Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes.
Journal: 2019/April - Women's Health
ISSN: 1745-5065
Abstract:
The postpartum period represents the time of risk for the emergence of maternal postpartum depression. There are no systematic reviews of the overall maternal outcomes of maternal postpartum depression. The aim of this study was to evaluate both the infant and the maternal consequences of untreated maternal postpartum depression.We searched for studies published between 1 January 2005 and 17 August 2016, using the following databases: MEDLINE via Ovid, PsycINFO, and the Cochrane Pregnancy and Childbirth Group trials registry.A total of 122 studies (out of 3712 references retrieved from bibliographic databases) were included in this systematic review. The results of the studies were synthetized into three categories: (a) the maternal consequences of postpartum depression, including physical health, psychological health, relationship, and risky behaviors; (b) the infant consequences of postpartum depression, including anthropometry, physical health, sleep, and motor, cognitive, language, emotional, social, and behavioral development; and (c) mother-child interactions, including bonding, breastfeeding, and the maternal role.The results suggest that postpartum depression creates an environment that is not conducive to the personal development of mothers or the optimal development of a child. It therefore seems important to detect and treat depression during the postnatal period as early as possible to avoid harmful consequences.
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Women's Health. Dec/31/2018; 15
Published online Apr/28/2019

Consequences of maternal postpartum depression: A systematic reviewof maternal and infant outcomes

Abstract

Introduction:

The postpartum period represents the time of risk for the emergence ofmaternal postpartum depression. There are no systematic reviews of theoverall maternal outcomes of maternal postpartum depression. The aim of thisstudy was to evaluate both the infant and the maternal consequences ofuntreated maternal postpartum depression.

Methods:

We searched for studies published between 1 January 2005 and 17 August 2016,using the following databases: MEDLINE via Ovid, PsycINFO, and the CochranePregnancy and Childbirth Group trials registry.

Results:

A total of 122 studies (out of 3712 references retrieved from bibliographicdatabases) were included in this systematic review. The results of thestudies were synthetized into three categories: (a) the maternalconsequences of postpartum depression, including physical health,psychological health, relationship, and risky behaviors; (b) the infantconsequences of postpartum depression, including anthropometry, physicalhealth, sleep, and motor, cognitive, language, emotional, social, andbehavioral development; and (c) mother–child interactions, includingbonding, breastfeeding, and the maternal role.

Discussion:

The results suggest that postpartum depression creates an environment that isnot conducive to the personal development of mothers or the optimaldevelopment of a child. It therefore seems important to detect and treatdepression during the postnatal period as early as possible to avoid harmfulconsequences.

Introduction

Pregnancy and childbirth are two major events in a woman’s life. The birth of a babyinduces sudden and intense changes in a woman’s roles and responsibilities. Thus,the postpartum period represents the time of risk for the emergence of maternalpostpartum depression (PPD).1 PPD is a serious mental health problem. The Diagnostic andStatistical Manual of Mental Disorders (4th ed.; DSM-IV) defines PPD asa specifier for major depressive disorder (MDD).2 PPD is also defined symptomatically as exceeding a given threshold on ascreening measure, such as the Edinburgh Postnatal Depression Scale(EPDS).3,4In general, PPD occurs within 4 to 6 weeks after childbirth, and symptoms similar toMDD that may be present include depressed mood, loss of interest or pleasure inactivities, sleep disturbance, appetite disturbance, loss of energy, feelings ofworthlessness or guilt, diminished concentration, irritability, anxiety, andthoughts of suicide.5

The prevalence of PPD varies substantially depending on the definition of thedisorder, country, diagnostic tools used, threshold of discrimination chosen for thescreening measure, and period over which the prevalence is determined.3,6 For example, Halbreich and Karkun7 performed a review of the literature and found a PPD prevalence that variedbetween 0.5% and 60% among countries, as estimated by the self-reported 10-item EPDSquestionnaire. The prevalence of PPD varies from 1.9% to 82.1% in developedcountries, with the lowest prevalence reported in Germany and the highest prevalencein the United States.7,8In developing countries, the prevalence varies from 5.2% to 74.0%, with the lowestprevalence reported in Pakistan and the highest prevalence in Turkey.8 This tremendous variation in the prevalence of PPD could be explained byheterogeneous study designs or the use of different diagnostic tools (e.g. the EPDS,Center for Epidemiologic Studies Depression Scale (CES-D), or Beck DepressionInventory (BDI)).9

Untreated PPD seems to have negative consequences for both infants and mothers.Nonsystematic reviews have indicated that the risks to children of untreateddepressed mothers (compared to mothers without PPD) include problems such as poorcognitive functioning, behavioral inhibition, emotional maladjustment, violentbehavior, externalizing disorders, and psychiatric and medical disorders inadolescence.5,1017 These nonsystematic reviewsreported the outcomes of these children from birth to adolescence. Othernonsystematic and systematic reviews have also explored specific maternal risks whenmothers’ PPD is untreated, including more weight problems,18,19 alcohol and illicit drug use,20 social relationship problems,21 breastfeeding problems,22 or persistent depression23 compared with women who have received treatment. Nevertheless, there are nowell-established systematic reviews of the overall maternal and/or infant outcomesof maternal PPD. Thus, the aim of this study was to evaluate all the maternalconsequences of untreated PPD and its effects on children between 0 and 3 years ofage.

Methods

To the extent possible, this research adhered to the PRISMA (Preferred ReportingItems for Systematic Reviews and Meta-Analyses) statement.24

Search strategy

We searched for all studies published between 1 January 2005 and 17 August 2016,using the following databases: MEDLINE via Ovid, PsycINFO, and the CochranePregnancy and Childbirth Group trials registry. The following keywords wereapplied in the databases during the literature search: “postpartum depression”OR “postnatal depression” OR “puerperal depression.” The research was limited tohuman studies published in the English language. The search strategy and searchterms used for this research are detailed in Appendix 1. Additional studies wereidentified through a manual search of the bibliographic references of therelevant articles and existing reviews.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (a) cohort and cross-sectionalepidemiological and qualitative individual studies; (b) studies that includedmothers of all ages who suffered from PPD (all combinations of comparison groupswere possible: PPD vs no PPD, severe PPD vs mild PPD, etc.); and (c) studiesthat included health (physical or psychological) or social outcomes of PPD inthe results.

The exclusion criteria were as follows: (a) meta-analyses, systematic andnonsystematic reviews, randomized controlled trials, and case studies; and (b)studies that included mothers who received treatment for PPD. Meta-analyses andsystematic and nonsystematic reviews were only accessed to review theirbibliographic references.

It is also important to note that there are many factors (e.g. comorbidconditions (anxiety, posttraumatic stress disorder, or substance abuse),socioeconomic status, education level, co- or single-parenting, and number ofprevious pregnancies) that could play an important role in the experience ofPPD. Nevertheless, in the present systematic review, these factors were notconsidered as exclusion criteria; instead, they were treated as potentialconfounding factors. Moreover, because these confounding factors are difficultto account for in a systematic review, the adjusted results were used anddiscussed in this article when available.

After duplicates were removed, studies identified by the search strategy wereexported to an Excel spreadsheet for study selection.

Study selection

In the first step, two investigators performed the study selection and assessedthe titles and abstracts of the studies to exclude articles that were immaterialto the systematic review based on the inclusion criteria. In the second step,the same two investigators selected, read and evaluated the full-text studiesthat met the inclusion criteria. Given the large number of abstracts andfull-text articles that needed to be read, the two investigators selected thestudies independently.

Data extraction

The studies were divided between the two investigators for data extraction.However, if there was doubt regarding an article, the article was discussed bythe two investigators, and a consensus was reached. The two investigatorsextracted the data from the selected studies according to a standardized dataextraction form. The following data were isolated for each study: authors;journal name; year of publication; country of origin; objective of the study;study population data (type of population, mean age, sex ratio of the children,and age, if provided); sample size; design (length of intervention, number ofgroups, and description of groups); tools used to assess maternal PPD; reportedprevalence of maternal PPD; types of infant and/or maternal outcomes and main(adjusted) results; and conclusion. To ensure that as many studies as possiblewere included in our systematic review, we systematically contacted the authorsor co-authors when the full-text paper was not available.

Analysis and synthesis of the results

To facilitate data extraction, the included studies were initially groupedaccording to three types of outcomes: physical (e.g. weight, length,anthropometric indices, motor development, and physical health); psychological(e.g. mental health, cognitive development, language development, and bonding);or “other” (e.g. social relationships, quality of life, breastfeeding, and riskybehaviors). Each outcome group was then thematically analyzed, coded by topic,and divided into more appropriate subgroups. The outcome subgroups were based oninformation obtained from the studies included in this review. In terms of thestudies’ outcomes, key words were labeled and classified into groups withsimilar consequences. For example, the subcategories “weight,” “length,” and“anthropometric indices” were combined into the more general category of“anthropometry.”

This systematic review of the literature used a narrative synthesis methodology.Each included study was described in a commentary that reported the findings.Similarities and differences among the studies were also synthesized to drawconclusions within the subgroups.

Results

Included studies

Of the 3712 references retrieved from the bibliographic databases (Figure 1), we identified122 eligible studies that evaluated the consequences of PPD: 68 that evaluatedthe maternal consequences and 73 that evaluated the infant consequences. Amongthe included studies, 19 examined both the infant and the maternal consequencesof PPD.

Figure 1.
Flowchart of the selection of relevant literature.

The group of studies that evaluated the maternal consequences of PPD included 46cohort studies2572 and 21 cross sectionalstudies7392 (including 1 qualitative study).93 The majority of the studies were performed in the United States (28 of68) and Europe (22 of 68), 10 studies were performed in Asia, and 8 studies wereperformed in Australia and New Zealand. All studies included women aged between13 and 45 years. The number of participants ranged from 1593 to 22,118,28 and the duration of follow-up varied from 2 weeks32 to 6 years33 for the cohort studies.

PPD was mainly diagnosed according to the 10-item EPDS (46 studies); however,there were studies that used the BDI (6 studies), the World Health OrganizationComposite International Diagnostic Interview—Short Form (CIDI-SF; 3 studies),the Mini International Neuropsychiatric Interview (MINI; 3 studies), thePostpartum Depression Screening Scale (PDSS; 4 studies), and the CES-D (2studies). To assess PPD, other studies used other questionnaires (e.g. thePatient Health Questionnaire depression module (PHQ-942 or PHQ-874), the Brief Symptom Inventory (BSI),31 or the Hamilton Depression Rating Scale (HDRS)30). The prevalence of PPD varied from 4.5% in a population of Canadianmothers at 6 weeks postpartum89 to 68.8% in a population of Australian mothers at 4 months postpartum.64

The group of studies that evaluated the infant consequences of PPD included 61cohort studies31,34,37,45,48,49,52,53,56,6466,6972,94138 and 12 cross-sectionalstudies.9092,139147 Most of the studies wereperformed in the United States (27 of 73) and Europe (20 of 73), 12 studies wereperformed in Asia, 10 studies were performed in Africa, and 4 studies wereperformed in Australia and New Zealand. All studies included women aged between14 and 49 years and a percentage of baby girls that varied between 37.7%49 and 57.5%.147 The number of participants ranged from 28123 to 24,263,98 and the duration of follow-up varied from 2 months31,118,123 to 5 years96 for the cohort studies.

PPD was mainly diagnosed according to the 10-item EPDS (37 studies); however,there were studies that used the CES-D (9 studies), the BDI (7 studies), and thedepression section of the Structured Clinical Interview for DSM-IV (SCID; 4studies). To assess PPD, other studies used various types of questionnaires(e.g. the PHQ-9135,136 or the BSI100). Only one study did not specify the questionnaire that was used todetect PPD.98 The prevalence of PPD varied from 2.7% in a population of Pakistanimothers at 18 months postpartum94 to 68.8% in a population of Australian mothers at 4 months postpartum.64

The outcomes were separated into three sections: “maternal consequences of PPD,”“infant consequences of PPD,” and “mother–child interactions.” The firstsection, “maternal consequences of PPD,” reported results for 5 different typesof outcomes: physical health (3 studies),35,67,88 including health carepractices and utilization measures (2 studies);63,78 psychological health,including anxiety and depression (6 studies);36,37,42,44,66,88 quality of life (8studies);27,37,39,48,66,85,86,88 relationships, including social relationships andrelationships with the partner and sexuality (7 studies);37,38,44,66,73,74,85 and riskybehaviors, including addictive behavior (smoking behavior and alcoholconsumption: 4 studies)55,68,84,87 and suicidal ideation (7 studies).28,30,33,76,81,85,93 The secondsection, “infant consequences of PPD,” reported results for 9 different types ofoutcomes: anthropometry, including weight, length, and anthropometric indices(13 studies);97,100,104,109,110,112,113,119,125,126,131,140,142 infant health (10 studies);48,104,119,122124,135,136,138,142 infant sleep (3studies);104,108,130 motor development (7 studies);66,94,95,97,103,107,141cognitive development (11 studies);94,95,99,101103,107,134,139,141,147 language development (13studies);66,94,95,102,103,105,116,117,129,131,132,139,141 emotional development (5 studies);9496,115,121 social development (4studies);66,115,141,143 and behavioral development (12 studies).49,52,96,110,111,114,115,120,121,131,133,141 Finally,the third section, “mother–child interactions,” reported results for 3 differenttypes of outcomes: bonding and attachment, including mother-to-infant andinfant-to-mother bonding (15 studies);29,31,34,37,43,44,47,52,54,56,61,64,82,106,127 breastfeeding (22studies);25,26,32,41,45,59,60,62,65,6972,77,8992,118,119,130,137 and maternal role,including maternal behaviors (9 studies),26,40,49,52,53,62,79,83,85 maternal competence (2studies),51,75 maternal care for the infant (6 studies),37,53,130,137,145,146 infanthealth care practices or utilization measures (8 studies),26,37,57,63,98,128,130,142 maternalperception of the infant’s patterns (5 studies),40,46,50,58,80 and the risk ofmaltreatment (2 studies).130,144

Maternal consequences of PPD

Physical health

Only three studies evaluated the physical health of depressed mothers (Table 1). Onestudy found that compared to the general population of women, depressedmothers scored significantly lower on the 36-Item Short Form Health Survey(SF-36) physical component summary score (assessed based on physicalfunctioning, role limitations due to physical health, bodily pain, andgeneral health perceptions).88 However, this study indicated that the severity of the depressed moodwas not associated with a worse physical health status, whereas a worseaerobic capacity emerged as a significant independent contributor tophysical health status. The two last studies evaluated postpartum weightretention (PPWR) and found that significantly more women with PPWR hadhigher scores on the PPD scale.35,67

Table 1.
Characteristics of the studies included in the evaluation of maternalphysical health.
Physical healthHealth care practices and utilizationmeasures
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Biesmans35Belgium
Mean age: 30.1 ± 4.3 years
Gender of newborns: not given
75Cohort study
14 months
Two groups:
- PPWR
- No PPWR
EPDS
(Depressed = EPDS ⩾ 10)
PPWR: 30.8%
No PPWR: 8.3%
PPWR52% of the women did not reach their pre-pregnancyweight 1 year after childbirth. Women with PPWR weighedapproximately 2 (M = 2.3; SD = 2.8) kg above theirweight from before the last pregnancy. There weresignificantly more women with higher scores on the PPDscale in the group with PPWR (p = 0.015).
Da Costa88Canada
Mean age: 33.2 ± 4.6 years
Genderof newborns: not given
78Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
63%Physical health status; mental health status;health-related quality of lifeCompared to Canadian normative data, women experiencingpostpartum depressed mood scored significantly lower onall SF-36 domains and on the SF-36 physical and mentalcomponent summary scores. Severity of depressed mood wasnot associated with worse physical health status, whilepoorer aerobic capacity emerged as a significantindependent contributor of physical health status.
Herring67USA
Mean age: 33.0 ± 4.7 years
Gender ofnewborns: not given
850Cohort study
18 months
Four groups:
- None
- Pregnancy only
- Postpartum only
- Pregnancy andpostpartum
EPDS
(Depressed = EPDS > 12)
4%Risk of substantial weight retentionIn multivariate logistic regression analyses, afteradjustment for weight-related covariates, maternalsociodemographics, and parity, new-onset PPD wasassociated with more than double the risk of retainingat least 5 (OR = 2.54, 95% CI = 1.06, 6.09) kg.
Eilat-Tsanani63Israel
Age: 18 years and above
Gender ofnewborns: not given
527Cohort study
2 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
(+survey)
9.9%Women’s’ consultations with physicians (familyphysicians, gynecologists, and/or pediatricians)Women with PPD differed from those without PPD in termsof the frequency of and reasons for consultations. Therate of PPD was significantly higher in women whoconsulted for medical reasons than those who came forroutine care (13% vs 4%, p = 0.001). Women with multiplevisits (four or more) to all doctors had higher rates ofPPD than the others (16.7% vs 7%, p = 0.002). Women withPPD consulted more with family physicians (20.6% vs7.8%, p = 0.01) and pediatricians (18.3% vs 7.1%,p = 0.001). No significant difference in PPD rates wasfound in relation to the number of visits togynecologists.
McCallum78Australia
Mean age: 33.0 ± 4.5 years
Gender of newborns: not given
875Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 9)
16.7%Health service usePoorer maternal mental health was also implicated with aone-point increase in the EPDS associated with a 4%(0.4%–8%) increase in the likelihood of using more thanthree services (adjusted for socioeconomic position,partner status, language, gestational age, and unsettledinfant behavior). Women with worse depressive symptomswere more likely to consult a general practitioner ormental health professional, but not other services.
PPD: postpartum depression; PPWR: postpartum weight retention;EPDS: Edinburgh Postnatal Depression Scale; SD: standarddeviation; SF-36: 36-Item Short Form Health Survey; OR: oddsratio; CI: confidence interval.

Health care practices and utilization measures

Two studies63,78 demonstrated an effect of maternal PPD onhealth care practices and utilization measures (Table 1). One of these studiesdemonstrated that women with worse depressive symptoms were more likelyto consult a general practitioner or mental health professional thanwomen with milder depressive symptoms.78 The other study showed that women with PPD consulted with familyphysicians more often than nondepressed mothers did.63

Psychological health

Six studies (Table2) evaluated the association between PPD and psychologicalhealth; five studies focused on overall psychological health,37,42,44,66,88 twostudies focused on anxiety,36,37 and three studiesfocused on depression.36,37,66

Table 2.
Characteristics of the studies included in the evaluation of thematernal psychological health.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Da Costa88Canada
Mean age: 33.2 ± 4.6 years
Genderof newborns: not given
78Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
63% (EPDS ⩾ 12)Physical health status; mental health status;health-related quality of lifeDepressed mood was a significant predictor (β = −0.44,p < 0.0001) of mental health status, explaining 18%of the variance. After controlling for depressed mood,the occurrence of pregnancy complications (p = 0.001),cesarean delivery (p = 0.005), poorer sleep quality(p = 0.009), lower perceived social support (p = 0.045),and greater life stress (p = 0.003) were significantindependent determinants of worse mental health status.Together, the variables in the second step explained anadditional 30% of the variance.
Gollan42USA
Mean age (years):
Depressed:27.5 ± 6.8
Nondepressed: 30 ± 4.9
Gender of newborns: not given
80Cohort study
15 weeks
Two groups:
- PPD
- No PPD
DSM-IV
PHQ-9
QIDS-SR
33.8%Affective reactivity (affective informationprocessing)Results of the GLM analyses of variance for postpartumratings of valence and arousal revealed a significantmain effect for group (p < 0.05) in which postpartumwomen with major depression demonstrated significantlylower arousal ratings for negative stimuli compared withhealthy women (p < 0.001). In addition, postpartumwomen with major depression had significantly lowervalence ratings for negative stimuli (p = 0.03) comparedwith healthy women.
Lilja44Sweden
Mean age: 27.8 years
Gender ofnewborns: not given
419Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
22.2%Women’s mood over the first year postpartum; women’srelationship with their infant; women’s relationshipwith their partnerMothers who scored high on the EPDS on day 10 ratedtheir mood lower, for example, they reported being lesshappy and more dysphoric and sad than mothers who scoredlow on the EPDS. Significant positive correlations werefound between the EPDS and the mood scale at day 3(r = 0.355, p < 0.001), day 10 (r = 0.615,p < 0.001), 6 months (r = 0.349, p < 0.001), and12 months (r = 0.370, p < 0.001). Thus, a moderatelyincreased score on the EPDS on day 10 postpartumpredicted a low mood over the first yearpostpartum.
Prenoveau36UK
Age (years):
GAD and MDD: 32.5 ± 5.3
GAD only: 31.8 ± 5.1
MDD only:32.3 ± 5.6
No diagnosis: 32.6 ± 4.8
Female babies (%):
GAD and MDD: 41.5
GAD only: 50
MDD only: 52.5
No diagnosis: 51.9
296Cohort study
21 months
Four groups:
- GAD and MDD
- GAD only
- MDDonly
- No diagnosis
EPDS
(cut-off value not given)
GAD and MDD: 13.9%
GAD only: 27.0%
MDDonly: 13.5%
GAD
MDD
Women diagnosed with MDD at 3 months postpartum weresignificantly more likely to meet diagnostic criteriafor MDD at least once during the follow-up period thanthose who were not diagnosed with MDD at 3 months (MDDonly → MDD only (coefficient): 3 months → 6 months:23.7; 6 months → 10 months: 28.6; 10 months → 14 months:37.3; 14 months → 24 months: 135.0, p < 0.001). Womenwith MDD at 3 months were also significantly more likelyto present with GAD at 6 months (3 months → 6 months:10.9, p < 0.05), but not after.
Wang66Taiwan
Age (years):
Depressed:28.34 ± 5.52
Nondepressed: 29.45 ± 4.13
Female babies: 55.0%
60Cohort study
1 year
Two groups:
- PPD
- No PPD
BDI-II48.3%Psychosocial healthAt 1 year after childbirth, women in the depressed groupstill suffered mild depression and reported greaterperceived stress and lower perceived social support andself-esteem than women in the nondepressed group. Womenat 6 weeks after childbirth suffered mainly frommoderate-to-severe depression (23.76 ± 6.25 on the BDI),and symptoms improved to mild-to-moderate depression at1 year (14.66 ± 7.22 on the BDI).
Vliegen37Belgium
Mean age (years):
T1:29.39 ± 4.40
T2: 32.95 ± 4.51
Gender ofnewborns: not given
41Cohort study
3.5 years
Two groups:
- PPD
- No PPD
BDI-II
(Depressed = BDI ⩾ 13)
39%Maternal depression; treatment after hospitalization;life events; relationshipMothers who were depressed at follow-up had not onlysignificantly elevated scores for severity of depressionbut also significantly elevated levels of state andtrait anxiety, state and trait anger, and negativeaffect compared to nondepressed mothers. Depressedmothers also had significantly higher levels of anger,lower scores on anger control, and lower levels ofpositive affect. Regarding emotional availability, theyshowed a significantly lower level of mutual attunement,but no differences were found on the other indices ofemotional availability. The number of depressiveepisodes between Time 1 and Time 2 did not differbetween mothers with and mothers without currentdepression at follow-up. However, currently depressedmothers had significantly longer depressive episodes(M = 90 weeks, SD = 80) compared to the mothers withoutcurrent depression (M = 42 weeks, SD = 45, p < 0.05).
Regarding treatment after hospitalization, theproportion of mothers who were hospitalized during thefollow-up period was approximately 20% and did notdiffer between samples.

