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Introduction
The postpartum period is a critical transitional phase for women, characterized by
significant physical and psychological changes. During this period, the prevalence
of depression is reported to be more than twice as high as at other times in a
woman’s life [1]. Postpartum depression
(PPD) is considered a precursor to major depressive disorder and is defined by
symptoms such as sadness, excessive crying, anxiety, agitation, low mood, loss of
interest, and sleep disturbance [2]. PPD can
progress to long-term depressive illness, particularly when accompanied by thoughts
of self-harm [3]. PPD typically begins 6 weeks
after childbirth and ranges in severity from mild to severe [4,5]. The prevalence of
PPD has been estimated at 17.2%, with reported rates in Asia ranging from 13.53% to
22.32% [6]. Despite its prevalence, PPD
remains among the most underdiagnosed and undertreated forms of depression, and
there is limited awareness regarding the importance of prevention and
intervention.
Several instruments have been used to identify PPD promptly, including the Edinburgh
Postnatal Depression Scale (EPDS), the PPD Screening Scale, and Beck's
Depression Inventory. The EPDS is considered the most reliable of these instruments
in terms of its sensitivity, specificity, and clinical validity for measuring PPD in
the postpartum period [7]. Moreover, the EPDS
includes a specific item on suicidal ideation, which is critical for evaluating the
severity of depression and facilitating timely referrals to mental health services
[8].
PPD is associated with various demographic and psychosocial factors, including low
economic status, low education, single motherhood, major stressful events, lack of
social and family support, history of depression, and unplanned pregnancy [9,10]. In
Asian cultures, traditional support from in-laws or female relatives can provide
physical and psychological comfort; however, it can also lead to interpersonal
conflict and emotional distress [4,5,11].
Furthermore, a longstanding cultural preference for male offspring, particularly for
the first child, is found in regions such as Eastern Asia, South-eastern Asia,
Western Asia (including Arab countries and Türkiye), and Southern Asia
(including India), which may contribute to the development of PPD [5].
Studies have systematically reviewed the prevalence and associated factors of PPD.
However, these studies were limited in scope, either focusing on single countries
within Asia [12,13] or providing broad reviews of the global literature [6] that lacked an Asia-specific context. In
2024, a systematic review was conducted in Asian cultural contexts [5], but it did not address the characteristics
of the EPDS in these contexts, such as culture-specific cutoff points, nor did it
explore cultural factors influencing PPD.
To fill this research gap, this study aimed to compare and analyze the prevalence of
PPD across Asian countries, examine the EPDS cutoffs used in each country, and
identify the cultural, psychosocial, and demographic factors associated with
PPD.
Methods
Ethical statement
As a scoping review of the existing literature, this study did not require
approval from the institutional review board or informed consent.
Study design
This study employed a scoping review design following the five-step framework
proposed by Arksey and O'Malley [14]. The process included (a) identification of research questions,
(b) literature search, (c) selection of relevant literature, (d) data analysis,
and (e) summarizing and reporting the findings [14]. The study adhered to the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA ScR)
reporting guidelines for topical scoping reviews [15].
Step 1: identification of the research question
The primary research question was: "What are the recent research trends in
Asian countries regarding maternal PPD?" The specific research questions
were: (a) What is the prevalence of PPD among Asian mothers, (b) How do the EPDS
cutoffs differ across Asian countries, and (c) What are the cultural,
psychosocial, and demographic factors influencing PPD?
Step 2: literature search
A literature search was conducted between October 7 and October 14, 2024, in five
electronic databases: PubMed, Embase, CINAHL (EBSCO), PsycINFO, and Web of
Science, using a combination of three main search terms: “postpartum
depression,” “EPDS,” and “Asia.” Asian
countries were defined based on the United Nations Geoscheme [16], including countries from Eastern Asia,
South-eastern Asia, Southern Asia, and Western Asia.
Search strategies were developed by two researchers (authors L, M) using Boolean
operators to combine Medical Subject Headings (MeSH) with keywords and synonyms.
