Abstract
Background
Anemia and postpartum depression (PPD) are common perinatal morbidities. Recognition of postpartum anemia as a major risk factor for PPD is crucial for postpartum maternal health. This study aimed to examine the association between anemia and PPD in low-income minority Arab-Bedouin mothers in southern Israel.
Methods
The study was conducted in 2017–2018 and included 332 women aged 18 to 45 years who were 2–4 months postpartum. Retrospective data on postpartum anemia (defined as a hemoglobin level < 12 g/dL) was extracted from women’s medical records in the clinics. PPD was measured by the Edinburgh Postnatal Depression Scale (EPDS) score ≥ 10 through face-to-face interviews.
Results
Of the total sample, 69% had anemia and 23% had PPD. The prevalence of PPD was higher among women with anemia compared to those without anemia (28.4% vs. 11.7%). Multivariate analysis showed that women with anemia have a nearly threefold increased risk of PPD (95%CI = 1.4–5.6), after adjusting for a range of socioeconomic and obstetrics factors. Additional factors contributing to a higher risk of PPD included living in unrecognized villages (95%CI = 1.2–3.8), a history of one or more miscarriages (95%CI = 1.0-3.3), and being 2 months postpartum compared to 3–4 months (95%CI = 1.1–3.3).
Conclusions
Postpartum anemia is associated with a higher risk of PPD. This suggests that women with anemia require closer monitoring of PPD symptoms for early detection and treatment. Tailored health policies, education, and enhanced maternal care practices about anemia and PPD can improve maternal health outcomes and reduce disparities.
Keywords: Anemia, Arab-Bedouin, Hemoglobin, Minority, Postpartum depression
Background
Postpartum depression (PPD) is a significant public health problem, affecting approximately 14% of mothers worldwide with variations in incidence based on country, culture, and economic status [1]. PPD is one of the most common non-obstetric complications associated with childbearing age or childbirth [2]. PPD can have serious implications for maternal mental health, mother-child bonding, and child development [3]. PPD symptoms may range from mild to severe including feelings of sadness, hopelessness, or emptiness, sleep and appetite disturbance, impaired concentration, anhedonia, feelings of worthlessness or guilt, and anxiety [4].
Anemia, another common perinatal condition, is defined as a reduction in the hemoglobin concentration below a certain threshold that can result from micronutrient deficiencies, infections, chronic diseases, or blood loss [5]. The World Health Organization (WHO) thresholds defining anemia as a hemoglobin concentration less than 12.0 g/dL for non-pregnant and lactating women and less than 11.0 g/dL for pregnant women [6, 7]. Approximately, half of anemia cases are due to iron deficiency, which reduces hemoglobin production [8].
Postpartum anemia is mainly caused by untreated antenatal iron deficiency and excessive blood loss during or after childbirth [9], and its prevalence in women after delivery remains unacceptably high in both developed (22–50%) and developing (50–80%) countries [9, 10]. Anemia and PPD share common symptoms such as fatigue, irritability and impaired cognition, which may exacerbate maternal health issues [11].
Previous research indicates that perinatal anemia significantly increases the risk of PPD [12]. Iron deficiency may affect neurological functioning and mood regulation [13]. Anemia impairs the health and well-being of women and increases the risk of adverse maternal outcomes [14].
Postpartum anemia can lead to cognitive challenges and emotional issues. Mood is strongly affected by brain iron levels, especially iron deficiency [15]. A review of the literature reported that 8 of 10 studies identified a higher risk for PPD in women with anemia [16]. A recent study reported that mothers with iron deficiency were three times more likely to have PPD [17].