GAD: generalized anxiety disorder; MDD: major depressivedisorder; PPD: postpartum depression; EPDS: Edinburgh PostnatalDepression Scale; DSM-IV: Diagnostic and StatisticalManual of Mental Disorders (4th ed.); PHQ-9:Patient Health Questionnaire depression module; QIDS-SR: QuickInventory of Depressive Symptomatology (Self-Report); BDI-II:Beck Depression Inventory-II; GLM: general linear models; SD:standard deviation.

Overall psychological health

Several studies showed that depressed mothers presented lower mood scoresin the long term (1 year after childbirth) than mothers withoutdepression. One study highlighted that compared to the generalpopulation of women, depressed mothers scored significantly lower on theSF-36 mental component summary score (based on vitality, socialfunctioning, role limitations due to emotional problems, and mental health).88 This study also showed that depressed mood was a significantpredictor of mental health status in the future (explaining 18% of its variance).88 Another study showed that women with PPD had lower self-esteemthan mothers without depression.66 Depressed mothers also reported being less happy, more dysphoric,and sadder than mothers without depression.44 In addition, women with high depression scores had significantlyhigher levels of anger, lower scores for anger control, and lower levelsof positive affect than mothers with low depression scores.37 Finally, mothers with PPD were generally less responsive tonegative stimuli, with lower ratings for intensity and reactions tonegative pictorial stimuli, than mothers without PPD.42

Anxiety

One study showed that depressed mothers had significantly elevated levelsof state and trait anxiety at 1 year and 3.5 years after childbirthcompared with nondepressed mothers.37 Another study highlighted that depressed mothers at 3 monthspostpartum were more likely to exhibit an anxiety disorder thannondepressed mothers at 6 months postpartum, but not after this time point.36

Depression

Compared to nondepressed women, women who were diagnosed with depressionin the first weeks after childbirth continued to suffer from depressionat 1 year after childbirth.36,37,66 However, one studyunderlined that although mothers continued to suffer from depression,the symptoms appeared to improve, progressing from moderate-to-severedepression at 6 weeks to mild-to-moderate depression at 1 year.66 Therefore, there appeared to be a slight improvement in theseverity of depression over time with or without treatment.66 Another study used a life history calendar method and found thatcompared to currently nondepressed mothers, mothers who were depressedat follow-up (3.5 years) did not have more depressive episodes; however,they had longer depressive episodes, received more psychotherapy afterhospitalization, and experienced more negative life events during thefollow-up period.37

Quality of life

Eight studies27,37,39,48,66,85,86,88 examined the overall quality of life of depressedmothers compared with nondepressed mothers (Table 3). Three studies48,86,88demonstrated a significantly negative association between maternaldepressive symptoms and quality of life. Women with PPD had lower scores onall dimensions of quality of life (e.g. SF-36 or a generic Health-RelatedQuality of Life (HRQoL) questionnaire) than women without PPD. However, oneof the three studies showed that after controlling for mental health-relatedquality of life earlier in the postpartum period, there was no difference inthe subsequent mental health-related quality of life according to thepresence of significant depressive symptoms later in the postpartum period.48

Table 3.
Characteristics of the studies included in the evaluation of thematernal quality of life.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Curtis27USA
Mean age: 25.0 ± 6.0 years
Femalebabies: 48%
2974Cohort study
3 years
Two groups:
- PPD
- No PPD
CIDI-SF12.6%Homelessness or risk of homeless (lack of fixed,regular, and adequate night-time residence or residencein a temporary accommodation or space not intended forresidence)Mothers who experienced depression were significantlymore likely than those who did not to become homeless(6% vs 2%) and to be at risk of homelessness(conditional on not having become homeless; 14% vs 9%).Depression during the postpartum year was associatedwith more than twice the odds of homelessness(OR = 2.29, 95% CI = 1.08, 4.85) and almost 1.5 timesthe odds of being at risk of homelessness (OR = 1.40,95% CI = 1.12, 1.75) at 3 years.
Da Costa88Canada
Mean age: 33.2 ± 4.6 years
Genderof newborns: not given
78Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
63% (EPDS ⩾ 12)Physical health status; mental health status;health-related quality of lifeWomen who were depressed during postpartum scoredsignificantly lower on all eight SF-36 dimensions and onboth summary component scores compared toage-appropriate normative means.
Darcy48USA
Mean age: 30.3 years
Gender ofnewborns: not given
217Cohort study
1 year
Two groups:
- PPD
- No PPD
CES-D32.7%Maternal health-related quality of life (mentalcomponent and physical component)Mothers with significant depressive symptoms hadsignificantly worse physical (p = 0.02) and mental(< 0.0001) health-related quality of life. Aftercontrolling for mental health-related quality of lifeearlier in the postpartum period, there was nodifference in subsequent mental health-related qualityof life based on the presence of significant depressivesymptoms later in the postpartum period.
De Tychey86France
Age: not given
Female babies:48.1%
181Cross-sectional study
Three groups:
- Nodepression
- Mild depression
- Severedepression
EPDS
(Mild, ⩾8 and <12; Severe, ⩾12)
Mild depression: 22.1%
Severe depression:9.4%
Postnatal quality of lifePostnatal depression strongly and negatively influencedall dimensions of life quality explored through theSF-36, e.g., physical functioning (PF), physical role(RP), bodily pain (BP), mental health (MH), emotionalrole (RE), social functioning (SF), vitality (VT),general health (GH), standardized physical component(PCS), and standardized mental component (MCS).
Posmontier85USA
Mean age (years):
No PPD:31.0 ± 4.5
PPD: 30.0 ± 5.5
Femalebabies (%):
No PPD: 78.3
PPD:30.4
46Cross-sectional study
Two groups:
- PPD
- No PPD
MININot applicable (number of PPD and no PPD women werefixed at the beginning of the study)
Nondepressed: n = 23
Depressed:n = 23
Functional status (physical infant care, personal care,household care, social activities, and occupationalactivities)Specifically, lower levels of household, social, andpersonal functioning were correlated with PPD. Inmultiple regression analyses, PPD predicted loweroverall functional status (p < 0.001), householdfunction (p < 0.05), social function (p < 0.001),and personal function (p < 0.001).
Wang66Taiwan
Age (years):
Depressed:28.34 ± 5.52
Nondepressed: 29.45 ± 4.13
Female babies: 55.0%
60Cohort study
1 year
Two groups:
- PPD
- No PPD
BDI-II48.3%Psychosocial healthSignificant differences were found between the depressedand the nondepressed groups for depression, perceivedstress, social support, and self-esteem. At 1 year afterchildbirth, women in the depressed group still sufferedfrom mild depression and showed greater perceived stressand lower perceived social support and self-esteem thanwomen in the nondepressed group.
Taylor39Australia
Mean age: 30.3 ± 5.0 years
Gender of newborns: not given
615Cohort study
24 weeks
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
T1: 9.2%
T2: 9.4%
T3: 8.4%
T4:7.0%
FatigueOne week after birth, state anxiety (0.47) and moredepressive symptoms (0.28) were significantly (< 0.05to < 0.01) correlated with fatigue. At 6 weeks, 3months, and 6 months, depression was no longerassociated with fatigue, but maternal state anxiety wasa major predictor of fatigue (ranging from β = 0.38 to0.51).
Vliegen37Belgium
Mean age (years):
T1:29.39 ± 4.40
T2: 32.95 ± 4.51
Gender ofnewborns: not given
41Cohort study
3.5 years
Two groups:
- PPD
- No PPD
BDI-II
(Depressed = BDI ⩾ 13)
39%Maternal depression; treatment after hospitalization;life events; relationshipCurrently depressed mothers reported significantly morenegative life events, indicating greater distress anddiscontinuity. More specifically, currently depressedmothers reported more financial problems (69% vs 31%,p < 0.05) and more illness among close relatives(100% vs 46%, p < 0.05).
PPD: postpartum depression; CIDI-SF: Composite InternationalDiagnostic Interview—Short Form; EPDS: Edinburgh PostnatalDepression Scale; CES-D: Center for Epidemiologic StudiesDepression Scale; MINI: Mini International NeuropsychiatricInterview; BDI-II: Beck Depression Inventory-II; OR: odds ratio;CI: confidence interval.

Studies also showed that PPD was associated with greater perceived stress,66 more negative life events (indicating greater distress anddiscontinuity), more financial problems, and more illness among close relatives.37 Depressive symptoms were also associated with fatigue during thefirst week but not at 6 weeks, 3 months, and 6 months after childbirth.39

Regarding the life environment, one study showed that PPD predicted lowerlevels of household functioning (household care).85 Another study demonstrated that mothers who experienced depressionwere twice as likely to become homeless and approximately 1.5 times morelikely to be at risk for homelessness than nondepressed mothers.27

Relationships

Seven studies evaluated social and couple relationships in relation tomaternal depressive symptoms (Table 4); four studies were relatedto social relationships,37,66,73,85 and four studies wererelated to relationships with partners and sexuality.37,38,44,74

Table 4.
Characteristics of the studies included in the evaluation of thematernal social and couple relationship.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Dagher73USA
Mean age: 29.3 ± 5.6 years
Gender ofnewborns: not given
882Cross-sectional study
Two groups:
- PPD
- No PPD
PDSS-SF62.0%Return to work and intention to return to workTending to the baby and being depressed suppressed thereturn to paid work. Nondepressed mothers withunintended pregnancies returned to work the soonest.Compared with mothers who were not depressed and had anunintended pregnancy, the RR of returning to paid work(0.70) was significantly lower for mothers who weredepressed and had an intended pregnancy. Mothers whowere not depressed and had an intended pregnancy alsohad a significantly lower RR (0.60) of returning to paidwork than those who were not depressed and had anunintended pregnancy.
Faisal-Cury38Brazil
Mean age: 25 years
Gender ofnewborns: not given
644Cohort study
Approximately 2 years
Fourgroups:
- None
- Pregnancy only
- Postpartum only
- Pregnancy andpostpartum
SRQ-20Pregnancy only: 15.2%
Postpartum only: 12.1%
Pregnancy and postpartum: 15.7%
Sexual lifeThe mean time to the resumption of sexual activityduring the postpartum period was 2.1 (range = 1–12)months. In the multivariable analysis after adjustmentfor wealth score, episiotomy, forceps delivery, previouspregnancies and marriage status, depression duringpregnancy and postpartum (RR = 3.17, 95% CI = 2.18,4.59), depression during only the postpartum period(RR = 3.45, 95% CI = 2.39, 4.98), a previousmiscarriage, and patient age were significantlyassociated with sexual decline.
Khajehei74Australia
Mean age: 29.8 years
Femalebabies (%):
FSD: 49.3
No FSD:51.7
325Cross-sectional study
Two groups:
- FSD
- No FSD
PHQ-8FSD: 14.8%
No FSD: 9.5%
Sexual dysfunction during the first year afterchildbirthDepression (OR = 2.876; 95% CI = 1.318, 6.276;p = 0.008) was a significant risk factor for sexualdysfunction during the first year after childbirth.
Lilja44Sweden
Mean age: 27.8 years
Gender ofnewborns: not given
419Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
22.2%Women’s mood over the first year postpartum; women’srelationship with their infant; women’s relationshipwith their partnerMothers who scored high on the EPDS at 10 dayspostpartum tended to rate their relationship with theirpartner lower at all observations during the first yearthan mothers who had low EPDS scores on day 10. The sameapplied to the relationship between EPDS at day 3 andthe relationship scales. Thus, mothers with a high scoreon the EPDS early in the postpartum period rated theirrelationship with their partner as more distant, coldand difficult, and felt less confident than mothers withlow EPDS scores over the first year.
Posmontier85USA
Mean age (years):
No PPD:31.0 ± 4.5
PPD: 30.0 ± 5.5
Femalebabies (%):
No PPD: 78.3
PPD:30.4
46Cross-sectional study
Two groups:
- PPD
- No PPD
MININot applicable (number of PPD and no PPD women werefixed at the beginning of the study)
Nondepressed: n = 23
Depressed:n = 23
Functional status (physical infant care, personal care,household care, social activities, and occupationalactivities)Specifically, lower household, social, and personalfunctioning were correlated with PPD. In multipleregression analyses, PPD predicted lower overallfunctional status (p < 0.001), household function(p < 0.05), social function (p < 0.001), andpersonal function (p < 0.001).
Wang66Taiwan
Age (years):
Depressed:28.34 ± 5.52
Nondepressed: 29.45 ± 4.13
Female babies: 55.0%
60Cohort study
1 year
Two groups:
- PPD
- No PPD
BDI-II48.3%Psychosocial healthSignificant differences were found between the depressedand the nondepressed groups in depression, perceivedstress, social support, and self-esteem. At 1 year afterchildbirth, women in the depressed group still sufferedmild depression and reported greater perceived stressand lower perceived social support and self-esteem thanwomen in the nondepressed group.
Vliegen37Belgium
Mean age (years):
T1:29.39 ± 4.40
T2: 32.95 ± 4.51
Gender ofnewborns: not given
41Cohort study
3.5 years
Two groups:
- PPD
- No PPD
BDI-II
(Depressed = BDI ⩾ 13)
39%Maternal depression; treatment after hospitalization;life events; relationshipCurrently depressed mothers reported having to move moreoften (92% vs 73%, ns) and having more relationshipdifficulties, including romantic break-ups (46% vs 35%,ns).
FSD: female sexual dysfunction; PPD: postpartum depression;PDSS-SF: Postpartum Depression Screening Scale—Short Form;SRQ-20: Self-Reporting Questionnaire-20; PHQ-8: Patient HealthQuestionnaire depression module; EPDS: Edinburgh PostnatalDepression Scale; MINI: Mini International NeuropsychiatricInterview; BDI-II: Beck Depression Inventory-II; RR: risk ratio;CI: confidence interval; OR: odds ratio.

Social relationships

PPD was associated with more relationship difficulties37 and therefore with lower social function.85 Depressed mothers also presented lower (perceived) social supportscores than nondepressed mothers.66 Regarding the probability of returning to paid work, one studyshowed that there was no difference between depressed and nondepressed mothers.73 The authors of this study specified that most mothers experienceddepressive symptoms during the first year after childbirth; thus,depression was not an independent predictor of how quickly mothers wouldreturn to work.

Partner relationships and sexuality

Depressed mothers rated their relationship with their partner as moredistant, cold and difficult, and felt less confident than nondepressedmothers over the first year after childbirth.44 Depressed mothers also reported having more relationshipdifficulties, including romantic break-ups, than nondepressed mothers;however, this difference was not significant.37 Regarding sexual life during the first year after childbirth,mothers who had resumed sexual activity had lower depression scores thanmothers who did not resume sexual activity during the postpartum period.38 In addition, depression appeared to cause nearly three times moresexual dysfunction during the first year after childbirth.74

Risky behaviors

Addictive behavior

Three studies55,84,87 evaluated the influence of PPD on smokingbehavior (Table5). One study showed that smoking and depression oftenco-occurred among mothers during the postpartum period.87 The prevalence of PPD was higher among smokers than nonsmokers;conversely, smoking was also more common among mothers with a majordepressive episode. The two other studies demonstrated that women whoquit smoking during pregnancy might be more likely to relapse if theyexperience negative emotions or depressive symptoms.55,84 Inaddition, one study evaluated the influence of PPD on postpartum “risky”drinking at 3 months among women who were frequent drinkers before pregnancy.68 This study emphasized that there was no significant associationbetween maternal PPD and risky drinking.

Table 5.
Characteristics of the studies included in the evaluation of thematernal risky behavior.
Addictive behaviorSuicidal ideation
First author’s nameSociodemographic data:
1.Country
2. Maternal mean age
3.Gender of newborns
Sample sizeDesign:
1. Study design
2. Time of follow-up
3. Number ofgroups
4. Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Allen84USA
Age (years):
<20: 15.3%
20–24: 37.8%
25–29: 27.0%
>29: 19.9%
Gender of newborns:not given
2566Cross-sectional study
Two groups:
- PPD
- No PPD
Specific to the survey18.8%Relapse of smoking during postpartumCompared to women who did not experience postpartumdepressive symptoms, women who did were 1.86 (95% CI= 1.31, 2.65) times as likely to relapse during thepostpartum period. After adjusting for demographiccharacteristics, intensity of smoking, and timesince delivery, the association decreased slightly(adjusted OR = 1.77, 95% CI = 1.21, 2.59).
Jagodzinski68USA
Age (years):
18–25: 42.3%
26–35: 44.6%
⩾36: 12.3%
Missing: 0.8%
Gender of newborns:not given
381Cross-sectional study (recruitment phase of arandomized clinical trial)
Two groups:
- Low risk of drinking
- At risk ofdrinking
EPDS
(Depressed = EPDS > 12)
16.0%Postpartum risky drinkingAt 3 months postpartum, the risk of drinking was notsignificantly different between women who had anEPDS score >12 and women who had an EPDS score⩽12 (adjusted OR (95% CI) = 1.1 (0.5, 2.5)).
Park55USA
Mean age: 28.8 ± 6.1 years
Gender of newborns: not given
65Cohort study
22 weeks
Two groups:
- Smokers
- Nonsmokers
BDINot given
Mean BDI: 5.8 ± 4.7
Postpartum relapse of smokingIn a regression model, the slope of BDI scores frombaseline to the 12-week follow-up differed betweennonsmokers and smokers (−0.12 vs +0.11 units/week,p = 0.03). The mean slope of BDI scores betweenbaseline and 24 weeks postpartum decreased (−0.07units/week) among nonsmokers and rose (+0.05units/week) among those who smoked (p = 0.01).
Whitaker87USA
Age (years):
<20: 17.9%
20–29: 59.2%
⩾30: 22.9%
Gender of newborns: not given
4353Cross-sectional study
Two groups:
- PPD
- No PPD
CIDI-SF13.6%Smoking behaviorAfter adjusting for sociodemographiccharacteristics, the prevalence (95% CI) of a majordepressive episode was higher among smokers thannonsmokers: 17.7% (15.7, 19.8) vs 12.1% (10.9,13.3). Smoking was also more common among motherswho had had a major depressive episode than amongthose who had not: 34.0% (30.6, 37.4%) vs 25.5%(24.1, 26.8%).
Barr93Australia
Age: between 20 and 34 years
Gender of newborns: not given
15Cross-sectional study (qualitative study)
One group:
- PPD
Not given100%Thoughts of infanticide that did not lead to theactWomen who experienced nonpsychotic depressionpreferred not to disclose their thoughts ofinfanticide to health professionals, includingtrusted general practitioners or psychiatrists.These women were more likely to mention theirsuicidal thoughts than their infanticidal thoughtsto obtain health care.
Do33USA
Mean age: not given
Gender ofnewborns: not given
178,714Cohort study
6 years
Four groups:
Active component servicewomen:
- PPD
- No PPD
Dependent spouses:
- PPD
- No PPD
ICD-9-CMActive component service women: 9.9%
Dependent spouses: 8.2%
Suicide attemptService women with PPD had higher odds ofsuicidality compared to service women without PPD(OR = 42.2, 95% CI = 28.8, 61.9). Dependent spouseswith PPD also had higher odds of suicidalitycompared to dependent spouses without PPD(OR = 14.5, 95% CI = 10.8, 19.4).
Kim28USA
Mean age (years):
Suicidalideation: 32.2 ± 6.3
No suicidal ideation:32.2 ± 5.6
Gender of newborn: not given
22,118Cohort study
23 weeks
Two groups:
- Suicidal ideation
- No suicidalIdeation
EPDS
(Depressed = EPDS ⩾ 12)
Not givenSuicidal ideationAmong 22,118 EPDS questionnaires studied, suicidalideation was reported on 842 (3.8%, 95% CI = 3.5,4.1) and was positively associated with pre-existingpsychiatric diagnosis during the postpartum (12.0%compared with 5.8%, p = 0.001). Among perinatalwomen screened for depression, 3.8% reportedsuicidal ideation; 1.1% of this subgroup was at highrisk of suicide. Multivariable postpartum models didnot retain the PPD.
Paris81USA
Mean age: 32.5 ± 5.6 years
Gender of newborns: not given
32Cross-sectional study
Two groups:
- Low suicidality
- Highsuicidality
PDSS100%Suicidality (suicidal ideation)Overall, women in this clinical sample had wideranging levels of suicidal thinking. When dividedinto low and high suicidality groups, the motherswith high suicidality experienced greater mooddisturbances and cognitive distortions, and moresevere postpartum symptomatology.
Pope30UK
Mean age: 29.0 ± 5.5 years
Genderof newborns: not given
147Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(use of item 10 on the EPDS referringto “thoughts of self-harm”)
HDRS
Not applicable
(only women with MDD (64%) orbipolar disorder (36%) were included in thestudy)
Thoughts of self-harm; suicidal ideationWomen with suicidal ideation were more likely tohave higher levels of depression than women withoutsuicidal ideation (EPDS: 21.5 vs 9.9, p = 0.03;HDRS: 18.6 vs 7.73, p = 0.04). Women with thoughtsof self-harm were more likely to have higher levelsof depression than women without thoughts ofself-harm (EPDS: 16.4 vs 9.5, p = 0.04; HDRS: 13.0vs 7.5, p = 0.05). Women with hypomanic symptomsduring the postpartum period were also more likelyto have thoughts of self-harm or suicidalideation.
Posmontier85USA
Mean age (years):
No PPD:31.0 ± 4.5
PPD: 30.0 ± 5.5
Femalebabies (%):
No PPD: 78.3
PPD:30.4
46Cross-sectional study
Two groups:
- PPD
- No PPD
MININot applicable (number of PPD and no PPD women werefixed at the beginning of the study)
Nondepressed: n = 23
Depressed:n = 23
Functional status (physical infant care, personalcare, household care, social activities, andoccupational activities)Depressed mothers presented more suicidal thoughts(6.52, SD = 3.64) than nondepressed mothers (4.25,SD = 0.25, p < 0.01).
Tavares76Brazil
Age (years):
13–19: 20.0%
20–34: 69.9%
35–45: 10.1%
Gender of newborns: not given
919Cross-sectional study
Two groups:
- PPD
- No PPD
MINI8.5%Suicide riskLower education levels and psychiatric disorderswere associated with suicide risk. The mothers whoexperienced depressive episodes had a 12.6 (95% CI =7.0, 22.6) times greater risk of presenting withsuicidal signs. Women who had hypomanic episodeswere 7.01 (95% CI = 3.54, 13.9) times more likely toshow signs of suicide risk compared to those withouthypomanic episodes. Bipolar disorder was thepsychiatric disorder with the highest impact onsuicide risk.
PPD: postpartum depression; EPDS: Edinburgh PostnatalDepression Scale; BDI: Beck Depression Inventory; CIDI-SF:Composite International Diagnostic Interview—Short Form;ICD-9-CM: International Classification of Diseases, NinthRevision, Clinical Modification; PDSS: Postpartum DepressionScreening Scale; HDRS: Hamilton Depression Rating Scale;MINI: Mini International Neuropsychiatric Interview; MDD:maternal major depressive disorder; OR: odds ratio; CI:confidence interval; SD: standard deviation.

