Role of psychological resilience and social support in perinatal depression: a systematic review and meta-analysis

Abstract

Background

Perinatal Depression (PND) is a prevalent mental health disorder with adverse effects on both maternal and infant outcomes. Although psychological resilience and social support are widely considered protective factors against PND, the existing evidence is quite inconsistent. Consequently, this meta-analysis aimed to systematically assess and quantify the associations among PND, psychological resilience, and social support.

Methods

This systematic review and meta-analysis were conducted in accordance with the PRISMA 2020 guidelines. Six electronic databases, grey literature, and reference lists were searched up to March 18, 2025. Studies were eligible if they investigated the association between perinatal depression and resilience or social support. The study quality was assessed using the AHRQ checklist for cross-sectional studies and the Newcastle–Ottawa Scale for cohort designs. A random-effects meta-analysis was conducted in R to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Twenty-nine studies (N = 18,213) were included. The overall meta-analysis showed no significant association between the combined protective factors of resilience and social support with perinatal depression (OR = 0.83, 95% CI: 0.66–1.05). In subgroup analyses based on exposure levels, studies that compared women with higher resilience to those with lower levels showed a reduced risk of postpartum depression (OR = 0.73, 95% CI: 0.62–0.87), while studies that used low resilience as the exposure group reported increased odds (OR = 3.54, 95% CI: 2.34–5.34). A similar pattern was observed for social support: studies using greater support as the exposure found a protective effect (OR = 0.65, 95% CI: 0.50–0.84), whereas those using minimal support as the exposure reported higher odds (OR = 3.90, 95% CI: 2.46–6.18). These contrasting directions reflect differences in how primary studies defined the reference group, and the pooled estimates were therefore derived from distinct study sets rather than from the same data. Effect sizes also varied by maternal age and study design. Sensitivity analyses confirmed the robustness of the findings, and no evidence of publication bias was detected.

Conclusion

High resilience and strong social support are associated with reduced risk of PND, whereas low resilience and minimal support are linked to increased risk. Although the overall pooled association was not statistically significant, subgroup findings underscore the importance of considering study context and reference group definitions. These results highlight the value of integrating resilience-building and social support interventions into perinatal mental health strategies.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12884-026-09466-7.

Introduction

The perinatal period, a critical transition in a woman’s life, is characterised by a high prevalence of mental health disorders, among which perinatal depression (PND) is a prominent public health concern with serious implications for maternal and child outcomes [1]. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), PND is defined as a major depressive episode occurring during pregnancy or within one year post-delivery and is one of the most prevalent complications of pregnancy and childbirth [1, 2]. In addition to adversely affecting maternal health, PND has been linked to impaired mother–infant bonding, adverse birth outcomes, and long-term cognitive, emotional, and behavioural difficulties in children [3–7]. Recent studies have reported prevalence rates of approximately 26% for PND, 29% for antenatal depression (AND), and 28% for postpartum depression (PPD) [8]. Such discrepancies likely reflect differences in how primary studies defined perinatal, antenatal, and postpartum periods, as well as variation in screening tools and sample characteristics.

Multiple demographic, psychosocial, obstetric, and biological determinants contribute to PND and often interact in complex ways [9, 10]. Among protective factors, psychological resilience and social support have received increasing attention. The American Psychological Association defines resilience as the ability to adapt positively in the face of adversity, trauma, or stress [11]. Once regarded as a stable trait [12], resilience is now considered a dynamic process that can change over time [11, 13]. Evidence suggests that resilience regulates depression, anxiety, and post-traumatic stress disorder in perinatal women [14–17]. Social support, optimism, financial stability, and related factors can further enhance resilience [18, 19].

Resilience levels are generally higher during pregnancy than postpartum, yet postpartum resilience and its underlying mechanisms have been less thoroughly examined [20]. Higher resilience has been associated with reduced risks of PPD and post-traumatic stress disorder [21]. Nevertheless, resilience may not operate independently. Several studies have reported that social support, rather than resilience alone, mediated the relationship between life events and depression in early pregnancy and moderated the impact of adverse experiences on postnatal depression [19, 22, 23]. Although research on postpartum resilience remains limited, emerging evidence suggests that higher resilience is linked to lower depressive and anxiety symptoms, and may mediate or moderate the effects of stressors and social support on postpartum mental health [24–26]. The role of social support in perinatal mental health is also well established: low levels of support increase vulnerability to depression and anxiety, whereas higher levels buffer the effects of stress and improve maternal and infant outcomes [27–31]. Moreover, resilience and social support are interrelated, as resilient individuals are more likely to build and sustain supportive relationships [32].

Despite their recognised importance, the pathways by which social support and psychological resilience influence perinatal depressive symptoms remain only partially understood. Growing evidence indicates that these factors may operate through mechanisms such as stress appraisal, sleep quality, and emotion regulation, with effects that vary between antenatal and postpartum stages [20, 26, 33]. Therefore, this study aimed to synthesize available evidence on the associations of psychological resilience and social support with PND, and to examine moderators across antenatal and postnatal stages.

Methodologies

This systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [34, 35], and the protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD420251012756; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251012756).

Inclusion and exclusion criteria

The inclusion and exclusion criteria were developed based on the PICOS framework to ensure rigour and comparability.

