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. 2011 May 26;89(8):607–615D. doi: 10.2471/BLT.11.088187

Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis

اكتئاب الأمهات والنمو المبكر للأطفال في البلدان النامية: مراجعة منهجية وتحليل تلوي

Depresión materna y crecimiento durante la primera infancia en los países en vías de desarrollo: revisión sistemática y metaanálisis

Dépression maternelle et croissance de la petite enfance dans les pays en développement: examen systématique et méta-analyse

Материнская депрессия и рост детей в раннем возрасте в развивающихся странах: систематический обзор и мета-анализ

发展中国家母亲抑郁和儿童早期发育:系统评价和荟萃分析

Pamela J Surkan a,✉, Caitlin E Kennedy b, Kristen M Hurley b, Maureen M Black b
PMCID: PMC3150769  PMID: 21836759

Abstract

Objective

To investigate the relationship between maternal depression and child growth in developing countries through a systematic literature review and meta-analysis.

Methods

Six databases were searched for studies from developing countries on maternal depression and child growth published up until 2010. Standard meta-analytical methods were followed and pooled odds ratios (ORs) for underweight and stunting in the children of depressed mothers were calculated using random effects models for all studies and for subsets of studies that met strict criteria on study design, exposure to maternal depression and outcome variables. The population attributable risk (PAR) was estimated for selected studies.

Findings

Seventeen studies including a total of 13 923 mother and child pairs from 11 countries met inclusion criteria. The children of mothers with depression or depressive symptoms were more likely to be underweight (OR: 1.5; 95% confidence interval, CI: 1.2–1.8) or stunted (OR: 1.4; 95% CI: 1.2–1.7). Subanalysis of three longitudinal studies showed a stronger effect: the OR for underweight was 2.2 (95% CI: 1.5–3.2) and for stunting, 2.0 (95% CI: 1.0–3.9). The PAR for selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms 23% to 29% fewer children would be underweight or stunted.

Conclusion

Maternal depression was associated with early childhood underweight and stunting. Rigorous prospective studies are needed to identify mechanisms and causes. Early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries.

Introduction

Research in developing countries suggests that poor maternal mental health, in particular maternal depression, may be a risk factor for poor growth in young children.1 In addition, the risk of depression in women is approximately twofold higher than in men2 and women are particularly prone in the postpartum period because of hormonal changes associated with childbirth and stressors associated with parenting.3,4 The combination of women’s vulnerability to depression, their responsibility for childcare and the high prevalence of maternal depression in developing countries5 means that maternal mental health in these countries could have a substantial influence on growth during childhood.

Childhood growth is a key indicator of child health and nutritional status. According to recent estimates from developing countries, stunting and underweight have an overall prevalence of 32% and 20%, respectively.6 Inadequate growth during childhood can result in reduced adult stature, low educational performance, reduced economic productivity, impaired work capacity and heightened disease risk.7–12 Rapid physical growth and development occur in early life when infants are dependent on the primary caregiver for their social and nutritional needs,13 which makes young children vulnerable to the effects of their caregivers’ mental health problems.

Recent research on the relationship between maternal depressive symptoms and child stunting or underweight has produced inconsistent results. Two descriptive reviews have provided a summary of research findings14,15 but, to the best of our knowledge, no quantitative synthesis of research results has been produced. Our study goals were to review systematically the literature on maternal depression and childhood growth in developing countries and to summarize and compare any associations found across populations using meta-analytical techniques.

Methods

The study used standard methods for systematic reviews and meta-analyses in accordance with PRISMA (Preferred reporting items for systematic reviews and meta-analyses) and MOOSE (Meta-analysis of observational studies in epidemiology) statements.16,17

Study inclusion criteria

A study was included in the meta-analysis if it: (i) quantitatively assessed the relationship between maternal depression or depressive symptoms (or mental disorders in which depression was a major component) and child growth using an odds ratio (OR) or included data that could be used to calculate an OR; (ii) was published in a peer-reviewed journal up until April 2010; and (iii) was not an intervention study. We restricted our search to developing countries but applied no other population or language restrictions.

Maternal depression and childhood growth can both be assessed using several methods. Depression can be diagnosed through standardized diagnostic interviews, such as the Structured Clinical Interview of the Diagnostic and statistical manual of mental disorders, 4th edition18 or the interview for the Schedules for Clinical Assessment in Neuropsychiatry,19 while depressive symptoms can be assessed directly using a questionnaire, such as the Edinburgh Postnatal Depression Scale20 or assessed as a major component of mental disorders using, for example, the World Health Organization (WHO) Self-Reporting Questionnaire.21 Childhood growth can be quantified in terms of weight-for-age or height-for-age. Underweight and stunting are commonly defined using WHO criteria: more than two standard deviations (SDs) below the mean weight-for-age and the mean height-for-age, respectively (i.e. a z-score < −2). In this analysis we also included studies with more relaxed or more stringent criteria. Overall, the studies included in the analysis measured maternal depression or depressive symptoms and childhood growth in a variety of ways.

