Postpartum depression

Symptoms of PPD can occur at any time in the first year postpartum. Typically, a diagnosis of postpartum depression is considered after signs and symptoms persist for at least two weeks. • Frustration, irritability, restlessness, anger • Feelings of hopelessness or helplessness Behavioral • Lack of interest or pleasure in usual activities • Changes in appetite More robust studies on neural activation regarding PPD have been conducted with rodents than humans. These studies have allowed for greater isolation of specific brain regions, neurotransmitters, hormones, and steroids. ==Onset and duration ==

Postpartum depression onset usually begins between two weeks to a month after delivery. A study done at an inner-city mental health clinic has shown that 50% of postpartum depressive episodes began before delivery. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) PPD is not recognized as a distinct condition but rather a specific type of a major depressive episode. In the DSM-5, the specifier "with peripartum onset" can be applied to a major depressive episode if the onset occurred either during pregnancy or within the four weeks following delivery. The prevalence of postpartum depression differs across different months after childbirth. Studies done on postpartum depression amongst women in the Middle East show that the prevalence in the first three months of postpartum was 31%, while the prevalence from the fourth to twelfth months of postpartum was 19%. PPD may last several months or even a year. ==Consequences on maternal and child health==

Postpartum depression can interfere with normal maternal-infant bonding and adversely affect acute and long-term child development. Infants of mothers with PPD have higher incidences of excess crying, temperamental symptoms, and sleeping difficulties. Problems with sleeping in infants may exacerbate or be exacerbated by concurrent PPD in mothers. Maternal outcomes of PPD include withdrawal, disengagement, and hostility. Additional patterns observed in mothers with PPD include lower rates of initiation and maintenance of breastfeeding. Children and infants of PPD-affected mothers experience negative long-term impacts on their cognitive functioning, inhibitory control, and emotional regulation. In cases of untreated PPD, violent behaviors and psychiatric and medical conditions in adolescence have been observed. Suicide rates of women with PPD are lower than those outside of the perinatal period. Fetal or infant death in the first year postpartum has been associated with a higher risk of suicide attempt and higher inpatient psychiatric admissions. ==Postpartum depression in fathers ==

Paternal postpartum depression is a poorly understood concept with a limited evidence-base. However, postpartum depression affects 8 to 10% of fathers. There are no set criteria for men to have postpartum depression. Causes of paternal postpartum depression include hormonal changes during pregnancy, which can be indicative of father-child relationships. Postpartum depression in men leads to an increased risk of suicide, while also limiting healthy infant-father attachment. Men who experience PPD can exhibit poor parenting behaviors, and distress, and reduce infant interaction. Reduced paternal interaction can later lead to cognitive and behavioral problems in children. Children as young as 3.5 years old may experience problems with internalizing and externalizing behaviors, indicating that paternal postpartum depression can have long-term consequences. Studies suggest that children raised by fathers experiencing depression or other mental illnesses have approximately a 33% to 70% higher risk of developing emotional or behavioral difficulties. Furthermore, if children as young as two are not frequently read to, this negative parent-child interaction can harm their expressive vocabulary. ==Adoptive parents==

Postpartum depression may also be experienced by non-biological parents. While not much research has been done regarding post-adoption depression, difficulties associated with parenting post-partum are similar between biological and adoptive parents. Women who adopt children undergo significant stress and life changes during the postpartum period, similar to biological mothers. This may raise their chance of developing depressive symptoms and anxious tendencies. Postpartum depression presents in adoptive mothers via sleep deprivation similar to birth mothers, but adoptive parents may have added risk factors such as a history of infertility. ==Issues for LGBTQ people==

Additionally, preliminary research has shown that childbearing individuals who are part of the LGBTQ community may be more susceptible to prenatal depression and anxiety than cisgender and heterosexual people. According to two other studies, LGBTQ people were discouraged from accessing postpartum mental health services due to societal stigma adding a social barrier that heteronormative mothers do not have. Lesbian participants expressed apprehension about receiving a mental health diagnosis because of worries about social stigma and employment opportunities. Concerns were also raised about possible child removal and a parent's diagnosis including mental illness. From the studies conducted thus far, although limited, it is evident that there is a much larger population that experiences depression associated with childbirth than just biological mothers. ==Causes==