Inclusion criteria: (1) Population (P)—perinatal women, including pregnant (during gestation) and postpartum women (up to 1 year post-delivery);(2) Intervention/Exposure (I)—studies on psychological resilience and/or social support, including related constructs (e.g., self-efficacy, coping strategies) and types of support (emotional, informational, instrumental); (3) Comparison (C)—with or without control groups, or comparisons across resilience/support levels; (4) Outcomes (O)—perinatal depression (antenatal or postpartum), measured with validated tools (e.g., EPDS, BDI) or clinical diagnosis; (5) Study design (S)—observational studies (cohort, longitudinal, cross-sectional); (6) Language (L)—peer-reviewed articles published in English.

Exclusion criteria: non-perinatal populations; studies not assessing resilience/support; insufficient data; outcomes not involving PND or assessed with unvalidated tools; reviews, case reports, abstracts, qualitative studies; and studies without full text. For duplicate datasets, the most complete version was retained.

Literature searching

Two complementary strategies were used to identify eligible studies. First, six databases (Web of Science, PubMed, EBSCO, Embase, Cochrane Library, and ScienceDirect) as well as grey literature sources (e.g., Google Scholar) were systematically searched. Boolean operators (“AND”, “OR”), controlled vocabulary, and database-specific functions were applied, and the searches were independently conducted by two authors (DQ and TT).

Keywords were organized according to the PICO framework, covering population (e.g., pregnancy, antenatal, perinatal, postpartum, motherhood*), exposure/intervention (e.g., social support [MeSH], family relations [MeSH], peer support [MeSH], partner support, community support, support network), and outcomes (e.g., depression, depressive symptoms, mood disorder, affective disorder, psychiatric disorders*). The full electronic search strategies for each database are provided in Appendix A.

Second, the reference lists of the included studies were manually screened to identify additional eligible articles.

Study selection

All search results were imported into Zotero (v.6.0), where duplicates and irrelevant records were removed. Two reviewers (DQ and TT) independently screened titles, abstracts, and full texts, achieving high inter-rater agreement (≥ 97%). Disagreements were resolved through discussion or by consulting a third reviewer (senior co-author).

Data extraction

Data from each included study were independently extracted by two reviewers (DQ and TT) using a standardised form developed a priori. Extracted variables included:

• Study characteristics: first author, year of publication, country, study design, and sample size.

• Participant details: maternal age, parity, gestational or postpartum stage.

• Exposure measures: assessment tools for psychological resilience and/or social support, as well as the timing of measurement.

• Outcomes: perinatal depression diagnosis or validated screening tool scores (e.g., EPDS, BDI).

• Effect measures: odds ratios (ORs), relative risks (RRs), correlation coefficients (r), and 95% confidence intervals (CIs). Where necessary, effect estimates were transformed into log(ORs).

• Discrepancies in extracted data were resolved through discussion or arbitration by a third reviewer.

Quality assessment of included studies

Two reviewers independently appraised methodological quality. Cross-sectional studies were evaluated with the 11-item Agency for Healthcare Research and Quality (AHRQ) classified as low (0–3), moderate (4–7), or high quality (8–11). Cohort and longitudinal studies were assessed using the Newcastle–Ottawa Scale (NOS), which evaluates selection, comparability (with a maximum of 2 points), and outcome assessment (with a total score of 0–9; scores of 7–9 indicate high quality) [36]. Disagreements were resolved by consensus or with a third reviewer.

Data analysis and synthesis

All analyses were conducted in R (v.4.2.1) using the meta and metafor packages. Pooled effect sizes (ORs, 95% CIs) were calculated. For studies reporting correlation coefficients (r) instead of odds ratios (ORs), r values were converted into log ORs using standard formulas to ensure comparability across effect size metrics [37, 38]. Heterogeneity was assessed with Cochran’s Q and I². Random-effects models were applied when heterogeneity was moderate/high (Qp < 0.10, I² > 50%); otherwise, fixed-effect models were used. A random-effects model was chosen as the primary approach to account for between-study variation. Subgroup analyses were performed by resilience level, study design, and participant age. Meta-regression explored potential moderators. Sensitivity analyses (leave-one-out) tested robustness. Publication bias was examined with funnel plots and Egger’s regression test.”

We conducted stratified analyses according to study design (cross-sectional vs. cohort), maternal age (< 30 vs. ≥ 30 years), and exposure levels (high vs. low resilience/support). For maternal age, a cut-off of 30 years was prespecified, as this threshold aligns with common categorisations in perinatal epidemiology (e.g., 20–29, 30–34, ≥ 35 years) [39]. Prior studies have reported differential risks of perinatal depression across this boundary, with women aged 30–39 years showing higher risk compared with those aged 20–29 years [40], and distinct profiles observed between younger (< 30 years) and older mothers in population-based cohorts [41]. Accordingly, we adopted a cutoff of < 30 years vs. ≥ 30 years to maximise comparability across studies and ensure sufficient power.

Results

Included studies

Herein, six databases were initially searched from inception to March 18, 2025, yielding 12,568 records, of which 2,711 were retained after preliminary screening of titles and abstracts. Following de-duplication, 447 articles were retained for further assessment, of which 289 were subsequently excluded for non-conformity with the inclusion criteria based on title and abstract screening. The full texts of the remaining 158 articles were further assessed for eligibility, leading to the exclusion of 97 studies for not evaluating the effects of psychological resilience and/or social support on PND, three studies for not meeting the study design criteria, five articles with retracted or unavailable full texts, five studies with low methodological quality, nine studies that only reported prevalence rates without analysing the associated factors, and ten studies with populations that did not meet the inclusion criteria. Ultimately, only 29 studies were included in the final analysis. Figure 1 details the study selection process.

