Review of the Depression Rate among Pregnant Women during the COVID-19 Pandemic

Maiko Manaka, Nana Sasano, Sachi Chikazawa, Ayako Sasaki

Faculty of Nursing, Osaka Medical and Pharmaceutical University, Takatsuki, Japan.

DOI: 10.4236/health.2023.151003                

Abstract

Purpose: To determine the incidence of depression among pregnant women during the coronavirus disease (COVID-19) pandemic. Methods: A literature search was conducted on July 2022 through PubMed, CINAHL, MEDLINE, CiNii, and the Japan Medical Abstract Society using the keywords “COVID-19”, “Pregnant Women” and “Depression”. The titles/abstracts were screened based on three selection criteria: 1) inclusion of pregnant women; 2) description of depression; 3) description of COVID-19. Results: Of the 213 articles that were extracted, 104 were excluded owing to duplication and 14 were excluded because they comprised other article types, including reviews and commentaries. Finally, 49 were excluded by title, abstract, and full-text screening. Among the 46 articles that met the inclusion criteria, 13 articles (28.3%) were from China, 8 (17.4%) were from Turkey, 4 (8.7%) were from the United States, and 3 (6.5%) were from Japan. The most common scales used to measure depression were the Edinburgh Postnatal Depression Scale (EPDS) used in 18 articles (39.1%), followed by the Patient Health Questionnaire (PHQ-9) used in 11 articles (23.9%). Furthermore, 46 sources reported a suspected depression rate of 30.0% (20,338/67,860 pregnant women). The rate of depression was 15.1% - 33.5% using EPDS ≥ 9 in three articles and 12.0% - 43.2% using EPDS ≥ 13 in nine articles. The five articles using PHQ-9 ≥ 5 reported 25.8% - 48.7%, and seven articles reported 5.3% - 59.2% using PHQ-9 ≥ 10. Conclusion: Depression was a concern for one out of every three to four pregnant women during the COVID-19 pandemic. This suggests that depression among pregnant women during COVID-19 might have worsened, highlighting the need for mental health support for them.

Keywords

COVID-19, Pregnant Women, Depression, EPDS, PHQ-9

1. Introduction

Perinatal depression is a major issue in maternal and child health. Depression affects mother-baby bonding, child development, and family health [1] [2]. The most severe consequence of depression is maternal suicide [3]. In Japan, the Tokyo Metropolitan Medical Examiner’s Office reported 63 suicide victims (8.7/100,000 live births) among the unusual maternal deaths that occurred during pregnancy, or less than one year postpartum, between 2005 and 2014 in Tokyo, an incidence rate higher than that in both the United Kingdom and Sweden [4].

According to some studies [5] [6], the COVID-19 pandemic has increased depressive symptoms among pregnant women compared to their state before the pandemic. However, there is some contradicting data, as can be seen in Overbeck et al. [7]. Depression rates among pregnant women were reviewed from December 2019 to February 2021. Consequently, the study reported that depression was a concern for 25.6% of a total of 47,677 pregnant women based on data from 37 previous studies [8]. Notably, COVID-19 has persisted even after 2021. Furthermore, the domestic and international rates of depression among pregnant women during COVID-19 have been investigated. However, the actual status of depression among pregnant women has not been determined since Tomfohr-Madsen et al.’s study [8]. Therefore, this study determined the rates of pregnant women suspected to have depression or depressive symptoms during the COVID-19 pandemic.

2. Methods

2.1. Data Collection

A literature search was conducted in July 2022 (last search July 19, 2022) through Pub-Med, CINAHL, MEDLINE, CiNii, and the Japan Medical Abstract Society. The keywords used were “COVID-19”, “Pregnant Women” and “Depression”. The search terms and formulas for the database and search results are shown in Table 1.

2.2. Inclusion and Exclusion Criteria

The literature selection process for this study is illustrated in Figure 1. The literature search yielded 213 references, of which 104 duplicates were excluded while 14 were excluded due to reviews, commentaries, protocols, and introductions to initiatives.

Title screening was based on three selection criteria: 1) Inclusion of pregnant women; 2) Description of mental health; 3) Description of COVID-19. Consequently, one article was excluded from the literature that targeted postpartum mothers rather than pregnant women. Screening of abstracts was also conducted based on three criteria: 1) Inclusion of studies that exclusively analyzed pregnant women; 2) Description of depression; 3) Description of COVID-19. This process excluded 28 references that did not mention depression. Subsequently, we reviewed the text and excluded 19 references that did not clearly describe the number or percentage of people who were suspected of having depression or depressive symptoms, and one reference that did not clearly describe a depression measurement scale.