Suicidal ideation

Five studies showed that higher levels of depressive symptoms wereassociated with an increased prevalence of suicidal ideation30,33,76,81,85(Table5). Mothers with high suicidality risks experienced greater mooddisturbances and more severe postpartum symptomatology than mothers withlow suicidality risks.81 One of the five studies also demonstrated that women who reportedhigher levels of depression were also significantly more likely toreport thoughts of self-harm than women with low levels of depression.30 The sixth study28 showed a significant association between PPD and suicidalideation in an unadjusted analysis, but not in adjusted analysis. Anadditional study demonstrated that mothers who experienced PPD couldimagine acts of infanticide.93 The authors of this study explained that many mothers preferredto describe their suicidal thoughts rather than their infanticidalthoughts when seeking health care.

Infant consequences of PPD

Anthropometry

The characteristics and main results of the studies included in theevaluation of anthropometric parameters are presented in Table 6.

Table 6.
Characteristics of the studies included in the evaluation of infantanthropometric outcomes.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Adewuya119Nigeria
Mean age: not given
Gender ofnewborns: not given
242Cohort study
8 months
Two groups:
- PPD
- No PPD
SCID-NP49.6%Infants’ physical growth (weight and length); cases ofdiarrhea and other childhood illnesses in infants;breastfeedingThe differences in weight and length gradually increasedstarting at the 6th week, peaked at the 6th month, anddeclined afterwards.
Avan110South Africa
Age (years):
<35: 91.5%
⩾35: 8.5%
Female babies: 49.9%
1035Cohort study
18 months
Two groups:
- PPD
- No PPD
Pitt Inventory24.0%Child growth; child behavioral problems (Richman ChildBehavior Scale)Two-year-old children with depressed mothers had anincreased risk of stunted growth compared to those withnondepressed mothers.
Bakare140Nigeria
Mean age: 28.2 ± 5.1 years
Female babies: 47.8%
408Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 9)
24.8%Weight; length; head circumferenceMaternal PPD was significantly associated with infants’weight and length, but not their headcircumference.
Ertel109USA
Mean age: 33.0 ± 4.5 years
Femalebabies: 52.3%
872Cohort study
3 years
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
7.3%Height and linear growthExposure to PPD was associated with a greaterheight-for-age z-score and longer leg length starting at6 months and continuing to age 3 years.
Ertel112USA
Mean age: 33.0 ± 4.46 years
Femalebabies: 52.2%
838Cohort study
3.5 years
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
7.04%BMI z-score; WHZ; sum of SS and TR skinfold thicknessfor overall adiposity; sum of SS and TR skinfoldthickness ratio for central adiposityIn multivariable models, PPD was only associated with ahigher sum of SS and TR skinfold thickness (SS + TR) foroverall adiposity (adjusted OR (95% CI) = 1.14 (0.11,2.18)), but this association was not significant. Theresults for other outcomes showed very small effectestimates. For example, regarding the associationbetween PPD and child WHZ, the estimated associationswere similar for each age from 6 months to 3 years: 0.08(95% CI = −0.14, 0.30) when controlling for child sexand age at assessment, maternal age, race/ethnicity,household income, pre-pregnancy BMI, pregnancy weightgain, gestational diabetes or impaired glucoseintolerance, gestational age at delivery, andbirthweight-for-gestational age.
Ertel100The Netherlands
Mean age: 30.3 ± 5.24 years
Female babies: 49.5%
6782Cohort study
41 months
Two groups:
- PPD
- No PPD
BSI8.25% at 2 months
8.85% at 6 months
Child overweightThere was no association between perinatal depressionand child BMI at any time point.
Gress-Smith104USA
Mean age: 26.5 ± 5.59 years
Genderof newborns: not given
NB: very low-incomepopulation
132Cohort study
9 months
Three groups:
- No PPD
- Significant levels ofdepressive symptoms (CES-D ⩾ 16)
- Severedepressive symptoms (CES-D ⩾ 24)
CES-D5 months: 33% of depressive symptoms; 12% of severedepressive symptoms
9 months: 38% of depressivesymptoms; 18% of severe depressive symptoms
Infant weight; infant health; infant sleepHigher depressive symptoms at 5 months postpartum wereassociated with less infant weight gain from 5 to 9months.
Grote113Belgium, Germany, Italy, Poland, Spain
Age(years):
<28: 27.3%
28 ⩽ 33: 39.1%
33–44: 33.6%
Female babies: 51.7%
929Cohort study
2 years
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
11.0%Weight; length; TR skinfold thickness; SS skinfoldthickness; weight for lengthInfant weight, length, and BMI at 24 months of age didnot differ between high and normal EPDS groups. TRskinfold thickness and SS skinfold thickness did notdiffer between the two groups.
Kalita131India
Age (years):
Depression:28.2 ± 0.93
Anxiety: 29.8 ± 1.68
Notdiagnosed: 28.3 ± 1.28
Female babies: 52.0%
100Cohort study
6 months
Three groups:
- PPD
- Anxiety
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
18.0%Weight; communication; symbolic behaviorsInfants with mothers suffering from PPD hadsignificantly lower weights at 6 months of age comparedto infants born to mothers who did not suffer fromPPD.
Nasreen97Bangladesh
Mean age: 24.2 ± 6.7 years
Female babies: 50.7%
652Cohort study
1 year
Four groups:
- No depression
- PPD during pregnancyonly
- PPD during pregnancy and postpartum
- PPD during postpartum only
EPDS
(Depressed = EPDS ⩾ 10)
14.1% at 2–3 months
31.7% at 6–8 months
Infant’s growth (underweight at 6–8 months, stunting at6–8 months); infant’s motor developmentMaternal depressive symptoms at 2–3 months postpartumwere associated with infant underweight at age 6–8months. No significant association was found betweenmaternal postpartum depressive symptoms at 2–3 monthsand infant stunting at 6–8 months.
Ndokera142Zambia
Age (years):
⩽18: 9%
19–24: 35.6%
25–30: 33.1%
⩾31: 22.3%
Female babies: 45.3%
278Cross-sectional study
Two groups:
- PPD
- No PPD
SRQ-209.7%Weight; length; diarrheal episodes; incompletevaccinationInfants of depressed mothers were lighter and shorterthan infants of nondepressed mothers after adjustmentfor age, gender, and maternal weight.
Tomlinson126South Africa
Age (years):
<20: 15.3%
20–24: 26.5%
25–29: 32.7%
30–39: 25.5%
Female babies: 44.9%
147Cohort study
18 months
Two groups:
- PPD
- No PPD
SCID34.7% at 2 months
12% at 18 months
Infant weight; infant lengthThere were no significant relationships at 2 and 18months between maternal depression and mean standardizedinfant weight or length.
Wright125UK
Mean age: not given
Gender ofnewborns: not given
915
(923 infants)
Cohort study
13 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
12.0%Overall infant weight gain; weight falteringInfants of depressed mothers showed slower overallweight gain and an increased rate of weight falteringfrom birth to 4 months. However, over the 12-monthperiod, there was no difference in weight gain betweenthe infants of depressed and nondepressed mothers.
PPD: postpartum depression; CES-D: Center for EpidemiologicStudies Depression Scale; SCID-NP: Structured Clinical Interviewfor DSM-IV, Non-Patient edition; EPDS: Edinburgh PostnatalDepression Scale; BSI: Brief Symptom Inventory; SRQ-20:Self-Reporting Questionnaire-20; BMI: body mass index; WHZ:weight-for-height z-score; SS: subscapular; TR: triceps; OR:odds ratio; CI: confidence interval.

Weight

A total of 11 studies reported weight as an outcome. Among them, fivestudies97,104,131,140,142 demonstrated a significant effect of maternalPPD on the child’s weight; infants of depressed mothers gained lessweight than infants of nondepressed mothers. Four studies were conductedin low-resource countries (India,131 Nigeria,140 Zambia,142 and Bangladesh97), and one study was conducted in the United States with a verylow-income population.104 Two other studies (one in the United Kingdom125 and one in Nigeria119) showed that while there were differences in infant weight in thefirst months of life, they did not persist. Finally, four studiesdemonstrated that maternal PPD had no effect100,113,126 or a very small effect112 on the child’s weight. Two studies were conducted in high-incomecountries (a multicountry study that included Belgium, Germany, Italy,Poland, and Spain113 and one study conducted in the Netherlands100). The third study126 was conducted in South Africa; however, the authors stated thatthey were unable to test their hypothesis due to a lack of statisticalpower.

Length

Eight studies identified in this systematic review reported infant lengthas an outcome. Three of the studies110,140,142 showed asignificant effect of maternal PPD on stunting. The three studies wereconducted in low-resource countries (Nigeria,140 Zambia,142 and South Africa110). One other study119 showed differences in length in the first months of life;however, it was determined that these differences did not persist overtime (Nigeria). Three other studies97,113,126 demonstratedthat maternal PPD had no effect on stunting. One multicountry study113 evaluated high-income countries (Belgium, Germany, Italy, Poland,and Spain), and two studies were conducted in low-income countries,including Bangladesh97 and South Africa.126 The authors of the South African study stated that they wereunable to test their hypothesis due to a lack of statistical power.Another study109 conducted in a high-income country (the United States) showed theopposite effect: exposure to PPD was associated with a greaterheight-for-age z-score and a longer leg length.

Anthropometric indices

Four studies evaluated anthropometric indices, and two of them showed noeffect of maternal PPD. One study140 found that maternal PPD was not associated with headcircumference (Nigeria). Two studies demonstrated that the triceps andsubscapular skinfold thicknesses did not differ between infants ofdepressed and nondepressed mothers (one study was conducted in Belgium,Germany, Italy, Poland, and Spain;113 the other was from the United States112). In contrast, one study from the United States109 showed that PPD was associated with higher subscapular andtriceps skinfold thickness scores, which indicated overalladiposity.

Infant health

Of the 10 cohort studies, 9 indicated a significant association betweenmaternal PPD and health concerns in infants (Table 7). Maternal depressivesymptoms at 5 months seemed to predict more overall physical health concernsfor infants at 9 months104 and a greater proportion of childhood illnesses.119 Three studies showed that infants of depressed mothers hadsignificantly more diarrheal episodes per year than those of nondepressedmothers,119,122,138 and one study reported that infants of depressedmothers had more days of illness with diarrhea.138 Harriet et al. specified that these associations with diarrhealepisodes were accurate only within the first 3 months. One study alsoassociated maternal depressive symptoms with infant colic.124 Two studies reported greater overall pain in the infants of depressed mothers48 and a stronger infant pain response during routine vaccinations.123 One study demonstrated that maternal PPD at 4 months predicted worsehealth-related quality of life for the infant in the following months.48 One study indicated a robust and predictive association betweenmaternal PPD and febrile disease in children.135 Another study136 showed that probable postnatal depression was associated with anapproximately three-fold increased risk of mortality in infants up to 6months of age, with an approximately two-fold increased risk of mortality upto 12 months of age. This study also showed that probable postnataldepression was associated with an increased risk of infant morbidity. Onlyone cross-sectional study reported a nonsignificant association between ahigh risk of maternal depression and serious illness or diarrheal episodesafter adjusting for infant age and other possible confounders.142 Nevertheless, the occurrence of these two outcomes was proportionallyhigher among infants of depressed mothers.

Table 7.
Characteristics of the studies included in the evaluation of infanthealth.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Adewuya119Nigeria
Mean age: not given
Gender ofnewborns: not given
242Cohort study
8 months
Two groups:
- PPD
- No PPD
SCID-NP49.6%Infant physical growth (weight and length); cases ofdiarrhea and other childhood illnesses in the infants;breastfeedingBy the 9th month, the average number of cases ofdiarrhea and other childhood illnesses in the infants ofdepressed mothers was 5.23 (SD = 2.37), while theaverage number of those illnesses in infants ofnondepressed mothers was 3.70 (SD = 4.14). Thedifference was statistically significant(p = 0.001).
Akman124Turkey
Age (years):
Infant colic+:31.1 ± 6.0
Infant colic−: 29.6 ± 4.8
Female babies: 50.0%
78Cohort study
6 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
12.9%Infant colicInfant colic was present in 17 infants (21.7%), and12.9% of the mothers had an EPDS score >13. The meanEPDS score of mothers whose infants had infant colic(10.2 ± 6.0) was significantly higher than that ofmothers of infants without colic (6.3 ± 4.0).
Darcy48USA
Mean age: 30.3 years
Gender ofnewborns: not given
217Cohort study
1 year
Two groups:
- PPD
- No PPD
CES-D32.7%Infant health-related quality of life (pain/discomfortand health-related concerns)Mothers with significant depressive symptoms reportedgreater pain in their infant and had more health-relatedconcerns about their child. Maternal depressive symptomsat 4 months predicted poorer health-related quality oflife for the infant at 8, 12, and 16 months.
Gress-Smith104USA
Mean age: 26.5 ± 5.59 years
Genderof newborns: not given
NB: very low-incomepopulation
132Cohort study
9 months
Three groups:
- No PPD
- Significant levels ofdepressive symptoms (CES-D ⩾ 16)
- Severedepressive symptoms (CES-D ⩾ 24)
CES-D5 months: 33% of depressive symptoms; 12% of severedepressive symptoms.
9 months: 38% of depressivesymptoms; 18% of severe depressive symptoms.
Infant weight; infant health; infant sleepMaternal depressive symptoms at 5 months predicted morephysical health concerns in the infants at 9 months(B = 0.05, SE = 0.03, p < 0.05).
Guo135Côte d’Ivoire, Ghana
Mean age: 29.1 ± 5.4 years
Female babies: 48.9%
654Cohort study
2 years
Two groups:
- PPD
- No PPD
PHQ-93 months: 11.8% in Côte d’Ivoire; 8.9% in Ghana.
12 months: 16.1% in Côte d’Ivoire; 7.2% inGhana.
Febrile illnessThe hazard of febrile disease in children of depressedmothers was 57% higher than the hazard in children ofnondepressed mothers. Country and SES were identified asconfounders. After adjusting for both, the hazard ofdeveloping a febrile illness was 32% higher in childrenwhose mothers had depression than in children whosemothers did not have depression. The authors constructeda cumulative depression exposure by categorizing themothers as “never depressed” or “depressed one time” and“depressed 2 or 3 times.” The crude and adjusted hazardratios for children of recurrently depressed motherscompared to those for children of mothers with fewerepisodes of depression were 2.20 (95% CI = 1.51, 3.19)and 1.90 (95% CI = 1.32, 2.75), respectively.
Harriet138Ghana
Mean age: 28.5 ± 0.3 years
Genderof newborns: not given
NB: HIV-infectedmothers
552Cohort study
12 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
10.0%DiarrheaIn the first 3 months of life, infants of mothers whoreported PND symptoms had almost twice the number ofdiarrheal episodes (p = 0.0005) and more than twice asmany days ill with diarrhea (p = 0.0002) compared toinfants whose mothers reported no PND symptoms. Nosignificant association was observed after 3months.
Moscardino123Italy
Mean age: 33.3 ± 5.1 years
Femalebabies: 50.0%
28Cohort study
2.5 months
Two groups:
- PPD
- No PPD
EPDS
(cut-off value not given)
Not given (mean EPDS score = 7.5)Infant response to vaccinationHigher levels of depressed maternal mood were predictiveof a stronger infant pain response to routinevaccination. Infants exhibiting a stronger pain responseduring the inoculation procedure at 4.5 months were morelikely to have mothers who reported higher levels ofdepressed mood at 2 months (p = 0.032) and at 4.5 months(p = 0.016). The mothers’ PND at 2 months was onlymarginally related to the infant pain response(p = 0.086).
Ndokera142Zambia
Age (years):
⩽18: 9%
19–24: 35.6%
25–30: 33.1%
⩾31: 22.3%
Female babies: 45.3%
278Cross-sectional study
Two groups:
- PPD
- No PPD
SRQ-209.7%Weight; length; diarrheal episodes; incompletevaccinationAll outcomes were proportionally higher among theinfants of “depressed” mothers, although none of thesedifferences were statistically significant. Logisticregression analysis to adjust for infant age and otherpossible confounders showed no significant associationbetween a high risk of maternal depression and seriousillness or diarrheal episodes.
Rahman122Pakistan
Mean age: 26.0 years
Femalebabies: 49.8%
265Cohort study
1 year
Two groups:
- PPD
- No PPD
Schedules for Clinical Assessment in Neuropsychiatrydeveloped by the WHO49.1%Diarrheal illnessInfants of depressed mothers had significantly morediarrheal episodes per year than those in the controlgroup. The RR of having >5 diarrheal episodes peryear in infants of depressed mothers was 2.3 (95% CI =1.6, 3.1). The association remained significant afterother risk factors were adjusted by a multivariateanalysis (RR = 3.1; 95% CI = 1.8, 5.6;p < 0.01).
Weobong136Ghana
Mean age: not given
Gender ofnewborns: not given
16,560Cohort study
6 months
Two groups:
- PPD
- No PPD
PHQ-93.5%Infant mortality; infant morbidityAll-cause infant mortality from the time of the PNDassessment up to 6 months of age (adjusted RR = 2.86,95% CI = 1.58, 5.19) was almost three times higher forinfants of depressed mothers compared to those whosemothers were not depressed, and there was almost atwo-fold increase in all-cause infant mortality up to 12months of age (adjusted RR = 1.88, 95% CI = 1.09, 3.24).Among the potential confounders included in the model,only time of delivery (preterm) was also associated withan almost five-fold increased risk of infant deaths upto 6 months of age (adjusted RR = 4.61, 95% CI = 2.02,10.51). An increased risk of infant morbidity indicatorswas associated with probable PND.
PPD: postpartum depression; CES-D: Center for EpidemiologicStudies Depression Scale; SCID-NP: Structured Clinical Interviewfor DSM-IV, Non-Patient edition; EPDS: Edinburgh PostnatalDepression Scale; PHQ-9: Patient Health Questionnaire depressionmodule; SRQ-20: Self-Reporting Questionnaire-20; WHO: WorldHealth Organization; SD: standard deviation; CI: confidenceinterval; SES: socioeconomic status; PND: postnatal depression;RR: risk ratio.

Infant sleep

Three studies evaluated the association between maternal depressive symptomsand infant sleep patterns (Table 8). Two studies showed thathigher depressive symptoms were associated with an increased incidence ofinfant night-time awakenings and predicted more problematic infant sleeppatterns.104,108 One of the two studies demonstrated that childrenwhose mothers had severe and/or chronic depressive symptoms had a higherrisk of sleep disorders than those with mothers who had mild depressive symptoms.108 The third study reported that significantly fewer children of motherswith depressive symptoms were placed in the recommended back-to-sleepposition compared with children of women who had not experienced depression.130

Table 8.
Characteristics of the studies included in the evaluation of infantsleep.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Gress-Smith104USA
Mean age: 26.5 ± 5.59 years
Genderof newborns: not given
NB: very low-incomepopulation
132Cohort study
9 months
Three groups:
- No PPD
- Significant levels ofdepressive symptoms (CES-D ⩾ 16)
- Severedepressive symptoms (CES-D ⩾ 24)
CES-D5 months: 33% of depressive symptoms; 12% of severedepressive symptoms
9 months: 38% of depressivesymptoms; 18% of severe depressive symptoms
Infant weight; infant health; infant sleepHigher depressive symptoms at 5 months were associatedwith increased infant night-time awakenings at 9 months(p = 0.001). A multinomial logistic regression analysiswas performed to investigate the relationship betweenmaternal depressive symptoms at 5 months and infantsleep at 9 months while controlling for infant sleep at5 months. Maternal depressive symptoms at 5 monthssignificantly predicted more problematic infant sleep at9 months (B = 0.03, p = 0.01).
Tavares Pinheiro108Brazil
Mean age: 26.2 ± 6.6 years
Genderof newborns: not given
366Cohort study
10 months
Two groups:
- PPD
- No PPD
EPDS
(mild = 10–12; severe ⩾ 13)
22.7% in direct PP
24.6% at 12 months
Infant sleep disordersThe risk of sleep problems for children whose motherspresented with a new onset and severe depression at 12months was higher than the risks observed among childrenborn to mildly depressed mothers. When chronicity wasconsidered, an additional risk of 2.20 (95% CI = 0.62,7.86) was observed for mild and chronically depressedmothers, which was even higher (2.58; 95% CI = 1.15,5.63) for chronic and severe cases. Moreover, a lineartrend toward a higher risk of sleep problems as theseverity and chronicity of the mother’s depressivesymptoms increased could be observed (p = 0.05).
Zajicek-Farber130USA
Age (years):
Depressed: 22.3 ± 4.3
Nondepressed: 22.6 ± 3.9
Female babies:54.0%
134Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 11)
PHQ
55.2%Infant health practicesSignificantly fewer children of depressed women wereplaced in the recommended back-to-sleep positioncompared to children of women who had never experienceddepression (68.9% vs 85.0%). The RR of sleeping in a“wrong” position was two times greater for children ofdepressed women than those of women who were neverdepressed.
PPD: postpartum depression; CES-D: Center for EpidemiologicStudies Depression Scale; EPDS: Edinburgh Postnatal DepressionScale; PHQ: Patient Health Questionnaire; CI: confidenceinterval; RR: risk ratio.

Motor development

Three of seven studies showed a significant effect of maternal PPD on themotor development of infants (Table 9). The first study,97 conducted in Bangladesh, showed that symptoms of maternal PPD thatwere present at 2–3 months predicted impaired motor development in infantsat 6–8 months. The second study95 included Greek mothers in Crete and demonstrated that symptoms ofmaternal PPD were associated with lower fine motor scores in infants at 18months of age (a 5-unit decrease on the scale of fine motor development).The third study94 showed a nonsignificant impact of maternal depression on the fine andgross motor development of children at 2 and 6 months that becamesignificant at 12 months for gross motor development and at 18 months forfine motor development (Pakistan). The fourth study141 underlined the indirect effect of maternal PPD on motor developmentas a consequence of the effects of maternal depressive symptoms on thequality of the home environment. This mechanism had a direct effect on earlychild development. Three studies66,103,107 demonstrated thatmaternal PPD had no effect on motor development (Table 9). Two studies66,107explained the nonsignificant results by stating that most of the mothers inthe depressed group had moderate-to-severe depression symptoms that weresimilar to a general description of psychological difficulty during thepostnatal period and were less severe than a psychiatric diagnosis of adepressive illness (France and Taiwan). The third study103 emphasized that the home environment remained a significant predictorof infant development in Australia.