Fig. 1.

Flowchart of the PRISMA-based study selection process

The data extracted included basic study information (authors, publication year, country, study type, and total sample size), PPD prevalence, subject ages, education level, follow-up duration, social support and/or psychological resilience, and PPD assessment scales and timing (Table 1).

Table 1.

Characteristics of the included studies and extracted data

Ref	Author (Year)	Country	Study Type	Education Level	Sample Size	Age (Mean ± SD)	Study frequency	Exposure Tool(s)	Outcom Tool(s)	PPD Incidence	Exposure Type	Period	Study Results
[42]	Sarah et al. (2024)	Belgium	Longitudinal study	Intervention: Higher education 91.6%; Control: Higher education 93.7%	n = 102	M = 31.4 SD = 3.86	6	CD-RISC MSPSS EPDS	EPDS	−	R or SS	28–32 weeks of pregnancy; 32–36 weeks; 3 weeks after delivery; 9–12 weeks after delivery; 6 months and 12 months after delivery	Resilience remained stable, and participants strengthened social support during restrictions
[43]	Berg et al. (2021)	Netherlands	Longitudinal study	Higher education: 89.6%	n = 1406	M = 30.6	2	EPDS	EPDS	8.00%	SS	3 weeks and 12 months postpartum	Social support reduced depressive symptoms partly via enhanced maternal self-efficacy
[44]	Zheng et al. (2018)	China	Longitudinal study	Higher education: 64.6%	n = 420	M = 27.28 SD = 3.22	2	EPDS PSSS	EPDS	6 week: 21.4% 12 week: 18.2%	SS	6 weeks postpartum, 2 weeks postpartum	Among primiparous women, social support rose and depressive symptoms declined between 6–12 weeks postpartum
[45]	Zhang & Jin (2016)	China	Cross-sectional	Not reported	n = 427	M = 26.17 SD = 2.16	1	EPDS MSPSS	EPDS	-	SS	6–10 weeks postpartum	Higher social support was linked to fewer postpartum depressive symptoms
[19]	Kishore et al. (2018)	India	Cohort study	Secondary or college education: 80.2%	n = 589	M = 23.13 SD = 3.44	2	EPDS CDRS-10 SRRS	EPDS	6.50%	R or SS	between 6 and 20 weeks of gestation at the time of first contact	Resilience had a weak link to PND, whereas social support buffered stress-related depressive symptoms
[46]	Haga et al. (2012)	Norway	Longitudinal study	Higher education: 42%	n = 737	M = 32 SD = 4.32	3	EPDS BSSS	EPDS	10.00%	SS	6 weeks, 3 months, and 6 months postpartum	Perceived social support correlated strongly with fewer depressive symptoms across postpartum assessments
[47]	Lara et al. (2016)	Mexico	Longitudinal study	Mean years of education: M = 13.0 SD = 3.8	n = 210	M = 29.5 SD = 6.3	2	PHQ-9 RESI PDPI-R	PHQ-9	15%	SS	at 6 weeks and 6 months postpartum	Low resilience and social support predicted PND at 6 weeks and 6 months postpartum
[48]	Nie et al. (2017)	China	Cross-sectional	University: 61.05%	n = 126	M:30.0.5 SD = 0.65	1	EPDS SSRS CD-RISC	EPDS	Low resilience:50.0% High resilience: 27.7%	R	Women with threatened preterm labor at 28 to 37 weeks;6–8 weeks postpartum	Resilience protected against depressive symptoms in threatened preterm labor and was linked to greater perceived support
[49]	Maxson et al. (2016)	USA	Cohort study	Above high school: 49.8%	n = 1852	M = 27 SD = 3.5	2	ISEL CES-D	CES-D	-	R or SS	18 to 28 weeks of pregnancy	Low partner/paternal support predicted more depressive symptoms, stress, and health risks in pregnancy
[50]	Dadi et al. (2020)	Ethiopia	Cohort study	Above high school: 63.1%	n = 916	M: 26.5 SD = 4.5	2	EPDS OSSS-3	EPDS	6.50%	SS	Late pregnancy, one month after delivery	Depression’s links with preterm birth and low birth weight were mitigated by partner support and coping skills
[51]	Shang et al. (2022)	China	Cross-sectional	University: 78.2%	n = 234	M = 29.21 SD = 3.9	1	SSRS CD-RISC EPDS	EPDS	−	R or SS	at 6–8 weeks after birth	Social support mediated the link between resilience and postpartum depression
[52]	Surati et al. (2024)	India	Cross-sectional	Below high school: 78.9%	n = 403	M = 28.57 SD = 3.59	1	EPDS MSPSS	EPDS	50.10%	SS	Women who have given birth within the past 12 months	Low and moderate support predicted higher risk of PND compared with high support, even after adjustment
[53]	Zhang et al. (2020)	China	Cohort study	Most participants held a bachelor's degree	n = 508	M = 28.64 SD = 4.344	7	EPDS BRS SSRS	EPDS	34.10%	R	First trimester (13 weeks gestation or earlier), second trimester (17–20 weeks and 21–24 weeks), third trimester (31–32 weeks and 35–40 weeks), and postpartum (7 days and 6 weeks postpartum)	Resilience was the strongest predictor of postpartum depression across stages
