Editing Postpartum depression (section)

==Epidemiology==

=== North America ===
==== United States ====

Within the United States, the prevalence of postpartum depression was lower than the global approximation at 11.5% but varied between states from as low as 8% to as high as 20.1%.<ref name="Ko_2017">{{cite journal | vauthors = Ko JY, Rockhill KM, Tong VT, Morrow B, Farr SL | title = Trends in Postpartum Depressive Symptoms - 27 States, 2004, 2008, and 2012 | language = en-us | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 66 | issue = 6 | pages = 153–158 | date = February 2017 | pmid = 28207685 | pmc = 5657855 | doi = 10.15585/mmwr.mm6606a1 }}</ref> The highest prevalence in the US is found among women who are American Indian/Alaska Natives or Asian/Pacific Islanders, possess less than 12 years of education, are unmarried, smoke during pregnancy, experience over two stressful life events, or have full-term infant is low-birthweight or was admitted to a NICU. While US prevalence decreased from 2004 to 2012, it did not decrease among American Indian/Alaska Native women or those with full term, low-birthweight infants.<ref name="Ko_2017" />

Even with the variety of studies, it is difficult to find the exact rate as approximately 60% of US women are not diagnosed and of those diagnosed, approximately 50% are not treated for PPD.<ref name="Ko_2017" /> Cesarean section rates did not affect the rates of PPD. While there is discussion of postpartum depression in fathers, there is no formal diagnosis for postpartum depression in fathers.<ref>{{cite journal | vauthors = Schumacher M, Zubaran C, White G | title = Bringing birth-related paternal depression to the fore | journal = Women and Birth | volume = 21 | issue = 2 | pages = 65–70 | date = June 2008 | pmid = 18479990 | doi = 10.1016/j.wombi.2008.03.008 }}</ref>

==== Canada ====
Canada has one of the largest refugee resettlement in the world with an equal percentage of women to men. This means that Canada has a disproportionate percentage of women who develop postpartum depression since there is an increased risk among the refugee population.<ref>{{cite journal | vauthors = Brown-Bowers A, McShane K, Wilson-Mitchell K, Gurevich M | title = Postpartum depression in refugee and asylum-seeking women in Canada: A critical health psychology perspective | journal = Health | volume = 19 | issue = 3 | pages = 318–335 | date = May 2015 | pmid = 25389234 | doi = 10.1177/1363459314554315 | s2cid = 206717561 }}</ref> In a blind study, where women had to reach out and participate, around 27% of the sample population had symptoms consistent with postpartum depression without even knowing.<ref>{{cite journal | vauthors = Bowen A, Muhajarine N | title = Prevalence of antenatal depression in women enrolled in an outreach program in Canada | journal = Journal of Obstetric, Gynecologic, and Neonatal Nursing | volume = 35 | issue = 4 | pages = 491–498 | date = 2006 | pmid = 16881993 | doi = 10.1111/j.1552-6909.2006.00064.x }}</ref> Also found that on average 8.46 women had minor and major PPDS was found to be 8.46 and 8.69% respectively. The main factors that were found to contribute to this study were the stress during pregnancy, the availability of support after, and a prior diagnosis of depression were all found to be factors.<ref name="Lanes_2011">{{cite journal | vauthors = Lanes A, Kuk JL, Tamim H | title = Prevalence and characteristics of postpartum depression symptomatology among Canadian women: a cross-sectional study | journal = BMC Public Health | volume = 11 | issue = 1 | page = 302 | date = May 2011 | pmid = 21569372 | pmc = 3118237 | doi = 10.1186/1471-2458-11-302 | doi-access = free }}</ref> Canada has specific population demographics that also involve a large amount of immigrant and indigenous women which creates a specific cultural demographic localized to Canada. In this study, researchers found that these two populations were at significantly higher risk compared to "Canadian-born non-indigenous mothers".<ref name="Lanes_2011" /> This study found that risk factors such as low education, low-income cut-off, taking antidepressants, and low social support are all factors that contribute to the higher percentage of these populations developing PPDS.<ref name="Lanes_2011" /> Specifically, indigenous mothers had the most risk factors than immigrant mothers with non-indigenous Canadian women being closer to the overall population.<ref>{{cite journal | vauthors = Daoud N, O'Brien K, O'Campo P, Harney S, Harney E, Bebee K, Bourgeois C, Smylie J | title = Postpartum depression prevalence and risk factors among Indigenous, non-Indigenous and immigrant women in Canada | journal = Canadian Journal of Public Health | volume = 110 | issue = 4 | pages = 440–452 | date = August 2019 | pmid = 30767191 | pmc = 6964473 | doi = 10.17269/s41997-019-00182-8 }}</ref>