Recognition of postpartum anemia as a major risk factor for PPD is crucial for postpartum maternal health. Iron deficiency is the most common cause of maternal anemia because of insufficient maternal iron stores at conception, increased pregnancy-related iron requirements, and iron losses due to blood loss during childbirth [18, 19]. Anemia is associated with PPD, fatigue, impaired cognition, and impeded maternal‐infant bonding [20]. Additionally, infants born to mothers with anemia are more vulnerable to anemia in the first year of life [21]. Moreover, mothers with anemia might have reduced iron levels in their breast milk, potentially leading to their babies receiving insufficient mineral content for optimal growth and development [22]. Women belonging to minority or ethnic groups can have an elevated risk of anemia [14, 23]. Ethnic minority women tend to live in remote areas with low socioeconomic status, low levels of education, and unique dietary habits [24] and have lower access to healthcare services. Moreover, they are more likely to lack knowledge on prenatal healthcare [24]. Research has shown that women from ethnic minority background tends to experience higher rates of postpartum anemia due to various social, economic, and healthcare-related factors [25].
Arab-Bedouin women minority in southern Israel have higher levels of anemia compared to women in other population groups. One study reported that severe anemia (hemoglobin < 8 g/dl) was more prevalent in Bedouin women than in Jewish women (8.1% vs. 6.3%) [26]. Several factors might explain this disparity, including socioeconomic challenges, limited access to healthcare services (HCS), living conditions particularly in unrecognized villages [27], and a lack of nutritional and anemia prevention awareness.
Bedouin society is a unique social group within the Arab minority in Israel, that comprises 27.4% of the population of the Negev region [28]. Most (60%) Bedouin Arabs live in eight planned towns while the rest (40%) live in unrecognized villages [28]. The standard of living among the Bedouin population, particularly among those residing in unrecognized villages, is considerably lower than the average in other areas in Israel. Bedouin local authorities mostly lack basic welfare, educational, and healthcare services [28]. Bedouin women’s low socioeconomic status has been associated with a high prevalence of PPD [29, 30]. The prevalence of PPD among Bedouin women as high as 31%, of which 19.1% were assessed as having moderate-to-severe symptoms (Edinburgh Postnatal Depression Scale [EPDS] ≥ 13) [29]. Despite the high PPD rates and high prevalence of postpartum anemia in Bedouin women, empirical evidence on the association between these two health issues is lacking.
Given the elevated rates of both anemia and PPD in this underserved population, the present study aimed to examine whether anemia is associated with an increased risk of PPD among Arab Bedouin mothers in southern Israel. The research question guiding this study was: Is postpartum anemia associated with an increased risk of postpartum depression among Arab Bedouin mothers in southern Israel? Understanding this relationship is crucial for developing targeted maternal health interventions to improve the health of both mothers and infants.
Methods
Study design and participants
This cross-sectional study included a convenience sample of 332 women aged 18–45 years, who were recruited during visits to women’s health clinics. The required sample size was estimated using WinPepi software, assuming a significance level of α = 0.05, 80% statistical power, and expected odds ratio of 2.0, the minimum required sample size was 331 participants, and the final analytic sample included 332 women. Participants were individually interviewed at 2–4 months postpartum as part of a larger study [30]. Women younger than 18 years and those unable to speak Arabic were excluded from the study.
Study procedures and data collection
Data collection took place in two women’s health clinics in southern Israel. Eligible women were approached by a physician or nurse, who provided a brief description of the study and requested their participation. Eligible women who agreed to participate, received written information about the study in Arabic and signed a consent form. Participants were interviewed face-to-face by a trained nurse and research assistant. The interviews took place in a private clinic room using a structured questionnaire in Arabic language. The questionnaire included questions on PPD and other sociodemographic and socioeconomic variables. Retrospective data on anemia and obstetrics history data were obtained from medical records. We used each women’s ID to collect the relevant data, ensuring confidentiality throughout the process. Participant recruitment and face-to-face interviews were conducted between October 2017 and July 2018. In 2021, following additional ethical approval, supplementary clinical and obstetric data were retrospectively retrieved from participants’ medical records. Specifically, we collected hemoglobin (Hb) levels, focusing on the most recent recorded Hb result before the interview. This allowed us to link obstetric history and anemia data with the timing of our interviews, providing a clearer picture of each participants’ health status.