Table 9.
Characteristics of the studies included in the evaluation for motordevelopment in children.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Ali94Pakistan
Mean age: 26.3 years
Femalebabies: 48.8%
420Cohort study
30 months
Two groups:
- PPD
- No PPD
AKUADS1 month: 4.8%
2 months: 4.7%
6 months:5.7%
12 months: 9.2%
18 months: 2.7%
24 months: 6.1%
Delayed gross motor, fine motor, emotional, cognitive,and language developmentAt the 2- and 6-month follow-ups, there was nosignificant impact of maternal depression on children’sgross motor development. However, there was anapproximately three-fold higher impact at the 12-monthfollow-up (adjusted OR = 2.8, 95% CI = 1.2, 6.6). At the2-, 6-, and 12-month follow-ups, there was nosignificant impact of maternal depression on children’sfine motor development. At the 18-month follow-up, therewas a significant impact; children of depressed mothershad a four times higher risk (adjusted OR = 4.0, 95% CI= 1.4, 11.3).
Chen141Taiwan
Mean age: 26.6 ± 4.2 years
Femalebabies: 42.6%
NB: immigrant mothers
60Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
31.1%Child development (global score for cognitive, language,motor, self-regulation, and social development); qualityof the home environmentMaternal depressive symptoms had a direct and negativeeffect on the quality of the home environment (−0.32,p < 0.05). Maternal depressive symptoms did not havea direct effect on child development (0.05,p > 0.05). The quality of the home environment had asignificant and positive effect on child development(0.55, p < 0.001).
Koutra95Crete
Mean age: 30.09 ± 4.53 years
Female babies: 45.5%
470Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
Not givenFine motor, gross motor, cognitive, and social-emotionaldevelopment; receptive and expressive communicationHigh levels of maternal PPD (EPDS score ⩾ 13) wereassociated with 5-unit decrease in the fine motordevelopment scale score at 18 months of age.
Nasreen97Bangladesh
Mean age: 24.2 ± 6.7 years
Female babies: 50.7%
652Cohort study
1 year
Four groups:
- No depression
- Pregnancy only
- Pregnancy and postpartum
- Postpartumonly
EPDS
(Depressed = EPDS ⩾ 10)
14.1% at 2–3 months
31.7% at 6–8 months
Infant growth (underweight at 6–8 months, stunting at6–8 months); infant motor developmentMaternal depressive symptoms at 2–3 months postpartumpredicted impaired infant motor development at 6–8months.
Piteo103Australia
Age: not given
Female babies:53%
360Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
19%Motor, cognitive, and language developmentIn the first 6 months postpartum, there were nosignificant associations between maternal depression andmotor development after controlling for infantprematurity, breastfeeding status, and socioeconomiclevel. There were no significant differences betweenmaternal depression groups for motor development at 18months based on unadjusted analyses. However, the homeenvironment was a significant predictor of languagedevelopment.
Sutter-Dallay107France
Mean age: 29.6 ± 4.2 years
Femalebabies: 47.8%
515Cohort study
2 years
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
6 weeks: 4.7%
3 months: 4.5%
6 months:4.3%
12 months: 3.7%
18 months: 5.8%
24 months: 4.3%
Psychomotor Developmental Index; Mental DevelopmentalIndexNo association was found between PND 6 weeks afterdelivery and the child’s motor performance over thefollow-up period. No association was found between EPDSscores and motor scores (B = 0.60, p = 0.24).
Wang66Taiwan
Age (years):
Depressed:28.34 ± 5.52
Nondepressed: 29.45 ± 4.13
Female babies: 55.0%
60Cohort study
1 year
Two groups:
- PPD
- No PPD
BDI-II48.3%Gross motor, fine motor, expressive language,comprehension-conceptual, situational help, self-help,personal-social, and general developmentNo significant difference was found between the infantdevelopment variables in the two groups (gross motordevelopment: p = 0.514; fine motor development:p = 0.514).
PPD: postpartum depression; AKUADS: Aga Khan University Anxietyand Depression Scale; EPDS: Edinburgh Postnatal DepressionScale; BDI-II: Beck Depression Inventory-II; CI: confidenceinterval; OR: odds ratio; PND: postnatal depression.

Cognitive development

Of the 11 studies, 794,95,99,101,102,107,147 indicated a significant and negative associationbetween maternal postpartum depressive symptoms and cognitive development inchildren (Table10). One of the studies147 specifically emphasized the important role of maternal insensitivityin delays in children’s cognitive development. The eighth study141 underlined the indirect effect of maternal PPD on cognitivedevelopment, which occurred as a result of maternal depressive symptoms thatimpacted the quality of the home environment and had a direct effect onearly child development. Three studies103,134,139 showed that maternalPPD was not significantly correlated with children’s cognitive development.One of the studies found a nonsignificant effect of maternal PPD andindicated that the home environment was a more important predictor of infantcognitive development in Australia.103

Table 10.
Characteristics of the studies included in the evaluation of childcognitive development.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborn
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Ali94Pakistan
Mean age: 26.3 years
Femalebabies: 48.8%
420Cohort study
30 months
Two groups:
- PPD
- No PPD
AKUADS1 month: 4.8%
2 months: 4.7%
6 months:5.7%
12 months: 9.2%
18 months: 2.7%
24 months: 6.1%
Delayed gross motor, fine motor, emotional, cognitive,and language developmentAt the 2-month follow-up, maternal depression showed nosignificant impact on children’s cognitive development.However, the impact of maternal depression on delayedcognitive development of the child was approximatelythree-fold at the 6-month follow-up (adjusted OR = 3.3,95% CI = 1.1, 9.9) and approximately seven-fold at the12-month follow-up (adjusted OR = 6.8, 95% CI = 3.0,15.7).
Azak99Norway
Mean age: 64.3 years
Femalebabies: 50%
50Cohort study
1 year
Two groups:
- PPD
- No PPD
CES-DNot applicable (number of PPD and no PPD women werefixed at the beginning of the study)
Nondepressed: n = 24
Depressed:n = 26
Trajectories of cognitive developmentMaternal depression was significantly related to theMSEL composite score. Infants of depressed mothers had astable lower cognitive score over a 12-month period(6–18 months of age) compared to infants of nondepressedmothers. Over the same time period, girls tended to showa greater increase in cognitive scores compared toboys.
Chen141Taiwan
Mean age: 26.6 ± 4.2 years
Femalebabies: 42.6%
NB: immigrant mothers
60Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
31.1%Child development (global score for cognitive, language,motor, self-regulation, and social development); qualityof the home environmentMaternal depressive symptoms had a direct and negativeeffect on the quality of the home environment (−0.32,p < 0.05). Maternal depressive symptoms did not havea direct effect on child development (0.05,p > 0.05). The quality of the home environment had asignificant and positive effect on child development(0.55, p < 0.001).
Evans134UK
Age (years):
Depressed: 28.0 ± 5.3
Nondepressed: 28.6 ± 4.7
Female babies:48.4%
6735Cohort study
33 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
13.1%Cognitive developmentAfter multiple imputations for missing data, there wasno effect of PND on child IQ independent of depressionthat may have occurred at other times.
Kaplan102USA
Mean age: 29.9 ± 5.1 years
Femalebabies: 45.7%
97Cohort study
8 months
Two groups:
- PPD
- No PPD
BDI-II
DSM-IV
4 months:
42.3% (BDI-II)
12.4% (DSM-IV)
12 months:
17.5% (BDI-II)
2.1%(DSM-IV)
Cognitive development; ability to associate a face witha segment of an unfamiliar nondepressed mother’sinfant-directed speechAt 4 months, all infants learned the voice–faceassociation. At 12 months, even though none of themothers were still clinically depressed, the averageinfant of mothers with chronically elevatedself-reported depressive symptoms or elevatedself-reported depressive symptoms at 4 months, but not12 months, did not learn the association. For infants ofmothers diagnosed with depression who were in remission,learning at 12 months was negatively correlated with thepostpartum duration of the mother’s depressiveepisode.
Kaplan139USA
Mean age: 29.9 ± 5.2 years
Femalebabies: 56.0%
91Cross-sectional study
Two groups:
- PPD
- No PPD
BDI-II33.0%Cognitive development; language development (receptiveand expressive communication)BDI-II scores did not significantly correlate withcognitive scale percentiles (p > 0.10).
Kaplan147USA
Mean age: 30.9 years
Female babies:57.6%
136
(165 infants)
Cross-sectional study
Two groups:
- PPD
- No PPD
BDI-II14.7%Infant learningCurrent depression diagnosis accounted for a significantproportion of the variance in infant learning. After theeffects of maternal depression were accounted for, therewas a significant effect of maternal hostility(p = 0.01). Finally, there was a further significanteffect of maternal sensitivity (p = 0.02); after thiseffect was accounted for, the effects of maternalhostility were no longer significant (p = 0.16), but theeffect of maternal depression remained significant(p < 0.05). Both maternal depression and maternalinsensitivity negatively and additively predicted poorlearning.
Koutra95Crete
Mean age: 30.09 ± 4.53 years
Female babies: 45.5%
470Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
Not givenFine motor, gross motor, cognitive, and social-emotionaldevelopment; receptive and expressive communicationHigh levels of maternal PPD (defined as an EPDS score⩾13) were associated with 5.6-unit decrease in thecognitive development scale (B = −5.64, 95% CI = −9.56,–1.72).
USA
Mean age at birth: 32.6 ± 5.8
Femalebabies: 50.4%
NB: mothers of preterm infants(<35 weeks)
137Cohort study
12 months
Two groups:
- PPD
- No PPD
CES-D
(Depressed = CES-D ⩾ 16)
20.4%Infant cognitive functionPND at 4 months was associated with lower cognitivefunction in children at 16 months after controlling fora host of socioeconomic characteristics (meandifference = −5.22, 95% CI = −10.19, −0.25). Beingfemale and in a household with a family income greaterthan $60,000 was associated with higher cognitivefunction. There appeared to be a maternal supportgradient in infant cognitive function for mothers withfewer depressive symptoms. That is, among mothers withfewer depressive symptoms, more maternal support wasassociated with higher cognitive function. Among motherswith elevated depressive symptoms, the maternal supportslope was relatively flat.
Piteo103Australia
Age: not given
Female babies:53%
360Cohort study
17 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
19%Motor, cognitive, and language developmentThere were no significant associations between maternaldepression in the first 6 months postpartum andcognitive development after controlling for infantprematurity, breastfeeding status, and socioeconomiclevel. However, home environment was a significantpredictor of language development.
Sutter-Dallay107France
Mean age: 29.6 ± 4.2 years
Femalebabies: 47.8%
515Cohort study
2 years
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
6 weeks: 4.7%
3 months: 4.5%
6 months:4.3%
12 months: 3.7%
18 months: 5.8%
24 months: 4.3%
Psychomotor Developmental Index; Mental DevelopmentalIndexChildren of mothers with a 6-week PND were significantlymore likely than children of nonsymptomatic mothers tohave a poor cognitive outcome.

PPD: postpartum depression; AKUADS: Aga Khan University Anxietyand Depression Scale; CES-D: Center for Epidemiologic StudiesDepression Scale; EPDS: Edinburgh Postnatal Depression Scale;BDI-II: Beck Depression Inventory-II; DSM-IV: Diagnosticand Statistical Manual of Mental Disorders (4thed.);

OR: odds ratio; CI: confidence interval; MSEL: Mullen Scales ofEarly Learning; PND: postnatal depression.

Language development

A series of different variables may be used to assess language development.Across all studies included in the review (Table 11), language developmentwas evaluated using the following measures: overall languagedevelopment,94,103,105,117 expressive and receptive communication,66,95,102,139parent-to-child reading,116 composite speech,131 and literacy and enrichment literacy activities combined with anunderstanding of vocabulary and production.132

Table 11.
Characteristics of the studies included in the evaluation of childlanguage development.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborn
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Ali94Pakistan
Mean age: 26.3 years
Femalebabies: 48.8%
420Cohort study
30 months
Two groups:
- PPD
- No PPD
AKUADS1 month: 4.8%
2 months: 4.7%
6 months:5.7%
12 months: 9.2%
18 months: 2.7%
24 month: 6.1%
Delayed gross motor, fine motor, emotional, cognitive,and language developmentThere was a significant interaction between a mother’sdepression and her husband’s income. Among women whosehusband’s income was ⩾3500 rupees/month, there was nosignificant impact of maternal depression on children’slanguage development. Children of depressed motherswhose husband’s income was <3500 rupees/month hadmore than a five-fold risk of delayed languagedevelopment relative to children whose mothers were notdepressed and whose father’s income was ⩾3500rupees/month (adjusted OR = 5.4, 95% CI = 2.3,12.4).
Chen141Taiwan
Mean age: 26.6 ± 4.2 years
Femalebabies: 42.6%
NB: immigrant mothers
60Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
31.1%Child development (global score for cognitive, language,motor, self-regulation, and social development); qualityof the home environmentMaternal depressive symptoms had a direct and negativeeffect on the quality of the home environment (−0.32,p < 0.05). Maternal depressive symptoms did not havea direct effect on child development (0.05,p > 0.05). The quality of the home environment had asignificant and positive effect on child development(0.55, p < 0.001).
Friedman129USA
Mean age: 28.8 ± 6.58 years
Femalebabies: 42.6%
122Cohort study
4 months
Two groups:
- PPD
- No PPD
CES-D26.2%Infant vocal affect qualitiesMaternal depression was a predictor of less silence andaccounted for 3.5% of the variability in silence(B = −0.186). Depression was a predictor of infantneutral/positive/high positive vocalizations andaccounted for 3.5% of the variability inneutral/positive/high positive vocalizations(B = 0.186). Infants were most likely to maintain theirvocal state in the following order: silence, cry,fuss/whimper, high positive, angry protest, andneutral/positive. Infants of depressed mothers were morelikely to maintain fuss v2 (p < 0.001). Infants ofnondepressed mothers were more likely to maintainsilence v2 (p < 0.01). Infants of depressed motherswere more likely to maintain positive v2 (p < 0.01).Infants of depressed mothers were more likely tomaintain high positive vocalizations (rare behavior,p < 0.001) than infants of nondepressed mothers.Finally, the ratio of maintaining vocal affect states totransitioning vocal affect states was 5.36:1 for infantsof depressed mothers vs 5.69:1 for infants ofnondepressed mothers.
Kalita131India
Age (years):
Depression:28.2 ± 0.93
Anxiety: 29.8 ± 1.68
Notdiagnosed: 28.3 ± 1.28
Female babies: 52.0%
100Cohort study
6 months
Three groups:
- PPD
- Anxiety
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
18.0%Weight; communication; symbolic behaviorPPD in the mothers had a negative effect on infantdevelopment. Composite speech scores (on the CSBS-DP)were lower in the depressed group (3.0 ± 0.33 vs5.9 ± 0.28, p < 0.001).
Kaplan102USA
Mean age: 29.9 ± 5.1 years
Femalebabies: 45.7%
97Cohort study
8 months
Two groups:
- PPD
- No PPD
BDI-II
DSM-IV
4 months:
42.3% (BDI-II)
12.4% (DSM-IV)
12 months:
17.5% (BDI-II)
2.1%(DSM-IV)
Cognitive development; ability to associate a face witha segment of an unfamiliar nondepressed mother’sinfant-directed speechAt 4 months, all infants learned the voice–faceassociation. At 12 months, even though none of themothers were still clinically depressed, the infants ofmothers with chronically elevated self-reporteddepressive symptoms and those with elevatedself-reported depressive symptoms at 4 months, but not12 months, did not learn the association on average. Forinfants whose mothers were diagnosed with depression butwere in remission, learning at 12 months was negativelycorrelated with the postpartum duration of the mother’sdepressive episode.
Kaplan139USA
Mean age: 29.9 ± 5.2 years
Femalebabies: 56.0%
91Cross-sectional study
Two groups:
- PPD
- No PPD
BDI-II33.0%Cognitive development; language development (receptiveand expressive communication)BDI-II scores were significantly and negativelycorrelated with the Bayley expressive communicationscale percentiles (p = 0.01) but did not correlatesignificantly with receptive communication scalepercentiles (p > 0.1).
Koutra95Crete
Mean age: 30.09 ± 4.53 years
Female babies: 45.5%
470Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
Not givenFine motor, gross motor, cognitive, and social-emotionaldevelopment; receptive and expressive communicationThere was no significant association between PPD andreceptive communication (B = –2.37, p > 0.05) orbetween PPD and expressive communication (B = −0.71,p > 0.05).
Paulson116USA
Age (years):
<20: 1.8%
20–34: 69.9%
35+: 28.3%
Femalebabies: 47.8%
4109Cohort study
16 months
Two groups:
- PPD
- No PPD
CES-D14.0%Child language development (expressive language)Depression at 9 months was negatively associated withcontemporaneous parent-to-child reading. Depression wasa significant problem that impacted reading to the childand, subsequently, the child’s languagedevelopment.
Piteo103Australia
Age: not given
Female babies:53%
360Cohort study
17 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
19%Motor, cognitive, and language developmentThere were no significant differences in child languagedevelopment at 18 months between maternal depressiongroups based on unadjusted analyses. However, the homeenvironment was a significant predictor of languagedevelopment.
Quevedo105Brazil
Age (years):
>19: 18.9%
20–34: 65.3%
⩾35: 15.8%
Femalebabies: 47.4%
296Cohort study
11 months
Four groups:
- No PPD
- Postpartum
- Current
- Postpartum and present
MINI25.5%Language developmentMaternal depression at both time points (postpartum andat 12 months) was significantly associated with thelanguage development of infants at 12 months of age.Children whose mothers were depressed at bothassessments had worse language development than thechildren of mothers who were depressed at only one timepoint or not at all (–2.87, 95% CI = −5.01, −0.64).
Stein117UK
Age: minimum 16 years
Gender ofnewborns: not given
1036Cohort study
33 months
Two groups:
- PPD
- No PPD
EPDS
(cut-off value not given)
Not givenLanguage developmentMaternal depressive symptomatology in the firstpostnatal year (but not at 36 months) was associatedwith worse child language skills at 36 months; maternalcaregiving was positively associated with language.Depression was associated with worse caregiving but wasnot independently associated with language. When thesample was split by socioeconomic factors, the effectsof depression on caregiving were stronger in theless-advantaged group.
Wang66Taiwan
Age (years):
Depressed:28.34 ± 5.52
Nondepressed: 29.45 ± 4.13
Female babies: 55.0%
60Cohort study
1 year
Two groups:
- PPD
- No PPD
BDI-II48.3%Gross motor, fine motor, expressive language,compressive-conceptual, situational help, self-help,personal-social, and general developmentNo significant difference was found in expressivelanguage development between the two groups(p = 0.638).
Zajicek-Farber132USA
Mean age: 24.6 ± 5.5 years
Femalebabies: 52.0%
198Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 11)
55.0%Emergent language; children’s exposure toliteracy-oriented stimulation activitiesDepressed mothers were significantly less likely toinvolve their child in direct literacy-orientedstimulation (p = 0.001) or enrichment literacyactivities (p = 0.001). On average, children withdepressed mothers had significantly lower languagecompetence in the areas of understanding (p = 0.003) andproducing (p = 0.013) the amount of age-expectedvocabulary compared with children whose mothers werewithout symptoms.

PPD: postpartum depression; AKUADS: Aga Khan University Anxietyand Depression Scale; EPDS: Edinburgh Postnatal DepressionScale; CES-D: Center for Epidemiologic Studies Depression Scale;BDI-II: Beck Depression Inventory-II; DSM-IV: Diagnosticand Statistical Manual of Mental Disorders (4thed.); MINI: Mini International Neuropsychiatric Interview; OR:odds ratio; CI: confidence interval; CSBS-DP: Communication andSymbolic Behavior Scales Developmental Profile.

Of 13 studies, 6102,105,116,131,132,139 demonstrated a significant effect of maternal PPDon the language development of infants. Four studies demonstrated anindirect effect on language development; in particular, one study117 showed that maternal depressive symptomatology in the postnatal yearwas indirectly associated with worse child language skills at 36 months.Moreover, depression was associated with worse caregiving, and maternalcaregiving was positively associated with language. In addition, the effectsof depression on caregiving were stronger in less-advantaged socioeconomicgroups. Another study141 underlined the indirect effect of maternal PPD on languagedevelopment via maternal depressive symptoms that impacted the quality ofthe home environment and had a direct effect on early child development. Thethird study,94 conducted in Pakistan, showed that a child’s language development wasaffected by maternal PPD only when the father’s income was high. The fourth study129 reported that maternal PPD was a predictor of less silence and ofneutral, positive, and high positive infant vocalizations. This study alsofound that infants of depressed mothers were more likely to maintain highpositive vocalizations than infants of nondepressed mothers, which is a rarevocal quality affective behavior.

The last three studies66,95,103 showed that maternalPPD had no effect on the language development of infants. One study66 justified the nonsignificant results because the majority of themothers in the depressed group suffered from moderate-to-severe depressivesymptoms that were less severe than a psychiatric diagnosis of a depressiveillness (Taiwan). The third study103 highlighted that the home environment remained the significantpredictor of infant development in Australia.

Emotional development

Four of five studies94,96,115,121 demonstrated a significant effect of maternal PPDon the emotional development of infants (Table 12). Infants of depressedmothers also had a significantly higher fear score115,121 and higher degreesof emotional disorders that included anxiety96 than infants of nondepressed mothers. In addition, one study showedthat mothers with a low depression score after birth and a high depressionscore after several months postpartum had children with significantly higherfear scores than women with decreasing or stable depressive symptomatology.121 One study indicated a nonsignificant effect of maternal PPD on thesocial-emotional development of children at 18 months of age.95 The last study showed that maternal PPD was not associated withseparation anxiety.96

Table 12.
Characteristics of the studies included in the evaluation of childemotional development.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborn
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Ali94Pakistan
Mean age: 26.3 years
Femalebabies: 48.8%
420Cohort study
30 months
Two groups:
- PPD
- No PPD
AKUADS1 month: 4.8%
2 months: 4.7%
6 months:5.7%
12 months: 9.2%
18 months: 2.7%
24 months: 6.1%
Delayed gross motor, fine motor, emotional, cognitive,and language developmentWhen other variables were adjusted in the model,maternal depression placed children at an approximatelysix-fold risk of delayed emotional development (adjustedOR = 5.9, 95% CI = 3.0, 11.9).
Feldman115Israel
Mean age: 30.7 ± 3.4 years
Femalebabies: 47.0%
100Cohort study
9 months
Two groups:
- PPD
- No PPD
BDI-II22.0%Child social engagement; fear regulation; cortisolreactivity; behaviorThe infants of depressed mothers scored the worst on alloutcomes at 9 months. More negative emotionality and thehighest cortisol reactivity were noted in anxious dyads,which received lower scores for maternal sensitivity andinfant social engagement than the controls.
Koutra95Crete
Mean age: 30.09 ± 4.53 years
Female babies: 45.5%
470Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
Not givenFine motor, gross motor, cognitive, and social-emotionaldevelopment; receptive and expressive communicationPostpartum depressive symptoms were not associated withchildren’s social-emotional development at age 18months.
Moehler121Germany
Age: 33.3 years
Female babies:44.6%
101Cohort study
14 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 9)
Not givenInfant’s fear score; behavioral inhibitionPostpartum depression at 4 months, as measured by theEPDS, was strongly associated with the fear score andbehavioral inhibition of toddlers at 14 months. Motherswith low depression and anxiety at 6 weeks and highdepression at 4 months postpartum had children withsignificantly higher fear scores than women withdecreasing or stable depressive symptomatology betweenthe 6-week and 4-month period.
Walker96Canada
Age (years):
25–34: 68.4%
15–24: 18.8%
⩾35: 12.8%
Femalebabies: 49.2%
1452Cohort study
5 years
Two groups:
- PPD
- No PPD
Specific to the survey8.4% in the year following birth of the child; 8.3% whenthe child was 2–3 years of age.Hyperactivity inattention; emotional disorder-anxiety;physical aggression-opposition; separation anxietyPPD was not significantly associated with most childbehavioral or emotional outcomes. However, children ofmothers who had PPD were 2.61 times more likely todisplay high degrees of emotional disorder in the formof anxiety (OR = 2.61, 95% CI = 1.40, 4.86). PPD was notassociated with separation anxiety (OR = 1.34, 95% CI =0.75, 2.40).
PPD: postpartum depression; AKUADS: Aga Khan University Anxietyand Depression Scale; BDI-II: Beck Depression Inventory-II;EPDS: Edinburgh Postnatal Depression Scale; OR: odds ratio; CI:confidence interval.