[15]	Julian et al. (2021)	USA	Longitudinal study	Not reported	n = 233	M = 30.35 SD = 5.96	2	EPDS SLE PMS DSES	EPDS	25%	R	At approximately 4 to 8 weeks after birth,	Optimism and mastery predicted fewer depressive symptoms; spirituality had no effect; family support was key
[54]	Baattaiah et al. (2023)	Saudi Arabia	Cross-sectional	University: 75.5%	n = 1409	M = 29 SD = 5	1	EPDS BRS	EPDS	26%	R	Women who are two weeks to one year postpartum	Resilience inversely predicted PND, confirming its protective role
[26]	Wang et al. (2024)	China	Cross-sectional	University education: 59.95%	n = 1074	M = 28 SD = 4.5	1	EPDS PSSS CD-RISC-10	EPDS	19.40%	R or SS	Pregnant women undergoing pregnancy test	Resilience was the strongest determinant of antenatal depression; higher resilience/support reduced risk
[55]	Ma et al. (2019)	China	Longitudinal study	Not reported	n = 2813	M = 29.45 SD = 4.10	3	RSA CES-D	CES-D	10.30%	R	During weeks 12 to 16, 24 to 28, and 32 to 36 of pregnancy and at delivery	Resilience buffered stress effects on depression and anxiety directly and indirectly
[56]	Sarah et al. (2016)	Germany	Longitudinal study	Not reported	n = 297	M = 32.35 SD = 4.46	3	RS-11 F-SozU K-14 BDI-V EPDS	EPDS	Pregnancy and 6 weeks postpartum: 10% 12 weeks postpartum: 6%	R	Six weeks before birth, six weeks after birth, and twelve weeks after birth	Low resilience and support predicted higher antenatal depression risk
[57]	Patil et al. (2021)	India	Cross-sectional	Below secondary school: 74.45%	n = 458	M = 28 SD = 4.5	1	EPDS CD-RISC MSPSS	EPDS	-	R or SS	8 weeks postpartum	Trauma history and limited social support increased depression risk of depression during pregnancy
[58]	Marie et al. (2022)	Rwanda	Cross-sectional	Below high school: 86.6%	n = 396	M = 30.8 SD = 6.58	1	EPDS MSSS	EPDS	26.60%	SS	Pregnancy is 6 months or more	Lack of partner support increased the risk of antenatal depression
[59]	Zhang et al. (2020)	China	Cross-sectional	University: 50.7%	n = 605	M = 30	1	CES-D	CES-D	28.40%	R	Pregnant women between 12 and 40 weeks of gestation	Positive maternal–fetal relationships and high resilience mitigated antenatal depression risk
[33]	Brandão et al. (2024)	Portugal	Cross-sectional	Higher education: 69.9%	n = 160	M = 33 SD = 4.94	1	EPDS MSPSS	EPDS	-	SS	Postpartum time ranged from 1 to 12 months	Social support was negatively correlated with postpartum depressive symptoms
[60]	Tobe et al. (2020)	Japan	Longitudinal study	University: 85.9%	n = 531	M = 32.47 SD = 4.57	2	EPDS Sukemune-Hiew	EPDS	16.80%	R	Surveys in late pregnancy and one month after delivery	Trait anger predicted postpartum depression, partly mediated by poor adaptation in pregnancy
[61]	García-León et al. (2019)	Spain	Longitudinal study	Not reported	n = 151	M = 33.01 SD = 4.42	2	CD-RISC EPDS	EPDS	-	R	26–32 weeks of pregnancy, 10–12 weeks postpartum	High resilience was associated with better wellbeing, fewer psychopathological symptoms, and lower PND scores
[62]	Leigh & Milgrom (2008)	Australia	Longitudinal study	Not reported	n = 367	M = 30.8 SD = 5.1	2	EPDS BDI	EPDS	Prenatal: 16.9%, postnatal: 11.2%	SS	26–32 weeks of pregnancy, 10–12 weeks postpartum	Predictors of antenatal depression included low self-esteem, poor social support, and negative cognition
[63]	Golbasi et al. (2010)	Türkiye	Cross-sectional	≤ 5 years education: 64%	n = 258	M = 25.7 SD = 5.4	1	EPDS MSPSS	EPDS	27.50%	SS	Pregnant women	Perceived social support was inversely associated with antenatal depression
[64]	Waqas et al. (2015)	Pakistan	Cross-sectional	Below high school: 92%	n = 500	M = 27.41 SD = 5.65	1	SPS HADS	HADS	31.00%	SS	Pregnant women	Lack of support was a significant risk for antenatal depression/anxiety, while higher support reduced risk
[65]	Dibaba et al. (2013)	Ethiopia	Cohort study	Low education: 95.3%	n = 627	M = 26 SD = 5.02	1	EPDS MSSS	EPDS	19.90%	SS	Pregnant women	Unintended pregnancy raised depression risk, buffered by strong social support
[66]	Agostini et al. (2015)	Italy	Longitudinal study	Higher education: 90.3%	n = 404	M = 31.8 SD = 4.3	2	EPDS MSSS	EPDS	14.90%	SS	From pregnancy to 12 months postpartum	Higher perceived social support reduced antenatal depression symptoms