Search strategy and study selection

The following online computer databases were searched for studies on maternal depression and child growth: PubMed, PsycINFO, CINAHL Plus, Web of Science, SCOPUS and EMBASE. Medical Subject Heading (MeSH) terms in PubMed were used to identify a string of search terms that were applied in the six databases: (“mother” OR “maternal”) AND (“depression” OR “depressive disorder” OR “mental health”) AND (“child” OR “infant”) AND (“nutritional disorders” OR “growth disorders” OR “nutritional status” OR “body size”). Where available, full-text searches and explosion-of-terms searches were carried out. In an explosion-of-terms search, the initial search terms are linked to a web of similar search terms provided by the database. A search of secondary references was conducted by scanning the reference lists of relevant articles and by cross-referencing with previous reviews on the topic. In addition, experts in the field were contacted to identify additional citations.

Studies that were clearly not relevant were excluded by reviewing their titles and abstracts. The remaining studies were then read in full by at least two authors of this study and selected for inclusion in the analysis by consensus. Articles identified as relevant by both authors were invariably included; those considered relevant by only one author were discussed among all authors to assess their suitability for inclusion.

Data extraction

A systematic coding form was used to record each study’s objective, location, population, design and sample size; the children’s ages; exposure and outcome measures; confounding variables; and the study’s method of analysis, results, conclusions and limitations. Discrepancies in coding were resolved by consensus. The rigour of each study was evaluated using an adaptation of the Newcastle–Ottawa Scale for assessing the quality of nonrandomized studies in meta-analyses.22 Each study was classified by design as either a longitudinal cohort, case–control or cross-sectional study and each was assessed to determine if it satisfied four criteria: (i) the women and children were representative of the community studied; (ii) the response rate (i.e. the percentage of individuals in the selected population sample who agreed to participate in the study and completed follow-up) was 80% or higher; (iii) a diagnostic measure of depression had been used; and (iv) the results had been adjusted for at least two confounding variables.

Meta-analysis

We converted different estimates of effect size to the common metric of an OR since most studies compared two groups and reported dichotomous outcomes. However, three studies reported outcomes as continuous variables.23–25 We converted data from the first of these three studies to ORs using Comprehensive Meta-Analysis V2.2 software (Biostat Inc., Englewood, United States of America). For the other two studies, the original authors either re-analysed the primary data to generate ORs or provided data for us to calculate them. We used standard meta-analytical methods to estimate the standardized effect sizes using the inverse variance approach and random effects models.26 The heterogeneity of the different studies’ findings was assessed using the Q-statistic. Publication bias was assessed from funnel plots of the standard error against the log OR using both Begg and Mazumdar’s rank correlation test and Egger's test of the intercept to determine statistical significance.

Meta-analysis was conducted for the two outcomes of interest – underweight and stunting – using weight-for-age and height-for-age as variables, respectively. When different follow-up times were used in a given study, we used the longest follow-up time. If a study assessed depression at several time points, we used the assessment closest to delivery. We conducted subanalyses of studies that used strict criteria of underweight and stunting (i.e. a weight-for-age and height-for-age z-score < −2 or a weight-for-age and height-for-age below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts27), studies that used a measure of depression or depressive symptoms but not of mental disorders of which depression was a major component, and longitudinal studies.

The population attributable risk (PAR) for underweight and stunting was calculated on the basis of four studies that were selected because they reported significant findings and a prevalence of maternal depressive symptoms near the lower or higher end of the range. For each study, the overall relative risk (RR) of child underweight was calculated using the adjusted OR obtained in that study and the prevalence of underweight in children with depressed mothers. The RR for stunting was similarly obtained. These RRs were then used to calculate the PARs.28

Results

The computer database search yielded 312 citations and two additional records were identified through other sources. After removing duplicates, 210 citations were available for assessment. The initial screening of titles and abstracts identified 51 citations that potentially met the inclusion criteria. After the texts were reviewed in full, 14 articles reporting on 17 separate studies met the inclusion criteria.

The studies came from several regions: four from Africa, six from South America and the Caribbean, six from southern Asia and one from south-eastern Asia. Although the studies covered a mix of urban and rural settings, most were carried out among participants with a low socioeconomic status (Table 1, available from: http://www.who.int/bulletin/volumes/89/8/11-088187).

Table 1. Studies included in systematic review of maternal depression and child growth in developing countries, 1996–2010.