The cause of PPD is unknown. Hormonal and physical changes, personal and family history of depression, and the stress of caring for a new baby all may contribute to the development of postpartum depression. Evidence suggests that hormonal changes may play a role. Understanding the neuroendocrinology characteristic of PPD has proven to be particularly challenging given the erratic changes to the brain and biological systems during pregnancy and postpartum. A review of exploratory studies in PPD has observed that women with PPD have more dramatic changes in HPA axis activity, however, the directionality of specific hormone increases or decreases remain mixed. Hormones that have been studied include estrogen, progesterone, thyroid hormone, testosterone, corticotropin releasing hormone, endorphins, and cortisol. Aberrant steroid hormone-dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important in conferring biological risk. The use of synthetic oxytocin, a birth-inducing drug, has been linked to increased rates of postpartum depression and anxiety. Estradiol, which helps the uterus thicken and grow, is thought to contribute to the development of PPD. Profound lifestyle changes that are brought about by caring for the infant are also frequently hypothesized to cause PPD. However, little evidence supports this hypothesis. Mothers who have had several previous children without experiencing PPD can nonetheless experience it with their latest child. Despite the biological and psychosocial changes that may accompany pregnancy and the postpartum period, most women are not diagnosed with PPD. Many mothers are unable to get the rest they need to fully recover from giving birth. Sleep deprivation can lead to physical discomfort and exhaustion, which can contribute to the symptoms of postpartum depression. Risk factors While the causes of PPD are not understood, several factors have been suggested to increase the risk. These risks can be broken down into two categories, biological and psychosocial: Biological • Administration of labor-inducing medication synthetic oxytocin • Genetic history of PPD • Hormone irregularities The risk factors for postpartum depression can be broken down into two categories as listed above, biological and psychosocial. Certain biological risk factors include the administration of oxytocin to induce labor. Chronic illnesses such as diabetes, or Addison's disease, as well as issues with hypothalamic-pituitary-adrenal dysregulation (which controls hormonal responses), A correlation between postpartum thyroiditis and postpartum depression has been proposed but remains controversial. There may also be a link between postpartum depression and anti-thyroid antibodies. Psychosocial • Prenatal depression or anxiety • A personal or family history of depression • Stressful life events experienced during pregnancy • Postpartum blues • Childhood trauma • Previous stillbirth or miscarriage • A lack of strong emotional support from spouse, partner, family, or friends • Infant temperament problems/colic • Maternal age, family food insecurity, and violence against women The psychosocial risk factors for postpartum depression include severe life events, some forms of chronic strain, relationship quality, and support from partner and mother. There is a need for more research regarding the link between psychosocial risk factors and postpartum depression. Some psychosocial risk factors can be linked to the social determinants of health. Rates of PPD have been shown to decrease as income increases. Women with fewer resources may be more likely to have an unintended or unwanted pregnancy, increasing the risk of PPD. Women with fewer resources may also include single mothers of low income. Single mothers of low income may have more limited access to resources while transitioning into motherhood. These women already have fewer spending options, and having a child may spread those options even further. Low-income women are frequently trapped in a cycle of poverty, unable to advance, affecting their ability to access and receive quality healthcare to diagnose and treat postpartum depression. Sexual orientation has also been studied as a risk factor for PPD. In a 2007 study conducted by Ross and colleagues, lesbian and bisexual mothers were tested for PPD and then compared with a heterosexual sample group. It was found that lesbian and bisexual biological mothers had significantly higher Edinburgh Postnatal Depression Scale scores than the heterosexual women in the sample. Lesbian women have a higher risk of depression because they are more likely to have been treated for depression and to have attempted or contemplated suicide than heterosexual women. Different risk variables linked to postpartum depression (PPD) among Arabic women emphasize regional influences.  Risk factors that have been identified include the gender of the infant and polygamy. Studies have also shown a correlation between postpartum depression in mothers living within areas of conflicts, crises, and wars in the Middle East. The phrase ‘integration of care’ describes an approach in healthcare in which multiple providers from differing specialties collaborate to manage a patient’s care. Integrating care in postpartum patients showed similar rates of depression in comparison to the non-integrated healthcare approach. The same study mentions it also may not impact rates of substance abuse. In addition, for women receiving breastfeeding support, the location where education was given also did not have a noticeable impact on depression or anxiety. About one-third of women throughout the world will experience physical or sexual violence at some point in their lives. Violence against women occurs in conflict, post-conflict, and non-conflict areas. The research reviewed only looked at violence experienced by women from male perpetrators. Studies from the Middle East suggest that individuals who have experienced family violence are 2.5 times more likely to develop PPD. Further, violence against women was defined as "any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women". Psychological and cultural factors associated with increased incidence of postpartum depression include family history of depression, stressful life events during early puberty or pregnancy, anxiety or depression during pregnancy, and low social support. Violence against women is a chronic stressor, so depression may occur when someone is no longer able to respond to the violence. ==Diagnosis==