OR Odds Ratio, CI Confidence Interval, β Beta Coefficient (β), R Pearson Correlation Coefficient, M-W Test Mann–Whitney U Test, RR Relative Risk, SSRS Social Support Rating Scale, MOS-SS Medical Outcomes Study Social Support Survey, CD-RISC Connor-Davidson Resilience Scale, EPDS Edinburgh Postnatal Depression Scale, BDI-II Beck Depression Inventory-II, SPS Social Provision Scale, PSSS Perceived Social Support Scale, PSSS Postpartum Social Support Scale, RSA Resilience Scale for Adults, CES-D Center for Epidemiologic Studies Depression Scale, RS-13 Resilience Scale-13, DSES Daily Spiritual Experience Scale, LOT-R Life Orientation Test-Revised, Pearlin and Schooler, Mastery Scale; F-SozU K-14 = Perceived Social Support Questionnaire, BDI-V Beck Depression Inventory, HIS Hispanic Stress Inventory, MOS Medical Outcome Study, MSSS Multidimensional Scale of Social Support, USA United States of America

Characteristics of the included studies

Overall, 29 studies published between 2008 and 2024 were included, comprising 18,213 participants with sample sizes ranging from 102 to 2,813 [42, 55]. Most studies were conducted in Asia, particularly in China, whereas relatively few originated from Europe or Africa, indicating geographic gaps that may limit the generalizability of the findings.

In terms of design, 12 studies were longitudinal, 12 were cross-sectional, and 5 were cohort investigations. Longitudinal and cohort studies commonly followed participants from early pregnancy through 12 months postpartum.

Perinatal depression was assessed using validated instruments in all studies. The Edinburgh Postnatal Depression Scale (EPDS) was the most widely applied (24 studies), followed by the Centre for Epidemiologic Studies Depression Scale (CES-D, 3 studies), the Patient Health Questionnaire-9 (PHQ-9, 1 study), and the Hospital Anxiety and Depression Scale (HADS, 1 study). Thirteen studies employed more than one tool. The timing of depression assessment varied considerably, from 6 weeks of gestation to 12 months postpartum, with several studies including multiple time points.

The reported prevalence of PND ranged from 6.5% to 50.1%, reflecting heterogeneity in populations, measurement instruments, and assessment timing.

Regarding research focus, 14 studies examined social support in relation to PND, 11 investigated psychological resilience or related constructs (e.g., self-efficacy, emotion regulation, coping), and 4 addressed both factors simultaneously. While most studies considered single protective factors, few assessed their combined effects, underscoring the need for more integrative research frameworks. Detailed study characteristics are summarised in Table 1.

Quality evaluation

Among the AHRQ-assessed cross-sectional studies, 9 were rated as high quality (scores > 8/11) [26, 33, 45, 51–53, 58, 63, 64]. In addition, all longitudinal (n = 10) and cohort (n = 4) studies evaluated using the NOS achieved high quality (scores > 5/9) [19, 42–44, 46, 47, 49, 50, 55, 56, 61, 62, 65, 66]. A detailed summary of the quality assessments is provided in Appendix B.

Narrative analyses

Psychological resilience and PND

Ten of the 29 studies consistently reported significant negative associations between resilience and PND, indicating that resilience is a protective factor across populations. For example, a Chinese study found resilience to be the strongest predictor of PPD (mean score = 3.10, SD = 0.37) [59], while a Saudi study reported a strong negative correlation with EPDS scores (r = –0.530, p < 0.001) and confirmed resilience as a predictor of depressive symptoms (β = –0.393, R² = 0.37) [54]. A U.S. cohort study further showed that women with higher resilience profiles—characterised by greater self-efficacy and support—experienced fewer depressive symptoms and better pregnancy outcomes compared with those with low resilience [49]. Similar protective associations were also reported in Germany, Japan, and Spain [56, 60, 61].

In addition to direct effects, resilience moderated stress–depression pathways. A Chinese study demonstrated that resilience predicted lower PND risk (standardised effect = –0.27) and partially mediated pregnancy stress [55]. However, a Belgian longitudinal observational study reported that resilience scores increased over time, although no significant changes were observed in depression outcomes [42].

Social support and PND

Thirteen studies reported that social support was inversely associated with PND. Large-scale studies in China, Turkey, Pakistan, and India found that low social support independently predicted higher EPDS scores, even after adjustment for confounders [44, 52, 63, 64]. Similarly, Ethiopian, Rwandan, and Italian studies confirmed that women with higher social support had significantly lower odds of antenatal depression [58, 65, 66].

Beyond its direct effect, social support also acted as a mediator and moderator. Studies in China and Portugal found that support enhanced self-efficacy and emotion regulation, thereby reducing depression [33, 45]. A Dutch study further highlighted the mediating role of self-efficacy in the support–depression association [43]. Research from India and Norway emphasised that specific types of support, particularly perceived availability, were most protective (β = –0.33) [46].

Interaction effects were also observed. For instance, an Ethiopian study reported nearly a fivefold increased risk of preterm birth in depressed women with low social support [50]. Similarly, an Indian study identified both low support (AOR = 2.51) and prior depression (AOR = 2.94) as significant predictors of PPD [52].

Combined effects of resilience and social support

Six studies examined the combined impact of resilience and social support. An Indian study found that resilience did not significantly predict perinatal depression under stress (OR = 0.95, p = 0.22), whereas social support exerted a strong moderating effect (OR = 0.75, p < 0.001) [19]. Similarly, one study reported that social support predicted lower EPDS scores, while resilience did not mediate the effect of trauma [57]. In Mexico, both low social support and traditional female roles contributed to PPD at 6 weeks and 6 months postpartum [47]. In contrast, a Chinese study reported lower EPDS scores (M = 9.9 vs. 13.8, p < 0.001) and higher support levels among women with high resilience [48].