=== South America ===
A main issue surrounding PPD is the lack of study and the lack of reported prevalence that is based on studies developed in Western economically developed countries.<ref name="Halbreich_2006">{{cite journal | vauthors = Halbreich U, Karkun S | title = Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms | journal = Journal of Affective Disorders | volume = 91 | issue = 2–3 | pages = 97–111 | date = April 2006 | pmid = 16466664 | doi = 10.1016/j.jad.2005.12.051 }}</ref> In countries such as Brazil, Guyana, Costa Rica, Italy, Chile, and South Africa reports are prevalent, around 60%. An itemized research analysis put a mean prevalence at 10-15% percent but explicitly stated that cultural factors such as perception of mental health and stigma could be preventing accurate reporting.<ref name="Halbreich_2006" /> The analysis for South America shows that PPD occurs at a high rate looking comparatively at Brazil (42%) Chile (4.6-48%) Guyana and Colombia (57%) and Venezuela (22%).<ref name="Evagorou_2016">{{cite journal | vauthors = Evagorou O, Arvaniti A, Samakouri M | title = Cross-Cultural Approach of Postpartum Depression: Manifestation, Practices Applied, Risk Factors and Therapeutic Interventions | journal = The Psychiatric Quarterly | volume = 87 | issue = 1 | pages = 129–154 | date = March 2016 | pmid = 25986531 | doi = 10.1007/s11126-015-9367-1 | s2cid = 1285417 }}</ref> In most of these countries, PPD is not considered a serious condition for women and therefore there is an absence of support programs for prevention and treatment in health systems.<ref name="Evagorou_2016" /> Specifically, in Brazil PPD is identified through the family environment whereas in Chile PPD manifests itself through suicidal ideation and emotional instability.<ref name="Evagorou_2016" /> In both cases, most women feel regret and refuse to take care of the child showing that this illness is serious for both the mother and child.<ref name="Evagorou_2016" />

=== Asia ===
From a selected group of studies found from a literature search, researchers discovered many demographic factors of Asian populations that showed significant association with PPD. Some of these include the age of the mother at the time of childbirth as well as the older age at marriage.<ref name="Mehta_2014">{{cite journal | vauthors = Mehta S, Mehta N | title = An Overview of Risk Factors Associated to Post-partum Depression in Asia | journal = Mental Illness | volume = 6 | issue = 1 | pages = 14–17 | date = March 2014 | pmid = 25478140 | pmc = 4253395 | doi = 10.1108/mi.2014.5370 | doi-access = free }}</ref> Being a migrant and giving birth to a child overseas has also been identified as a risk factor for PPD.<ref name="Mehta_2014" /> Specifically for Japanese women who were born and raised in Japan but who gave birth to their child in Hawaii, USA, about 50% of them experienced emotional dysfunction during their pregnancy.<ref name="Mehta_2014" /> All women who gave birth for the first time and were included in the study experienced PPD.<ref name="Mehta_2014" /> In immigrant Asian Indian women, the researchers found a minor depressive symptomatology rate of 28% and an additional major depressive symptomatology rate of 24% likely due to different healthcare attitudes in different cultures and distance from family leading to homesickness.<ref name="Mehta_2014" />

In the context of Asian countries, premarital pregnancy is an important risk factor for PPD. This is because it is considered highly unacceptable in most Asian cultures as there is a highly conservative attitude toward sex among Asian people than people in the West.<ref name="Mehta_2014" /> In addition, conflicts between mother and daughter-in-law are notoriously common in Asian societies as traditionally for them, marriage means the daughter-in-law joining and adjusting to the groom's family completely. These conflicts may be responsible for the emergence of PPD.<ref name="Mehta_2014" /> Regarding the gender of the child, many studies have suggested dissatisfaction with an infant's gender (birth of a baby girl) is a risk factor for PPD. This is because, in some Asian cultures, married couples are expected by the family to have at least one son to maintain the continuity of the bloodline which might lead a woman to experience PPD if she cannot give birth to a baby boy.<ref name="Mehta_2014" />