Criteria Postpartum depression in the DSM-5 is known as "depressive disorder with peripartum onset". Peripartum onset is defined as starting anytime during pregnancy or within the four weeks following delivery. Nevertheless, the majority of experts continue to diagnose postpartum depression as depression with onset anytime within the first year after delivery. Symptoms typically resolve within two weeks. Symptoms lasting longer than two weeks are a sign of a more serious type of depression. Women who experience "baby blues" may have a higher risk of experiencing a more serious episode of depression later on. Psychosis Postpartum psychosis is not a formal diagnosis, but is widely used to describe a psychiatric emergency that appears to occur in about 1 in 1000 pregnancies, in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions begin suddenly in the first two weeks after delivery; the symptoms vary and can change quickly. It is different from postpartum depression and maternity blues. It may be a form of bipolar disorder. It is important not to confuse psychosis with other symptoms that may occur after delivery, such as delirium. Delirium typically includes a loss of awareness or inability to pay attention. Childbirth-Related/Postpartum Posttraumatic Stress Disorder Parents may suffer from post-traumatic stress disorder (PTSD), or suffer post-traumatic stress disorder symptoms, following childbirth. While there has been debate in the medical community as to whether childbirth should be considered a traumatic event, the current consensus is childbirth can be a traumatic event. The DSM-IV and DSM-5 (standard classifications of mental disorders used by medical professionals) do not explicitly recognize childbirth-related PTSD, but both allow childbirth to be considered as a potential cause of PTSD. Childbirth-related PTSD and postpartum depression have some common symptoms. Although both diagnoses overlap in their signs and symptoms, some symptoms specific to postpartum PTSD include being easily startled, recurring nightmares and flashbacks, avoiding the baby or anything that reminds one of birth, aggression, irritability, and panic attacks. Real or perceived trauma before, during, or after childbirth is a crucial element in diagnosing childbirth-related PTSD. Currently, there are no widely recognized assessments that measure postpartum post-traumatic stress disorder in medical settings. Existing PTSD assessments (such as the DSM-IV) have been used to measure childbirth-related PTSD. The percentage of individuals with childbirth-related PTSD is approximately 15–18% in high-risk samples (women who experience severe birth complications, have a history of sexual/physical violence, or have other risk factors). Childbirth-related PTSD has several negative health effects. Research suggests that childbirth-related PTSD may negatively affect the emotional attachment between mother and child. However, maternal depression or other factors may also explain this negative effect. Childbirth-related PTSD in the postpartum period may also lead to issues with the child's social-emotional development. Current research suggests childbirth-related PTSD results in lower breastfeeding rates and may prevent parents from breastfeeding for the desired amount of time. ==Screening==

Screening for postpartum depression is critical as up to 50% of cases go undiagnosed in the US, emphasizing the significance of comprehensive screening measures. In the US, the American College of Obstetricians and Gynecologists suggests healthcare providers consider depression screening for perinatal women. Additionally, the American Academy of Pediatrics recommends pediatricians screen mothers for PPD at 1-month, 2-month, and 4-month visits. However, many providers do not consistently provide screening and appropriate follow-up. For example, in Canada, Alberta is the only province with universal PPD screening. This screening is carried out by Public Health nurses with the baby's immunization schedule. In Sweden, Child Health Services offers a free program for new parents that includes screening mothers for PPD at 2 months postpartum. However, there are concerns about adherence to screening guidelines regarding maternal mental health. The Edinburgh Postnatal Depression Scale, a standardized self-reported questionnaire, may be used to identify women who have postpartum depression. If the new mother scores 13 or more, she likely has PPD and further assessment should follow. The Edinburgh Postnatal Depression Scale is used within the first week of the newborn being admitted. If mothers receive a score less than 12 they are told to be reassessed because of the depression testing protocol. It is also advised that mothers in the NICU get screened every four to six weeks as their infant remains in the neonatal intensive care unit. Mothers who score between twelve and nineteen on the EPDS are offered two types of support. The mothers are offered LV treatment provided by a nurse in the NICU and they can be referred to the mental health professional services. If a mother receives a three on item number ten of the EPDS they are immediately referred to the social work team as they may be suicidal. It is critical to acknowledge the diversity of patient populations diagnosed with postpartum depression and how this may impact the reliability of the screening tools used. There are cultural differences in how patients express symptoms of postpartum depression; those in non-western countries exhibit more physical symptoms, whereas those in Western countries have more feelings of sadness. Depending on one's cultural background, symptoms of postpartum depression may manifest differently, and non-Westerners being screened in Western countries may be misdiagnosed because their screening tools do not account for cultural diversity. Aside from culture, it is also important to consider one's social context, as women with low socioeconomic status may have additional stressors that affect their postpartum depression screening scores. ==Prevention==