The final search strategies were reviewed by a professional librarian at the
authors’ institution. The search strategies for each database are
detailed in Supplement
1. The search was restricted to titles and abstracts using the final
search strategy in each database. Additionally, a supplementary search for
relevant literature not identified by the database search was conducted using
Google Scholar for 7 days following October 14, 2024.
Step 3: selection and exclusion criteria
Studies were included if they 1) were peer-reviewed journal articles addressing
the prevalence and factors associated with PPD in Asian mothers, 2) included the
usage of EPDS, 3) were written in English, and 4) were published from January 1,
2020 to September 30, 2024. The exclusion criteria were as follows: 1) gray
literature such as dissertations, case reports, posters, or abstracts; (b)
review articles or qualitative studies; (c) articles for which the full text was
not available; (d) studies that did not include outcomes at 6–8 weeks
postpartum; and (e) studies that did not address cultural, psychosocial, or
demographic factors associated with PPD (e.g., only included biological markers,
etc.).
The screening process was conducted independently by two researchers (authors L,
M). In the first phase, titles and abstracts of all retrieved studies were
reviewed based on the inclusion and exclusion criteria. In the second phase, the
full texts of the selected studies were reviewed using the same criteria for the
final selection. Any disagreements at any stage were resolved through
discussion. If no consensus was reached, a third researcher (author K) was
consulted.
The initial search yielded 2,480 studies. After excluding duplicates, 850 studies
remained for screening. Based on titles and abstracts, 629 studies were
excluded, leaving 221 studies for full-text review. After applying the inclusion
and exclusion criteria to the full texts, 202 studies were excluded, and 19
studies [4,8–10,17–31] were finally selected for analysis (Fig. 1). The bibliographic management software EndNote 20
was used to store retrieved studies and remove duplicates.
Step 4: data analysis
A draft analysis framework was developed to record the data from the selected
literature, and the final analysis framework was finalized through research
meetings. The framework consisted of five main categories: publication
characteristics, study characteristics, EPDS characteristics, participant
characteristics, and study outcomes. All data were extracted, and frequency
analysis and descriptive statistics were performed using Microsoft Excel
2020.
Results
General characteristics of the selected studies
Table 1 summarizes the general
characteristics of the selected studies. The analysis of 19 studies revealed
that publications originated from 10 countries. China accounted for the largest
share with 7 studies (36.8%) [19–25], followed by
India with 3 studies (15.79%) [26–28], and Saudi
Arabia with 2 studies (10.53%) [8,31]. One study (5.26%) each was conducted
in Bhutan [17], Cambodia [18], South Korea [29], Laos [10],
Myanmar [4], the Philippines [30], and Türkiye [9].
Table 1.
General characteristics of the selected studies (n=19)
| UN Geoscheme | Country | References | Study design | Recruitment site |
|---|---|---|---|---|
| Eastern Asia | China | Chen and Shi [19] | Cross-sectional study | Hospital |
| He et al. [20] | Cross-sectional study | Hospital | ||
| Liu et al. [21] | Cross-sectional study | Hospital | ||
| Liu et al. [22] | Cross-sectional study | Hospital | ||
| Peng et al. [23] | Cross-sectional study | Hospital | ||
| Xiong and Deng [24] | Cross-sectional study | Hospital | ||
| Yi and Ahn [25] | Cross-sectional study | Hospital | ||
| South Korea | Yoo et al. [29] | Prospective cohort study | Hospital | |
| South-Eastern Asia | Cambodia | Guechhorng et al. [18] | Cross-sectional study | Primary healthcare institutions |
| Laos | Inthaphatha et al. [10] | Cross-sectional study | Hospital | |
| Myanmar | Wyunn et al. [4] | Cross-sectional study | Hospitals | |
| Philippines | Labrague et al. [30] | Cross-sectional study | Primary healthcare institutions | |
| Western Asia | Saudi Arabia | Alhusaini et al. [31] | Cross-sectional study | Hospital |
| Alshowkan and Shdaifat [8] | Cross-sectional study | Hospital | ||
| Türkiye | Çankaya [9] | Prospective longitudinal cohort study | Hospital | |
| Southern Asia | Bhutan | Zangmo et al. [17] | Cross-sectional study | Hospital |
| India | Begum et al. [26] | Cross-sectional study | Hospital | |
| Murry [27] | Cross-sectional study | Hospital | ||
| Priya et al. [28] | Cross-sectional study | Hospital |
The distribution of studies over the past 5 years showed an increasing trend,
despite a dip during the COVID-19 pandemic. Specifically, 6 studies (31.58%)
were published in 2020 [9,10,21,24,27,30], 3 studies
(15.79%) in 2021 [22,23,29], and 1 study (5.26%) each in 2022 and 2023 [19,31]. The year 2024 saw a significant rise, with 8 studies (42.11%)
[4,8,17,18,20,25,26,28].