Study measures
Dependent variable
Arabic version of the Edinburgh Postnatal Depression Scale (EPDS) was used to assess PPD symptoms [31, 32]. The EPDS asks women about the frequency of various depressive symptoms over the past week. The EPDS Arabic version has been widely used in the Middle East, including in Bedouin women in Israel [29]. It includes a 10-item scale with responses measured on a Likert scale, ranging from not at all (0) to yes, all the time (3). The EPDS score ranges from 0 to 30, with higher scores indicating a greater likelihood of PPD. In this study, PPD was measured as a dichotomous variable, with an EPDS score ≥ 10 was used to indicate significant symptoms of PPD [31]. Women who scored 10 or higher, and those who reported thoughts of self-harm (item #10), were identified as having PPD symptoms and were referred to the clinic for further assessment and treatment. The internal consistency for postpartum parameters was high in the current study (Cronbach’s α = 0.80).
Independent variable
Anemia
Data on anemia were obtained retrospectively from the medical records and were based on hemoglobin levels measured 2–4 months postpartum. Postpartum anemia was defined as a hemoglobin level below 12 g/dL [7, 33]. For the current data analysis, a dichotomous anemia variable was primarily used with a cutoff of 12 g/dL. First, anemia was categorized into four groups: severe anemia.
(< 8.0 g/dL), moderate anemia (8.0–10.9 g/dL), mild anemia (11.0–11.9 g/dL), and no-anemia (≥ 12.0 g/dL), according to World Health Organization guidelines [7].
Sociodemographic characteristics
We collected data on women’s age (categorized 15–24, 25–34, and ≥ 35 years), residence type (recognized/unrecognized), and number of children (0, 1–3, and ≥ 4).
Socioeconomic status
We measured education by two levels (High school diploma or lower education / Secondary and higher education), women’s and husband’s employment status were dichotomized into employed and unemployed, and family income categorized as lower than the monthly average [< ILS 15,149/month (3,938.74 USD)], similar to the average, or higher than the average.
Reproductive health variables
Miscarriages: Based on women’s reports, we initially we asked the participants: “How many miscarriages have you had in the past?” However, for the analysis, we categorized this into a dichotomous variable, with one group including women who had experienced one or more miscarriages and the other group including women who did not report any miscarriages. According to the miscarriage was defined as pregnancy loss before 22 completed weeks of gestation [34]. Other variables included planned pregnancy (yes/no), mode of delivery (spontaneous/cesarean section), number of months postpartum, use of iron supplements postpartum (yes/no), history of general depression (yes/no), and history of PPD (yes/no, history of PPD referred to a prior episode of PPD following a previous pregnancy and did not refer to PPD symptoms assessed during the current postpartum period).
Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics for Windows, version 28. Data were analyzed using descriptive statistics to summarize participants’ characteristics and the prevalence of PPD symptoms and anemia. Univariate analyses were performed to examine the associations between anemia and PPD, as well as between independent variables and PPD, using the chi-square test and t-test. In addition, multivariate logistic regression analysis was conducted to estimate the associations (odds ratios and 95% confidence intervals) between anemia and PPD symptoms while adjusting for potential confounding variables that were significantly (p < 0.05) associated with PPD (EPDS scores ≥ 10 in the univariate analysis) and their clinical relevance. Two models were used: an unadjusted model (Model 1) and an adjusted model (Model 2) that included variables significantly associated with PPD (EPDS ≥ 10) in the univariate analysis were included in the adjusted model. These variables included residence type (sociodemographic factor), history of miscarriages and months postpartum (reproductive/obstetric factors), and history of general depression and history of postpartum depression (mental health factors).