==== The Middle East ====

With a prevalence of 27%, postpartum depression amongst mothers in the [[Middle East]] is higher than in the Western world and other regions of the world.<ref name="Alshikh_Ahmad_2021" /> Despite the high number of postpartum depression cases in the region in comparison to other areas, there is a large literature gap in correlation with the Arab region, and no studies have been conducted in the [[Middle East]] studying interventions and prevention to tackle postpartum depression in Arab mothers.<ref>{{cite journal | vauthors = Ahmed SR, Watt F, Mahfoud ZR, Korayem M, Buhmaid S, Alberry M, Ibrahim IM, Tandon SD | title = Examining Feasibility, Acceptability, and Preliminary Outcomes of a Culturally Adapted Evidence-Based Postpartum Depression Preventive Intervention for Women in Doha, Qatar: Protocol for a Randomized Controlled Trial | language = EN | journal = JMIR Research Protocols | volume = 12 | issue = 1 | pages = e11623 | date = August 2023 | pmid = 37566449 | pmc = 10457694 | doi = 10.2196/11623 | doi-access = free }}</ref> Countries within the Arab region had a postpartum depression prevalence ranging from 10% to 40%, with a PPD prevalence in [[Qatar]] at 18.6%, [[United Arab Emirates|UAE]] between 18% and 24%, [[Jordan]] between 21.2 and 22.1, [[Lebanon]] at 21%, [[Saudi Arabia]] between 10.1 and 10.3, and [[Tunisia]] between 13.2% and 19.2%, according to studies carried out in these countries.<ref name="Ayoub_2020" /><ref name="Haque_2015">{{Cite journal | vauthors = Haque A, Namavar A, Breene KA |date=2015 |title=Prevalence and Risk Factors of Postpartum Depression in Middle Eastern/Arab Women |journal=Journal of Muslim Mental Health |volume=9 |issue=1 |doi=10.3998/jmmh.10381607.0009.104 |hdl=2027/spo.10381607.0009.104 |issn=1556-5009|doi-access=free }}</ref>

There are also examples of nations with noticeably higher rates, such as [[Iran]] at 40.2%, [[Bahrain]] at 37.1%, and [[Turkey]] at 27%. The high prevalence of postpartum depression in the region may be attributed to socio-economic and cultural factors involving social and partner support, poverty, and prevailing societal views on [[pregnancy]] and [[mother]]hood.<ref name="Ayoub_2020" /> Another factor is related to the region's women's lack of access to care services because many societies within the region do not prioritize mental health and do not perceive it as a serious issue. The prevailing crises and wars within some countries of the region, lack of education, polygamy, and early childbearing are additional factors.<ref name="Ayoub_2020"/><ref name="Haque_2015" /><ref name="Alshikh_Ahmad_2021" /> Fertility rates in Palestine are noticeably high; higher fertility rates have been connected to a possible pattern where birth rates increase after violent episodes. Research conducted on Arab women indicates that more cases of postpartum depression are associated with increased parity.<ref name="Qandil_2016"/> A study found that the most common pregnancy and birth variable reported to be associated with PPD in the Middle East was an unplanned or unwanted pregnancy while having a female baby instead of a male baby is also discussed as a factor with 2 to 4 times higher risk.<ref name="Ayoub_2020" />

=== Europe ===
There is a general assumption that Western cultures are homogenous and that there are no significant differences in psychiatric disorders across Europe and the USA. However, in reality, factors associated with maternal depression, including work and environmental demands, access to universal maternity leave, healthcare, and financial security, are regulated and influenced by local policies that differ across countries.<ref name="Di_Florio_2017">{{cite journal | vauthors = Di Florio A, Putnam K, Altemus M, Apter G, Bergink V, Bilszta J, Brock R, Buist A, Deligiannidis KM, Devouche E, Epperson CN, Guille C, Kim D, Lichtenstein P, Magnusson PK, Martinez P, Munk-Olsen T, Newport J, Payne J, Penninx BW, O'Hara M, Robertson-Blackmore E, Roza SJ, Sharkey KM, Stuart S, Tiemeier H, Viktorin A, Schmidt PJ, Sullivan PF, Stowe ZN, Wisner KL, Jones I, Rubinow DR, Meltzer-Brody S | title = The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale | journal = Psychological Medicine | volume = 47 | issue = 5 | pages = 787–799 | date = April 2017 | pmid = 27866476 | pmc = 5369767 | doi = 10.1017/S0033291716002087 }}</ref> For example, European social policies differ from country to country contrary to the US, all countries provide some form of paid universal maternity leave and free healthcare.<ref name="Di_Florio_2017" /> Studies also found differences in symptomatic manifestations of PPD between European and American women.<ref>{{Cite journal|date=1999-05-01|title=Postpartum depression: a cross-cultural perspective |journal=Primary Care Update for OB/GYNS|language=en|volume=6|issue=3|pages=82–87|doi=10.1016/S1068-607X(99)00003-7 | vauthors = Bashiri N, Spielvogel AM }}</ref> Women from Europe reported higher scores of [[anhedonia]], self-blaming, and anxiety, while women from the US disclosed more severe [[insomnia]], depressive feelings, and thoughts of self-harming.<ref name="Di_Florio_2017" /> Additionally, there are differences in prescribing patterns and attitudes towards certain medications between the US and Europe which are indicative of how different countries approach treatment, and their different stigmas.<ref name="Di_Florio_2017" />