A 2013 Cochrane review found evidence that psychosocial or psychological intervention after childbirth helped reduce the risk of postnatal depression. These interventions included home visits, telephone-based peer support, and interpersonal psychotherapy. Across different cultures, traditional rituals for postpartum care may be preventative for PPD but are more effective when the support is welcomed by the mother. In couples, emotional closeness and global support by the partner protect against both perinatal depression and anxiety. In 2014, Alasoom and Koura found that compared to 42.9 percent of women who did not get spousal support, only 14.7 percent of women who got spousal assistance had PPD. Further factors such as communication between the couple and relationship satisfaction have a protective effect against anxiety alone. In those who are at risk counseling is recommended. The US Preventative Services Task Force (USPSTF) conducted a review of evidence which supported the use of counseling interventions such as therapy for the prevention of PPD in high-risk groups. Women who are considered to be high-risk include those with a past or present history of depression, or with certain socioeconomic factors such as low income or young age. Preventative treatment with antidepressants may be considered for those who have had PPD previously. However, as of 2017, the evidence supporting such use is weak. Community perinatal mental health teams were launched in England in 2016 to improve access to mental healthcare for pregnant women. They aim to prevent and treat episodes of mental illness during pregnancy and after birth. Researchers found that in areas of the country where teams were available, women who had previous contact with psychiatric services (many of whom had a previous diagnosis of anxiety or depression) were more likely to access mental health support and had a lower risk of relapse requiring hospital admission in the year after giving birth. ==Treatments==

Source: Light aerobic exercise is useful for mild and moderate cases. Therapy Both individual social and psychological interventions appear equally effective in the treatment of PPD. Social interventions include individual counseling and peer support, while psychological interventions include cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Support groups and group therapy options focused on psychoeducation around postpartum depression have been shown to enhance the understanding of postpartum symptoms and often assist in finding further treatment options. Other forms of therapy, such as group therapy, home visits, counseling, and ensuring greater sleep for the mother may also have a benefit. While specialists trained in providing counseling interventions often serve this population in need, results from a 2021 systematic review and meta-analysis found that nonspecialist providers, including lay counselors, nurses, midwives, and teachers without formal training in counseling interventions, often provide effective services related to perinatal depression and anxiety which promotes task-sharing and telemedicine. Interpersonal therapy Interpersonal therapy (IPT) has shown to be effective in focusing specifically on the mother and infant bond. Psychosocial interventions are effective for the treatment of postpartum depression. Interpersonal therapy otherwise known as IPT is a wonderfully intuitive fit for many women with PPD as they typically experience a multitude of biopsychosocial stressors that are associated with their depression, including several disrupted interpersonal relationships. Medication A 2010 review found few studies of medications for treating PPD noting small sample sizes and generally weak evidence. The first-line anti-depressant medication of choice is sertraline, an SSRI, as very little of it passes into the breast milk and, as a result, to the child. Therefore, it is not completely clear which antidepressants, if any, are most effective for the treatment of PPD, and for whom antidepressants would be a better option than non-pharmacotherapy. Additionally, none of the existing studies included women who were breastfeeding. Oxytocin is an effective anxiolytic and in some cases antidepressant treatment in men and women. Exogenous oxytocin has only been explored as a PPD treatment with rodents, but results are encouraging for potential application in humans. Some trials have demonstrated an effect on PPD within 48 hours from the start of infusion. Other new allopregnanolone analogs under evaluation for use in the treatment of PPD include zuranolone and ganaxolone. The mother is to be enrolled before receiving the medication. It is only available to those at certified healthcare facilities with a healthcare provider who can continually monitor the patient. The infusion itself is a 60-hour, or 2.5-day, process. People's oxygen levels are to be monitored with a pulse oximeter. Side effects of the medication include dry mouth, sleepiness, somnolence, flushing, and loss of consciousness. It is also important to monitor for early signs of suicidal thoughts or behaviors. Breastfeeding The use of SSRIs for the treatment of PPD is not a contraindication for breastfeeding. While antidepressants are excreted in breastmilk, the concentrations recorded in breastmilk are very low. Extensive research has shown that the use of SSRI's by women who are lactating is safe for the breastfeeding infant/child. Regarding allopregnanolone, very limited data did not indicate a risk for the infant. Other Electroconvulsive therapy (ECT) has shown efficacy in women with severe PPD who have either failed multiple trials of medication-based treatment or cannot tolerate the available antidepressants. As of 2013, it is unclear if acupuncture, massage, bright lights, or taking omega-3 fatty acids are useful. == Resources ==