Ethical considerations
This study was conducted in accordance with the declaration of Helsinki and was approved by the Ethics Review Committees of Ben-Gurion University of the Negev and Clalit Health Services Helsinki committee (0004–16-COM2; date of approval, October 2017). Additional ethical approval (COM-0107-21; November 2021) was obtained for acquiring data from participants’ medical records [30]. All participants received written and verbal information about the purpose of the study, study procedures, and the expected time required to complete the interview. Participation was voluntary, and participants were informed that they could withdraw from the study at any time without any consequences for their medical care. Written informed consent was obtained from all participants before data collection. To ensure confidentiality, all data were anonymized and stored securely with restricted access available only to the research team. Personal identifiers were removed from the dataset prior to analysis. Data were stored in password-protected files in accordance with institutional data protection policies. Participants were informed that the data would be used for research purposes only. Contact information for the research team was provided to participants in case they had questions about the study.
Results
332 women were included in the study. Table 1 presents the characteristics of the study participants. Mean age was 28 (6) years, with an age range of 18–45, half of the participants (53.9%) were aged 25–34 years. Almost one quarter lived in unrecognized villages (26%). About half 45% had 1–3 children. In addition, 76.6% had a high school diploma or lower education. Most participants were unemployed (82.8%), while their husbands were mostly employed (87.0%). Notably, 87.7% reported family income below the national average, indicating potential economic challenges. About a third of the women had unplanned pregnancies, and most births were spontaneous (81.9%). Moreover, 33.7% had experienced miscarriages, and only 47.3% took postpartum iron supplements. Finally, 9.6% had a history of general depression, and 9% reported a history of PPD (Table 1).
Table 1.
Socio-demographic characteristics of study participants (N = 332)
| Variables | Total sample N = 332 |
|---|---|
| N (%) | |
| Maternal age (mean (SD), range) | 28.5 (6.0), 18–45 |
| 18–24 | 93 (28.0) |
| 25–34 | 179 (53.9) |
| 35–45 | 60 (18.1) |
| Residence type | |
| Recognized village | 244 (73.5) |
| Unrecognized village | 88 (26.5) |
| Number of children | |
| 0 | 97 (29.2) |
| 1–3 | 151 (45.5) |
| 4–12 | 84 (25.3) |
| Woman’s education | |
| ≤ High school | 252 (76.6) |
| > Secondary and higher education | 77 (23.4) |
| Woman’s employment status | |
| Employed | 57 (17.2) |
| Unemployed | 275 (82.8) |
| Husband’s employment status | |
| Employed | 289 (87.0) |
| Unemployed | 43 (13.0) |
| Family income | |
| Below the national average | 291 (87.7) |
| Above/similar to the national average | 41 (12.3) |
| Number of miscarriages | |
| 0 | 220 (66.3) |
| ≥ 1 | 112 (33.7) |
| Planned pregnancy | |
| Yes | 206 (62.0) |
| No | 126 (38.0) |
| Mode of delivery | |
| Spontaneous | 272 (81.9) |
| Cesarean section | 60 (18.1) |
| Number of months postpartum | |
| 2 months | 118 (35.5) |
| 3–4 months | 207 (62.3) |
| Use of iron supplements postpartum | |
| Yes | 157 (47.3) |
| No | 175 (52.7) |
| History of general depression | |
| No | 32 (9.6) |
| Yes | 300 (90.4) |
| History of PPD | |
| No | 30 (9.0) |
| Yes | 302 (91.0) |
The distribution of four levels of hemoglobin is shown in Fig. 1. Among the women with anemia (a hemoglobin level ≤ 12 g/dL), 115 (34.6%) were classified as having mild anemia (11–11.9 g/dL), 108 (32.5%) as having moderate anemia (8–10.9 g/dL), and 6 (1.8%) as having severe anemia (< 8 g/dL). The prevalence of anemia among women in the study sample was 69.0% (Fig. 1).
Fig. 1.
Frequency distribution of four levels of hemoglobin among the study participants (N = 332)
PPD symptoms (EPDS ≥ 10) were detected in 23.2% of the women in the total study sample (Fig. 2).
Fig. 2.