Social development

The results of the four studies included in the evaluation of socialdevelopment are presented in Table 13. One study indicated thatthe infants of depressed mothers had lower social engagement scores at 9months than infants of nondepressed mothers.115 In this study, the effect of MDD on social engagement was moderatedby maternal sensitivity. Another study showed the indirect effect ofmaternal PPD on social development via the impact of maternal depressivesymptoms on the quality of the home environment, which directly affectedearly child development.141

Table 13.
Characteristics of the studies included in the evaluation of childsocial development.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Chen141Taiwan
Mean age: 26.6 ± 4.2 years
Femalebabies: 42.6%
NB: immigrant mothers
60Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
31.1%Child development (global score for cognitive, language,motor, self-regulation, and social development); qualityof the home environmentMaternal depressive symptoms had a direct and negativeeffect on the quality of the home environment (−0.32,p < 0.05). Maternal depressive symptoms did not havea direct effect on child development (0.05,p > 0.05). The quality of the home environment had asignificant and positive effect on child development(0.55, p < 0.001).
Feldman115Israel
Mean age: 30.7 ± 3.4 years
Femalebabies: 47.0%
100Cohort study
9 months
Two groups:
- PPD
- No PPD
BDI-II22.0%Child social engagement; fear regulation; cortisolreactivity; behaviorThe infants of depressed mothers scored the poorest onall three outcomes at 9 months: lowest socialengagement, less mature regulatory behaviors, and morenegative emotionality. The effect of MDD on socialengagement was moderated by maternal sensitivity.
Hartley143South Africa
Age (years):
15–19: 4.8%
20–29: 57.8%
30–39: 33.7%
⩾40: 3.6%
Female babies: 56.6%
NB: HIV-infected mothers
83Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
42.2%Social withdrawalOne-third of infants (31%) were socially withdrawn.Maternal depression did not predict infant socialwithdrawal, as measured by the m-ADBB. Infant socialwithdrawal was also not significantly associated withgender or failure to thrive.
Wang66Taiwan
Age (years):
Depressed:28.34 ± 5.52
Nondepressed: 29.45 ± 4.13
Female babies: 55.0%
60Cohort study
1 year
Two groups:
- PPD
- No PPD
BDI-II48.3%Gross motor, fine motor, expressive language,compressive-conceptual, situational help, self-help,personal-social, and general developmentNo significant difference was found in personal-socialdevelopment between the two groups (p = 0.204).
PPD: postpartum depression; EPDS: Edinburgh Postnatal DepressionScale; BDI-II: Beck Depression Inventory-II; m-ADBB: ModifiedAlarm Distress Baby Scale.

One study did not find differences between infants of depressed ornondepressed mothers in the area of social development,66 and another study showed that maternal PPD did not predict infantsocial withdrawal (in infants of HIV-infected mothers).143

Behavioral development

Of 12 studies, 10 demonstrated a significant effect of maternal postpartumdepressive symptoms on negative behavior in infants (Table 14). Studies describedmultiple behavioral traits in children with depressed mothers, including anincrease in child behavioral problems at age 2 years,110 more mood disorders and a more difficult temperament,114 more internalizing of problems,111,120 lower scores on theCommunication and Symbolic Behavior Scales Developmental Profile,131 less mature regulatory behaviors,115 and higher fear scores that increased behavioral inhibition.121 One study examined the bidirectional effect of depressed maternalmood on mother–infant engagement using a picture book activity and foundthat infants of mothers with a depressed mood tended to push away and closebooks more often.49 Another study showed a detrimental effect of maternal PPD ondysregulated behavior in infants only when PPD was associated with acomorbid personality disorder.133 Another study demonstrated that depression explained a significantportion of children’s warmth-seeking behavior toward their mothers (for allmothers) and infant attention and arousal (only for adolescent mothers).52

Table 14.
Characteristics of the studies included in the evaluation of childbehavioral development.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborns
Sample sizeDesign:
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesMain results
Avan110South Africa
Age (years):
<35: 91.5%
⩾35: 8.5%
Female babies: 49.9%
1035Cohort study
18 months
Two groups:
- PPD
- No PPD
Pitt Inventory24.0%Child growth; child behavioral problems (Richman ChildBehavior Scale)Maternal postnatal depression was significantlyassociated with child behavioral problems at age 2years, independent of socioeconomic status (B = 0.353,p = 0.015).
Bagner111USA
Mean age: 27.5 ± 2.77 years
Femalebabies: 52.0%
167Cohort study
1 year
K-SADS20.4%Child behavior problems (Children’s Internalizing,Externalizing, and Total Behavioral Problem scores)MMD during the sensitive period was a significantpredictor of internalizing and total problem scores onthe CBCL when several demographic variables werecontrolled (e.g. child and mother age, and childgender). Maternal depression prior to the pregnancy andduring the prenatal period did not significantly predictlater behavioral problems in the child, which suggestedthat the effect was not driven by the presence ofprevious MMD and was specific to the first year oflife.
Chen141Taiwan
Mean age: 26.6 ± 4.2 years
Femalebabies: 42.6%
NB: immigrant mothers
60Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
31.1%Child development (global score for cognitive, language,motor, self-regulation, and social development); qualityof the home environmentMaternal depressive symptoms had a direct and negativeeffect on the quality of the home environment (−0.32,p < 0.05). Maternal depressive symptoms did not havea direct effect on child development (0.05,p > 0.05). The quality of the home environment had asignificant and positive effect on child development(0.55, p < 0.001).
Conroy133USA
Mean age: 30.7 ± 6.58 years
Femalebabies: 52.5%
200Cohort study
18 months
Two groups:
- PPD
- No PPD
SCID53%Infant behaviorAt 18 months, the children of women with depression atTime 1 and those born to women with PD had significantlyhigher mean scores for dysregulated, externalizing, andinternalizing behaviors. There was a significantinteraction between Time 1 depression and PD in themodel (p = 0.005). This interaction showed that thedetrimental effect of maternal depression on infantdysregulated behavior was evident only among motherswith comorbid PD (p = 0.001) and that maternaldepression had no effect on the dysregulation in theabsence of PD (p = 0.6). Children of mothers with adepressive episode at Time 1 had significantly lowerBayley MDI scores compared to the children of women withno depressive episodes (p = 0.02).
Feldman115Israel
Mean age: 30.7 ± 3.4 years
Femalebabies: 47.0%
100Cohort study
9 months
Two groups:
- PPD
- No PPD
BDI-II22.0%Child social engagement; fear regulation; cortisolreactivity; behaviorThe infants of depressed mothers scored the poorest onall three outcomes at 9 months: lowest socialengagement, less mature regulatory behaviors, and morenegative emotionality. The effect of MDD on socialengagement was moderated by maternal sensitivity.
Gao120New Zealand
Age (years):
<20: 7.6%
20–29: 50.9%
30–39: 38.1%
⩾40: 3.3%
Female babies: 47.4%
1021Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12/ 13)
16.1%Child behavioral problemsPrevalence rates for internalized problems weresignificantly higher in the children of mothers who hadself-reported symptoms of psychological disorder (11.9%for those with no symptoms, 27.8% for those with earlysymptoms of postnatal depression, 21.1% for those withlate symptoms of psychological disorder, and 42.9% forthose with persistent or recurrent symptoms). Theadjusted OR of a child having internalized problems was1.38 (95% CI = 0.79, 2.43) among those whose mothersreported early symptoms of postnatal depression.
Hanington114UK
Mean age: not given
Gender ofnewborns: not given
10,325Cohort study
19 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
8.8% (Time 1)
9.9% (Time 2)
Child temperamentMaternal depression at Time 1 predicted a child’s mooddisorder at Time 2 (p < 0.001). Maternal depressionat Time 1 significantly predicted higher child intensityscores (higher scores indicate more difficulttemperament, p < 0.001). Maternal depression at Time1 significantly predicted child temperament at Time 2for both genders.
Kalita131India
Age (years):
Depressed:28.2 ± 0.93
Anxious: 29.8 ± 1.68
Notdiagnosed: 28.3 ± 1.28
Female babies: 52.0%
100Cohort study
6 months
Three groups:
- PPD
- Anxiety
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
18.0%Weight; communication; symbolic behaviorThe infants were rated using the CSBS-DP. The meanvalues on the three components of the scale weresignificantly lower in the infants born to depressed oranxious mothers compared to those born to motherswithout depression. These scores did not differsignificantly between the infants born to mothers withdepressive and anxiety disorders.
Lanzi52USA
Mean age: 19.8 years
Female babies:53.5%
660Cohort study
11 months
Four groups:
- No depression
- Mild-to-moderatedepression
- Moderate-to-severe depression
- Severe depression
BDI23.7% of mild-to-moderate depression; 7.5% ofmoderate-to-severe depression; 2.7% of severedepressionBabies’ warmth-seeking (toward their mothers); babies’attention and arousalFor each grouping of mothers, data suggested that asdepression increased, both the mothers and babies scoredless favorably on each significant domain. For the totalsample of mothers, analyses indicated that depressionexplained a significant portion of the unique variancein the warmth-seeking behaviors of children (B = −13,p < 0.01). For adolescent mothers, depressionexplained a significant portion of the unique variancein the babies’ attention and arousal (B = −15,p < 0.05).
Moehler121Germany
Age: 33.3 years
Female babies:44.6%
101Cohort study
14 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 9)
Not givenInfant fear score; behavioral inhibitionPPD at 4 months, as measured by the EPDS, was stronglyassociated with toddlers’ fear scores and increasedbehavioral inhibition at 14 months.
Reissland49UK
Mean age: not given
Female babies:37.7%
61Cohort study
3 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 9)
44.3% (visit 1)
27.9% (visit 2)
Infant nonverbal behaviorsThere was a significant effect of depressed mood onnegative behaviors; infants of mothers with a depressedmood tended to push away and close books moreoften.
Walker96Canada
Age (years):
25–34: 68.4%
15–24: 18.8%
⩾35: 12.8%
Femalebabies: 49.2%
1452Cohort study
5 years
Two groups:
- PPD
- No PPD
Specific to the study8.4% in the year following birth of the child; 8.3% whenthe child was 2–3 years of age.Hyperactivity inattention; emotional disorder-anxiety;physical aggression-opposition; separation anxietyPPD was not significantly associated with hyperactivitywith inattention (OR (95% CI) = 1.65 (0.89, 3.04)) orphysical aggression in the form of opposition (1.94(0.98, 3.81)).
PPD: postpartum depression; K-SADS: Kiddie Schedule for AffectiveDisorders and Schizophrenia; EPDS: Edinburgh PostnatalDepression Scale; SCID: Structured Clinical Interview forDSM-IV; BDI-II: Beck Depression Inventory-II; MMD: maternal mooddisorder; CBCL: Child Behavior Checklist; PD: personalitydisorders; MDD: major depressive disorder; MDI: Major DepressionInventory; OR: odds ratio; CI: confidence interval; CSBS-DP:Communication and Symbolic Behavior Scales DevelopmentalProfile.

One study141 reported the indirect effect of maternal PPD on self-regulatorybehaviors via maternal depressive symptoms, which had an impact on thequality of the home environment and directly affected early childdevelopment.

Only one study explored hyperactivity with inattention and physicalaggression in the form of opposition; it did not identify an associationbetween maternal PPD and children’s behavioral outcomes.96

Mother–child interactions

Bonding and attachment

Mother-to-infant bonding

A total of 11 studies29,31,34,37,43,44,47,52,56,61,82 demonstrated anegative effect of maternal depression on mother-to-infant bonding(Table15). These studies showed that maternal depression might be arisk factor in the development of the mother–infant relationship. Forexample, O’Higgins et al.34 demonstrated that women who scored ⩾13 on the EPDS at week 4 werefive times more likely to be experiencing poor bonding at the same timeas women who scored <13 on the EPDS. Despite these results, Muzik et al.43 concluded that all women, regardless of whether they aredepressed, showed increased bonding with their infant over the first 6months postpartum. Unfortunately, depressed women showed consistentlygreater impairment in bonding scores at all time points thannondepressed mothers. However, one study showed that mother–infantbonding appeared to be negatively affected by maternal PPD only in thefirst months;61 these studies did not identify an effect of PPD on maternalbonding at 14 months, despite finding negative effects at 2 weeks, 6weeks, and 4 months postnatally.

Table 15.
Characteristics of the studies included in the evaluation ofbonding/attachment between mother and infant.
Mother-to-infant bondingInfant-to-mother bonding
First author’s nameSociodemographic data:
1.Country
2. Maternal mean age
3.Gender of newborn
Sample sizeDesign:
1. Study design
2. Time of follow-up
3. Number ofgroups
4. Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesType of consequences
Dubber29Germany
Mean age: 32.8 ± 4.4 years
Female babies: 51.9%
80Cohort study
21 weeks
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
Not given
Mean EPDS: 4.36 ± 3.86
Postpartum bondingMaternal education, MFAS, PRAQ-R, EPDS, and STAI-Twere significantly correlated with the PBQ-16. Thefinal regression mode revealed that maternal–fetalbonding (B = −0.076, SE = 0.026, p < 0.01) andpostpartum depressive symptoms (B = 0.529,SE = 0.183, p = 0.01) remained significant forexplaining postpartum bonding. The results supportthe hypothesized negative relationship betweenmaternal–fetal bonding and postpartum maternalbonding impairment as well as the role of postpartumdepressive symptoms.
Edhborg47Bangladesh
Mean age: 24.6 ± 6.1 years
Female babies: 50.8%
671Cohort study
3 months
Four groups:
- Depressive symptoms
- Anxietysymptoms
- Both depressive and anxietysymptoms
- Neither depressive nor anxietysymptoms
EPDS
(Depressed = EPDS ⩾ 10)
Depressive symptoms: 11%; anxiety symptoms: 35%;both depressive and anxiety symptoms: 3.4%; neitherdepressive nor anxiety symptoms: 51%Maternal emotional bonding to the infantIn the adjusted model, maternal depressive symptomsshowed a direct association with the mother’semotional bonding to the infant, indicating anegative impact on maternal bonding to the infant ifthe mother shows depressive symptoms 2–3 monthspostpartum.
Figueiredo82Portugal
Mean age: 26.6 years
Femalebabies: 47.6%
315Cross-sectional study
Three groups:
- Positive bonding
- Negativebonding
- Unclear bonding
EPDS
(Depressed = EPDS ⩾ 13)
EPDS > 9: 15.7%
EPDS > 13: 5.9%
Emotional involvement; bondingLower emotional involvement with the newborn wasobserved when the mother was unemployed, unmarried,had less than a grade-9 education, had previousobstetrical/psychological problems, or wasdepressed, and when the infant was female, hadneonatal problems, or was admitted to the intensivecare unit. Lower total bonding results weresignificantly predicted when the mother wasdepressed and had a lower educational level; beingdepressed, unemployed, and single predicted morenegative emotions toward the infant as well.
Korja56Finland
Mean age: 28.8 ± 5.05 years
Female babies: 43.0%
NB: mothers ofpreterm infants
30Cohort study
6 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
12.6%Mother–infant interactionPCERA scores on the maternal positive affectiveinvolvement scale (p = 0.03) and maternal positivecommunication scale (p = 0.009) were lower inmothers with depressive symptoms compared to motherswho did not have symptoms of depression. The numberof depressive features did not affect any of theinfant scales. In dyadic variables, mothers withdepressive symptoms had slightly, but notstatistically significantly, lower scores on dyadicmutuality scales (p = 0.09) and dyadic flatnessscales (p = 0.06).
Korja54Finland
Mean age (years):
Preterminfants: 28.3 ± 5.1
Full-term infants:28.2 ± 4.8
Female babies (%):
Preterm infants: 45
Full-terminfants: 49
NB: mothers of preterm andfull-term infants
83Cohort study
1 year
Two groups:
- Preterm infants
- Full-terminfants
EPDS
(cut-off value not given)
Not givenMaternal attachment representations (balanced,disengaged, and distorted)The relationship between the EPDS score and the mainthree representation categories (balanced,disengaged, and distorted) showed that the meanscore on the EPDS was higher for the mothers in thedistorted category (M = 8.69, SD = 6.42) than forthe mothers in the disengaged (M = 5.50, SD = 3.00)and balanced (M = 5.27, SD = 3.9) categories(χ2 = 6.62, p = 0.037).
Lanzi52USA
Mean age: 19.8 years
Femalebabies: 53.5%
660Cohort study
11 months
Four groups:
- No depression
- Mild-to-moderatedepression
- Moderate-to-severe depression
- Severe depression
BDI23.7% of mild-to-moderate depression; 7.5% ofmoderate-to-severe depression; 2.7% of severedepressionContingent responsiveness and general verbalness;maternal warmth and sensitivityFor each grouping of mothers, the data suggestedthat as depression increased, both the mothers andthe babies scored less favorably on warmth andsensitivity.
Lilja44Sweden
Mean age: 27.8 years
Genderof newborn: not given
419Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
22.2%Women’s mood over the first year postpartum; women’srelationship with their infant; women’s relationshipwith their partnerThe mothers who scored high on the EPDS 10 dayspostpartum rated their relationship less positive onthe infant relationship scale throughout the entirefirst year (at 6 months and 1 year) compared withthe mothers who scored low on the EPDS 10 dayspostpartum. Mothers who scored high on the EPDS onday 3 scored significantly lower on the infantrelationship scale on day 3 (t = −4.269,p < 0.001) and day 10 than mothers with low EPDSscores on day 3 postpartum (t = −4.074,p < 0.001). This relationship was not found at 6and 12 months postpartum. In addition, women withdepressive symptoms showed less closeness and warmthand experienced more difficulties in theirrelationship with their child during the firstyear.
McMahon64Australia
Mean age: 31.4 ± 4.2 years
Female babies: 47.0%
111Cohort study
11 months
Three groups:
- Never depressed
- Brief depression
- Chronic depression
CIDI68.8%: 33.9% of brief depressed and 34.8% of chronicdepressedInsecure state of mind regarding attachmentMothers diagnosed as depressed were more likely tohave an insecure state of mind regarding attachment.Logistic regression analyses (secure vs insecure)revealed a significant main effect for depressiongroup (Wald χ2(2) = 6.47, p < 0.05).Chronically depressed mothers were significantlymore likely than never depressed mothers to beclassified as having an insecure state of mindregarding attachment (Wald χ2(1) =5.44,p < 0.025, OR = 4.03), with a similar butnonsignificant trend (after Bonferroni correction)emerging when briefly depressed mothers werecompared with never depressed mothers (Waldχ2(1) = 4.01, p < 0.05,OR = 3.01).
Moehler61Germany
Mean age: 33.3 years
Femalebabies: 45.0%
101Cohort study
14 months
Two groups:
- PPD
- No PPD
EPDS;
SCL-90-R
Not givenMaternal bonding to the infant and childMaternal depressive symptoms at 2 weeks, 6 weeks,and 4 months postnatally, but not at 14 months, werefound to be strongly associated with lower qualityof maternal bonding to the infant and child from 2weeks to 14 months postnatal age. EPDS scores at 4months were correlated with bonding at 2 weeks(r = 0.28), 6 weeks (r = 0.39), 4 months (r = 0.35),and 14 months (r = 0.28). Mothers with postnataldepressive symptoms at 4 months postnatal age hadmore negative bonding patterns starting before 2weeks postnatally and lasting at least until 14months postnatally. Even mild and unrecognizedmaternal depressive symptoms had a significantimpact on maternal bonding if they occurred duringthe first four months of life.
Muzik43USA
Mean age (years):
Event+:29.26 ± 5.93
Event–: 28.3 ± 5.15
Gender of newborn: not given
150Cohort study
5 months
Two groups:
- PPD
- No PPD
PDSSNot givenMother–infant bondingAll women, independent of risk status, showedincreased bonding with their infant over the first 6months postpartum; however, women with postpartumpsychopathology (depression and PTSD) showedconsistently greater bonding impairment scores atall time points.
O’Higgins34UK
Mean age: 33.5 years
Femalebabies: 45.5%
79Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
63.3%Mother-to-infant bondingA comparison of the bonding scores for the depressedand the nondepressed groups (defined by the EPDSscore at 4 weeks) showed differences between them inthe early weeks (1–4 weeks: p < 0.001), at 9weeks (p = 0.001), at 16 weeks (p < 0.5), and at1 year postnatal (p < 0.05). Women who scored ⩾13on the EPDS at week 4 were 5.13 times more likely toexperience poor bonding (MIBQ ⩾ 2) at the same time(p < 0.01). Both EPDS at 4 weeks and bonding inthe early weeks were associated with bonding at 1year. However, when both factors were enteredsimultaneously into a logistic regression, only theearly bonding scores predicted bonding at 1 year(p < 0.01).
Orün31Turkey
Mean age: 25.1 ± 5.2 years
Female babies: 54%
189Cohort study
2 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
BSI
16.9%Mother-to-infant bondingThe PBQ score was significantly correlated withdepression (r = 0.225, p = 0.002). Significantcorrelations were found between the MIBS and EPDSscores (r = 0.377, p < 0.001) and between the PBQand EPDS scores (r = 0.449, p < 0.001). The MIBSscore was correlated with the depression subscalesof the BSI (r = 0.150, p = 0.041). Mother–infantbonding and later interaction were associated withmaternal psychopathologies, especially PPD.
Vliegen37Belgium
Mean age (years):
T1:29.39 ± 4.40
T2: 32.95 ± 4.51
Gender of newborn: not given
41Cohort study
3.5 years
Two groups:
- PPD
- No PPD
BDI-II
(Depressed = BDI ⩾ 13)
39%Maternal depression; treatment afterhospitalization; life events; relationshipsRegarding emotional availability, a significantlylower level of mutual attunement was observed, butno differences were found in the other indices ofemotional availability.
Korja56Finland
Mean age: 28.8 ± 5.05 years
Female babies: 43.0%
NB: mothers ofpreterm infants
30Cohort study
6 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
12.6%Mother–infant interaction at 6 and 12 monthscorrected agePCERA scores on the maternal positive affectiveinvolvement scale (p = 0.03) and the maternalpositive communication scale (p = 0.009) were lowerin mothers with depressive symptoms. The number ofdepressive features did not affect any of the infantscales (evaluated as expressed positive and negativeaffect and characteristic mood, behavior/adaptiveabilities, activity level, and communicationskills). In dyadic variables, mothers withdepressive symptoms had slightly but notstatistically significantly lower scores on thedyadic mutuality scales (p = 0.09) and the dyadicflatness scales (p = 0.06).
Lanzi52USA
Mean age: 19.8 years
Femalebabies: 53.5%
660Cohort study
11 months
Four groups:
- No depression
- Mild-to-moderatedepression
- Moderate-to-severe depression
- Severe depression
BDI23.7% of mild-to-moderate depression; 7.5% ofmoderate-to-severe depression; 2.7% of severedepressionBabies’ warmth-seeking (toward their mothers);babies’ attention and arousalFor each grouping of mothers, data suggested that asdepression increased, both the mothers and thebabies scored less favorably on each significantdomain. For the total sample of mothers, analysesindicated that depression explained a significantportion of the unique variance in the children’swarmth-seeking (B = −13, p < 0.01).
McMahon64Australia
Mean age: 31.4 ± 4.2 years
Female babies: 47.0%
112Cohort study
11 months
Three groups:
- Never depressed
- Brief depression
- Chronic depression
CIDI68.8%: 33.9% of brief depressed and 34.8% of chronicdepressedInsecure child attachment; disorganized childattachmentInfants of chronically depressed mothers weresignificantly more likely than infants of motherswho had never experienced depression to beclassified as insecure (p < 0.025, OR = 3.31),while infants of briefly depressed mothers did notdiffer from infants of mothers who had never beendepressed. 17% of the infants of never-depressedmothers were classified as disorganized orunstable-resistant, compared to 18% of the infantsof briefly depressed mothers and 40% of the infantsof mothers in the chronically depressed group.Neither the logistic regression analysis nor theplanned comparisons results were significant.
O’Higgins34UK
Mean age: 33.5 years
Femalebabies: 45.5%
79Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
63.3%Mother–infant bondingA comparison of the bonding scores between thedepressed and the nondepressed groups showed adifference in the early weeks (1–4 weeks,p < 0.001), at 9 weeks (p = 0.001), at 16 weeks(p < 0.5), and 1 year postnatal (p < 0.05).Women who scored ⩾13 on the EPDS at week 4 were 5.13times more likely to experience poor bonding(MIBQ ⩾ 2) at the same time (p < 0.01).
Orün31Turkey
Mean age: 25.1 ± 5.2 years
Female babies: 54%
189Cohort study
2 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
BSI
16.9%Mother-to-infant bondingThe PBQ score was significantly correlated todepression (r = 0.225, p = 0.002). The MIBS scorewas correlated with the depression subscales of theBSI (r = 0.150, p = 0.041). Significant correlationswere also found between the MIBS and EPDS scores(r = 0.377, p < 0.001) and between the PBQ andEPDS scores (r = 0.449, p < 0.001).
Tharner106The Netherlands
Age: ±32 years
Female babies: 49.9%
627Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
8.5%Infant attachment (attachment insecurity anddisorganization)Postnatal depressive symptoms were not related toattachment insecurity or disorganization at 14months.
Tomlinson127South Africa
Age (years):
<20:15.3%
20–24: 26.5%
25–29: 32.7%
30–39: 25.5%
Female babies:44.9%
147Cohort study
16 months
Two groups:
- PPD
- No PPD
SCID34.7% at 2 months 12.4% at 18 monthsInfant attachmentPostpartum depression at 2 months and indices ofpoor parenting at both 2 and 18 months wereassociated with insecure infant attachment. Thecritical 2-month predictor variables for insecureinfant attachment were maternal intrusiveness andremoteness, and early maternal depression. Whenconcurrent maternal sensitivity was considered, thequality of the early mother–infant relationshipremained important, but maternal depression was nolonger predictive.
PPD: postpartum depression; EPDS: Edinburgh PostnatalDepression Scale; BDI: Beck Depression Inventory; CIDI:Composite International Diagnostic Interview; SCL-90-R:Symptom Checklist-90—Revised; PDSS: Postpartum DepressionScreening Scale; BSI: Brief Symptom Inventory; SCID:Structured Clinical Interview for DSM-IV; MFAS:Maternal–Fetal Attachment Scale; PRAQ-R: Pregnancy RelatedAnxiety Questionnaire—Revised; STAI-T: State-Trait AnxietyInventory—Trait version; PBQ-16: Postpartum BondingQuestionnaire-16; PCERA: Parent–Child Early RelationalAssessment; OR: odds ratio; SD: standard deviation; PTSD:posttraumatic stress disorder; MIBQ: Mother–Infant BondingQuestionnaire; MIBS: Mother-to-Infant Bonding Scale.