=== Africa ===
Africa, like all other parts of the world, struggles with the burden of postpartum depression. Current studies estimate the prevalence to be 15-25% but this is likely higher due to a lack of data and recorded cases. The magnitude of postpartum depression in South Africa is between 31.7% and 39.6%, in Morocco between 6.9% and 14%, in Nigeria between 10.7% and 22.9%, in Uganda 43%, in Tanzania 12%, in Zimbabwe 33%, in Sudan 9.2%, in Kenya between 13% and 18.7% and, 19.9% for participants in Ethiopia according to studies carried out in these countries among postpartum mothers between the ages of 17–49.<ref name="Atuhaire 2020">{{cite journal | vauthors = Atuhaire C, Brennaman L, Cumber SN, Rukundo GZ, Nambozi G | title = The magnitude of postpartum depression among mothers in Africa: a literature review | journal = The Pan African Medical Journal | volume = 37 | page = 89 | date = 2020 | pmid = 33244352 | pmc = 7680231 | doi = 10.11604/pamj.2020.37.89.23572 }}</ref> This demonstrates the gravity of this problem in Africa and the need for postpartum depression to be taken seriously as a public health concern in the continent. Additionally, each of these studies was conducted using Western-developed assessment tools. Cultural factors can affect diagnosis and can be a barrier to assessing the burden of disease.<ref name="Atuhaire 2020"/> Some recommendations to combat postpartum depression in Africa include considering postpartum depression as a public health problem that is neglected among postpartum mothers. Investing in research to assess the actual prevalence of postpartum depression, and encourage early screening, diagnosis, and treatment of postpartum depression as an essential aspect of maternal care throughout Africa.<ref name="Atuhaire 2020"/>

=== Issues in reporting prevalence ===

Most studies regarding PPD are done using self-report screenings which are less reliable than clinical interviews. This use of self-reporting may have results that underreport symptoms and thus postpartum depression rates.<ref name="Hahn-Holbrook_2018">{{cite journal | vauthors = Hahn-Holbrook J, Cornwell-Hinrichs T, Anaya I | title = Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries | journal = Frontiers in Psychiatry | volume = 8 | page = 248 | date = 2018 | pmid = 29449816 | pmc = 5799244 | doi = 10.3389/fpsyt.2017.00248 | doi-access = free }}</ref><ref name="Ko_2017" />

Furthermore, the prevalence of postpartum depression in Arab countries exhibits significant variability, often due to diverse assessment methodologies.<ref name="Ayoub_2020" /> In a review of twenty-five studies examining PPD, differences in assessment methods, recruitment locations, and timing of evaluations complicate prevalence measurement.<ref name="Ayoub_2020" /> For instance, the studies varied in their approach, with some using a longitudinal panel method tracking PPD at multiple points during pregnancy and postpartum periods, while others employed cross-sectional approaches to estimate point or period prevalences. The Edinburgh Postnatal Depression Scale (EPDS) was commonly used across these studies, yet variations in cutoff scores further determined the results of prevalence.<ref name="Ayoub_2020" />

For example, a study in Kom Ombo, Egypt, reported a rate of 73.7% for PPD, but the small sample size of 57 mothers and the broad measurement timeframe spanning from two weeks to one year postpartum contributes to the challenge of making definitive prevalence conclusions (2). This wide array of assessment methods and timing significantly impacts the reported rates of postpartum depression.<ref name="Ayoub_2020" />