Geographical region and study Country, study design and sample sizea Depression measure and timing of assessment Growth measure and timing of assessment Findings Notes
Southern or south-eastern Asia
Anoop et al. 200429 India, case–control (matched); n = 144 (72 malnourished cases and 72 well nourished controls) Measure: major depression diagnosis using the DSM III R (SCID). Timing: postpartum depression 1 month after birth. Current depression during the past month – after growth assessment Measure: 50–80% versus > 80% of expected weight-for-age. Timing: 6–12 months postpartum Significant finding: postpartum depression, underweight: adjusted OR: 7.4, 95% CI: 1.6–38.5. Non-significant finding: current major depression, underweight: adjusted OR: 3.1, 95% CI: 0.9–9.7 Note: Interactions between current maternal depression and low birth weight and between postpartum depression and low maternal intelligence were statistically significant. The severity of malnutrition was significantly associated with postpartum depression and low maternal intelligence. Covariates included maternal intelligence, low birth weight, socioeconomic status, duration of exclusive breastfeeding, duration of supplementary breastfeeding, immunization status and mother’s literacy.
Black et al. 2009b,24 Bangladesh, cross-sectional, n = 221 Measure: CES-D using a cut off of ≥ 16. Timing: 12 months postpartum Measure: underweight, height-for-age z-score and weight-for-height z-score; stunting, height-for-age z-score < −2. Timing: 6 and 12 months postpartum Significant findings: 12-month height-for-age z-score, adjusted β: –0·01 (P = 0·01); stunting, unadjusted OR: 2.2, 95% CI: 1.3–3.8. Non-significant finding: 12-month weight-for-height z-score, adjusted β: –0·01 (P > 0.05) Note: The relationship between depressive symptoms and infant growth was partially mediated by caregiving. Covariates at 12 months included 6-month weight-for-height z-score, maternal education, poverty status, infant sex, birth order, receipt of zinc or iron, HOME score, maternal perceptions of infant temperament and months of breastfeeding (models were also presented without either infant temperament or the HOME score or both).
Harpham et al. 200530 India, cross-sectional, n = 1 823 Measure: SRQ-20 using a cut off of 7–8. Timing: 6–18 months postpartum Measure: underweight, weight-for-age z-score < −2; stunting, height-for-age z-score < −2. Timing: 6–18 months postpartum Significant finding: stunting, adjusted OR: 1.4, 95% CI: 1.2–1.6. Non-significant finding: underweight, adjusted OR: 1.1, 95% CI: 0.9–1.4 Note: Covariates included maternal age and education, child sex, age and birth weight, and household composition, wealth index and geographical location.
Harpham et al. 200530 Viet Nam, cross-sectional, n = 1 570 Measure: SRQ-20 using a cut off of 7–8. Timing: 6–18 months postpartum Measure: underweight, weight-for-age z-score < −2; stunting, height-for-age z-score < −2. Timing: 6–18 months postpartum Significant finding: underweight, adjusted OR: 1.4, 95% CI: 1.1–1.8. Non-significant finding: stunting, adjusted OR: 1.3, 95% CI: 0.9–1.7 Note: Covariates included maternal age and education, child sex, age and birth weight and household composition, wealth index and geographical location
Patel et al. 2003a,31 India, hospital-based cohort, n = 171 (23% of infants had depressed mothers) Measure: EPDS using a cut off of 11–12. Timing: 6–8 weeks postpartum Measure: underweight, weight-for-age < 5th percentile; stunting, height-for-age < 5th percentile. Timing: 6–8 weeks and 6 months postpartum Significant findings: underweight, adjusted OR range: 2.7–3.6; stunting, adjusted OR range: 3.2–3.8 Note: Significant findings remained after adjusting for the following confounding variables one by one: maternal and paternal education, infant birth weight, sex and feeding practice, infant illness in the first 6 weeks of life and prematurity.
Rahman et al. 200432 Pakistan, case–control, n = 172 (82 cases, 90 controls). Adjusted analyses: n = 107 (48 cases, 59 controls) due to missing data Measure: SRQ-20 using a cut off of ≥ 10. Timing: infant at mean 9.7 months (SD: 0.9) postpartum Measure: underweight, cases, weight-for-age < 3rd percentile; controls, weight-for-age > 10th percentile. Timing: mean 9.7 months (SD: 0.9) postpartum Significant findings: underweight, unadjusted OR: 3.9, 95% CI: 1.9–7.8; adjusted OR: 2.8, 95% CI: 1.2–6.8 Note: Covariates included infant birth weight, number of young children in the household and socioeconomic status.