Regarding study design, the majority were cross-sectional (n=17, 89.47%) [4,8,10,17–28,30,31], one was a prospective cohort study (5.26%) [29], and one was a prospective longitudinal
study (5.26%) [9]. The number of
participants ranged from 65 to 4,813. One study [29] included both mothers and their spouses. Two studies [18,30] recruited participants from primary health care centers, while
17 studies [4,8–10,17,19–29,31] recruited participants from
hospitals.
General characteristics of the participants
The general characteristics of the participants are summarized in Table 2. Twelve studies reported the mean
age of participants, which was calculated to be 28.06±4.44 years. The age
range of participants varied across the studies; some included mothers aged 16
years and older [10], while others
included those aged 17 years and older [17,31]. Additionally, two
studies [19,24] focused on older mothers, aged 35 years or older.
Table 2.
Detailed characteristics of the selected studies (n=19)
| References | Country | Sample | EPDS | Findings | ||||
|---|---|---|---|---|---|---|---|---|
| Size | Characteristics | Time frame (postpartum) | EPDS version | Cutoff/mean | PPD prevalence n (%) | Factors associated with PPD | ||
| Zangmo et al. [17] | Bhutan | 314 |
- Age range: 17−48
years - Included mothers with a history of psychiatric disorders |
4–8 weeks | Translated and pilot-tested (n=30) |
- ≥11 - Mean score of suspected PPD: 14.17±3.44 |
47 (14.97%) |
- Poor relationship with
friends/in-laws - Perceived changes in body image, perceived increased stress during pregnancy, and perceived stress after delivery - History of pregnancy complications, negative delivery experience, and poor health status of the newborn |
| Guechhorng et al. [18] | Cambodia | 440 |
- Mean age: 28.6 years - Included mothers with a history of psychiatric disorders - Mothers with singleton pregnancy, and no thyroid disorders |
6–8 weeks | Translated and pilot-tested (n=11) |
- ≥10 - Mean score: 6.65±4.27 |
133 (30.2%) |
- Poor relationship with spouse and
mother-in-law - Dissatisfaction with economic status, unplanned pregnancy, and spouse’s employment in manual labor/farming/factory work |
| Chen and Shi [19] | China | 239 |
- Mothers ≥35 years - Excluded mothers with a history of psychiatric disorders |
6 weeks | No information on EPDS version | ≥9 | 51 (21.34%) |
- Lower familial support - Lower level of education (<high school education), and history of pregnancy complications |
| He et al. [20] | China | 503 |
- Mean age of PPD mothers:
28.25±3.785 (vs 29.57±4.123 in non-PPD) - Excluded history of psychiatric disorders, pregnancy complications, and medical conditions |
6–7 weeks | Chinese version | ≥10 | 73 (14.5%) |
- Co-habitation with in-laws - Younger maternal age and history of pregnancy complications |
| Liu et al. [21] | China | 1,204 |
- Mothers ≥18 years, with
healthy term births, and no postpartum complications - No information on psychiatric history |
6 weeks | Chinese version |
- ≥13 - Mean score: 8.18±5.80 |
279 (23.2%) |
- Lower familial support, lower social
support from colleagues or friends, mother-in-law as the primary
caregiver of mother and newborn, and dissatisfaction with
childbirth experiences - Lower level of education, unplanned pregnancy, and lower economic status |
| Liu et al. [22] | China | 1,136 |
- Mean age: 30.16±3.91 - No information on psychiatric history - Mothers with singleton pregnancy, and no postpartum complications |
6–8 weeks | Chinese version |
- ≥13 - Mean score: 9.54±4.46 |
267 (23.5%) |
- Lower social support, symptoms of