2.3. Statistical Analysis

The number of references by country and the scales used to measure depression among pregnant women were tabulated. We also extracted the cut-off values for the scales that are used to measure depression among pregnant women, the number of pregnant women, and the number and percentage of pregnant women with suspected depression or depressive symptoms for each cut-off value. However, each cut-off value is presented individually for studies using different values.

Table 1. The search results yielded from the search terms and formulas used for the database search results.

Note. Abbreviations: MH = Medical Subject Headings; TH = Thesaurus Headings; AL = All Headings.

Figure 1. The literature selection process for this study.

The total number of pregnant women with suspected depression or depressive symptoms in the selected literature was divided by the total number of pregnant women and subsequently multiplied by 100 to calculate the percentage. Additionally, we focused on the most frequently used scales to examine the actual state of depression among pregnant women.

3. Results

The current study identified 46 references that met the current objectives, all of which were in English. In total, 17 countries were reported: 13 references from China (28.3%), 8 from Turkey (17.4%), 4 from the United States (US; 8.7%), and 3 from Japan (6.5%; Table 2).

Table 2. Number of references by country.

3.1. Measuring Depression among Pregnant Women during the COVID-19 Pandemic

A total of 12 instruments were used to measure depression among pregnant women during the COVID-19 pandemic (Table 3).

Table 3 indicates that the most frequently employed instrument was the Edinburgh Postnatal Depression Scale (EPDS) with 18 references (39.1%), followed by Patient Health Questionnaire-9 Items (PHQ-9) in 11 references (23.9%), Beck Depression Inventory (BDI) in 4 references (8.7%), Hospital Anxiety and Depression Scale (HADS) in 3 references (6.5%), and the Depression, Anxiety and Stress Scale-21 Items (DASS-21) in 3 references (6.5%). Particularly, the EPDS and PHQ-9 were used most frequently to measure depression in pregnant women during the COVID-19 pandemic and were found in 29 references (63.0%).

3.2. Depression Screened among Pregnant Women during the COVID-19 Pandemic

The scales used to screen depression, the cut-off values for each scale, and the percentage of pregnant women with suspected depression or depressive symptoms are presented in Table 4. The total number of pregnant women included in the 46 references [5] [6] [9] - [52] was 67,860, while the number of those with suspected depression or depressive symptoms was 20,338 (Table 4). Equation (1) shows the rate of pregnant women with suspected depression or depressive symptoms being around 30.0%.

$20,338÷67,860\times 100=\text{29}\text{.9705276}$ (1)

Table 3. Scales used to measure depression among pregnant women during the COVID-19 pandemic.

Table 4. Cut-off values for each scale and percentage of pregnant women with suspected depression and depressive symptoms.

3.3. Depression Screened Using the EPDS and PHQ-9

The current study focused on EPDS and PHQ-9, which have been used widely to screen depression in pregnant women.

The EPDS was used in 21 references to indicate the percentage of pregnant women with suspected depression, which ranged from 8.2% to 44.9%. The EPDS used different cut-off values, even for references from the same country. Therefore, the percentage of pregnant women with suspected depression is presented for each cut-off value (Table 4). EPDS ≥ 9 was used in three references (two in Japan and one in the U.S.), while the percentage of suspected depressed pregnant women ranged from 15.1% to 33.5% [9] [10] [11]. Furthermore, EPDS ≥ 10 was used in five references (two in China, two in Spain, and one in Italy), with a percentage ranging from 16.1% to 44.9% [6] [12] [13] [14] [15]. A Dutch study with EPDS ≥ 11 found a rate of 34.9% in the first trimester and EPDS ≥ 10 in the second and third trimesters [16]. Moreover, an Iranian study that used EPDS ≥ 12.5 found a rate of 42.1% [17]. For the 9 studies with EPDS ≥ 13 (two per country: Japanese literature, Netherlands, Spain, Australia Turkey, the U.S., Canada, and Sweden), the rate ranged from 12.0% to 43.2% [11] [13] [18] - [24]. An American study that used EPDS ≥ 15 had a percentage of 23.6% [25].

This study found 12 references (with two duplicates); however, for studies that screened pregnant women for depression using the PHQ-9, the percentage of depressive symptoms varied from 5.3% to 59.2%. Therefore, the proportion of pregnant women with depressive symptoms was also extracted for each cut-off value for PHQ-9. Particularly, PHQ-9 ≥ 5 was used in five Chinese references, and the percentage of pregnant women with depressive symptoms ranged from 25.8% to 48.7% [26] [27] [28] [29] [30]. Furthermore, PHQ-9 ≥ 10 was used in seven references (five from China and one each from Vietnam and Brazil), and the rate of depressive symptoms was 5.3% to 59.2% [26] [31] - [36].