Prevalence of PPD (EPDS ≥ 10) among the total study sample (N = 332)
Table 2 presents the univariate associations between independent variables and PPD, as measured by EPDS scores, revealing significant associations between anemia and PPD (EPDS ≥ 10). Women with anemia had more than twice the rate of PPD compared to mothers without anemia (28.4% vs. 11.7%). In addition, residing in unrecognized villages was significantly associated (p = 0.005) with higher PPD rates (34% versus 19% respectively). Women with a history of depression reported more PPD symptoms compared to those without a history of depression, (40% versus 21% respectively). Miscarriages showed a borderline association with PPD (p = 0.053), with approximately one-third of women who experienced miscarriages reporting PPD symptoms, compared to those who did not experience miscarriages (29.5% versus 20% respectively). No significant associations were found between age, number of children, education, employment, family income, planned pregnancy, delivery mode, and postpartum iron intake and PPD (Table 2).
Table 2.
Univariate associations between independent variables and PPD (N = 332)
| Variables | EPDS < 10 N = 255 (76.8%) N (%) |
EPDS ≥ 10 N = 77 (23.2%) N (%) |
P-value |
|---|---|---|---|
| Anemia status | < 0.001 | ||
| Hemoglobin ≥ 12 | 91 (88.3) | 12 (11.7) | |
| Hemoglobin < 12 | 164 (71.6) | 65 (28.4) | |
| Maternal age (mean (SD), range) | 0.754 | ||
| 18–24 | 73 (78.5) | 20 (21.5) | |
| 25–34 | 138 (77.1) | 41 (22.9) | |
| 35–45 | 44 (73.3) | 16 (26.7) | |
| Residence type | 0.005 | ||
| Recognized village | 197 (80.7) | 47 (19.3) | |
| Unrecognized village | 58 (65.9) | 30 (34.1) | |
| Number of children | 0.400 | ||
| 0 | 76 (78.4) | 21 (21.6) | |
| 1–3 | 119 (78.8) | 32 (21.2) | |
| 4–12 | 60 (71.4) | 24 (28.6) | |
| Woman’s education | 0.581 | ||
| ≤ High school | 192 (76.2) | 60 (23.8) | |
| > Secondary and higher education | 61 (58.4) | 16 (18.2) | |
| Woman’s employment status | 0.444 | ||
| Employed | 46 (80.7) | 11 (19.3) | |
| Unemployed | 209 (76.0) | 66 (24.0) | |
| Husband’s employment status | 0.691 | ||
| Employed | 223 (77.2) | 66 (22.8) | |
| Unemployed | 32 (67.2) | 11 (25.6) | |
| Family income | 0.806 | ||
| Below the national average | 145 (76.3) | 45 (23.7) | |
| Above/similar to the national average | 110 (77.5) | 32 (22.5) | |
| Number of miscarriages | 0.053 | ||
| 0 | 176 (80.0) | 44 (20.0) | |
| ≥ 1 | 79 (70.5) | 33 (29.5) | |
| Planned pregnancy | 0.071 | ||
| Yes | 168 (80.0) | 42 (20.0) | |
| No | 87 (71.3) | 35 (28.7) | |
| Mode of delivery | 0.757 | ||
| Spontaneous | 208 (76.5) | 64 (23.5) | |
| Cesarean section | 47 (78.3) | 13 (21.7) | |
| Number of months postpartum | 0.044 | ||
| 2 months | 83 (70.3) | 35 (29.7) | |
| 3–4 months | 166 (80.2) | 41 (19.8) | |
| Use of iron supplements postpartum | 0.713 | ||
| Yes | 122 (77.7) | 35 (22.3) | |
| No | 133 (76.0) | 42 (24.0) | |
| History of general depression | 0.014 | ||
| No | 236 (78.7) | 64 (21.3) | |
| Yes | 19 (59.4) | 13 (40.6) | |
| History of PPD | 0.022 | ||
| No | 237 (78.5) | 65 (21.5) | |
| Yes | 18 (60.0) | 12 (40.0) |
Table 3 presents the results of a multivariate logistic regression models comparing women with PPD (EPDS scores ≥ 10) to women with no PPD (scores below 10). In both models, women with anemia consistently showed a higher risk of PPD symptoms compared to those with no anemia. In the unadjusted model (Model 1), women with postpartum anemia were three times more likely to report PPD symptoms than those without anemia, unadjusted odds ratio (OR) and 95% confidence intervals (CI) = 3.0 (1.5–5.8). In model 2, after adjusting for independent variables, women with anemia had higher odds of PPD compared with women without anemia (OR = 2.8, 95% CI = 1.4–5.6). Additionally, the likelihood of experiencing PPD was almost twice as higher for women living in unrecognized village compared to whom living in recognized village (OR = 2.1, 95% CI = 1.2–3.8), nearly twice as higher of women with a history of one or more miscarriages compared to those who did not experience miscarriages (OR = 1.9, 95% CI = 1.0-3.3), and 1.8 times higher for those 2 months postpartum compared to those 3–4 months postpartum (OR = 1.8, 95% CI = 1.1–3.3).