Rahman et al. 200433 Pakistan, prospective cohort, n = 320 infants (160 with depressed mothers,160 with psychologically well mothers) Measure: diagnosis of depressive disorder using SCAN. Timing: third trimester and 2, 6 and 12 months postpartum Measure: underweight, weight-for-age z-score < −2; stunting, height-for-age z-score < −2. Timing: 2, 6 and 12 months postpartum Significant findings: prenatal depression, underweight at 6 months, adjusted OR: 3.5, 95% CI: 1.5–8.6; stunted at 6 months, adjusted OR: 3.2, 95% CI: 1.1–9.9; underweight at 12 months, adjusted OR: 3.0, 95% CI: 1.5–6.0; stunted at 12 months, adjusted OR: 2.8, 95% CI: 1.3–6.1 Note: Chronic depression carried a greater risk for a poor child growth outcome than episodic depression. Covariates included low birth weight, early breastfeeding cessation < 6 months, ≥ 5 diarrhoeal episodes per year, mother’s and father’s education, maternal financial empowerment and relative poverty. Other analyses included calculations of the relative risks of stunting and underweight in children of depressed mothers. Relative risks were also calculated for underweight and stunting in children aged 6 and 12 months of chronically depressed mothers (at four time points) versus depressed at no time point.
Africa
Adewuya et al. 200734 Nigeria, longitudinal case–control, n = 242 (120 depressed cases and 122 non-depressed matched controls) Measure: major depression diagnosis using the DSM-III-R (SCID-NP). Timing: 6-weeks postpartum Measure: malnutrition, < 5th percentile of weight-for-age or height-for-age. Timing: 6 weeks and 3, 6 and 9 months postpartum Significant findings: malnutrition, weight for age at 3 months, unadjusted OR: 3.2, 95% CI: 1.2–8.4; height for age at 3 months, unadjusted OR: 3.3, 95% CI: 1.03–10.5; weight for age at 6 months, unadjusted OR: 4.2, 95% CI: 1.4–13.2; height for age at 6 months, unadjusted OR: 3.3, 95% CI: 1.2–9.6. No statistically significant results at 6 weeks or 9 months Note: Depressed mothers were more likely to stop breastfeeding early and their infants were more likely to have episodes of diarrhoea or other infectious illnesses. Covariates were not included in the models.
Harpham et al. 200530 Ethiopia, cross-sectional, n = 1 722 Measure: SRQ-20 using a cut off of 7–8. Timing: 6–18 months postpartum Measure: underweight, weight-for-age z-score < −2; stunting, height-for-age z-score < −2. Timing: 6–18 months postpartum Non-significant findings: underweight, adjusted OR: 0.9, 95% CI: 0.6–1.2; stunting, adjusted OR: 1.1, 95% CI: 0.9–1.4 Note: Unadjusted and adjusted associations between maternal mental health and infant growth were not significant. Covariates included maternal age and education, the child’s sex, age and birth weight, and household composition, wealth index and geographical location.
Stewart et al. 200823 Malawi, cross-sectional, n = 501 Measure: SRQ-20 using a cut off of 7–8. Timing: median infant age at time of survey: 9.9 months postpartum Measure: mean weight-for-age z-score, mean height-for-age z-score. Timing: depended on child Significant findings: height-for-age z-score: adjusted β: −0.27 (P = 0.01). Non-significant findings: weight-for-age z-score: adjusted β: −0.02 (P = 0.87) Note: Multivariate analyses adjusted for maternal height, maternal weight, wealth index, education to Standard 6 or above, ≥ 4 surviving children, maternal occupation, marital status, paternal occupation, mother able to confide in husband or relative, recent infant diarrhoea, recent infant fever, infant age, infant sex and weight-for-age z-score at first postnatal weighing.
Tomlinson et al. 200635 South Africa, prospective cohort, n = 147 at baseline; n = 98 at 18 months Measure: major depression diagnosis using the DSM-IV (SCID). Timing: 2 and 18 months postpartum Measure: height-for-age z-score < 10th percentile; weight-for-age z-score < 10th percentile; height z-score and weight z-score (using Tanner scales). Timing: 2 and 18 months postpartum Non-significant findings: using depression at 2 months to predict infant growth at 18 months, height-for-age z-score < 10th percentile, unadjusted OR: 2.3, 95% CI: 0.9–6.0; weight-for-age z-score < 10th percentile, unadjusted OR: 2.5, 95% CI: 0.98–6.5; weight-for-age z-score adjusted for birth weight, β: 0.2, 95% CI: −0.21 to 0.78; height-for-age z-score, unadjusted β: 0·56, 95% CI: −0·16 to 1·3 Note: The attrition rate was 33%. Birth weight was a covariate in one model.
South America and the Caribbean
Baker-Henningham et al. 200325 Jamaica, case–control (matched), n = 210 (139 malnourished cases and 71 well nourished controls) Measure: CES-D (adapted) used as a continuous variable. Timing: after initial growth assessment Measure: underweight, cases, history of weight-for-age z-score < −2 plus current weight-for-age z-score < −1.5; controls, weight-for-age z-score > −1 plus no history of undernutrition. Timing: 9–30 months postpartum Non-significant adjusted findings: underweight, mean = 26; normal weight, mean = 16.5; unadjusted comparison, P < 0.01 Note: In crude analyses, maternal depression was related to underweight. The relationship became non-significant after adjusting for confounding variables. Covariates included maternal height, economic stress, work skill level, absent father and possessions.