4. Discussion

The proportion of pregnant women with suspected depression or depressive symptoms during the COVID-19 pandemic was 30.0% in this study, indicating a rate of one in three to four. The rate of depression among pregnant women during the COVID-19 pandemic, from December 2019 to July 2020, until September 2020, and from December 2019 to February 2021 was reportedly 30%, 25%, and 25.6%, respectively [8] [53] [54]. The current results exceeded or equated with that. The factors associated with depression among pregnant women during the COVID-19 pandemic include unemployment during pregnancy, household financial difficulties, and poor perception of general support [55], and it is possible that the prolonged pandemic maintained or increased the rate of depression among pregnant women. Furthermore, the percentage of depression among pregnant women before the COVID-19 pandemic was 16.4% [56], suggesting that the depression rate among pregnant women increased 1.8 times from before the pandemic. Thus, depression rates among pregnant women may have worsened during the COVID-19 pandemic, suggesting a need for mental health support for this population.

Regarding the cut-off value of the EPDS, which assessed suspected depression in pregnant women, a review of the Japanese literature showed that two different cut-offs were used (i.e., 9 and 13 points). Further accumulation of research is needed on the cut-off value of the EPDS in this context. In the three studies that used EPDS ≥ 9, the percentage of suspected depression among pregnant women ranged from 15.1% to 33.5%. Silverman et al. [9] report that 15.1% of their study subjects were pregnant women of low socioeconomic status and about 90% had U.S. government-funded health insurance, as well as observe that depression in the pregnant women population during the COVID-19 pandemic was lower than in the pre-pandemic population. Although social distancing during the COVID-19 pandemic is a factor associated with elevated depressive symptoms [20] [22], it is an interesting finding that social constraints may have had a positive impact on the health and well-being of pregnant women with low economic status. Additionally, Kachi et al. [10] reported a 30.6% depression rate from their study, which was limited to employed women and excluded individuals with a history of mental illness. Notably, this low depression rate may indicate a high rate of depression among individuals who are unemployed [19] [24] [32] [50] and have a history of mental illness [5] [13] [14] [20] [39]. Obata et al. [11] reported a 33.5% depression rate, 59.6% of all pregnant women were from regions with a high incidence of COVID-19, and the high depression rate among pregnant women in the high epidemic regions [5] [13] [14] [20] [39] may indicate a higher percentage of suspected depression. The percentage of suspected depression in EPDS ≥ 13 ranged from 12.0% to 43.2%. Particularly, Vacaru et al. [18] reported a depression rate of 12.0% from a study on pregnant women during the lockdown period, from April to May 2020, in the Netherlands. Furthermore, Ho-Fung et al. [24] reported a depression rate of 43.2% upon studying pregnant women living in Sweden from May 2020 to February 2021. The researchers considered the possibility that Sweden’s loose social constraints may have increased the concern of pregnant women [24].

The PHQ-9 had mixed cut-off values of 5 and 10 points since the PHQ-9 ≥ 10 has a sensitivity of 88% and specificity of 88% for major depression [57], PHQ-9 scores of five or higher have mild and 10 or higher have moderate depressive symptoms [57] ; both 5 and 10 points were cut-off values. The proportion of suspected depression in PHQ-9 ≥ 5 ranged from 25.8% to 48.7%, and in PHQ-9 ≥ 10, from 6.9% to 59.5%. The study population of Wu et al. [32] [33], who reported a rate of 6.9%, excluded those with mental illness, which may have indicated a low proportion of pregnant women with depressive symptoms. The study population of Borges et al. [36], who reported a depression rate of 59.2%, was limited to pregnant women with hypertension or diabetes mellitus that started before or developed during pregnancy, with a median Body Mass Index of 31.6, and 58.2% of them had psychiatric disorders. The association between maternal depression and chronic physical illness before pregnancy [55], and that with obesity [1] [23] [58] may explain a higher proportion of pregnant women with depressive symptoms.

As mentioned above, the EPDS and PHQ-9 used various cut-off values and the characteristics of pregnant women were not constant, which may have resulted in a wide range in the proportion of those with depression. The EPDS and PHQ-9, which are widely used to measure depression in pregnant women during the COVID-19 pandemic, have different cut-off values. The data obtained in this study are significant because they can be compared with the depression status before the COVID-19 pandemic and in the future.

Future longitudinal observational studies are needed to determine whether pregnant women with suspected depression and depressive symptoms during the COVID-19 pandemic will recover postpartum.

5. Conclusion

A review of 46 references in this study indicated the following: The proportion of suspected depression among pregnant women during the COVID-19 pandemic was 30.0% and approximately one in three pregnant women was susceptible to depression. Depression among pregnant women during the COVID-19 pandemic may be worsening, suggesting the increased need for mental health to support them.

Acknowledgements

This work was supported by JSPS KAKENHI Grant-in-Aid for Research Activity Start-up Number JP22K21187.

Complement

This study was partially presented at the 26th East Asia Forum of Nursing Scholars Secretariat 2023.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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