postpartum post-traumatic stress disorder - Poor health condition of the newborn |
| Peng et al. [23] | China | 4,813 |
- Mean age of PPD mothers: 29
(27−32) - Included mothers with a history of psychiatric disorders |
6 weeks | Chinese version | ≥10 | 559 (11.6%) |
- Co-habitation with in-laws - Higher daily life stress - Housewife, primiparity |
| Xiong and Deng [24] | China | 1,124 |
- Mothers ≥35 years - Excluded mothers with a history of psychiatric disorders |
6 weeks | Chinese version | ≥13 | 202 (18%) |
- Demale newborn, gap between familial
expectations for fetal sex and actual sex of the newborn, poor
relationship with mother-in-law - Primiparity |
| Yi and Ahn [25] | China | 150 |
- Mean age: 26.25±3.90 - Excluded mothers with a history of psychiatric disorders - Mothers with Primiparity, and no pregnancy complications |
6 weeks | Chinese version |
- ≥10 - Mean score: 13.94±5.70 |
118 (78.7%) |
- Gap between familial expectations
for fetal sex and actual sex of the newborn, poor relationship
with spouse, mother-in-law, and one’s parents - Higher parenting stress, the gap between perceived and actual family support - Younger maternal age, lower economic status, and poor health condition of the newborn |
| Begum et al. [26] | India | 65 |
- Mean age: 21.58±2.31 - Excluded mothers with a history of psychiatric disorders - Mothers with no abortions/ medical terminations |
6–8 weeks | No information on EPDS version | ≥13 | 22 (33.8%) |
- Living in an extended family
structure, pressure from the family to become pregnant, pressure
for a female child, and poor relationship with spouse, in-laws,
and one’s parents - Younger maternal age, lower level of education, lower economic status, history of pregnancy complications, multiple fetuses, and unplanned pregnancy |
| Murry [27] | India | 284 |
- Mean age: 28.6±4.61 - No information on psychiatric history - Mothers excluding those with infants diagnosed with acute illnesses |
6–8 weeks | Hindi version |
- ≥12 - Mean score: 7.67±5.9 |
72 (25.3%) |
- Lower familial support, and poor
relationship with mother-in-law - Dissatisfaction with marriage - History of pregnancy complications |
| Priya et al. [28] | India | 426 |
- No information on maternal mean
age - Excluded mothers with a history of psychiatric disorders or neurological disorders |
6 weeks | English, Hindi | ≥10 | 74 (17.4%) |
- Living in a nuclear family, and
female newborn - Unplanned pregnancy, and multiparity |
| Yoo et al. [29] | South Korea | 183 and 130 of their spouses |
- Mean age: 32.9±3.41 - Excluded mothers with a history of psychiatric disorders - Mothers with a singleton pregnancy and their spouses |
At six points (at 20, 28, and 36 weeks of pregnancy and at 2, 6, and 12 weeks postpartum) | Korean version | ≥10 | 45 (24.6%) | - Lower social support, dissatisfaction with marriage, higher parenting stress, higher daily life stress, and lower level of self-esteem |
| Inthaphatha et al. [10] | Laos | 428 |
- Mean age: 28.1
(16−44) - Included mothers with a history of psychiatric disorders - Mothers with a singleton pregnancy, and no thyroid disorders |
6–8 weeks | Translated and pilot-tested (n=20) |
- ≥10 - Mean score: 7.1±4.6 |
136 (31.8%) |
- Poor relationship with spouse,
one’s parents, and mother-in-law - Dissatisfaction with childbirth experiences - Higher education levels of participants and spouses, unplanned pregnancy, multiparity, housewife, and spousal unemployment |
| Wyunn et al. [4] | Myanmar | 552 |
- Mean age: 27.9±4.8
(18−43) - No information on psychiatric history - Mothers with a singleton pregnancy |
6–8 weeks | Myanmar version |
- ≥10 - Mean score: 6.4±5.2 |
176 (31.9%) |
