Elsevier

Journal of Affective Disorders

Volume 277, 1 December 2020, Pages 1022-1037
Journal of Affective Disorders

Review article
Prevalence of perinatal depression and its determinants in Mainland China: A systematic review and meta-analysis

https://doi.org/10.1016/j.jad.2020.07.046Get rights and content

Highlights

  • First meta-analysis of perinatal depression in Mainland China with studies in English and Chinese

  • In Mainland China, 16.3% women had perinatal depression symptoms or diagnosis

  • An increasing trend was seen over the last decade and in underdeveloped regions

  • Poor socioeconomic status, ill health and lower social support were key risk factors

  • Better living conditions and higher level of education was protective factors

Abstract

Background

Perinatal depression is a maternal mental health condition that is associated with various adverse health outcomes both for the mothers and the babies. The study aim was to estimate the prevalence of perinatal depression and its risks and determinants in Mainland China.

Methods

Systematic searches were conducted in 10 major databases and random effect meta-analysis was performed to achieve the pooled variance of perinatal depression. Subgroup analyses were conducted based on region, scale, methods of diagnosis and study design. Meta-regression was performed with the variables such as age, quality assessment score and gross domestic product (GDP) of the province.

Results

Pooled prevalence of perinatal depression was 16.3% (CI=95%; 14.7% to 18.2%, P < 0.001), with antenatal depression 19.7% (CI=95%; 15.8% to 24.2%, P < 0.001) and postnatal depression 14.8% (CI=95%; 13.1% to 16.6%, P < 0.001). Significant publication bias was found and heterogeneity was I2= 98.13%. Lower socioeconomic status, poor physical health, anxiety about pregnancy and reduced social support were major risk factors while better living conditions and higher level of education were protective factors. The prevalence of perinatal depression showed a significant increasing trend in the last decade.

Limitations

The review does not include studies with small sample size (n <250). Moreover a narrative review of risk and protective factors was done, these were not included in meta-analysis.

Conclusion

The prevalence of perinatal depression in China is similar to low and middle-income countries. Urgent attention is needed to address this public health priority in China.

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).

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