Carvalhaes and Benício 200236 Brazil, case–control, n = 301 (101 cases and 200 controls) Measure: selected SRQ-20 subset of items: (i) three depressed mood items (scored 0/1–2/3), and (ii) four depressive symptoms (scored 0/1–2/3–4). Timing: sometime after initial screening of children at 12–23 months postpartum Measure: underweight, cases, < 5th percentile of weight-for-age; controls, > 25th percentile of weight-for-age. Timing: sometime after initial screening of children at 12–23 months postpartum Underweight, significant or marginally significant findings: maternal depressive symptoms, unadjusted OR: 4.1 (P < 0.01), adjusted OR: 3.1, 95% CI: 1.0–10.3. Non-significant findings: maternal depressed mood, unadjusted OR range: 1.8–1.9 (P = 0.3); adjusted results not shown Note: Models were adjusted for per capita household income, maternal education, presence of the partner, child’s age when the mother returned to work, hospitalization during gestation and alcoholism in the family.
De Miranda et al. 199637 Brazil, case–control, n = 139 for unadjusted analyses; n = 105 for adjusted analyses (60 controls and 45 cases) Measure: QMPA score > 6. Timing: cases, mean: 10.9 months (SD: 6.9) postpartum; controls, mean: 8.4 months (SD: 4.8) postpartum Measure: underweight, cases < 75% expected weight for age. Timing: cases, mean: 10.9 months (SD: 6.9); controls, mean: 8.4 months (SD: 4.8) postpartum Significant findings: underweight, unadjusted OR: 2.8, 95% CI: 1.2–6.9; adjusted OR: 2.9, 95% CI: 1.3–6.8 Note: Individual adjustments were made for the number of siblings, maternal age, infant birth weight, income and maternal education. The number of siblings, maternal age and infant birth weight were included in multivariate models.
Harpham et al. 200530 Peru, cross-sectional, n = 1949 Measure: SRQ-20 using a cut off of 7–8. Timing: 6–18 months postpartum Measure: underweight, weight-for-age z-score < −2; stunting, height-for-age z-score < −2. Timing: 6–18 months postpartum Non-significant findings: underweight, adjusted OR: 0.9, 95% CI: 0.6–1.2; stunting, adjusted OR: 1.1, 95% CI: 0.9–1.4 Note: Unadjusted and adjusted associations between maternal mental health and infant growth were not significant. Covariates included maternal age and education, the child’s sex, age and birth weight and household composition, wealth index and geographical location.
Santos et al. 201038 Brazil, longitudinal, n = 4 287 initially enrolled (3 748 remained at the 48-month follow-up) Measure: EPDS using a cut off of ≥ 13. Timing: 12, 24 and 48 months postpartum. (Meta-analysis included depression at 1–2 time points in relation to anthropometry at 48 months) Measure: underweight, weight-for-age z-score < −2; stunting, height-for-age z-score < −2. Timing: 48 months postpartum Non-significant findings: underweight, adjusted OR: 1.5, 95% CI: 0.8–2.8; stunting, adjusted OR: 1.0, 95% CI: 0.6- 1.5 Note: Models adjusted for family income, maternal skin colour, maternal schooling, parity, pre-pregancy body mass index, smoking during pregnancy, preterm birth and hospitalization in the first year of life. The underweight analysis also adjusted for the duration of breastfeeding and the stunting analysis adjusted for age.
Surkan et al. 200839 Brazil, cross-sectional, n = 595 Measure: CES-D using a cut off of ≥ 16. Timing: 6–24 months postpartum Measure: stunting, height-for-age z-score < −2. Timing: 6–24 months postpartum Significant findings: stunting, adjusted OR: 1.8, 95% CI: 1.1–2.9 Note: Covariates included the child’s gender, birth weight and age, breastfeeding duration, maternal education, sanitation score, socioeconomic status, living conditions, the number of children living in the household and participation in the Family Health Programme.
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CES-D, Center for Epidemiologic Studies Depression Scale; CI, confidence interval; DSM-III-R (SCID), Diagnostic and statistical manual of mental disorders, third edition, revised Structured Clinical Interview; DMS-III-R (SCID-NP), Diagnostic and statistical manual of mental disorders, third edition, revised Structured Clinical Interview – non-patient version; DSM-IV (SCID), Diagnostic and statistical manual of mental disorders, fourth edition, Structured Clinical Interview; EPDS, Edinburgh Post-natal Depression Scale; HOME, Home Observation for Measurement of the Environment; OR, odds ratio; QMPA, Adult Psychiatric Morbidity Questionnaire; SCAN, Schedules for Clinical Assessment in Neuropsychiatry; SD, standard deviation; SRQ-20, 20-item Self-Reporting Questionnaire.