- Living in a nuclear family and lower
familial support - Dissatisfaction with economic status - Unplanned pregnancy |
| Labrague et al. [30] | Philippines | 165 |
- Mean age: 23.98±5.74 - Excluded mothers with a history of psychiatric disorders |
6 weeks | No information on EPDS version | ≥10 | 27 (16.4%) | - Having a professional occupation, multiparity |
| Alhusaini et al. [31] | Saudi Arabia | 354 |
- Mean age: 31.58±5.8
(17−53) - Included mothers with a history of psychiatric disorders |
Twice, immediately after birth and 6 weeks | Arabic version | ≥13 | 18 (5.1%) | - Lower social support |
| Alshowkan and Shdaifat [8] | Saudi Arabia | 270 |
- Married mothers aged 18−49
years - Excluded mothers with a history of psychiatric disorders |
6 weeks | Arabic version |
- ≥10 - Mean score: 2.54±4.5 |
15 (5.6%) |
- Living in an extended family
structure - Lower level of education, spousal unemployment, lower economic status, multiple fetuses, history of pregnancy complications |
| Çankaya [9] | Türkiye | 245 |
- Mean age: 27.3±5.2 - Mean age of PPD mothers: 28.2±5.2 (vs 27.2±5.2 non-PPD) - No information on psychiatric history - Mothers with Primiparity and a singleton pregnancy |
6–8 weeks | Turkish version | ≥13 | 44 (18%) |
- Increased marital conflict - Increased perceived stress during pregnancy |
Regarding obstetric characteristics, 3 studies [9,22,25] focused on primiparity, and 6 studies [4,9,10,18,22,29] included only mothers of singleton
births. Nine studies [8,19,20,24–26,28–30] included
mothers with no psychiatric history, and 7 [10,18,20–22,25,28] recruited only participants with no health problems or
complications related to pregnancy and birth. One study [26] excluded mothers with a history of abortion or induced
termination of pregnancy, and another [27] excluded cases where the infant had health conditions.
Edinburgh Postnatal Depression Scale characteristics by country
Edinburgh Postnatal Depression Scale version
A total of 16 studies (84.21%) described the EPDS version used, with 13
(68.42%) using translated versions validated for reliability and validity in
their respective countries. Six of those used the Chinese version [20–25], followed by Hindi [27,28], Arabic [8,31], Korean [29], Burmese
[4], and Turkish [9] versions. Three studies (17.79%) used
translations done by the researchers, pilot-tested but without reported
psychometric analyses: these were from Bhutan [17], Cambodia [18], and Laos [10].
Edinburgh Postnatal Depression Scale cutoff points
The EPDS is typically validated for reliability and validity within each
country, with a standard cutoff of 13 or higher frequently adapted to fit
the local cultural context [32].
However, among these 19 studies, there was variability in cutoff points,
even within the same country.
A cutoff point of 10 or higher was most commonly used, appearing in 10 out of
the 19 studies (42.11%). These studies spanned various regions: India [28] in Southern Asia; Cambodia [18], Laos [10], Myanmar [4],
and the Philippines [30] in
Southeastern Asia; Saudi Arabia [8] in
Western Asia; and South Korea [29]
along with China [20,23,25] in Eastern Asia. Two studies from Cambodia [18] and Laos [10] cited research on EPDS cutoff points in primary
healthcare settings in non-English-speaking countries [33]. Meanwhile, studies from China [23], South Korea [29], Myanmar [10], and Saudi Arabia [8]
referenced validation studies of the EPDS translated into their respective
languages [34–37]. Additionally, 2 studies from China
[22,24] utilized cutoffs based on research assessing the
clinical significance of EPDS cutoffs in English-speaking mothers [38].
