prevalence of perinatal depression in Mainland China to provide important information for policy planning on effective preventive and curative services for this public health priority in the most populous country in the world.
Section snippets
Methods
A systematic review and meta-analysis was done according to PRISMA guidelines (Stewart et al., 2015). The protocol of this review was registered with PROSPRO CRD42018111466 (Nisar et al., 2019). Bilingual systematic search was done of ten electronic bibliographic databases: Medline, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, Cochrane Central Register, the China National Knowledge Infrastructure, the VIP Database for Chinese Technical Periodicals, and the Wan Fang Database for Chinese
Data extraction & meta-analysis
Two independent reviewers extracted the following information using a standard form. General information including study design, characteristics of the study sample, geographical setting (region) and geographical location's income classification (according to Chinese government's administrative records), study setting, (hospital or community), sampling method (random vs convenience), response rate, year of publication and the details of study outcome measures including the type of diagnostic or
Results
Our initial search yielded 10,902 records, 2143 duplicate records were removed. After title and abstract screening, 104 studies were found eligible for full text screening. Ninety-five studies were included in data analysis. Details of study selection process are shown in Fig. 1. A total of 95 studies from 23 regions of Mainland China were included in meta-analysis, with a pooled sample size of 96,096 Chinese women in perinatal period (Fig. 2).
Most studies were cross sectional (n = 87), with
Risk factors of perinatal depression
Significant risk and protective factors of perinatal depression were reviewed systematically and divided into three categories: (i) Maternal-related factors; (ii) Infant-related factors, and; (iii) Sociocultural factors (Shown in Table 3).
Protective factors of perinatal depression
Better economic and living conditions, easy access to good quality healthcare and emotional support during and after pregnancy, better childcare facilities, were all protective factors for perinatal depression (Gao et al., 2014; He et al., 2016a; Jiang et al., 2015; Liu et al., 2009; Qiu et al., 2014; Ying, 2014; Zhang et al., 2001). Higher education level and knowledge related to pregnancy were also found as protective factors for mothers (Guo et al., 2003; He et al., 2012; Huang et al., 2015;
Discussion
Perinatal depression is a public health priority, which has received significant global attention in recent years. To our knowledge, this is the first evidence synthesis effort pertaining to this condition in Mainland China. Key findings are that the weighted prevalence in Chinese women is 16.3%, with 19.7% of women in the antenatal period and 14.8% women in the postnatal period suffering from depression. There is a rise in prevalence reflected in studies conducted in the last decade, with the
Limitations
A few limitations of this review need to be mentioned. Studies of sample size below 250 participants were not included. Moreover, the study provides only a narrative review of the risk and protective factors of perinatal depression in Mainland China. These were not included in meta-analysis, which may have added further information about the differential impact of each risk factor.
For a precise calculation of the prevalence, randomized sampling in community is recommended instead of convenient
Conclusion
In summary, our systematic review and meta-analysis suggests that the prevalence of perinatal depression in Chinese women is higher than high-income countries and not dissimilar to low- and middle-income countries. Perinatal depression has seen a rise during the last decades. Since China has made great strides in improving the health and prosperity of its citizens in recent decades, we believe maternal mental health is a very important public health priority that needs immediate attention.
Declaration of Competing Interest
We declare no competing interests.
Contributors
AN, XL, DW and AR conceived the idea of the study and developed the study protocol. AN and AW did data searches and data extraction of the English language articles, JY and BX did literature searches and data extraction of the Chinese language articles. AW did meta-analysis. AN and AW wrote the first draft which all the authors revised and approved. AR and XL supervised the team and provided mentorship.
Acknowledgments
The author would like to thank Chinese Nursing Association for funding this study. The author would also like to thank the staff at School of Nursing, Xi'an Jiaotong University, for their assistance and support during the study.
Role of funding source
The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Source of Funding
The study was supported by Chinese Nursing Association; grant number (ZHKY201809).
References (95)
- et al.
Maternal stress during pregnancy predicts cognitive ability and fearfulness in infancy
J. Am. Acad. Child Adolesc. Psychiatry
(2007) - et al.
Prevalence and risk factors of postpartum depression in a population-based sample of women in Tangxia Community
Guangzhou. Asian Pac. J. Trop. Med.
(2014) - et al.
Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middleincome countries
Lancet Psychiatry
(2016) - et al.
Urbanisation and health in China
Lancet
(2012) - et al.
Realising equity in maternal health: China's successes and challenges
Lancet
(2019) - et al.