Table 3.
Unadjusted and adjusted regression models for the association between anemia and PPD (EPDS ≥ 10) among the total study sample (N = 332)
| Model 1 | Model 2 | |||
|---|---|---|---|---|
| Variables | OR (95% CI) | P-value | OR (95% CI) | P-value |
| Anemia status | ||||
| Hemoglobin ≥ 12 g/dl | 1 | 1 | ||
| Hemoglobin < 12 g/dl | 3.0 (1.5–5.8) | < 0.001 | 2.8 (1.4–5.6) | 0.003 |
| Residence type | ||||
| Recognized village | 1 | |||
| Unrecognized village | 2.1 (1.2–3.8) | 0.010 | ||
| Number of miscarriages | ||||
| 0 | 1 | |||
| ≥ 1 | 1.9 (1.0–3.3) | 0.029 | ||
| History of general depression | ||||
| No | 1 | |||
| Yes | 1.6 (0.6–3.7) | 0.309 | ||
| History of PPD | ||||
| No | 1 | |||
| Yes | 2.1 (0.9–5.1) | 0.078 | ||
| Number of months postpartum | ||||
| 2 months | 1.8 (1.1–3.3) | 0.026 | ||
| 3–4 months | 1 | |||
Discussion
This study aimed to examine the association between anemia and PPD in Bedouin mothers in southern Israel, a population with higher prevalence of these two conditions compared to other Israeli women. The results showed that 69% of participants had anemia, a finding consistent with previous research. For example, a recent systematic review and meta-analysis reported a 69% prevalence of anemia among postpartum women in Ethiopia [35]. Additionally, 23.2% of women in this study reported PPD symptoms 2–4 months postpartum, indicating potential clinical symptomology. This prevalence aligns with a recent meta-analysis of 15 studies conducted in various Middle East countries, which reported a 27% prevalence of PPD [36].
Our findings indicate that anemia is a significant risk factor for PPD, with women who had postpartum anemia being at nearly three times higher risk of PPD. These findings are consistent with previous studies. For instance, a recent study conducted in Gaza reported that mothers with iron deficiency were three times more likely to have PPD [17]. A meta-analysis confirmed that postpartum anemia significantly increases the risk of PPD, showing that in 10 studies, PPD prevalence was significantly higher among women with anemia than those without anemia [12]. Additionally, a recent study conducted among postpartum women from southern Malawi, indicated that maternal anemia at birth was associated with increased risk for moderate and/or severe early PPD [37]. Another study conducted among women from Australia by Xu et al., (2018) found that women with anemia were more likely to be hospitalized for depression compared to those without anemia [38].