A cutoff point of 9 or higher was reported in one study (5.26%) conducted in
China [19], referencing a prior
validation study of the Chinese version of the EPDS [39]. One study (5.26%) from Bhutan [17] used a cutoff of 11 or higher,
which based its criteria on a systematic review of EPDS cutoffs in the
global literature [40]. Another study
(5.26%) from India [27] used a cutoff
point of 12 or higher but did not provide details on a specific rationale or
evidence for this criterion.
In contrast, a cutoff point of 13 or higher was reported in six studies from
China [21,22,24], India
[26], Saudi Arabia [31], and Türkiye [9]. The rationale for this cutoff
included a validation study of the Turkish EPDS version [41] and a previously validated Arabic
version that was assessed for reliability and validity [42]. Conversely, two Chinese studies
[21,22] cited a systematic review of EPDS cutoff points in
global literature [43] and the
original developer’s publication on the EPDS [44]. Two other studies [24,26] did not provide a
rationale for their chosen cutoff points. However, the original developer of
the EPDS [44] recommended that cutoff
points for translated versions of the EPDS might not be universally
applicable across different cultures and emphasized the importance of
establishing semantic, technical, diagnostic, and conceptual equivalence
when adapting the EPDS for various cultural contexts.
Edinburgh Postnatal Depression Scale mean scores
Nine studies (47.37%) reported mean EPDS scores and SD, although one [17] provided only the mean for
participants suspected of having PPD. The remaining 8 studies [4,8,10,18,21,22,25,27] showed a mean EPDS score of 7.75±5.09.
The mean and SD of EPDS scores from studies conducted in South-Eastern Asia,
specifically in Cambodia [18], Laos
[10], and Myanmar [4], were calculated to be
6.72±4.71. A study from India [27] in Southern Asia reported slightly higher values
(7.67±5.9), while a study from Saudi Arabia [8] in Western Asia reported lower values
(2.54±4.5). The unusually low EPDS mean score in the Saudi study
[8] may be attributed to the
demographic characteristics of the participants, over 90% of whom had a
university education or higher and resided in nuclear family settings.
Prevalence and associated factors of postpartum depression
Prevalence
The prevalence of PPD ranged from 5.1% [8] to 78.7% [25]. In
Eastern Asia, South Korea [29]
reported 24.6%, while Chinese studies ranged from 11.6% [23] to 78.7% [25]. In South-eastern Asia, reported prevalence was
30.2% in Cambodia [18], 31.8% in Laos
[10], 31.9% in Myanmar [4], and 16.4% in the Philippines [30]. In Southern Asia, Bhutan [17] reported 14.9%, while rates in
India ranged from 17.4% [28] to 33.8%
[26]. In Western Asia,
Türkiye [9] reported 18%,
whereas Saudi Arabia reported the lowest rates (5.1% [31] and 5.6% [8]). Thus, the lowest prevalence was found in Saudi Arabia, while
the highest was found in China.
Cultural factors
Various cultural factors contributing to PPD were identified in 18 studies
(Table 3), with a particular
focus on family relationships. The most frequently mentioned factor was poor
relationships with in-laws (n=7), followed by negative relationships with
the spouse (n=4) and the mother's own parents (n=3). Additionally,
living with in-laws (n=2) and having the mother-in-law as the primary
caregiver for the mother and newborn (n=1) were also reported as
contributing factors.
Table 3.
Classification of factors associated with PPD
The influence of newborn sex also emerged as a significant cultural factor,
particularly when the newborn was female (n=2) or when there was a
discrepancy between family expectations and the actual sex of the newborn
(n=2). Additionally, one study identified family pressure to conceive as a
factor linked to PPD.
Psychosocial factors
Thirteen studies identified psychosocial factors associated with PPD [4,9,10,17–19,21–23,25,27,29,31]. The most commonly reported factors
were low family support and low social support from colleagues or friends,
each mentioned in four studies. Other factors included high levels of daily
life stress, parenting stress, dissatisfaction with marriage, childbirth
experiences, and economic status, each cited in two studies.