Validation of the Mainland Chinese version of the Edinburgh postnatal depression scale in Chengdu mothers
Int. J. Nurs. Stud.
(2010) - et al.
Postpartum depression prevalence and risk factors in Turkey: A systematic review and meta-analysis
Arch. Psychiatr. Nurs.
(2017) - et al.
The magnitude of and health system responses to the mental health treatment gap in adults in India and China
Lancet
(2016) - et al.
Delivering the Thinking Healthy Programme for perinatal depression through volunteer peers: a cluster randomised controlled trial in Pakistan
Lancet. Psychiatry
(2019) - et al.
The role of social support in family socio-economic disparities in depressive symptoms during early pregnancy: Evidence from a Chinese birth cohort
J Affect. Disord.
(2018)
A systematic review and meta-regression of the prevalence and incidence of perinatal depression
J. Affect. Disord.
Psychosocial interventions on perinatal depression in China: a systematic review and meta-analysis
Journal of Affective Disorders
Diagnostic and statistical manual of mental disorders (DSM-5)
American Psychiatric Pub
Investigation on Postpartum Depression in Wanzhou District of Chongqing
Maternal and Child Health Care in China
Maternal prenatal anxiety and stress predict infant illnesses and health complaints
Pediatrics
Son preference, children's gender and parents’ time allocation: evidence from China
Appl. Econ.
A survey of 627 pregnant women's prenatal depression
Qilu Journal of Nursing
Prevalence and risk factors of postpartum depression in a community of Shenzhen
Occupation and Health
Chinese classification of mental disorders (CCMD-3): towards integration in international classification
Psychopathology
Influencing factors of postpartum depression among pregnant and lying-in women in rural areas and suggestions for intervention measures
Public Health Management in China
Investigation on Effect factors of Antepartum Depression
Maternal and Child Health Care in China
Screening for postpartum depression and associated factors among women in China: a cross-sectional study
Front. Psychol.
Edinburgh postnatal depression scale (EPDS)
Br J psychiatry
Study on the Psychological Stress, Anxiety, Depression and Relevant Factors of Primipara in the Third Trimester
A prospective study of puerperal depression
Maternal and Child Health Care in China
Promote natural birth and reduce the cesarean rate
Beijing Med. J.
Cohort study of depressed mood during pregnancy and after childbirth
Br. Med.J.
Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review
Bull. World Health Organ.
Prenatal Depression and Anxiety in Pregnant Women and Its Influencing Factors
Anhui Medical Journal
Perinatal depression: Prevalence, screening accuracy, and screening outcomes: Summary
Evidence report summaries
A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction
Arch. Gen. Psychiatry
Postpartum Depression and Postpartum Domestic Violence
Chinese Journal of Mental Health
Investigation and analysis of depressive symptoms during pregnancy
Chinese Journal of Mental Health
The morbidity of postpartum depression in some pregnant women in Tengzhou City and the multivariate analysis of influencing factors
Preventive Medicine Forum
An Investigation of incidence related factors and prevention of post partum depression in 318 women
Primary Health Care in China
Prevalence and influencing factors of puerperal depression in Guangzhou
Maternal and Child Health Care in China
Analysis of incidence and influencing factors of perinatal depression in parturients
Guangdong Medical Journal
Investigation of perinatal depression among pregnant and lying-in women in Panyu District of Guangzhou City
Maternal and Child Health Care in China
Analysis of Pathogenic Factors of 324 Postpartum Depression Patients and the Effect of Community Medical Intervention
International Journal of Reproductive Health/Family Planning
Correalation analysis and community intervention strategies for prenatal depression level and social support level
Nursing and Rehabilitation
Analysis of perinatal depression and its influencing factors among pregnant and lying-in women in Wuhan
Maternal and Child Health Care in China
Risk factors of prenatal and postpartum depression
Chinese Nursing Research
Investigation of postpartum depression and its related psychosocial factors
Modern preventive medicine
Survey of Depressive state and influencing factors among pre delivery pregnant women
Journal of Clinical Psychosomatic Diseases
Evaluation of intervention and analysis of mental health state of pregnant women in Tian'he and Zeng'chen district of Guangzhou and its effect factors
Medical Journal of Chinese People's Health
Study on morbidity and related factors of postpartum depression in Shenzhen
Study on Maternal and Child Health in China
Follow-up of Anxiety and Depression in Pregnancy and Postpartum Period and Analysis of Psychosocial Factors
Practical medicine in China
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Atif Rahman and Xiaomei Li are joint senior authors.