In addition, women with depressive symptoms showed less closeness,44 warmth,44,52 and sensitivity44,52 and asignificantly lower level of mutual attunement (with regard to emotional availability)37 and experienced more difficulties in their relationships withtheir child44 during the first year than women without depressive symptoms.Lower emotional involvement with the newborn was observed among motherswho suffered from PPD.82

Finally, mothers who were diagnosed as depressed were more likely to havean insecure state of mind regarding attachment; they had more negativeperceptions of their relationship with their infant than nondepressedmothers.54,64 McMahon et al.64 highlighted that chronically depressed mothers were more likelyto be classified as feeling insecure about their attachment, whereasbriefly depressed mothers did not differ from mothers who had never beendepressed.

Infant-to-mother bonding

Four studies31,34,52,64 demonstrated a significantly negative effect ofmaternal PPD on infant–mother bonding (Table 15). One study showedthat infants of chronically depressed mothers were more likely to beinsecurely attached, while infants of briefly depressed mothers did notdiffer from infants of mothers who had never been depressed.64 Another study reported that as maternal depression increased,babies scored less favorably with respect to seeking warmth from their mothers.52

One study showed that scores on both the maternal positive affectiveinvolvement scale and the positive communication scale were lower inmothers with depressive symptoms than in mothers who did not havesymptoms of depression.56 Nevertheless, this study showed that the number of depressivefeatures did not affect infant scale scores (for preterm babies).Another study found that maternal PPD at 2 months was associated withinsecure infant attachment at 2 and 18 months.127 However, this study noted that when concurrent maternalsensitivity was considered, the quality of the early mother–infantrelationship remained important, although maternal depression was nolonger predictive. Two studies showed that postnatal depressive symptomswere not related to attachment insecurity106 or disorganization64,106 at 14months.

Breastfeeding

A total of 22 studies evaluated the association between maternal PPD andbreastfeeding,25,26,32,41,45,59,60,62,65,6972,77,8992,118,119,130,137 (Table 16). Ofwhich, 16 studies found a significant negative effect of maternal depressivesymptoms on breastfeeding and/or its parameters. Mothers with depressivesymptoms were significantly more likely to discontinue breastfeeding (earlyinterruption of exclusive breastfeeding in the first months),41,59,69,71,90,91,118,119,137engage in less-healthy feeding practices with their infant25,62,130(e.g. significantly more depressed women fed their children prematurely andinappropriately compared with nondepressed women),130 be unsatisfied with their infant feeding method,59 experience significant breastfeeding problems,59 report lower levels of breastfeeding self-efficacy,59,92 andexhibit a lack of breastfeeding confidence91 and bottle feed45,62,65 than mothers withoutdepressive symptoms. Higher depression scores were also associated withearly weaning.89

Table 16.
Characteristics of the studies included in the evaluation ofbreastfeeding.
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborn
Sample sizeDesign
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDOutcomesType of consequences
Adewuya119Nigeria
Mean age: not given
Gender ofnewborns: not given
242Cohort study
8 months
Two groups:
- PPD
- No PPD
SCID-NP49.6%Infant physical growth (weight and length); cases ofdiarrhea and other childhood illnesses in the infants;breastfeedingAt the 6 weeks and 3, 6, and 9 months postpartum, only75 (62.5%), 58 (48.3%), 37 (30.8%), and 26 (21.7%) ofthe depressed mothers, respectively, were stillbreastfeeding, compared to 100 (82.0%), 87 (71.3%), 63(51.6%), and 52 (42.6%) of the nondepressed mothers,respectively.
Annagür70Turkey
Mean age: 28.6 ± 5.0 years
Genderof newborns: not given
197Cohort study
6 weeks
Two groups:
- Exclusive breastfeeding
- Mixedfeeding (bottle feeding and/or partialbreastfeeding
EPDS
(Depressed = EPDS > 12)
14.2% at 48 h; 11.2% at 6 weeksExclusive breastfeedingAt 6 weeks postpartum, the majority of women (65.5%,n = 129) were exclusively breastfeeding, with 18.8%(n = 37) partially breastfeeding (both breast milk andformula) and 15.7% (n = 31) bottle feeding. There wereno significant differences between the depressed andnondepressed mothers (evaluation at 48 h: p = 0.67;evaluation at 6 weeks: p = 0.34).
Balbierz26USA
Mean age: 30.3 ± 6.1 years
Gender ofnewborn: not given
945Cohort study
3 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 10)
8.25%Parenting practices (safety practices, feedingpractices, and health care practices)Depressed mothers were more likely to introduce water,juice, or cereal to their infants’ diets (36% vs 25%,p = 0.04) earlier than nondepressed mothers. Feedingpractices at 3 months did not differ between motherswith depressive symptoms and those without depressivesymptoms in multivariable models.
Dennis59Canada
Mean age: 28.5 ± 5.0 years
Genderof newborn: not given
498Cohort study
8 weeks
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
1 week: 14.6%
4 weeks: 9.2%
8 weeks:7.6%
Infant feeding outcomesMothers with an EPDS score >12 at 1 week postpartumwere significantly more likely at 4 and/or 8 weeks todiscontinue breastfeeding, be unsatisfied with theirinfant feeding method, experience significantbreastfeeding problems, and report lower levels ofbreastfeeding self-efficacy.
Dunn89Canada
Age (years):
<24: 10.7%
25–34: 61.8%
⩾35: 26.0%
Genderof newborns: not given
526Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
4.5%WeaningHigher scores on the EPDS were associated with earlyweaning. Depression was related to early weaning afteradjusting for both age (p = 0.01) and education(p = 0.01), with stronger associations among women aged25 years or older and those who had completed highschool. Women who scored 12 or higher on the EPDS weremore likely to wean (OR = 0.28, 95% CI = 0.11, 0.71,p = 0.007) than women who scored less than 12.
Feldens69Brazil
Age (years):
<18: 81.9%
>18: 18.1%
Female babies: 42.5%
360Cohort study
12 months
Two groups:
- Discontinued breastfeeding before 12 months
- Continued breastfeeding before 12 months
BDI
(minimal: <2; low: 12–19; moderate tosevere: >19)
Minimal: 62.1%; low: 19.6%; moderate to severe:18.3%Discontinued breastfeeding before 12 monthsA multivariate Cox regression model revealed thatsymptoms of maternal depression (low levels: RR = 1.59,95% CI = 1.02, 2.47; moderate to severe: RR = 2.03, 95%CI = 1.35, 3.01) were independently associated with theoutcomes after adjusting for confounders.
Figueiredo72Portugal
Age (years):
⩽19: 5%
20–29: 47%
30–39: 47%
⩾40: 1%
Female babies: 40%
145Cohort study
1 year
Three groups:
- Exclusive breastfeeding, no initiation
- Exclusive breastfeeding, early cessation(0–3 months)
- Exclusive breastfeeding for ⩾3months
EPDS
(cut-off value not given)
Not givenExclusive breastfeeding durationDepression scores at 3 months postpartum were not foundto predict exclusive breastfeeding duration (B = 0.04,OR = 1.04, CI 95% = 0.91, 1.18).
Flores-Quijano91Mexico
Mean age: 27.3 ± 8.1 years
Genderof newborns: not given
163Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
24.5%Breastfeeding confidence; breastfeeding practiceA total of 40 women (24.5%) had an EPDS score compatiblewith the risk of a depressive episode, and 63 (41%) didnot feel confident about breastfeeding. These twovariables were significantly correlated to each other(14.6% of breastfeeding confidence in depressed women vs85.4% in nondepressed women; p < 0.001).
There was a significant correlation between PPDand confidence (r = 0.28, p < 0.01), andsignificantly fewer depressed women believed their milkwas sufficient for their babies (p = 0.001). Inaddition, PPD was individually correlated with exclusivebreastfeeding (67.5% of depressed women did notexclusively breastfeed, compared to 42.3% ofnondepressed women; p = 0.006).
Gagliardi45Italy
Mean age: 32.3 years
Gender ofnewborns: not given
592Cohort study
14 weeks
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
EPDS > 9: 15.7%; EPDS > 12: 6.8%Breastfeeding; breastfeeding problemsMothers with higher EPDS scores were more likely tobottle feed at 3 months; the odds of bottle feedingincreased with increasing EPDS results, even at lowscores (OR = 1.06, 95% CI = 1.01, 1.11). In amultinomial logistic regression, the OR of bottlefeeding associated with a one-point increase in the EPDSscore was 1.06 (95% CI = 1.01, 1.11, p = 0.02), and itremained the same after adjusting for the mother’sparity, mode of delivery, age and nationality(Italian/foreigner) and sex of the infant. This studyshowed that even low levels of depressive symptomsdetected by the EPDS were negatively associated withbreastfeeding.
Hasselmann118Brazil
Age (years):
<18: 12.1%
⩾18: 87.9%
Female babies: 49.0%
429Cohort study
2 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
22.5%Early interruption of exclusive breastfeedingChildren of mothers with postpartum depressive symptomswere at a higher risk of early interruption of exclusivebreastfeeding in the first and second months offollow-up (RR = 1.46, 95% CI = 0.98, 2.17; RR = 1.21,95% CI = 1.02, 1.45, respectively). Among mothers thatwere exclusively breastfeeding during the first month,PPD was not associated with the interruption ofexclusive breastfeeding in the second month (RR = 1.44,95% CI: 0.68, 3.06).
Hatton65USA
Age (years):
Lactating: 23.5 ± 5.0
No lactating: 20.0 ± 3.5
Gender ofnewborns: not given
377Cohort study
12 weeks
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 14)
Not given
Mean EPDS score: lactating: 7.8 ± 1.5;no lactating: 9.8 ± 1.6
BreastfeedingThere was an inverse relationship between depressivesymptoms and breastfeeding at 6 weeks postpartum(p < 0.001), but not at 12 weeks. Women who werebreastfeeding had significantly fewer depressivesymptoms (p < 0.05), even after controlling for age,income, education, and race as predictors ofbreastfeeding at 6 weeks (but not at 12 weeks)postpartum. The women with the greatest probability ofhaving an early MDD (EPDS ⩾ 14) were nonbreastfeeders.There was a significant drop-off in depressive symptomsbetween 6 and 12 weeks postpartum (p < 0.001) for allwomen studied at both time points. Unexpectedly, thosewho stopped breastfeeding after 6 weeks postpartum(n = 38) showed significantly greater improvement indepressive symptoms relative to those who continued tobreastfeed (Δ 2.76 ± 4.6 vs 0.89 ± 3.0)(p < 0.005).
Kawano32Japan
Mean age: 32.7 ± 4.5 years
Genderof newborns: not given
81Cohort study
2 weeks
Two groups:
- PPD
- No PPD
POMS + GHQNot given
Mean POMS: 5.5 ± 6.7
Breast milk secretory immunoglobulin A levelWeak negative correlations were observed between breastmilk SigA levels and all negative POMS states(tension-anxiety, depression-dejection, anger-hostility,fatigue, and confusion). However, no correlation wasobserved between breast milk SigA level and the positivePOMS state (vigor). These results indicate that thematernal psychological state may affect the immuneproperties of breast milk.
Kondo77Japan
Mean age: 30.7 ± 5.1 years
Genderof newborns: not given
129Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 9)
11.0%Concentrations of transforming growth factor-beta inbreast milkMothers with depression or poor self-rated health hadhigher TGF-β2 concentrations than mothers withoutdepression (OR for a higher TGF-β2 quartile: 3.11, 95%CI = 1.03, 9.37) and those reporting better health (OR:2.34, 95% CI = 1.21, 4.55).
Mallan25Australia
Mean age: 30.0 ± 5.0 years
Female babies: 52%
211Cohort study
2 years
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
Not givenMother-reported child-feeding practicesHigher EPDS scores were associated with less responsivefeeding practices when the child was 2 years old. Afteradjustments for key maternal and child covariates, ahigher EPDS score was significantly associated with morepressure to eat (B = 0.18, p = 0.01), restriction(B = 0.14, p = 0.05), instrumental feeding (B = 0.14,p = 0.04) and emotional feeding (B = 0.15, p = 0.03)practices.
McCarter-Spaulding60USA
Mean age: 30.5 years
Gender ofnewborns: not given
122Cohort study
14 months
One group:
- PPD
EPDS
(Mild, EPDS: 10–12; moderate, EPDS: 13–15;severe, EPDS > 16)
BDI-II
100%
Mild (EPDS: 10–12): 58.2%; moderate (EPDS:13–15): 20.9%; severe (EPDS: >16): 20%
BreastfeedingMaternal education was a significant predictor of eitherexclusive breastfeeding or combination feeding comparedto bottle feeding, but it was not a significantpredictor of exclusive versus combination feeding. Theseresults suggest that women with PPD symptoms whobreastfed, either exclusively or in combination withformula feeding, may be more similar to each other thanto mothers who chose to formula feed only. Severity ofdepression symptoms was not a significant predictor offeeding pattern at 4–8, 10–14, or 14–18 weekspostpartum. NB: compared to a random sample, the levelof exclusive breastfeeding was significantly lower inthis sample than the level of combination feeding.
McLearn137USA
Age (years):
<20: 13.3%
20–29: 50.6%
⩾30: 36.2%
Genderof newborns: not given
4874Cohort study
3 months
Two groups:
- PPD
- No PPD
CES-D17.8%Practices to promote child development;breastfeedingMothers with depressive symptoms had reduced odds ofcontinued breastfeeding (Adjusted OR = 0.73, 95% CI =0.61, 0.88).
Nishioka71Japan
Mean age: 31.3 ± 4.7 years
Genderof newborns: not given
405Cohort study
5 months
Two groups:
- Breastfeeding-based group
- Formulamilk-based group
EPDS
(Depressed = EPDS ⩾ 9)
19.5% at 1 month; 13.0% at 5 monthsBreastfeedingA high proportion of breastfeeding mothers at 1 monthpostpartum had EPDS scores ⩾9 at 5 months postpartum(p = 0.01). These mothers were more likely to switch toformula milk-based feeding at 5-month postpartum thanthe mothers in the breastfeeding-based group at both 1-and 5-month postpartum. The appearance of depressivesymptoms seems to promote the discontinuation ofbreastfeeding at 5-month postpartum.
Paulson62USA
Age (years):
<20: 3.9%
20–34: 74.7%
⩾35: 21.3%
Genderof newborns: not given
NB: two-parentfamilies
5089Cohort study
9 months
Two groups:
- PPD
- No PPD
CES-D14.0%Maternal health behaviors (putting the child to sleep onits back, putting the child to bed without a bottle,putting the child to sleep awake, and breastfeeding);Mother–child interaction behaviorsMothers who were depressed were 1.5 times more likely toengage in less healthy feeding practices with theirinfant. Depressed mothers were less likely to have everbreastfed their infants (OR: 1.48, p < 0.01), andmore likely to put their infants to bed with a bottle(OR: 1.53, p < 0.01).
Stuebe41North Carolina
Mean age: 31.6 ± 4.8 years
Gender of newborns: not given
47Cohort study
8 weeks
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 10)
2 weeks postpartum: 17.0%; 8 weeks postpartum: 8.5%Breastfeeding duration; neuroendocrine response toinfant feedingAt 2 weeks, baseline oxytocin was inversely correlatedwith EPDS score (Spearman’s R = −0.33, p = 0.03). Wefound no correlations between maternal EPDS score andbaseline cortisol, CRF, estradiol, progesterone,prolactin, FT4, or total T4. Mothers with higherdepressive symptoms reported feeling more depressed,overwhelmed, and stressed during feeding than motherswith lower symptoms (p < 0.05). At the 8 weeks, wefound statistically significant associations betweenmaternal mood and oxytocin, total T4, and affect duringfeeding. EPDS scores were inversely correlated withoxytocin measures during and after feeding and withoxytocin area under the curve (Spearman’s R for EPDS:−0.48, −0.53, and −0.44, respectively, all p < 0.01).Total T4 was inversely correlated with EPDS (Spearman’sR = −0.41, p = 0.01 before and R = −0.36, p = 0.03after). We found no significant correlations betweenmaternal mood measures and baseline cortisol, CRF,estradiol, progesterone, prolactin, or free T4(p > 0.05).
Thome90Iceland
Mean age: 28.3 years
Femalebabies: 51.5%
Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
14.0%Exclusive breastfeedingMothers who were exclusively breastfeeding had a lowermean EPDS scores than mothers who were not exclusivelybreastfeeding (5.9 (SD = 4.6) and 7.1 (SD = 4.9),p < 0.001). EPDS score remained a significantpredictor in the conditional regression model: a lowEPDS score increased the likelihood of exclusivebreastfeeding. An increase of 5 points on the EPDS scaleresulted in an almost 20% reduction in the likelihood ofexclusive breastfeeding. High maternal education level,low EPDS score and singleton birth increased thelikelihood of exclusive breastfeeding. In addition,single mothers were less likely to breastfeedexclusively (OR = 0.58) than those who were married orlived with a partner. Being a mother of twins decreasedthe likelihood of exclusive breastfeeding to a greatextent when other factors were held equal (p < 0.001,OR = 0.12).
Zajicek-Farber130USA
Age (years):
Depressed: 22.3 ± 4.3
Nondepressed: 22.6 ± 3.9
Female babies:54.0%
134Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 11)
PHQ
55.2%Infant health practicesSignificantly more depressed women fed childrenprematurely and inappropriately compared to women whowere never depressed (54.1% vs 23.3%). The RR forinappropriate feeding was 2.3 times greater fordepressed women than those who were neverdepressed.
Zubaran92Brazil
Mean age: 25.4 ± 7.0 years
Genderof newborns: not given
89Cross-sectional study
Two groups:
- Exclusive breastfeeding
- Partialbreastfeeding
EPDS
(Depressed = EPDS ⩾ 13)
PDSS
(Depressed = EPDS ⩾ 81)
EPDS: 22.5%
PDSS: 34.8%
Breastfeeding self-efficacyMothers who combined breastfeeding and bottle feedingpresented higher PDSS (73.2 ± 26.4 vs 70.3 ± 25.2;p = 0.66) and EPDS scores (9.1 ± 5.5 v. 8.0 ± 5.6;p = 0.42). However, these differences were notsignificant. The BSES-SF scores were higher in motherswho exclusively breastfed (65.6 ± 4.0 in women whoexclusively breastfed vs 56.6 ± 7.0 in women whopartially breastfed; p < 0.001) and were negativelyassociated with both EPDS (64.8 ± 5.3 in nondepressedwomen vs 59.0 ± 7.4 in depressed women; p = 0.003) andPDSS scores (65.3 ± 4.6 vs 60.2 ± 7.6; p = 0.002).
PPD: postpartum depression; SCID-NP: Structured ClinicalInterview for DSM-IV, Non-Patient edition; EPDS: EdinburghPostnatal Depression Scale; BDI: Beck Depression Inventory;POMS: Profile of Mood States; GHQ: General Health Questionnaire;CES-D: Center for Epidemiologic Studies Depression Scale; PHQ:Patient Health Questionnaire; PDSS: Postpartum DepressionScreening Scale; OR: odds ratio; CI: confidence interval; RR:risk ratio; MDD: major depressive disorder; TGF: transforminggrowth factor; CRF: corticotropin-releasing factor; FT4: plasmafree thyroxine; SD: standard deviation; BSES-SF: BreastfeedingSelf-Efficacy Scale—Short Form.

Hatton et al.65 showed conflicting results; they reported a significant inverserelationship between depressive symptoms and breastfeeding at 6 weekspostpartum, but not at 12 weeks.