International Postpartum Support International is the most recognized international resource for those with PPD as well as healthcare providers. It brings together those experiencing PPD, volunteers, and professionals to share information, referrals, and support networks. United States Educational interventions Educational interventions can help women struggling with postpartum depression (PPD) to cultivate coping strategies and develop resiliency. The phenomenon of "scientific motherhood" represents the origin of women's education on perinatal care with publications like Ms. circulating some of the first press articles on PPD that helped to normalize the symptoms that women experienced. Feminist writings on PPD from the early seventies shed light on the darker realities of motherhood and amplified the lived experiences of mothers with PPD. Instructional videos have been popular among women who turn to the internet for PPD treatment, especially when the videos are interactive and get patients involved in their treatment plans. Since the early 2000s, video tutorials on PPD have been integrated into many web-based training programs for individuals with PPD and are often considered a type of evidence-based management strategy for individuals. This can take the form of objective-based learning, detailed exploration of case studies, resource guides for additional support and information, etc. Training and education services are offered through the NICHD to equip women and their healthcare providers with evidence-based knowledge of PPD. Other initiatives include the Substance Abuse and Mental Health Services Administration (SAMHSA) whose disaster relief program provides medical assistance at both the national and local level. The disaster relief fund not only helps to raise awareness of the benefits of having healthcare professionals screen for PPD but also helps childhood professionals (home visitors and early care providers) develop the skills to diagnose and prevent PPD. The IECMH's initiatives seek to educate home visitors on screening protocols for PPD as well as ways to refer depressed mothers to professional help. Links to government-funded programs • www.nichd.nih.gov/ncmhep • www.nichd.nih.gov • www.samhsa.gov • www.samhsa.gov/iecmhc Psychotherapy Therapeutic methods of intervention can begin as early as a few days post-birth when most mothers are discharged from hospitals. Research surveys have revealed a paucity of professional, and emotional support for women struggling in the weeks following delivery despite there being a heightened risk for PPD for new mothers during this transitional period. Community-based support A lack of social support has been identified as a barrier to seeking help for postpartum depression. Peer support programs have been identified as an effective intervention for women experiencing symptoms of postpartum depression. In-person, online, and telephone support groups are available to both women and men throughout the United States. Peer support models are appealing to many women because they are offered in a group and outside of the mental health setting. The National Alliance on Mental Illness lists a virtual support group titled "The Shades of Blue Project," which is available to all women via the submission of a name and email address. Additionally, NAMI recommends the website "National Association of Professional and Peer Lactation Supports of Color" for mothers in need of a lactation supporter. Lactation assistance is available either online or in-person if there is support nearby. Story-telling and online communities reduce the stigma around PPD and promote peer-based care. Postpartum Progress is specifically relevant to people of color and queer folks due to an emphasis on cultural competency. Hotlines & telephone interviews Hotlines, chat lines, and telephone interviews offer immediate, emergency support for those experiencing PPD. Telephone-based peer support can be effective in the prevention and treatment of postpartum depression among women at high risk. Established examples of telephone hotlines include the National Alliance on Mental Illness: 800-950-NAMI (6264), National Suicide Prevention Lifeline: 800-273-TALK (8255), Postpartum Support International: 800-944-4PPD (4773), and SAMHSA's National Hotline: 1-800-662-HELP (4357). Postpartum Health Alliance has an immediate, 24/7 support line in San Diego/San Diego Access and Crisis Line at (888) 724–7240, in which you can talk with mothers who have recovered from PPD and trained providers. However, hotlines can lack cultural competency which is crucial in quality healthcare, specifically for people of color. Calling the police or 911, specifically for mental health crises, is thought to be dangerous for many people of color. Culturally and structurally competent emergency hotlines are a huge need in PPD care. Accessibility to care Those with PPD come across many help-seeking barriers, including lack of knowledge, stigma about symptoms, as well as health service barriers. Cultural responses must be adequate in PPD healthcare and resources. Different ethnic groups may believe that healthcare providers will not respect their cultural values or religious practices, which influences their willingness to use mental health services or be prescribed antidepressant medications. Additionally, resources for PPD are limited and often don't incorporate what mothers would prefer. The use of technology can be a beneficial way to provide mothers with resources because it is accessible and convenient. ==Epidemiology==