Other studies confirmed the joint protective role of both factors. For example, resilience (r = –0.41) and social support (r = –0.33) were each negatively correlated with PPD, while positively associated with one another (β = –0.255, p < 0.01) [51]. Likewise, regression analyses in China identified resilience (β = –0.129; 95% CI: –0.176 to –0.104; p < 0.001) and social support (β = –0.028; 95% CI: –0.053 to –0.006; p = 0.013) as significant predictors of antenatal depression [26]. A U.S. study further linked optimism and mastery—core components of resilience—to reduced depression, while spirituality showed no effect [15].

Overall synthesis

Across studies, both resilience and social support consistently functioned as protective factors against PND. Social support demonstrated a stronger, more consistent effect, while resilience moderated stress pathways and interacted with contextual factors. Together, these findings underscore the complementary roles of resilience and social support in mitigating perinatal depression.

Psychological resilience

The meta-analysis of ten studies showed no significant overall association between resilience and PND (OR = 0.88, 95% CI: 0.57–1.36; I² = 94.8%, τ² = 0.4503, p < 0.0001), indicating substantial heterogeneity (Fig. 2). Stratified by exposure level, low resilience was associated with markedly increased odds of PND (OR = 3.54, 95% CI: 2.34–5.34; I² = 0%), whereas high resilience was significantly protective (OR = 0.73, 95% CI: 0.62–0.87; I² = 94.6%). The between-group difference was statistically significant (Q = 47.44, p < 0.0001) (Fig. 2).

Fig. 2.

Forest plot of the association between psychological resilience and perinatal depression (PND)

Social support

The pooled analysis of studies examining social support found no significant association with PND (OR = 0.91, 95% CI: 0.59–1.41; I² = 98%). Stratified analyses showed that women with higher levels of support had significantly lower odds of PND (OR = 0.65, 95% CI: 0.50–0.84; I² = 93.6%), whereas minimal support was associated with substantially increased odds (OR = 3.90, 95% CI: 2.46–6.18; I² = 64.9%). The between-group difference was statistically significant (Q = 44.22, p < 0.0001) (Fig. 3).

Fig. 3.

Forest plot of the association between social support and perinatal depression (PND)

Taken together, the overall pooled effects of resilience and social support were non-significant, largely due to substantial heterogeneity across studies. However, stratified analyses showed consistent patterns: higher resilience and greater social support were associated with reduced odds of PND, whereas low resilience and minimal social support were associated with substantially increased odds. These findings suggest that heterogeneity was driven in part by how exposure levels were defined.

Combined protective factors

When resilience and social support were examined together, the pooled analysis showed no significant association with PND (OR = 0.83, 95% CI: 0.66–1.05; I² = 89.5%). The high heterogeneity suggests that combining these factors across diverse study definitions diluted the overall effect. Protective associations were observed only in stratified analyses, not in the overall combined model (Fig. 4).

Fig. 4.

Forest plot of the combined protective factors (resilience and social support) in relation to PND

Subgroup analysis

Study design and resilience. Cohort studies (n = 5) showed no significant association (OR = 1.10, 95% CI: 0.45–2.69; I² = 94.0%). Cross-sectional studies (n = 2) suggested a non-significant inverse association (OR = 0.81, 95% CI: 0.59–1.11; I² = 89.7%), while longitudinal studies (n = 3) indicated a protective effect (OR = 0.83, 95% CI: 0.78–0.87; I² = 51.5%). The subgroup difference was not statistically significant (Q = 0.40, p = 0.82) (Fig. 5).

Fig. 5.

Subgroup analysis of the association between psychological resilience and PND by study design

Study design and social support. Longitudinal studies (n = 6) showed no significant association (OR = 0.91, 95% CI: 0.66–1.23; I² = 91.6%). Cross-sectional studies (n = 3) showed a non-significant protective effect (OR = 0.61, 95% CI: 0.31–1.19; I² = 93.3%), although some reported stronger effects. Cohort studies (n = 2) demonstrated the most consistent protective association (OR = 0.34, 95% CI: 0.21–0.56; I² = 68.5%). The subgroup difference was significant (Q = 16.31, p = 0.001)(Fig. 6).

Fig. 6.

Subgroup analysis of the association between social support and PND by study design

Maternal age and resilience. Women < 30 years (n = 4) had no significant association (OR = 0.88, 95% CI: 0.32–2.46; I² = 95.0%), while women ≥ 30 years (n = 6) showed a significant protective effect (OR = 0.86, 95% CI: 0.79–0.94; I² = 84.3%). Subgroup difference was not significant (Q = 0.00, p = 0.97) (Fig. 7).

Fig. 7.

Subgroup analysis of the association between psychological resilience and PND by maternal age

Maternal age and social support. Women ≥ 30 years (n = 6) showed a non-significant protective effect (OR = 0.75, 95% CI: 0.54–1.02; I² = 92.7%), whereas women < 30 years (n = 8) showed no evidence of protection (OR = 1.08, 95% CI: 1.00–1.14; I² = 98.7%). Subgroup difference was not significant (Q = 0.79, p = 0.38) (Fig. 8).

Fig. 8.