The four remaining studies did not find a difference between depressedmothers and nondepressed mothers with respect to feedingpractices;26,60,70,72 one study showed that a delayed onset of lactationwithin the first 48 h, methodological breastfeeding problems, and nipplepain were significantly predictive of breastfeeding cessation.70

Breast milk concentration and endocrine response tobreastfeeding

Three studies evaluated the association between PPD and breast milkconcentration and/or the endocrine response to breastfeeding. Maternaldepressive symptoms appeared to be correlated with lower oxytocin,41 total T441 concentrations, and higher TGF-β2 concentrations.77 Kawano and Emori32 identified weak negative correlations between breast milksecretory immunoglobulin A levels (breast milk SigA level) and allnegative profile of mood states (POMS: tension–anxiety,depression–dejection, anger–hostility, fatigue, and confusion); however,there was no correlation between breast milk SigA level and positivePOMS state.

Maternal role

Studies that evaluated the association between PPD and the maternal role arepresented in Table17. Nine studies focused on maternal behaviors and PPD,26,40,49,52,53,62,79,83,85 twostudies focused on PPD and maternal competence,51,75 six studies focused onPPD and maternal care for infants,37,53,130,137,145,146 eight studiesfocused on PPD and infant health care practices or utilizationmeasures,26,37,57,63,98,128,130,142 five studies focusedon maternal perceptions of the infant’s patterns and depression,40,46,50,58,80 andtwo studies focused on PPD and the risk of maltreatment.130,144

Table 17.
Characteristics of the studies included in the evaluation of thematernal role.
Maternal behaviorsMaternal competenceMaternal care for infantInfant health care practices and utilizationmeasuresMaternal perception of infants’patternsRisk of maltreatment
First author’s nameSociodemographic data:
1. Country
2. Maternal mean age
3. Gender ofnewborn
Sample sizeDesign
1. Study design
2.Time of follow-up
3. Number of groups
4.Description of groups
Tool used to assess PPDPrevalence of PPDType of consequences
Balbierz26USA
Mean age: 30.3 ± 6.1 years
Gender ofnewborns: not given
945Cohort study
3 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 10)
8.25%Parenting practices (safety practices, feedingpractices, and health care practices)In the multivariable model, depressed mothers remainedless likely to put their infant to sleep on their backs(OR = 0.37, 95% CI = 0.22, 0.61), to use a car seat(OR = 0.44, 95% CI = 0.25, 0.79) and to have a workingsmoke alarm in the home (OR = 0.26, 95% CI = 0.12,0.56).
Cowley-Malcolm53New Zealand
Age (years):
<20: 3.81%
20–29: 50.7%
30–39: 40.6%
⩾40: 4.72%
Gender of newborns: notgiven
1207Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
17.5%Discipline; nurturing practices (behavior that promotesa child’s psychological growth)Low nurturance was significantly associated withpostnatal depression, alcohol consumption and gambling.High discipline scores were significantly associatedwith gambling, postnatal depression and lack ofalignment to either Pacific or to Europeantraditions.
De l’Etoile79USA
Mean age: 30.0 years
Female babies:46.6%
73Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 9 or any responseindicating suicidal ideation)
20.5%Acoustic parameters of infant-directed singingExtraction and analyses of vocal data revealed a maineffect of tempo, meaning that as mothers reported moredepressive symptoms, they tended to sing faster to theirinfants. In addition, an interaction effect indicatedthat mothers with depressive symptoms were more likelyto sing with tonal key clarity to their maleinfants.
Kerstis40Sweden
Mean age: 30.0 ± 5.0 years
Femalebabies: 49%
401Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 9)
18%Mother’s SOC (comprehensibility, manageability andmeaningfulness); parents’ perception of infant’stemperamentA higher proportion of the mothers with self-scoreddepressive symptoms had poor SOC compared with thosewithout depressive symptoms (p < 0.001).
Lanzi52USA
Mean age: 19.8 years
Female babies:53.5%
660Cohort study
11 months
Four groups:
- No depression
- Mild-to-moderatedepression
- Moderate-to-severe depression
- Severe depression
BDI23.7% of mild-moderate depression; 7.5% ofmoderate-to-severe depression; 2.7% of severedepressionContingent responsiveness and general verbalness;maternal warmth and sensitivityRegression analyses were conducted separately formaternal parenting behaviors such as positive affect,warmth and sensitivity, contingent responsiveness,physical intrusiveness, punitive tone, verbal content,and general verbalness. For each grouping of mothers,the data suggested that as depression increased, bothmothers and babies scored less favorably on eachsignificant domain.
Paulson62USA
Age (years):
<20: 3.9%
20–34: 74.7%
⩾35: 21.3%
Genderof newborns: not given
NB: two-parentfamilies
5089Cohort study
9 months
Two groups:
- PPD
- No PPD
CES-D14.0%Maternal health behaviors (putting the child to sleep onits back, putting the child to bed without a bottle,putting the child to sleep awake, andbreastfeeding)Depressed mothers were less likely to put their infantsto sleep on their backs (OR = 1.40, p < 0.01), lesslikely to have ever breastfed their infants (OR = 1.48,p < 0.01), and more likely to put their infants tobed with a bottle (OR = 1.53, p < 0.01). Depressedmothers were less likely to tell their child storiesevery day (OR = 1.42, p < 0.05) and played peekabooless often (OR = 1.57, p < 0.05).
Posmontier85USA
Mean age (years):
No PPD:31.0 ± 4.5
PPD: 30.0 ± 5.5
Femalebabies (%):
No PPD: 78.3
PPD:30.4
46Cross-sectional study
Two groups:
- PPD
- No PPD
MININot applicable (number of PPD and no PPD women werefixed at the beginning of the study)
Nondepressed: n = 23
Depressed:n = 23
Functional status (physical infant care, personal care,household care, social activities, and occupationalactivities)Functional status was negatively correlated with PPDwith the exception of infant care activities.Specifically, lower household, social, and personalfunctioning were correlated with PPD. In multipleregression analyses, PPD predicted lower overallfunctional status (p < 0.001), household function(p < 0.05), social function (p < 0.001), andpersonal function (p < 0.001). NB: functional statuswas evaluated using the IFSAC, a 52-item self-ratedscale that measures physical infant care, personal care,household care, social activities, and occupationalactivities.
Reissland83UK
Mean age: 31.8 years
Female babies:44.3%
79Cross-sectional study
Four groups:
- Stress and depression
- Onlydepression
- Only stress
- Neitherstress nor depression
EPDS
(Depressed = EPDS ⩾ 9)
Stress and depression: 16.4%; depression: 7.59%; stress:39.2%Cradling side of mothers (left or right)The results indicated that 86% of mothers who wereneither stressed nor depressed cradled to the left, and14% cradled to the right. When the cradling side ofstressed mothers was compared with that of the motherswho were neither stressed nor depressed, more in theformer group showed right-sided cradling. In contrast,mothers who were just depressed preferred to cradle tothe left. The lack of a left-sided cradling bias mightbe due to stress rather than depression experienced bymothers. Furthermore, this study provides evidence thatthe state of a mother’s mental health might be indicatedby the side on which she prefers to cradle herchild.
Reissland49UK
Mean age: not given
Female babies:37.7%
61Cohort study
3 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 9)
44.3% (visit 1)
27.9% (visit 2)
Mother–infant engagement with a picture book (mothergazes at book, at infant; mother restrains infant;mother keeps/pulls book away; infant gazes at book, atmother; infant pushes book away; and infant tries toclose book)The complexity of the effects of depressed mood onmothers and infants is highlighted by the fact that nosignificant differences were found when simply comparingmaternal behavior of depressed and nondepressed groups.In contrast, infants in these two groups of mothersshowed significant differences in their nonverbalbehaviors. Specifically, during the first visit, infantsof depressed mothers showed significantly more negativetouch behaviors compared with infants of nondepressedmothers.
Kohlhoff75Australia
Mean age: 32.2 ± 5.1 years
Female babies: 47.6%
83Cross-sectional study
Two groups:
- PPD
- No PPD
MINI; EPDS (cut-off value not given)32.5%Parenting self-efficacy (perceived parenting efficacy inparents)Significant predictors of parenting self-efficacy wererecollections of parental abuse, attachment avoidance,infant gender and depressive symptom severity (B =−0.42, p = 0.004). This suggests that women with higherparenting self-efficacy were less likely to reportdepressive symptoms.
Ngai51China
Mean age: 31.3 ± 3.8 years
Genderof newborns: not given
184Cohort study
Approximately 10 months
Twogroups:
- PPD
- No PPD
EPDS
(Depressed = EPDS 9/10)
Not given
Mean EPDS: 7.7 ± 4.7
Perceived maternal role competence; perceived maternalrole satisfactionPostnatal variables, including learned resourcefulness(B = 0.18, p < 0.05) and depressive symptoms (B =−0.56, p < 0.01), explained 33.6% of the variance ofthe final model predicting maternal role competence andsatisfaction at 6 weeks postpartum. Postpartumdepression was the strongest correlate of maternal rolecompetence and satisfaction at 6 weeks postpartum,accounting for 32.3% of the total variance.
Bank146USA
Mean age: not given
Gender ofnewborns: not given
84Cross-sectional study
Two groups:
- PPD
- No PPD
CES-DNot givenQuantity and content of infant media use; depressedmothers who sat and talked to their children duringtelevision use or consulted outside sources forinformation about mediaHaving a depressed mother predicted a significantproportion of the variance in weekday hours spentwatching television (p < 0.001), while ethnicity,socioeconomic status, maternal education, and childcarehours did not. The same pattern existed for weekendtelevision exposure (p < 0.001). There was asignificant difference between the average number ofboth weekday (p < 0.01) and weekend hours(p < 0.01) for the depressed (weekday, M = 4.81 h,SD = 4.04, weekend, M = 5.61 h, SD = 4.16) andnondepressed mothers (weekday, M = 2.26 h, SD = 1.60,weekend, M = 2.70, SD = 1.98). The infants of depressedmothers were exposed to significantly more children’sprogramming (M = 1 h 36 min, SD = 3 h 36 min) than theinfants of nondepressed mothers (M = 18 min, SD = 40min).
Cowley-Malcolm53New Zealand
Age (years):
<20: 3.81%
20–29: 50.7%
30–39: 40.6%
⩾40: 4.72%
Gender of newborns: notgiven
1207Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 12)
17.5%Discipline (yelling at child, threatening to punishchild, telling child that he or she is bad, smackingchild, and hitting child with an object); nurturingpractices (taking child to the park or playground,playing with child, child spends time with a partner orrelatives, etc.)High nurturance was significantly associated with Samoanethnicity and postschool qualifications, and lownurturance was significantly associated with postnataldepression, alcohol consumption and gambling. At theunivariate level, high discipline scores weresignificantly associated with gambling, postnataldepression and a lack of alignment to either Pacific orto European traditions.
Hibino145Japan
Mean age: 29.7 ± 4.7 years
Genderof newborns: not given
155Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 9)
11.6%Trouble with infant careEPDS scores were significantly correlated with increased“trouble with infant care” (B = 0.47,p < 0.001).
McLearn137USA
Age (years):
<20: 13.3%
20–29: 50.6%
⩾30: 36.2%
Genderof newborns: not given
4874Cohort study
3 months
Two groups:
- PPD
- No PPD
CES-D17.8%Practices to promote child development;breastfeedingMothers with depressive symptoms had a reducedprobability of sharing books (adjusted OR = 0.81; 95% CI= 0.68, 0.97), playing with the infant (adjustedOR = 0.70; 95% CI = 0.54, 0.90), talking to the infant(adjusted OR = 0.74; 95% CI = 0.63, 0.86), or followingroutines (adjusted OR = 0.61; 95% CI = 0.52, 0.72).
Vliegen37Belgium
Mean age (years):
T1:29.39 ± 4.40
T2: 32.95 ± 4.51
Gender ofnewborns: not given
41Cohort study
3.5 years
Two groups:
- PPD
- No PPD
BDI-II
(Depressed = BDI ⩾ 13)
39%Maternal/parental care; child treatmentA very important clinical finding was that almost allchildren (92%) of mothers without current depressionreceived continuous parental care, while proportionallymore children (31%) of mothers who were depressed atfollow-up experienced interruptions and breaks inparental care, with care taken over by family members orchildren who were placed in institutions or foster care.Almost all mothers with elevated levels of depression atT2 sought some form of professional help for theirchild. However, this was the only study that includedhalf of the nondepressed mothers.
Zajicek-Farber130USA
Age (years):
Depressed: 22.3 ± 4.3
Nondepressed: 22.6 ± 3.9
Female babies:54.0%
134Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 11)
PHQ
55.2%Infant health practicesSignificantly more depressed women had poor parentingpractices compared to women who were never depressed(63.5% vs 26.7%). The difference was statisticallysignificant (p < 0.001). The RR for having poorparenting practices was 2.4 times greater for depressedwomen than those who were never depressed.
Balbierz26USA
Mean age: 30.3 ± 6.1 years
Gender ofnewborns: not given
945Cohort study
3 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS > 10)
8.25%Parenting practices (safety practices, feedingpractices, and health care practices)Depressed mothers were more likely to bring their babiesfor emergency room visits (26 vs 16%, p = 0.03) thannondepressed mothers were. There was no significantdifference in routine childcare visits. Health careutilization did not differ for mothers with depressivesymptoms versus those mothers without depressivesymptoms in multivariable models (controlled for age,race, marital status, education, parity, interventionstatus, employment status and language).
Chee57Singapore
Mean age: 31 ± 4.7 years
Female babies: 50.1%
471Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 8)
15.3%Nonroutine visits to the infant’s doctorAfter adjusting for confounders, women who had broughttheir infants for three or more nonroutine visits to theinfant’s doctor had a significantly higher prevalence ofdepression (32.6%) than those with fewer visits (13.6%)(OR = 2.87; 95% CI = 1.41,5.85; p = 0.004).
Eilat-Tsanani63Israel
Age: 18 years and above
Gender ofnewborns: not given
527Cohort study
2 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 13)
(+survey)
9.9%Women’s consultations with physicians (familyphysicians, gynecologists, and/or pediatricians)Women with PPD differed from those without PPD in termsof the frequency of and reasons for consultations. Therate of PPD was significantly higher among women whosought medical consultations than those who came forroutine care (13 vs 4%, p = 0.001). Women with multiplevisits (four or more) to all doctors had higher rates ofPPD than the others (16.7 vs 7%, p = 0.002). Women withPPD consulted more with family physicians (20.6 vs 7.8%,p = 0.01) and pediatricians (18.3% vs 7.1%, p = 0.001).No significant difference in PPD rates was found inrelation to the number of visits to gynecologists.
Farr98USA
Age (years):
<25: 27.7%
25–29: 32%
30–34: 26.6%
⩾35:13.7%
Gender of newborns: not given
24,263Cohort study
±1 year
Four groups:
- No depression
- Pregnancy only
- Pregnancy and postpartum
- Postpartumonly
Not given13.4%Infant health care utilizationInfants of mothers with PPD had only a marginallyincreased risk of hospitalization (RR = 1.2; 95% CI =1.0, 1.4). Of the 128 hospitalizations among infants ofmothers diagnosed with PPD, 70.3% occurred before themother’s diagnosis. Compared to infants of motherswithout depression, infants of mothers with depressiondiagnosed during the postpartum period only (RR = 1.2;95% CI = 1.1, 1.2) were more likely to have ⩾6 sick oremergency visits.
Minkovitz128USA
Age (years):
<20: 13.3%
20–29: 50.5%
⩾30: 36.2%
Femalebabies: 50.1%
4896Cohort study
33 months
Two groups:
- PPD
- No PPD
CES-D17.8% at 2–4 months; 15.5% at 30–33 monthsChild’s receipt of acute and preventive health careservicesChildren whose mothers had depressive symptoms at 2 to 4months had 0.74 to 0.81 reduced odds of receivingage-appropriate well-child visits. This result wassignificant for visits between 6 and 24 months. Theassociation with maternal depressive symptoms andvaccinations was also significant for children who wereup to date on their vaccinations at 24 months and hadreceived an age-appropriate dose of MMR. The influenceof maternal depressive symptoms on the reception ofacute care persisted for ED visits in the previous yearand tended to continue during hospitalizations, asreported at 30 to 33 months. Mothers who had depressivesymptoms had increased odds of reporting that theirchildren sustained injuries in the preceding year butalso had decreased odds of their children using the EDspecifically for an injury in the year preceding the 30-to 33-month interview. Children whose mothers haddepressive symptoms at 2 to 4 months had fewer sickvisits through the first 32 months of life (p = 0.04)than children whose mothers did not have symptoms.However, in adjusted analyses, there was no significantassociation between depressive symptoms at 2 to 4 monthsand the number of sick visits. Children whose mothershad depressive symptoms at 2 to 4 months had anincreased likelihood of having an ED visit between 1.5and 2.5 years of age (OR = 1.38; CI = 1.12, 1.71).
Ndokera142Zambia
Age (years):
⩽18: 9%
19–24: 35.6%
25–30: 33.1%
⩾31: 22.3%
Female babies: 45.3%
278Cross-sectional study
Two groups:
- PPD
- No PPD
SRQ-209.7%Weight; length
diarrheal episodes; incompletevaccination
After adjustment for infant age and other possibleconfounders, a logistic regression analysis showed nosignificant association between a high risk of maternaldepression and incomplete immunization. Clinic locationand older infant age were significantly associated withincomplete vaccination.
Vliegen37Belgium
Mean age (years):
T1:29.39 ± 4.40
T2: 32.95 ± 4.51
Gender ofnewborns: not given
41Cohort study
3.5 years
Two groups:
- PPD
- No PPD
BDI-II
(Depressed = BDI ⩾ 13)
39%Maternal/parental care; child treatmentAlmost all mothers with elevated levels of depression atT2 sought some form of professional help for theirchild. However, this was the only study that included anequal number of nondepressed mothers.
Zajicek-Farber130USA
Age (years):
Depressed: 22.3 ± 4.3
Nondepressed: 22.6 ± 3.9
Female babies:54.0%
134Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 11)
PHQ
55.2%Infant health practicesOn average, the mothers with a history of depressioncompleted 5.91 (SD = 1.03) well-child health visits,whereas the women who were never depressed completed6.42 (SD = 0.77) visits (p < 0.002). Significantlyfewer children of women who were never depressed thanchildren of depressed women (16.7% vs 33.8%) hadinadequate (five or fewer) well-child visits.Significantly fewer children of women who were neverdepressed had an incomplete immunization series comparedto depressed women (11.7% vs 39.2%). On average,children of depressed mothers had 1.32 (SD = 1.4) acutecare visits, whereas children of mothers who had neverbeen depressed made no such visits to the emergencydepartment (p < 0.001). Significantly more depressedwomen spanked their infant within the week preceding theinterview compared to women who were never depressed(35.1% vs 8.3%).
Arteche46UK
Mean age: 33.2 ± 5.2 years
Femalebabies (%):
Control: 61.8
MDD: 61.9
GAD: 47.1
89Cohort study
15 months
Three groups:
- Control
- MDD
- GAD
EPDS
(Depressed = EPDS > 12)
GAD-Q
MDD: 23.6%
GAD: 38.2%
Infant facial expression identification by themotherPlanned contrasts revealed that participants withdepression were significantly less accurate atidentifying happy faces than controls (p = 0.005).
Participants with GAD identified happy faces ata significantly lower intensity than controlparticipants (p = 0.005), and participants withdepression, compared to control participants, showed anonsignificant trend in the same direction, (p = 0.05).Moreover, similar to the findings on all trials,analyses of sad faces revealed no significantdifferences between controls and either participantswith depression (p > 0.01), or participants with GAD(p > 0.01).
Gil80France
Mean age: not given
79Cross-sectional study
Two groups:
- PPD
- No PPD
EPDS
(Cut-off value not given)
30.4%Evaluation of emotional facial expressionsThe only difference between mothers with and withoutpostpartum depressive mood lays in their assessment ofthe babies’ faces, neutral baby faces being judged to beless neutral, thus demonstrating the specificity ofpostpartum affective disorders.
Kerstis40Sweden
Mean age: 30.0 ± 5.0 years
Femalebabies: 49%
401Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 9)
18%Mother’s SOC (comprehensibility, manageability andmeaningfulness); parents’ perception of infant’stemperamentA higher ICQ score indicated a perception of a “moredifficult” child temperament. Mothers with depressivesymptoms had a higher ICQ score then mothers withoutdepressive symptoms (p = 0.028) at 3 months postpartum,but not at 18 months (p = 0.145).
Orhon58Turkey
Age (years):
EPDS < 12:29.7 ± 4.8
EPDS ⩾ 12: 28.9 ± 3.2
Genderof newborns: not given
103Cohort study
1 year
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 12)
34.0%Maternal perceptions of infant patterns (infant feedingpatterns, sleeping patterns, infant cry-fuss problems,and infant temperament)Mothers with elevated depressive symptoms were moreinclined to report infant cry-fuss, sleeping andtemperamental problems through the follow-up. Postpartumdepressive symptoms may lead to negative maternalperceptions of infant patterns.
Stein50UK
Mean age (years):
Control:32.7 ± 5.0
Anxiety: 33.3 ± 5.0
Depression: 33.6 ± 5.3
Gender ofnewborns: not given
45Cohort study
3 months
Three groups:
- Controls
- Depressed mothers
- Anxious mothers
EPDS
(Depressed = EPDS > 12)
GAD-Q
Not applicable
(number of women were fixed atthe beginning of the study)
Mothers’ perceptions of infant facial expressionsMothers with postnatal depression were more likely torate negative infant faces shown for a longer periodmore negatively than controls. The differences werespecific to depression rather than an effect of generalpostnatal psychopathology as no differences wereobserved between anxious mothers and controls. Therewere no other significant differences in maternalratings of infant faces shown for short periods or forpositive or neutral valence faces shown for eitherlength of time.
Choi144Japan
Mean age: 30.4 ± 4.5 years
Femalebabies: 47.2%
413Cross-sectional study
Two groups:
- PPD
- No PPD
ZSDS41.4% of mild depression; 14.5% of major depressionViolence; neglect; emotional explosionDepression was strongly influenced by “worries aboutparenting” in all variances but was not associated with“abusive behavior.” “Worries about parenting” also had astrong influence on the “fear of being abusive,” but didnot affect “abusive behavior.” Low “maternal care” hadthe greatest influence on difficulty of bonding,” whichaffected “abusive behavior” only.
Zajicek-Farber130USA
Age (years):
Depressed: 22.3 ± 4.3
Nondepressed: 22.6 ± 3.9
Female babies:54.0%
134Cohort study
18 months
Two groups:
- PPD
- No PPD
EPDS
(Depressed = EPDS ⩾ 11)
PHQ
55.2%Infant health practicesThe RR for spanking a child was 4.2 times greater fordepressed women than those who were neverdepressed.
PPD: postpartum depression; MDD: major depressive disorder; GAD:generalized anxiety disorder; EPDS: Edinburgh PostnatalDepression Scale; BDI: Beck Depression Inventory; CES-D: Centerfor Epidemiologic Studies Depression Scale; MINI: MiniInternational Neuropsychiatric Interview; PHQ: Patient HealthQuestionnaire; SRQ-20: Self-Reporting Questionnaire-20; GAD-Q:Generalized Anxiety Disorder Questionnaire; ZSDS: ZungSelf-Rating Depression Scale; SOC: sense of coherence; IFSAC:Inventory of Functional Status after Childbirth; OR: odds ratio;CI: confidence interval; SD: standard deviation; RR: risk ratio;ED: emergency department; ICQ: Infant Care Questionnaire.