Demographic factors
The most commonly reported demographic factors included pregnancy
complications and unplanned pregnancies, each cited in six studies. These
were followed by low economic status, reported in five studies; low level of
education, in four studies; and young maternal age, multiparity, and poor
neonatal health, each noted in three studies. Less frequently mentioned
factors were spousal unemployment, the mother's occupation as a
housewife, primiparity, and multiple fetuses, each reported in two
studies.
Discussion
This study found that the prevalence of PPD was lowest in Saudi Arabia at 5.1% [8] and highest in China at 78.7% [25]. These findings are somewhat consistent
with previous reports, which have shown PPD prevalence in Asian countries to range
from 4.9% to 93% [5]. Earlier studies have
indicated variability in PPD prevalence across Asia, with the lowest rates reported
in South Korea [5,6] and the highest in Japan [5] or Afghanistan [6]. However,
considering that Korean nurses exhibited significantly higher rates of PPD (45.9%)
compared to their US counterparts (3.4%) [45], it is crucial to carefully examine variations in sampling methods,
participant characteristics, and the use of culturally sensitive cutoffs.
Among the cultural factors associated with PPD, a negative relationship with in-laws
has been identified as a contributing factor, consistent with findings from a
previous study in Japan [46]. This may be
linked to Confucian influences that emphasize recognition and affirmation by the
extended family in Asia. Similarly, the extended family—a traditional family
structure in Asian countries—has been reported to increase the risk of PPD
[46]. However, while some studies have
identified the extended family as a factor [8,26], others have pointed to the
nuclear family structure as associated with PPD [4,28]. Interestingly, living with
a mother-in-law was found to be a significant factor for PPD, aligning with results
from a previous study in China [47]. Our
findings regarding cultural factors related to the newborn’s sex also mirror
those of the earlier study conducted in China [47], suggesting that Confucian preferences for boys in Asian countries
may contribute to familial conflict and, consequently, increase the risk of PPD.
In terms of the psychosocial factors associated with PPD, a lack of family and social
support was identified as a key factor. Family support during the postpartum period
is crucial for maternal well-being, as close relationships and daily interactions
with the spouse and other family members offer both emotional and practical support
[4]. This observation aligns with the
findings of systematic reviews from Western Asia, which analyzed the relationship
between social support and PPD [1,48]. These insights suggest that healthcare
providers should consider the family environment and educate spouses and family
members about PPD. Regarding demographic characteristics, unplanned pregnancies, low
education levels, low income, and younger maternal age have been significantly
associated with PPD. These associations are consistent with studies conducted in
Western Asia [1,11].
This study has limitations. Strict inclusion criteria may have excluded some articles
that contained relevant insights into PPD. In addition, most included studies were
cross-sectional, limiting conclusions about causality. Some recent research suggests
that environmental factors (e.g., endocrine disruptors, and air pollution) could
also influence PPD [49,50]. Future research should consider these factors to gain a
more comprehensive understanding of PPD. Despite these limitations, this review
highlights the need for consistent use of the EPDS and the establishment of
standardized cutoff points to enhance the accuracy of PPD screening in Asian
countries. It also emphasizes the importance of strengthening family and community
support systems to improve maternal psychological well-being and prevent PPD.
Developing prevention strategies and programs that reflect Asia’s diverse
cultural and social contexts will be key to the early detection and prevention of
PPD.
In conclusion, the prevalence of PPD in Asian countries widely varied, ranging from
5.1% to 78.7%. Although most studies used translated EPDS versions that had been
previously validated for reliability and validity, there was variability in the EPDS
cutoff points, even within individual countries such as India, Saudi Arabia, and
China. This variability underscores the need for a standardized approach to using
the EPDS, including adopting internationally recognized standardized translations
and establishing consistent cutoff criteria that take into account the cultural
characteristics of Asian countries.
This study identified that cultural factors, including relationships with in-laws and
issues related to the sex of the newborn, are significant in the context of PPD
among Asian mothers. To definitively establish the connection between cultural
influences and PPD, further prospective cohort or population-based studies are
required.
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