a Each sample comprised a mother and child pair.

b Although the paper presented continuous outcomes and did not report adjusted results for underweight or stunting, we obtained the data from the authors and re-analysed it using multivariate logistic models to obtain the adjusted ORs for stunting and underweight included in the meta-analysis.

Seven studies were cross-sectional, six were case–control studies and four used a longitudinal cohort design. Nine of the 17 studies were based on representative community samples, four used a diagnostic measure of depression and 15 controlled for at least two confounding variables (Table 2, available from: http://www.who.int/bulletin/volumes/89/8/11-088187). In addition, 10 of the 13 studies that reported a response rate had a rate ≥ 80%.

Table 2. Qualitya of studies included in systematic review of maternal depression and child growth in developing countries, 1996–2010.

Study design Selection
 Exposure
 Comparability
Representative study sampleb Response rate ≥ 80%c Depression assessed using diagnostic testd Adjustment for 2 or more demographic variablese
Prospective longitudinal cohort
Patel et al. 200331 No Yes No No
Rahman et al. 200433 Yes Yes Yes Yes
Tomlinson et al. 200635 Yes No Yes No
Santos et al. 201038 Yes Yes No Yes
Case–control
Adewuya et al. 200834 No NA Yes Yes
Anoop et al. 200429 NA NA Yes Yes
Baker-Henningham et al. 2003f,25 No Yes No Yes
Carvalhaes et al. 200236 Yes Yes No Yes
de Miranda et al. 199637 No NA No Yes
Rahman et al. 200432 No NA No Yes
Cross-sectional
Black et al. 2009g,24 No No No Yes
Harpham et al. 200530 Yes Yes No Yes
Harpham et al. 200530 Yes Yes No Yes
Harpham et al. 200530 Yes Yes No Yes
Harpham et al. 200530 Yes No No Yes
Stewart et al. 200823 No Yes No Yes
Surkan et al. 200839 Yes Yes No Yes
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NA, not available (data were either incomplete or not reported); OR, odds ratio.

a Study quality was assessed using a checklist adapted from the Newcastle–Ottawa Scale for assessing the quality of nonrandomized studies in meta-analyses.

b Women and children included in the study were representative of the community.

c Individuals who refused to participate and those lost to follow-up were included in calculating the response rate.

d Individuals who were not assessed using a diagnostic test for depression were assessed using a measure of depressive symptoms or of common mental disorders.

e The analysis of the relationship between maternal depression and child growth was adjusted for at least two demographic variables.

f In this study, multivariate adjustments were made for more than two demographic variables. However, the data used in our meta-analysis were based on crude estimates because maternal depressive symptoms were not included in the final adjusted model due to the stepwise procedure.

g In this study, multivariate adjustments were made for growth outcomes as continuous variables but only the crude OR was presented in the paper. For the meta-analysis, ORs were based on an adjusted analysis of data obtained from the authors of the original study.

Most studies used the WHO criterion of a weight-for-age or height-for-age z-score < −2 to identify underweight or stunting, respectively. All 17 studies assessed underweight. They used a variety of measures: nine used a weight-for-age z-score < −2; three used a weight-for-age below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts;27 one used a weight-for-age below the equivalent 10th percentile; one used a weight-for-age below the third percentile; one used a weight-for-age of 50% to 80% of the expected value; one used a weight-for-age < 75% of the expected value and one used the combined measure of a current weight-for-age z-score < −1.5 plus a history of a weight-for-age z-score < −2. Twelve studies assessed stunting: nine used a height-for-age z-score < −2; two used a height-for-age below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts; and one used a height-for-age below the 10th percentile.

Studies used a wide range of indicators of maternal depression. Four used a diagnostic measure of depression based on either the Diagnostic and statistical manual of mental disorders18 (n = 3) or the International classification of diseases40 (n = 1); five used a measure of depressive symptoms such as the Edinburgh Postnatal Depression Scale20 (n = 2) or the Center for Epidemiologic Studies Depression Scale41 (n = 3); and eight used a measure of mental disorders such as the 20-item WHO Self-Reporting Questionnaire21 (n = 7) or the Adult Psychiatric Morbidity Questionnaire42 (n = 1). Some deviations from the standard use of these measures were observed: for example, one study analysed only items related to depression on the Self-Reporting Questionnaire.