Subgroup analysis of the association between social support and PND by maternal age

Timing of social support assessment. Studies assessing both prenatal and postnatal periods (n = 5) suggested a non-significant protective trend (OR = 0.62, 95% CI: 0.30–1.31; I² = 94.9%). Prenatal-only studies (n = 4) showed a non-significant protective association (OR = 0.86, 95% CI: 0.66–1.13; I² = 89.4%). Postnatal-only studies (n = 5) showed no protective effect (OR = 1.40, 95% CI: 0.54–3.67; I² = 99.1%). Subgroup differences were not significant (Q = 1.70, p = 0.43) (Fig. 9).

Fig. 9.

Subgroup analysis of the association between social support and PND by timing of assessment

Publication bias and sensitivity analyses

Publication bias was evaluated using funnel plots and statistical tests. Visual inspection suggested mild asymmetry; however, Egger’s test (bias = –0.42, SE = 2.58, p = 0.873) and Begg’s test (p = 0.873) showed no significant evidence of bias. Leave-one-out sensitivity analysis further confirmed robustness: pooled ORs remained stable (range: 0.79–1.00; overall OR: 0.91, 95% CI: 0.59–1.41), and heterogeneity estimates varied minimally (I² = 97.4–98.2%). These findings suggest that no single study had a material influence on the overall effect. Detailed results are provided in Supplementary Appendix C.

Discussion

This systematic review and meta-analysis synthesised 29 studies, involving 18,213 participants to examine the roles of psychological resilience and social support with perinatal depression (PND). Although the overall pooled effects were not statistically significant, stratified analyses across the included studies consistently demonstrated a protective pattern: women with higher levels of resilience or greater social support had a lower risk of PND, whereas those with low resilience or limited support were more vulnerable to depressive symptoms. This pattern was evident across studies conducted in diverse cultural and clinical contexts, including Europe, Asia, and Africa, and across both antenatal and postnatal periods [15, 19, 43, 53, 55, 61].

Several methodological and contextual features of the included studies likely contributed to the non-significant overall pooled estimates. First, substantial construct heterogeneity was present. Resilience and social support were assessed using a wide range of instruments and categorisation approaches, which limited comparability across studies and may have attenuated pooled associations [49, 55, 59, 61]. Second, the timing of exposure and outcome assessment varied considerably, with measurements conducted during pregnancy, postpartum, or across both periods [15, 43, 47, 55]. Evidence from longitudinal and cohort studies indicates that associations between psychosocial resources and depressive symptoms may differ by perinatal stage, and pooling estimates across heterogeneous time points may therefore obscure stage-specific relationships [44, 47, 56].

Third, heterogeneity in study design further contributed to between-study variability. Many included studies employed cross-sectional designs, which are inherently susceptible to simultaneity and residual confounding [63–65], whereas others used longitudinal or prospective designs that better captured temporal relationships [43, 44, 47]. The aggregation of these designs likely increased variance in the pooled estimates.

Despite these limitations, stratified analyses within the included studies revealed a consistent and interpretable pattern. When resilience or social support was categorised into higher versus lower exposure levels, protective associations with PND were more clearly observed [15, 19, 55, 59, 61]. Several studies further suggested that resilience and social support functioned as buffering or intermediary factors within broader psychosocial pathways linking stress, adverse life events, emotional regulation, or self-efficacy to perinatal depressive symptoms [15, 19, 51, 60].

The synthesis of included studies also underscores the contextual nature of social support. Studies conducted in different sociocultural settings highlighted considerable variation in the sources and functional meaning of support, including partner support, extended family involvement, and community or healthcare-based resources [44, 52, 58, 65]. Such contextual differences likely contributed to heterogeneity and cannot be fully captured by a single pooled estimate, but become more apparent when exposure levels are examined separately rather than averaged across heterogeneous populations.

Assessments of robustness supported the credibility of these findings. Funnel plot inspection indicated only mild asymmetry, and sensitivity analyses confirmed that no single study disproportionately influenced the pooled results. Importantly, exposure-level stratification was prespecified and conceptually coherent within the scope of this review, and the direction of associations was generally consistent across study design, timing of assessment, and age categories among the included studies.

From a clinical and public health perspective, the findings suggest that vulnerability to PND is not evenly distributed but is concentrated among women with limited psychosocial resources. Several included studies highlighted the importance of identifying women with low resilience or inadequate social support during routine antenatal and postnatal care[53–55, 58]. These women represent a priority group for preventive and supportive strategies to strengthen coping capacity and enhance available support networks.

Future research should address the limitations identified within the included studies by prioritising greater standardisation of exposure measurement, clearer definition of exposure thresholds, and wider use of longitudinal designs to clarify temporal relationships [43, 44, 47]. Individual participant data meta-analyses may further improve comparability by harmonising definitions and consistently adjusting for confounders. Greater attention to contextual moderators, including cultural and health service characteristics, will also be essential to move beyond heterogeneous average effects.

In summary, this review's findings indicate that the key issue is not whether resilience and social support are relevant to PND, but rather under what conditions their protective associations become detectable. When exposure level, timing, study design, and context are explicitly considered in the included evidence, a coherent pattern emerges: higher resilience and stronger social support are associated with a lower risk of PND, whereas low levels indicate vulnerability. The non-significant overall pooled estimate is therefore best interpreted as reflecting underlying heterogeneity rather than an absence of meaningful association.