North America United States Within the United States, the prevalence of postpartum depression was lower than the global approximation at 11.5% but varied between states from as low as 8% to as high as 20.1%. The highest prevalence in the US is found among women who are American Indian/Alaska Natives or Asian/Pacific Islanders, possess less than 12 years of education, are unmarried, smoke during pregnancy, experience over two stressful life events, or have full-term infant is low-birthweight or was admitted to a NICU. While US prevalence decreased from 2004 to 2012, it did not decrease among American Indian/Alaska Native women or those with full term, low-birthweight infants. Canada Canada has one of the largest refugee resettlement in the world with an equal percentage of women to men. This means that Canada has a disproportionate percentage of women who develop postpartum depression since there is an increased risk among the refugee population. In a blind study, where women had to reach out and participate, around 27% of the sample population had symptoms consistent with postpartum depression without even knowing. Also found that on average 8.46 women had minor and major PPDS was found to be 8.46 and 8.69% respectively. The main factors that were found to contribute to this study were the stress during pregnancy, the availability of support after, and a prior diagnosis of depression were all found to be factors. Canada has specific population demographics that also involve a large amount of immigrant and indigenous women which creates a specific cultural demographic localized to Canada. In this study, researchers found that these two populations were at significantly higher risk compared to "Canadian-born non-indigenous mothers". South America A main issue surrounding PPD is the lack of study and the lack of reported prevalence that is based on studies developed in Western economically developed countries. In countries such as Brazil, Guyana, Costa Rica, Italy, Chile, and South Africa reports are prevalent, around 60%. An itemized research analysis put a mean prevalence at 10–15% percent but explicitly stated that cultural factors such as perception of mental health and stigma could be preventing accurate reporting. In most of these countries, PPD is not considered a serious condition for women and therefore there is an absence of support programs for prevention and treatment in health systems. Being a migrant and giving birth to a child overseas has also been identified as a risk factor for PPD. Countries within the Arab region had a postpartum depression prevalence ranging from 10% to 40%, with a PPD prevalence in Qatar at 18.6%, UAE between 18% and 24%, Jordan between 21.2 and 22.1, Lebanon at 21%, Saudi Arabia between 10.1 and 10.3, and Tunisia between 13.2% and 19.2%, according to studies carried out in these countries. There are also examples of nations with noticeably higher rates, such as Iran at 40.2%, Bahrain at 37.1%, and Turkey at 27%. The high prevalence of postpartum depression in the region may be attributed to socio-economic and cultural factors involving social and partner support, poverty, and prevailing societal views on pregnancy and motherhood. For example, European social policies differ from country to country contrary to the US, all countries provide some form of paid universal maternity leave and free healthcare. Women from Europe reported higher scores of anhedonia, self-blaming, and anxiety, while women from the US disclosed more severe insomnia, depressive feelings, and thoughts of self-harming. This demonstrates the gravity of this problem in Africa and the need for postpartum depression to be taken seriously as a public health concern in the continent. Additionally, each of these studies was conducted using Western-developed assessment tools. Cultural factors can affect diagnosis and can be a barrier to assessing the burden of disease. Furthermore, the prevalence of postpartum depression in Arab countries exhibits significant variability, often due to diverse assessment methodologies. In a review of twenty-five studies examining PPD, differences in assessment methods, recruitment locations, and timing of evaluations complicate prevalence measurement. For instance, the studies varied in their approach, with some using a longitudinal panel method tracking PPD at multiple points during pregnancy and postpartum periods, while others employed cross-sectional approaches to estimate point or period prevalences. The Edinburgh Postnatal Depression Scale (EPDS) was commonly used across these studies, yet variations in cutoff scores further determined the results of prevalence. For example, a study in Kom Ombo, Egypt, reported a rate of 73.7% for PPD, but the small sample size of 57 mothers and the broad measurement timeframe spanning from two weeks to one year postpartum contributes to the challenge of making definitive prevalence conclusions (2). This wide array of assessment methods and timing significantly impacts the reported rates of postpartum depression. == History ==

