To our knowledge this study is the first to study the prevalence of postpartum depression among Syrian women who live in Damascus whether they are original inhabitants or have immigrated internally because of the Syrian crisis through the new pandemic of COVID-19 and its consequences.
The prevalence of possible PPD was 46% when the EPDS test was conducted after birth and 25.3% when it was conducted after 6 weeks. These findings are similar to findings among Middle Eastern women, but seem to be higher than those of other studies in Western countries. The predicted reasons that lead to this high prevalence in the Middle East might be related to the wide range of wars and crises and a bad economic situation [8]. The high prevalence recorded after birth, which may indicate a possible perinatal depression that occurs during or after pregnancy, could be because in perinatal time the mothers face great emotions and feelings of sadness and fatigue, and they may have fears about the delivery process itself, how to raise a child during bad economic situations and how to reach medical facilities during COVID-19 pandemic. It is important to take into account the mild mood changes and feelings of worry, unhappiness, and exhaustion during the first 2 weeks after birth which are also called baby blues and should be differentiate from postpartum depression, which lasts more than 2 weeks and needs treatment [4–9]. This may explain why the depression prevalence was high after birth in comparison with the prevalence after 6 weeks.
We used the Arabic version of the Edinburgh Postnatal Depression Scale questionnaire to identify depressed mothers; it consists of ten questions about the last 7 days [10].
We chose 10 ≤ as a cutoff point because we found that participants tended to underestimate their depressed situation and bad feelings, trying to cover sadness even though the questionnaire was personal, and we guaranteed that they would hide their names and keep their personal affairs secret. However, by making the questionnaire like an interview and person-to-person talking, not just a piece of paper, we ensured more cooperation and presented further required explanations and made the participants feel tranquility to obtain accurate responses as much as possible.
According to a systemic review that included 13 studies conducted in different countries of the Middle East, published between 2006 and 2020 and covering a total of 6074 women in the postpartum period using the Edinburgh Postnatal Depression Scale (EPDS), the rate of postpartum depression in Middle East women was 27% (95% CI 0.19–0.35), and this result is close to our rate of 25.3%, which was 6 weeks after birth [8].
We found only one similar study that was conducted among Syrian women between January and December 2017 in Damascus, Syria, aiming to identify the prevalence of postpartum depression and investigate its risk factors, and showed that 28.2% out of a total of 1105 women who participated had a score of 13 (probable depression) 30–45 days postnatal depending on the EPDS [11].
The risk factors for postpartum depression were classified into 4 categories: 1) sociodemographic factors, 2) obstetric characteristics of study participants, 3) health status of the women and newborns, 4) consequences of the Syrian crisis and COVID-19 symptoms.
Syria continues to face one of the most complex emergencies in the world. Nearly one-third of the housing stock in Syria was destroyed or damaged by early 2017 due to the ongoing conflict and led to continued displacements. The UNHCR estimated that the number of internally displaced individuals was over 6 million. In our study, we found that mothers whose houses were damaged so that they had to leave were more likely to be depressed [12–13]. Other researchers studied depression among Syrian refugees, such as a study that took place in Jordan and was conducted among Syrian refugee women living in northern Jordan, which showed a high level of PPD symptoms among Syrian refugee women because of poverty and limited social support [14]. A systematic review and meta-analysis showed that immigrant women are at higher risk of postpartum depressive symptoms than nonimmigrant women because they face high levels of stress and difficulties in reaching health and social services [15].
Furthermore, women who have experienced a dear person losing or injured due to conflict have a greater probability of being depressed in the postpartum period.
We did not find a statistically significant connection between COVID-19 infection and PPD. This could be because many women dealt with the pandemic as a secondary problem in comparison with their other major problems and considered it like a new economic snag in addition to bad economic conditions, although COVID-19 may have a significant effect on mothers' mental health which was suggested by many published papers, and its consequences, such as isolation and social distancing, which in turn led to decreased social support from family and friends [16–17]. Even so, more studies should be carried out to deeply understand the physical and mental effects of COVID-19.
The woman family and partner play an enormous role in postpartum depression as a medical condition because the depressed mother affects her children and partner badly; on the other hand, the family and the partner may be the first to recognize symptoms in the depressed mother and may advise her to consult a doctor or even be part of the treatment by offering emotional support and taking care of the newborn baby [18].
on the other hand, poor support from family members including husbands and parents, increases the risk of PPD in women [19].
However, we did not find a significant association between the sex of the baby and PPD, unlike other studies that showed associations between of newborn sex and PPD [19–20–21].
The mothers in our study seem to be more depressed when they preferred female gender regardless of the newborn gender; this may be because we live in a male-dominated society.
There were some limitations in this study, including the relatively small sample size. The sample may not represent the whole population because the study was conducted in a governmental hospital, which is a destination for poor people only in most cases and who cannot afford the financial costs of other paid hospitals, which may overlook the prevalence of postpartum depression among rich and high-income families. COVID-19 diagnosis status was determined based on self-reported symptoms, not by performing laboratory tests because of limited resources.
Health care providers, including doctors, nurses and midwives, should be well trained and rehabilitated to deal with psychological issues in pregnant women and during the postpartum period. Women should also be prepared and taught to cope with and face bad feelings, sadness and depression and share these feelings with others and not hesitate to consult a doctor when necessary.