Limitations

While the present findings provide valuable insights, several limitations warrant consideration. First, heterogeneity was moderate to high across several analyses, likely due to variation in measurement tools, participant characteristics, cultural contexts, and data-collection timing, which complicates cross-study comparability. Second, most included studies employed cross-sectional designs, which precluded causal inference. Cohort studies yielded more stable estimates, but their limited numbers underscore the need for additional longitudinal research. Third, considerable variation existed in the measurement of resilience and social support. A wide range of instruments was used, which may have introduced measurement bias and reduced comparability. In particular, the lack of standardization in evaluating social support (e.g., perceived vs. received support, partner vs. family sources) further complicates interpretation. Fourth, the concentration of studies in China, an upper-middle-income country, limits the generalizability of our findings to other cultural and socioeconomic contexts, particularly low-income regions where perinatal women face distinct psychosocial stressors and healthcare barriers, and indicates the need for more evidence from diverse settings. Fifth, age-stratified analyses were limited to < 30 versus ≥ 30 years, as very young (< 20) and advanced-age (> 40) mothers were rarely reported in primary studies, precluding reliable subgroup analysis. Finally, restricting inclusion to English-language publications may have led to incomplete coverage of the available evidence.

Conclusions

This review demonstrates that psychological resilience and social support function as protective factors against perinatal depression, with effects becoming most evident when exposure levels are explicitly considered. Stratified analyses indicated that associations varied across study designs, age groups, and perinatal periods, underscoring the importance of context in shaping outcomes. Collectively, these findings support stress-buffering theory and a life course perspective, emphasising psychosocial resources as key determinants of maternal mental health. Importantly, resilience-building strategies and social support enhancement should be incorporated into perinatal mental health interventions, particularly in resource-limited settings. Future high-quality longitudinal studies are essential to clarify causal pathways and optimise intervention timing across the perinatal continuum.

Significant findings

Our meta-analysis indicated that psychological resilience and social support were inversely associated with perinatal depression. Low resilience was linked to substantially higher risk of perinatal depression, whereas high resilience appeared protective. Similarly, strong social support was associated with a reduced risk, while minimal support was associated with a markedly increased risk. In stratified analyses, these protective effects were generally consistent across study designs, age groups, and perinatal stages, with stronger associations observed among women aged ≥ 30 years, although some subgroups showed substantial heterogeneity. Overall, these findings support the stress-buffering model, suggesting that resilience and social support help mitigate psychological strain during the perinatal period.

Implications for practice, policy, and research

This review has important implications for clinical practice, health policy, and future research.

Clinical practice: The demonstrated protective effects of resilience and social support highlight the need for early screening and stratified risk assessment of these factors within routine perinatal care. Healthcare providers, particularly midwives, nurses, and obstetricians, should employ validated tools to assess resilience and social support during antenatal and postnatal visits. Interventions such as resilience-enhancing programs, peer support groups, and family-based psychoeducation could reduce vulnerability to perinatal depression, especially among younger women or those with limited baseline support.

Health policy: This review provides evidence to support integrating mental health promotion strategies into existing maternal health systems, particularly in resource-limited settings. Given the stronger effects observed in cohort studies and among women aged 30 and older, public health initiatives should be demographically tailored and delivered across the continuum of maternal care. Policymakers are encouraged to prioritize access to social resources, including community-based support networks, and to foster cross-sector collaboration among health, social, and education services to address maternal mental health inequalities.

Research directions: While the protective roles of resilience and social support are well established, several gaps remain. More high-quality longitudinal and intervention studies are needed to clarify causal pathways and temporal dynamics. To enhance comparability, future studies should investigate how resilience is developed, and social support is mobilized, with explicit attention to cultural, socioeconomic, and interpersonal contexts. Standardization of measurement instruments—especially for social support—is essential. Finally, it is imperative for researchers to conduct cross-analyses (e.g., age × support type, resilience × trauma history) to inform the development of more precisely targeted interventions.

Conclusion: This review supports the inclusion of resilience and social support as integral components of maternal mental health frameworks and advocates for a multidisciplinary, evidence-based approach to reduce the burden of perinatal depression.

Abbreviations

PND

Perinatal Depression

NOS

Newcastle–Ottawa Scale

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

PPD

Postpartum Depression

APA

American Psychological Association

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PTSD

Post-Traumatic Stress Disorder

AND

Antenatal Depression

EPDS

Edinburgh Postnatal Depression Scale

BDI

Beck Depression Inventory

IDE

Integrated Development Environment

ORs

Odds Ratios

CIs

Confidence Intervals

CES-D

Center for Epidemiologic Studies Depression

PHQ-9

Patient Health Questionnaire-9

HADS

Hospital Anxiety and Depression Scale

AHRQ

Healthcare Research and Quality

SD

Standdard Deviation

A.U.S

A United States cohort study

Authors’ contributions

DongQin Peng (DQ) conducted the literature screening and data extraction, performed the data analysis, and drafted the initial manuscript. Mei Yan (MY) and Tingting Liao (TT) were responsible for the quality assessment of the included studies. Ling Chang (LC), Azlina Yusuf (AY), Azidah Abdul Kadir (AAK) and Norhasmah Mohd Zain (NMZ) provided critical feedback, contributed to the revision of the manuscript, and supervised the overall research process. All authors read and approved the final version of the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

This study is a systematic review and meta-analysis and did not involve the collection of original data from human participants. Therefore, ethical approval and informed consent were not required.

Consent for publication

Not applicable. This study does not contain any individual person’s data in any form.

Competing interests

The authors declare no competing interests.