The association between anemia and PPD among Bedouin women can be explained by several socioeconomic and other factors identified in the multivariate analysis. It appears that this relationship is influenced primarily by socioeconomic status and type of residence. Our findings showed a 69% rate of anemia with 34.6% classified as mild anemia, 32.5% as moderate anemia, and 1.8% as severe anemia. Similarly, a study conducted in the US reported a higher prevalence of anemia among minority women (48%) compared to non-minority women (27%) [39]. Another study further linked postpartum anemia to low socioeconomic status and ethnic minority background as significant contributing factors [40].Given the cross-sectional design, PPD symptoms may adversely affect self-care behaviors and adherence to nutritional supplementation. In a prospective study among pregnant women, persistent common mental disorder symptoms were associated with subsequent iron-deficiency anemia through a shorter duration of iron supplement use [41]. Similarly, a recent study found that adults with depressive symptoms had significantly lower odds of dietary supplement use compared with those without depressive symptoms [42]. These findings suggest that PPD symptoms could potentially contribute to persistent anemia through reduced adherence to iron supplementation. PPD symptoms also may contribute to poorer nutritional status through changes in appetite, motivation, dietary choices, and self-care behaviors. Previous studies have shown that depressive symptoms during the perinatal and postpartum periods are associated with less healthy eating patterns, including greater intake of takeaway foods, altered reward-related eating, lower vegetable intake, and reduced dietary variety [43, 44]. These behavioral pathways could potentially contribute to persistent iron deficiency or anemia.
Women from unrecognized villages had a significantly higher rate of PPD compared to those from recognized villages (34.1% vs. 19.3%), with the likelihood of experiencing PPD being 2.1 times greater for women living in an unrecognized village. This difference highlights the role of socioeconomic and structural factors in PPD risk. A previous study on general depression among Bedouin women in southern Israel also found a higher prevalence of depressive symptoms in women living in unrecognized villages compared to those living in recognized villages (57.9% and 41.9%) [45]. Our findings align with global research showing that women in rural areas face a higher risk of PPD compared to those in urban areas [46]. The higher prevalence of PPD among women living in unrecognized villages may be attributed to several factors, including the lack of basic services, economic disparities, limited access to healthcare, cultural stigma, and political and legal uncertainty. living in such conditions can create a sense of insecurity and anxiety, which may contribute to PPD [27]. Addressing the high prevalence of PPD in these areas requires a multifaceted approach, including improved access to essential services, reduced economic disparities, decreased social isolation, and increased awareness of mental health issues and support services.
The current study also found that women who experienced miscarriage were at an increased risk of developing PPD. Approximately one-third of women with a history of miscarriages reported PPD symptoms, compared to 20% of those who had never had a miscarriage, with the risk nearly doubling for women who had one or more miscarriages. Miscarriage can be both physically and emotionally traumatic event for many women. Similar findings have been observed in Israel, where a positive correlation was found between EPDS score and the number of spontaneous abortions and elective pregnancy terminations [47]. In addition, a recent study conducted in Kenya reported that pregnancy loss was five times higher among a large cohort of perinatal women with moderate-to-severe depression [48].
Our study also showed that PPD rates varied depending on when mothers were assessed: women who were 2 months postpartum had a higher rate of PPD (29.7%) compared to those who were 3–4 months postpartum (19.8%). Additionally, the likelihood of experiencing PPD was more than 1.8 times greater for mothers assessed at 2 months postpartum than those assessed 3–4 months. Other studies also report a high prevalence of PPD during the first 2–3 months after birth. For example, one study found an average PPD prevalence of 16.7% during the first 3 months postpartum [49]. A possible explanation for this finding is the combination of other factors influencing this report, particularly physiological and recovery processes following childbirth. During the immediate postpartum period (the first few weeks to 2 months after birth), women may experience anemia due to blood loss during delivery, particularly if there were complications such as postpartum hemorrhage [9]. In contrast, by 3–4 months postpartum, women have had more time to recover from childbirth, and their iron levels may have improved, either naturally or due to iron supplementation or better nutrition. As a result, the prevalence of anemia might decrease, and with it, there could be a potential reduction in PPD rates, given the association between anemia and PPD. This emphasizes the need for early screening and intervention for both anemia and PPD within the first few months after childbirth.