Prior to the 19th century Western medical science's understanding and construction of postpartum depression have evolved over the centuries. Ideas surrounding women's moods and states have been around for a long time, typically recorded by men. In 460 B.C., Hippocrates wrote about puerperal fever, agitation, delirium, and mania experienced by women after childbirth. Hippocrates' ideas still linger in how postpartum depression is seen today. She was a pilgrim known as "Madwoman" after having a tough labor and delivery. This distinction became important to emphasize the difference between postpartum depression and postpartum psychosis. A 16th-century physician, Castello Branco, documented a case of postpartum depression without the formal title as a relatively healthy woman with melancholy after childbirth, remained insane for a month, and recovered with treatment. Although this treatment was not described, experimental treatments began to be implemented for postpartum depression for the centuries that followed. The famous short story, "The Yellow Wallpaper", was published by Charlotte Perkins Gilman in this period. In the story, an unnamed woman journals her life when she is treated by her physician husband, John, for hysterical and depressive tendencies after the birth of their baby. Gilman wrote the story to protest the societal oppression of women as the result of her own experience as a patient. Also during the 19th century, gynecologists embraced the idea that female reproductive organs, and the natural processes they were involved in, were at fault for "female insanity." Approximately 10% of asylum admissions during this period are connected to "puerperal insanity," the named intersection between pregnancy or childbirth and female mental illness. It wasn't until the onset of the twentieth century that the attitude of the scientific community shifted once again: the consensus amongst gynecologists and other medical experts was to turn away from the idea of diseased reproductive organs and instead towards more "scientific theories" that encompassed a broadening medical perspective on mental illness. The phenomenon of baby blues was first named amid the surge of births following World War II and is understood as emotional distress of fluctuations that begin a couple days postpartum and can last up to two weeks, affecting 80% of new mothers. The definition of postpartum depression has been expanded into a spectrum of disorders under the umbrella term perinatal depression as per the DSM IV. ==Society and culture==

Legal recognition Recently, postpartum depression has become more widely recognized in society. In the US, the Patient Protection and Affordable Care Act included a section focusing on research into postpartum conditions including postpartum depression. Some argue that more resources in the form of policies, programs, and health objectives need to be directed to the care of those with PPD. Role of stigma When stigma occurs, a person is labeled by their illness and viewed as part of a stereotyped group. There are three main elements of stigmas, 1) problems of knowledge (ignorance or misinformation), 2) problems of attitudes (prejudice), and 3) problems of behavior (discrimination). Specifically regarding PPD, it is often left untreated as women frequently report feeling ashamed about seeking help and are concerned about being labeled as a "bad mother" if they acknowledge that they are experiencing depression. When this spirit is unsatisfied and venting resentment, it causes the mother to experience frequent crying, loss of appetite, and trouble sleeping, known collectively as "sakit meroyan". The mother can be cured with the help of a shaman, who performs a séance to force the spirits to leave. Some cultures believe that the symptoms of postpartum depression or similar illnesses can be avoided through protective rituals in the period after birth. These may include offering structures of organized support, hygiene care, diet, rest, infant care, and breastfeeding instruction. The relationship with the mother-in-law has been identified as a significant risk factor for postpartum depression in many Arab regions. Based on cultural beliefs that place importance on mothers, mothers-in-law have significant influences on daughters-in-law and grandchildren's lives in such societies as the husbands frequently have close relationships with their family of origin, including living together. After giving birth to five children in the coming years, she had severe depression and many depressive episodes. This led to her believing that her children needed to be saved and that by killing them, she could rescue their eternal souls. She drowned her children one by one over the course of an hour, by holding their heads underwater in their family bathtub. When called into trial, she felt that she had saved her children rather than harming them and that this action would contribute to defeating Satan. This was one of the first public and notable cases of postpartum psychosis, or the murder of children by their parents. Throughout history, both men and women have perpetrated this act, but the study of maternal filicide is more extensive. == See also ==