Maternal behaviors

Depressed mothers appeared to be more likely to engage in less-healthypractices with their infant compared to nondepressed mothers (Table 17).They were less likely to place their infant in the back-to-sleepposition,26,62 to use a car seat,26 and to have a working smoke alarm in the home.26 A higher proportion of the mothers with self-scored depressivesymptoms had a poor sense of coherence (comprehensibility,manageability, and meaningfulness) compared with mothers withoutdepressive symptoms.40 Depressive symptoms were also negatively associated withparticipation in positive enrichment activities with thechild.52,53,62 Mothers with PPD were less likely to tell theirchild stories every day62 and played games less often62 than nondepressed mothers. One study found no significantdifferences in mother–infant engagement with a picture book betweendepressed and nondepressed mothers.49 However, this study noted that the infants of these two groups ofmothers showed significant differences in their nonverbal behaviors.Depressed mothers also tended to sing faster to their infants thannondepressed mothers.79 Reissland et al.83 demonstrated that depressed mothers preferred to cradle theirinfant to the left, similar to stressed mothers; nondepressed mothersshowed right-sided cradling, similar to nonstressed mothers.Nevertheless, the authors added that the left-sided cradling bias mightbe due to stress rather than depression experienced by mothers. Inaddition, as depression increased, mothers scored less favorably onpositive affect, contingent responsiveness, physical intrusiveness,punitive tone, verbal content, and general verbalness.52 Low nurturance (defined as behaviors that promotes a child’spsychological growth) and high discipline scores were significantlyassociated with postnatal depression.53 Finally, one study showed that functional status, an evaluationof overall functional status, household function, social function,personal function, and infant care activities, was negatively correlatedwith PPD, with the exception of infant care activities.85

Maternal competence

Two studies showed that depressed mothers had a lower perception of theircompetence than nondepressed mothers (Table 17). The first studyhighlighted that women with lower parenting self-efficacy were morelikely to report depressive symptoms than women with higher parenting self-efficacy.75 The second study concluded that maternal depression was animportant factor (32.3% of the total variance) that affected perceivedmaternal role competence and satisfaction at 6 weeks postpartum.51

Maternal care for infant

All six studies indicated a significant association between maternal PPDand the care that mothers provided to their child (Table 17).Studies showed that EPDS scores were significantly correlated withincreased difficulty with infant care145 and that significantly more depressed women had poor parentingpractices than women who had not experienced PPD.130 One study highlighted that children of depressed mothersexperienced more interruptions and breaks in parental care.37 Another study indicated that mothers with depressive symptomsshowed books, played with or talked to the infant and followed routinessignificantly less often than nondepressed mothers.137 A further study demonstrated that low nurturance and highdiscipline scores were significantly associated with PPD (higher scoreswere indicative of greater nurturance and a greater use of discipline behaviors).53 Another study146 reported that children with a depressed mother had a greater meannumber of hours of household television exposure during both weekdaysand weekends. Bank et al.146 also showed that infants of depressed mothers were exposed tosignificantly more children’s programming than infants of nondepressedmothers.

Infant health care practices and utilization measures

Six out of eight studies demonstrated an effect of maternal PPD on infanthealth care practices and utilization (Table 17). The first study128 showed that children whose mothers had depressive symptoms at 2to 4 months had a reduced probability of receiving age-appropriatevaccinations or age-appropriate well-child visits between 6 and 24months. This study also showed that these children had an increasedlikelihood of visiting the emergency department between 1.5 and 2.5years of age. Mothers who had depressive symptoms also had an increasedprobability of reporting that their children had sustained injuries. Thesecond study130 highlighted that depressed women differed significantly fromwomen who had not experienced depression in their use of health servicesfor their child. Depressed women were less likely to complete expectedwell-health visits for their child. The relative risk (RR) of inadequatewell-child visits was two times greater for depressed women than forwomen who had never experienced depression. Children of depressed womenwere also less likely to complete immunizations within the expected timeframe, and they had significantly more visits to the emergencydepartment for acute care. The third study98 demonstrated that infants of mothers with PPD were more likely tohave ⩾6 sick or emergency visits and had an increased risk ofhospitalization compared to infants of mothers without depression. Thefourth study37 reported that most depressed women sought some form ofprofessional help for their child compared to nondepressed women. Thefifth study showed that women with PPD consulted more with familyphysicians and pediatricians than nondepressed mothers did.63 In addition, the rate of PPD was significantly higher in womenwho consulted health services for medical reasons (nonroutine care) thanfor those who visited for routine care only.57

Another study26 demonstrated that women with PPD had an increased likelihood ofbringing their babies for emergency room visits than women without PPD;however, this association was no longer significant in the adjustedmodel. Finally, one study142 did not demonstrate a significant effect of maternal PPD oninfant health care practices and utilization measures. This study showedthat a high risk of maternal depression did not have a negative impacton the completion of routine immunizations in Zambia. However, cliniclocation and older infant age were significantly associated withincomplete vaccinations.

Maternal perceptions of infants’ patterns

Postpartum depressive symptoms appear to lead to negative maternalperceptions of infant patterns (Table 17). One study showedthat mothers with depressive symptoms had a higher perception of theirchildren’s temperament as “more difficult” than nondepressed mothers.40 Another study highlighted that mothers with elevated depressivesymptoms were more inclined to report infant crying/fussing, sleepingand temperament problems than mothers without PPD.58 The third study reported that mothers who suffered from PPD weremore likely to rate negative infant faces shown for a longer period morenegatively than mothers without PPD.50 The authors of this third study concluded that their resultshighlighted the difficulties that these mothers have in responding totheir own infants’ signals. A fourth study demonstrated that the onlydifference between mothers with and without PPD was their assessment ofbabies’ faces; neutral baby faces were judged to be less neutral bydepressed mothers than by nondepressed mothers.80 Mothers with PPD were also less likely to accurately identifyhappy infant faces (no differences regarding sad faces were identified)than mothers without PPD.46

Risk of maltreatment

The studies included in the evaluation of the risk of maltreatment arepresented in Table17. One study found that depressed women had a significantlyhigher risk (4.2 times greater) for spanking their child compared withnondepressed women.130 Another study did not identify a direct effect of maternal PPD onabusive behaviors; however, it demonstrated that PPD strongly influencedworries about how to parent and concerns about how their parentingaffected the fear of being abusive.144 This study also highlighted that poor maternal care influenceddifficulty with bonding, which also affected abusive behaviors.

Discussion

The purpose of this study was to evaluate the maternal and infant consequences ofmaternal PPD.

First, as expected, maternal PPD was associated with more negative maternal physicaland psychological health and with a worse quality of life. Surprisingly, there werevery few results regarding maternal physical health. Only three studies included inthe present systematic review showed that depressed mothers presented morePPWR35,67 and lowerscores on all SF-36 domains,88 while a systematic review conducted in 2014 evaluated the impact of sleep,stress, and depression on PPWR and found conflicting results, as follows: of sevenstudies that examined PPD and weight retention, three studies reportednonsignificant associations and four studies reported positive associations.18 As it was decided to reject the systematic and nonsystematic review of thisresearch, this previous systematic review18 was not included. In addition, based on the inclusion criteria of oursystematic review, only one67 of the studies included in this previous systematic review18 could be considered in our results (of seven studies, two were publishedbefore 2005 and four were rejected based on the title and abstract). Indeed, thisstudy excluded treated PPD, while the previous systematic review18 did not. This is an important difference between the two studies, and itcould explain many of the discrepancies between our findings and those of thisprevious review. The two studies included in the examination of PPWR were bothcohort studies and seemed to be of good quality: one study included 75 womenfollowed for 14 months,35 and the other study included 850 women followed for 18 months.67 In addition, both studies used the EPDS to screen for PPD. However, they didnot use the same cut-off values: one study used a cut-off value of ⩾1035 and the other study used a cut-off of >12.67 Given this information, we can assert that our results seem to support therisk of PPWR among depressed mothers. As previously observed in cases of women’shealth, depressed mothers appeared to be more likely to consult generalpractitioners, pediatricians, or mental health professionals for medical reasons(nonroutine care) than for routine care.57,63,78 These results suggest thatdepressed women had more health expenditures than nondepressed women.

Depressed mothers also seemed to experience more difficulties in their socialrelationships (including relationships with their partners)37,44 and to feelthat they received lower quality social support85 than nondepressed mothers. These results are consistent with the qualitativestudy of Rodrigues et al.,148 who reported poor marital relationships and a lack of practical help andemotional support among depressed mothers. Depressed mothers seemed to have morerisky behaviors (including the risk of start smoking again after pregnancy55,84 and anincreased prevalence of suicidal ideations).30,33,76,81,85 These results are consistentwith a review conducted in 2013, which showed that women who had high depressivesymptom scores were also more likely than those with lower scores to engage in riskybehaviors (alcohol, illicit drug, or other substances use).20 Nevertheless, according to the inclusion criteria of our systematic review,none of the studies included in this previous review20 could be considered in our analyses (of 12 studies, 5 were published before2005 and 7 were rejected after reading the title and abstract). PPD thereforeappeared to be associated with higher risk behaviors, regardless of whether thewomen were treated for these symptoms.

Concerning the outcomes of children aged 0 to 3 years, it seemed that theanthropometric consequences of maternal PPD differed between high- and low-incomecountries. Maternal PPD seemed to have few associations with the weight and lengthof infants in high-income countries100,113 except during the transientperiod at the beginning of the newborn’s life.125 However, in low-income populations, maternal PPD seemed to be associated withless infant weight gain and stunting.97,104,110,131,140,142 Moreover, many studiesindicated significant and negative associations between maternal postpartumdepressive symptoms and infant cognitive development,94,95,99,101,102,107,141,147 languagedevelopment,94,102,105,116,117,131,132,139 infant behaviors,49,52,110,114,120,121,131,133 overall infant healthconcerns,48,104,119,122124,135,136,138 and qualityof sleep.104,108

In contrast, the impact of maternal PPD on infant motor development seemed to becontroversial: some studies94,95,97 demonstrated a clear effect of PPD on children’s gross and finemotor development, while other studies66,103,107 did not demonstrate thiseffect. Regardless of whether they showed an effect, all but one study (60 subjects)66 that evaluated the effect of PPD on child motor development were cohortstudies and included large samples of subjects (from 360103 to 652 subjects).97 Four of the six studies used the EPDS as a screening tool for depression; thetwo other studies used the Aga Khan University Anxiety and Depression Scale (AKUADS)or the BDI-II. The studies that used the EPDS did not use the same cut-off values:the two studies that used the EPDS that did not find an effect of PPD on motordevelopment used a cut-off value of ⩾12,103,107 while the two studies thatused the EPDS and found evidence in favor of this relationship used cut-off valuesof ⩾1395 and ⩾10.97 Regarding these conflicting results, there may be a confounding factor. Wesuggest that PPD could affect the life and home environments66,94,103,117,141 of theinfants, which could impact their development, particularly through a lack ofcaregiving from the mother. Similarly, maternal PPD did not seem to have a directeffect on child social development.66,143

Concerning mother–infant interaction, the majority of studies found a significantassociation between maternal PPD and the care that mothers provide their children.Therefore, it is reasonable to assume that maternal PPD has a real impact on how amother cares for her child. Maternal PPD seemed to be associated with poor maternalcare, which influenced bonding difficulties and insecure attachments.31,34 Althoughphysical contact does not appear to be necessary for the development of a healthybond,149,150 difficulty with mother–infant bonding could originate from(early) physical separation or a lack of maternal emotional availability.151 In addition, difficulties in mother-to-infant bonding could reduce thequality of parenting practices37,53,130,137,145,146 and could affect the ratesof abusive behavior.144 The quality of the mother–infant relationship seemed to have an influence onthe overall development of these infants; however, it was also affected by the waymothers cared for their child. Maternal PPD seemed to have a negative effect onthese parameters, which created a vicious circle around the mother–child couple. Itis interesting to note that successful treatment of PPD may not be sufficient toimprove infants’ attachment, temperament, and cognitive development.5 In addition, many studies identified a significantly negative effect ofmaternal depressive symptoms on breastfeeding and/or its parameters (e.g.discontinued breastfeeding, less-healthy feeding practices, breastfeeding problems,lower satisfaction, or reduced confidence).25,41,45,59,62,77,89,90,118,119,137 These results are consistentwith a systematic review published in 2014 that also showed negative effects of PPDon breastfeeding.22 In this systematic review, PPD was associated with a shorter breastfeedingduration in almost all studies; therefore, PPD appeared to be associated with morebreastfeeding problems, regardless of whether women were treated for PPD symptoms.The authors of several studies noted that PPD predicted and was predicted bybreastfeeding cessation.22 Many studies found a significant and negative association between maternalPPD and the duration of breastfeeding and a positive association between maternalPPD and breastfeeding problems. The Dias and Figueiredo’s22 systematic review included 48 studies, 14 which were included in the presentsystematic review (the other studies were published before 2005 (n = 17) or rejectedbased on the title and abstract (n = 17)).

Some studies64,108,121 compared theimpact of chronic depression versus transient depression on child development andfound that chronic maternal depression seemed to have a more serious impact on childdevelopment. In addition, some studies highlighted the importance of otherenvironmental factors on the delay in child development, such as the infants’ lifeenvironment66,94,103,117,141 or maternal sensitivity.115,127,147 Therefore, maternal PPDcould also indirectly impact a child’s development via a demonstrated lack ofcaregiving. The quality of the mother–infant relationship is critical for infantdevelopment, and maternal PPD could have a negative effect. Moreover, therelationship a mother develops with her child is dependent on the mother’s ownemotional health.94 One study explained that a potential implication of the results was that theinfants of mothers with PPD reacted to negative maternal nonverbal engagement bydisplaying negative behaviors, and they showed less interest in interacting.49 Infants’ dissatisfaction with their environment or their relationship withtheir mothers could explain their more difficult temperaments, greater display ofinternalization or communication problems, more problems relating to their mothers,and more difficulties in social development, particularly in their ability to relateto other individuals. In addition, lower socioeconomic groups seemed to be at ahigher risk. Thus, an unfavorable environment should be a warning signal forcaregivers. Therefore, in these subgroups (including populations from low-incomecountries), the prevention and early recognition of maternal PPD may improve theoptimal development of children and the care their mothers provide.

In conclusion, maternal PPD seems to have many negative effects on both child andmaternal health; however, it is important to highlight that the studies includedwere heterogeneous in their designs, the tools they used to assess PPD and the largegroup of confounding factors that was considered (even though adjusted results wereused when they were available). Nevertheless, efforts to screen and prevent maternalPPD are critical.

Need for a consensus regarding PPD diagnosis

A difficulty emerged during the evaluation of the maternal and infantconsequences of untreated PPD as a result of the heterogeneity of the PPDdiagnosis. While PPD is not a recent pathology, a consensus regarding the “bestdiagnostic tool” does not exist. The prevalence of maternal depression thereforedepends on the definition and/or the tool used to diagnose PPD.3,68 In addition, the prevalenceof PPD may depend on the cut-off values used with the same diagnostic tool.

The 122 studies included in this systematic review also used different diagnostictools. PPD was mainly diagnosed using the EPDS (68 studies); however, it wasalso assessed using various other questionnaires, such as the BDI (10 studies),the CES-D (10 studies), the MINI (4 studies), the SCID (4 studies), the DSM-IV(2 studies), the PHQ-9 (3 studies), the PHQ-8 (1 study), the PHQ-D (1 study),the CIDI (3 studies), the PDSS (3 studies), the BSI (2 studies), the SQR-20 (2studies), the GAD-Q (2 studies), and the HDRS (1 study). Therefore, theprevalence of PPD varied among these studies, from 2.7% in a population ofPakistani mothers at 18 months postpartum94 to 68.8% in a population of Australian mothers at 4 months postpartum.64

Concerning the cut-off values, there were also several disparities. For example,as shown Tables117, among the studies that used theEPDS, the authors used different cut-off values to establish the diagnosis ofPPD; cut-off values of 8,57 9,40 10,44 11,132 12,31 13,34 or 1465 were used to screen for postnatal depression. Cox et al.4 showed that a cut-off point of 13 or more on the EPDS indicates aprobable depression with a sensitivity of 86% and a specificity of 78% in thepostnatal period. Another study indicated that the optimal cut-off for probablemajor depression during the antenatal period may be higher (15 or more).152 Some authors used different cut-off values to classify depression asmild/moderate (e.g. EPDS ⩾ 886 or EPDS ⩾ 10 and ⩽12108) or severe (EPDS ⩾ 1286 or EPDS ⩾ 13108). Other authors considered the EPDS a screening tool that measuresprobable depression and does not provide a clinical diagnosis of depression;these authors considered an EPDS score of 13 indicative of PPD.112

Although previous research conducted a receiver operating characteristic curve(ROC) analysis comparing the EPDS, BDI, and HRSD scores with the SCID MoodModule and showed that these scales were highly predictive of a major depressive episode,153 future studies should develop a consensus to standardize the toolsresearchers use to diagnose depression during the postpartum period. The EPDS4 seems to be the most commonly used PPD diagnostic tool. Nevertheless,researchers must agree on cut-off values to ensure the validity and reliabilityof the tool. For example, in 2006, Matthey et al.154 recommended the use of a validated score of 13 or higher on the EPDS whenreporting probable major depression during the postnatal period and a score of15 or higher during the antenatal period (particularly for English-speakingwomen). However, it seems that these recommendations are not always followed. Inany case, it is sometimes difficult to compare the outcomes of PPD because ofthe heterogeneity of its diagnosis. It is important to be careful given that insome cases, the results of this systematic review combined results from studiesthat were heterogeneous in terms of design (cross-sectional vs cohort studies)and methodology (e.g. screening tools used for PPD or length of follow-up).

Implications for practice

Social support seems to have a protective effect against postnataldepression.8,155,156 However, depressed mothers presented lower perceivedsocial support than nondepressed mothers.66 Social support also seems to stimulate maternal self-efficacy,157 which plays a key role in the process of constructing parenthood.158 A study showed that mothers who had a strong belief in their maternalabilities had better outcomes in terms of emotional well-being, attachment tothe child and adaptation to their new role.159 In addition, maternal self-efficacy is positively associated with themothers’ coping strategies.

Even when everything seems to be going well, the majority of women seem to feelfears or anxiety at the beginning of maternity given the sudden changes in their role.160 It is normal for mothers to be worried about the safety and well-being oftheir child. Nevertheless, given all the identity disturbances related to thearrival of a baby, it is not uncommon for women to encounter episodes ofpsychological distress of varying duration and degrees of severity during thepostnatal period. Childbirth may be a traumatic experience for a woman.161 A lack of social support, pain during the first stage of labor, feelingsof powerlessness, unfulfilled expectations, and negative interactions withmedical personnel are examples of factors that can influence the perception of atraumatic experience following childbirth. These findings suggest severalintervention points for health care practitioners, including opportunities todiscuss the birth during the postpartum period.161

Nevertheless, one study indicated a discrepancy between professionals’perceptions of maternal needs and the needs that mothers actually had.162 Professionals seemed to be more concerned about needs during pregnancythan during the postpartum period. Moreover, they seemed to identify very fewunmet needs during the postnatal period, while the mothers tend to feelneglected during this period.162 However, many studies have shown that mothers have important physical andemotional needs during the year after childbirth.155,158,160,162179 In addition, the presentsystematic review shows that the health of infants and children is intimatelyassociated with the health of their mothers.

These elements suggest that the promotion of maternal health by professionalscannot end at the birth of the newborn or at the 6-week postpartum visit.164 The needs of mothers take longer than 6 weeks to resolve. Fahey and Shenassa164 noted that a healthy postnatal period depends on a woman’s ability toeffectively employ her own skills to satisfy her own needs and those of herfamily. Thus, postnatal care providers must understand that women’s health needsduring this transition period are not limited to physical recovery, and theymust identify care strategies that will help women develop the required skillsto appropriately meet their needs.

The recommendations in terms of maternal health promotion are increasingly movingtoward a holistic vision of women’s health. It is necessary to go beyond healthcare itself to meet the complete needs of mothers;164,180182 this is even more trueas maternity leave is increasingly shortened, thus presenting additional risksof insufficient education and health promotion models for mothers.183 It is important that professionals implement rigorous follow-upprocedures outside the hospital to continue to support parents during this life event.184

Strengths and limitations of the study

To our knowledge, this study is the first systematic review in several decades toevaluate the consequences of untreated maternal PPD in both mothers and theirchildren from 0 to 3 years of age. Our study included 122 studies andencompassed all outcomes for mothers and children that have been described sinceJanuary 2005. The limitations of this study are that given the number ofabstracts initially included in the review, study selection and data extractionwere not performed using a double-blinded method, and an assessment of thestudies’ methodological quality was not performed. Nevertheless, the inclusionand exclusion criteria were rigorously discussed and defined at the beginning ofthe study by the two researchers who performed the review. In addition, if therewas doubt regarding an abstract or an article, the article was discussed, andthe researchers reached a consensus regarding its inclusion or exclusion.Another limitation of this study is that given the substantial number ofmaternal PPD outcomes, the present review compares heterogeneous studies thatused various designs (cohort vs cross-sectional studies) and tools to assessPPD. Therefore, it is important to consider that potential confounding factorscould be present.

Conclusion

We conclude that maternal postnatal depression has negative consequences for bothmothers who suffer from this pathology and their children up to 3 years of age. PPDhas important impacts, mainly on mothers’ psychological health, quality of life, andinteractions with their infant, partner, and relatives. Depressed women are caughtin a vicious circle in which they become sadder and angrier and have increasinglylower perceptions of their competence. The accumulation of these elements creates anenvironment that is not conducive to the personal development of mothers or theoptimal development of a child. The present systematic review shows that the healthof infants and children is intimately associated with the health of their mothers.In addition, severe or chronic maternal depression seems to present a higher risk tochildren’s development than milder depression. Thus, maternal PPD has many directand indirect negative effects on the development of a child, including lower qualityof the home environment and decreased maternal sensitivity and caregiving. Ittherefore seems important to detect and treat depression in the postnatal period asearly as possible to avoid harmful consequences. The risks are greater for childrenin low-income populations. Consequently, more attention should be paid to theseareas.

Appendix

Appendix 1.
Search strategy and search terms used for this systematic research.
1. Postpartum depression.mp
2. Depression, Postpartum/
3. Post partum depression.mp
4. Post-partumdepression.mp
5. OR/1-4
6. Postnataldepression.mp
7. Post natal depression.mp
8.Post-natal depression.mp
9. OR/6-8
10. Puerperaldepression.mp
11. Exp postpartum depression/
12.Exp postanal depression/
13. OR/11-12
14.OR/5,9-10,13
15. Limit to English language
16.Limit 15 to yr =”2005-Current”
17. Limit 16 tohumans

Footnotes

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/orpublication of this article.

ORCID iD: Olivier Bruyère https://orcid.org/0000-0003-4269-9393

Acknowledgments

The author would like to thank all the co-authors of this article, especially GermainHonvo for helping in the data extraction.

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