Overall, most studies found a null or marginally significant relationship between maternal depression and poor child growth. However, the direction of the association was always the same: the worse the depression, the greater the growth deficit. Only 6 of the 17 studies on underweight and 5 of the 12 on stunting found a statistically significant relationship with maternal depression.

Underweight meta-analysis

The meta-analysis of the relationship between maternal depression and child underweight included effect size estimates from 17 studies (Fig. 1),23–25,29–39 covering a combined study population of 13 923 mother and child pairs. The pooled data showed a moderate, statistically significant relationship between maternal depression and underweight (OR: 1.5; 95% confidence interval, CI: 1.2–1.8). The heterogeneity of the findings was substantial (Q-statistic: 39.94; P = 0.001) across the studies. The funnel plot showed a statistically significant relationship between the standard error and the log OR using both tests of significance, an indication of a publication bias against small studies reporting non-significant findings.

Fig. 1.

Effect of maternal depression on child underweight reported in studies from developing countries included in meta-analysis, 1996–2010

CI, confidence interval; OR, odds ratio.

Note: The position of the square indicates the OR for the relationship between maternal depression and child underweight for the study and its size is proportional to the weight of that study in the meta-analysis. The length of the line represents the 95% CI for the OR. The diamond shape indicates the pooled OR for all studies included in the meta-analysis.

Fig. 1

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Fifteen studies used a strict definition of underweight: a weight-for-age z-score < −2 or a weight-for-age at or below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts.23,24,29–34,36–39 Meta-analysis of these studies showed that the relationship between maternal depression and underweight (OR: 1.5; 95% CI: 1.2–1.8) remained similar to that in the meta-analysis of all studies and the heterogeneity persisted (Q = 37.83, P = 0.001). When the meta-analysis was restricted to the nine studies that used measures of depression or depressive symptoms,24,25,29,31,33–35,38,39 the relationship between maternal depression and underweight strengthened and remained statistically significant (OR: 1.7; 95% CI: 1.2–2.4), and the findings remained heterogeneous (Q = 18.70; P = 0.017). Finally, when the meta-analysis was restricted to the four longitudinal cohort studies,31,33,35,38 the relationship strengthened further (OR: 2.2; 95% CI: 1.5–3.2) and high homogeneity was noted (Q: 2.47; P = 0.48).

Stunting meta-analysis

The meta-analysis of the relationship between maternal depression and child stunting included effect size estimates from 12 studies (Fig. 2)23,24,30,31,33–35,38,39 with a combined study population of 13 214 mother and child pairs. The pooled data showed a moderate, statistically significant relationship between maternal depression and stunting (OR: 1.4; 95% CI: 1.2–1.7). Substantial heterogeneity across studies was noted (Q: 26.85; P = 0.005). The relationship between the standard error and the log OR in the funnel plot was statistically significant using both tests of significance.

Fig. 2.

Effect of maternal depression on child stunting reported in studies from developing countries included in meta-analysis, 1996–2010

CI, confidence interval; OR, odds ratio.

Note: The position of the square indicates the OR for the relationship between maternal depression and child stunting for the study and its size is proportional to the weight of that study in the meta-analysis. The length of the line represents the 95% CI for the OR. The diamond shape indicates the pooled OR for all studies included in the meta-analysis.

Fig. 2

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Eleven studies used a strict definition of stunting: a height-for-age z-score ≤ −2 or a height-for-age at or below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts.23,24,30,31,33,34,38,39 Meta-analysis of these studies showed that the relationship between maternal depression and stunting (OR: 1.4; 95% CI: 1.2–1.7) remained similar to that in the meta-analysis of all studies and the heterogeneity persisted (Q = 25.00; P = 0.005). When the meta-analysis was restricted to the seven studies that used measures of depression or depressive symptoms,24,31,33–35,38,39 the relationship between maternal depression and stunting strengthened (OR: 2.0; 95% CI: 1.4–2.9) and homogeneity was noted (Q: 11.55; P = 0.073). Finally, when the meta-analysis was restricted to the four longitudinal cohort studies,31,33,35,38 the relationship was strengthened slightly (OR: 2.0; 95% CI: 1.0–3.9) and modest heterogeneity was found (Q: 9.30; P = 0.026).

Population attributable risk

The PAR for underweight was calculated for two studies: the study of Patel et al., which reported a low prevalence of depressive symptoms,31 and that of Surkan et al., which reported a high prevalence of depressive symptoms and a low prevalence of underweight (Table 3).39 The PAR in these studies was 22.5% and 29.4%, respectively.

Table 3. Effect of maternal depressive symptoms on child underweight or stunting in selected studies from developing countries, 1996–2010.