Despite the fact that previous research has highlighted the positive impact of iron supplementation on mental health our findings did not show a significant association between iron supplementation and PPD in the final model. Our results contradict with these findings from a systematic review of women of childbearing age found that cognitive scores significantly improved following iron treatment [50]. These finding suggest a strong relationship between iron supplementation and improved mental health outcomes. Therefore, interventions emphasizing a well-balanced diet rich in iron and other essential nutrients during pregnancy and the postpartum period are crucial. Iron supplementation, combined with emotional support, counseling, and lifestyle adjustments, should be integral to maternal health care.
Study limitations
This study has several limitations. First, the findings cannot be generalized to all Bedouin women, as participants were recruited from only two clinical settings in southern Israel. However, these clinics primarily serve Bedouin women. Second, the lack of clinical interviews with a psychiatrist or other licensed clinician limited our ability to validate self-reported PPD symptoms. Third, the observational design restricts our ability establish causality between anemia and PPD, as unmeasured factors such as birth-related blood loss, the type of iron supplementation, or nutritional status may have influenced the relationship over time. Despite these limitations, observational studies are valuable for providing insights and generating hypotheses for future research. Fourth, reliance on self-reports and the potential for socially desirable responses may have led to an underreporting of PPD symptoms. Fifth limitation of this study is that the exact dates of Hb measurements were not available in the analytic dataset, preventing assessment of variability in the timing of Hb measurement and its potential association with anemia status or PPD. Finaly, miscarriage history was also assessed only as a lifetime ever/never variable, without information on the timing of the pregnancy loss relative to the index pregnancy, preventing assessment of whether miscarriage recency was differentially associated with current PPD. These limitations should be considered when interpreting our findings and their implications for clinical practice and future research.
Conclusions
This study found a significant association between anemia and PPD among Bedouin women in southern Israel, a population characterized by high rates of anemia, low socioeconomic status, and limited access to healthcare services. The findings highlight the importance of recognizing postpartum anemia as a potential risk factor for maternal mental health. Early identification and treatment of anemia, along with improved perinatal nutrition and monitoring, may help reduce the risk of PPD in vulnerable populations. Additional factors such as residence in unrecognized villages and a history of miscarriages, further emphasizes the need for targeted maternal health interventions.
Future research using longitudinal designs and larger samples is needed to better understand the relationship between anemia and PPD.
Acknowledgements
We would like to thank the participants for taking part in this study. We also thank Clalit Healthcare Services for their assistance in facilitating this study.
Authors’ contributions
Conceptualization, S.A.-Z. and N.D.; methodology, S.A.-Z. and N.D.; submission to Helsinki Committee, S.A.-Z., Z.A., H.A.G., and N.D.; formal analysis, S.A.-Z., H.A.G., and N.D.; data duration, S.A.-Z. and Z.A.; writing—original draft preparation, S.A.-Z., H.A.G. and N.D.; writing-review and editing, S.A.-Z., H.A.G., and N.D.; supervision, N.D.; project administration, S.A.-Z., H.A.G., and N.D.; funding acquisition, S.A.-Z. and N.D.; All authors have read and agreed to the published version of the manuscript.
Funding
This study was funded by the Ministry of Science and Technology (#8762591), Israel.
Data availability
Anonymized data are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the declaration of Helsinki and was approved by the Ethics Review Committees of Ben-Gurion University of the Negev and Clalit Health Services Helsinki committee (0004–16-COM2, date of approval, October 2017). Additional ethical approval (COM-0107-21; November 2021) was obtained for acquiring data from participants’ medical records [30]. All participants received written and verbal information about the purpose of the study, study procedures, and the expected time required to complete the interview. Participation was voluntary, and participants were informed that they could withdraw from the study at any time without any consequences for their medical care. Written informed consent was obtained from all participants before data collection. To ensure confidentiality, all data were anonymized and stored securely with restricted access available only to the research team. Personal identifiers were removed from the dataset prior to analysis. Data were stored in password-protected files in accordance with institutional data protection policies. Participants were informed that the data would be used for research purposes only. Contact information for the research team was provided to participants in case they had questions about the study.
Consent for publication
Informed written consent was obtained from all study participants at recruitment.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Anonymized data are available from the corresponding author upon reasonable request.