Study Measure of depressive symptoms Mothers with depressive symptoms (%) Underweight or stunted children (%) Underweight or stunting prevalence (%) in children of mothers with depressive symptoms Adjusted OR RRa PAR (%)
Underweight
Patel et al. 200331 EPDS 23.0 16.4 30.0 2.8 2.26 22.5
Surkan et al. 200839 CES-D 55.0 4.0 5.8 1.8 1.75 29.4
Stunting
Patel et al. 200331 EPDS 23.0 12.3 25.0 3.2 2.65 27.5
Black et al. 200524 CES-D 52.0 36.9 45.3 2.3 1.71 27.0
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CES-D, Center for Epidemiologic Studies Depression Scale; EPDS, Edinburgh Postnatal Depression Scale; OR, odds ratio; PAR, population attributable risk; RR, relative risk.

a The relative risk for each study was calculated from the adjusted OR and the prevalence of underweight or stunting, as appropriate, in children of depressed mothers.

Similarly, the PAR for stunting was calculated for two studies: the study of Patel et al., which reported a relatively low prevalence of depressive symptoms,31 and that of Black et al., which reported a high prevalence (Table 3).24 The PAR was 27.5% and 27.0% for the two studies, respectively.

Discussion

Our analysis revealed a positive and significant association between maternal depression or depressive symptoms and impaired child growth in developing countries. Our meta-analysis of 17 studies, based on adjusted estimates when possible, showed that the children of depressed mothers were at an increased risk of both underweight and stunting: the combined OR was approximately 1.4. This finding emerged after combining the results of studies that had very different designs, came from a wide range of locations and included children of different ages.

Because the findings varied across studies, we conducted subanalyses to explore how they might be altered by applying stricter definitions of maternal depression and of child growth outcomes or by restricting the analysis to longitudinal studies alone. When strict definitions of underweight and stunting were used, the magnitude of the pooled estimate for the relationship between maternal depression and inadequate growth was almost unaffected. When a strict definition of maternal depression was used, the OR for poor child growth increased. Finally, when the analysis was restricted to longitudinal studies, the pooled results showed strong associations with maternal depression: the ORs for underweight and stunting were approximately 2.2 and 2.0, respectively. However, because this subanalysis was based on only four longitudinal studies, its findings must be considered preliminary and need to be confirmed by more prospective studies.

Using data from four selected studies, we estimated a PAR for inadequate growth in the range of 23–29%. However, this estimate is imprecise because the four studies used different measures of depressive symptoms and controlled for different confounding variables.

The mechanisms responsible for the association between maternal depression and inadequate child growth are not clear. Nor is it known whether these mechanisms vary between countries and regions. Cultural differences in caregiving and feeding and the degree of food insecurity may all play a role. Previous research suggests that maternal depression is associated with compromised parenting behaviour,43,44 nonresponsive caregiving practices43 and a lower likelihood or shorter duration of breastfeeding.45–47 The time at which child growth is measured may also influence the observed association with maternal depression: Stewart et al. hypothesized that, because caregivers other than the mother often become more involved after weaning, the effect of maternal depression may be more pronounced in the immediate postpartum period.14 Of the articles included in the meta-analysis, only two evaluated the influence of other factors on the relationship between maternal depressive symptoms and child growth. Black et al. found that the effect of maternal depressive symptoms on infant height-for-age was partially mediated by the home environment, whereas maternal perceptions of infant temperament had no effect.24 Surkan et al. found no evidence that the relationship between maternal depressive symptoms and stunting was mediated by parenting self-efficacy, which reflects the belief parents have in their ability to care for their children.39 Future research should examine the mechanisms linking maternal depressive symptoms and child growth.

The review was limited by the modest number of studies included: only 17 were available overall and only four were included in the subanalysis of longitudinal studies. Additionally, the studies varied in quality, as reflected in the way they adjusted for potential confounding variables: one study adjusted for covariates individually while another made no adjustments. In some regions, most studies were from the same country; for example, four of the five studies from South America were conducted in Brazil. As in any systematic review, publication bias may have affected our findings; significant findings may have been disproportionately reported in the literature, as suggested by the funnel plots for both underweight and stunting in the meta-analysis. Consequently, our meta-analysis may have overestimated the association between maternal depression and inadequate child growth. However, this is unlikely because most studies reported null results.

Although the definitions of underweight and stunting differed between the studies, height and weight were measured, not self-reported. In contrast, the diagnosis of maternal depression and its severity may have been less precise owing to the use of depression scales that were not validated in the study populations, particularly since different cultures have differing concepts of depression. In addition, there may be a reciprocal relationship between maternal mental health and child health given that a child’s poor health could generate depressive symptoms in the mother.48 Subsequent research should investigate the possibility that poor child growth increases the risk of maternal depression.

Estimates of the incidence of depression in women in developing countries vary widely, from 15–57%.49 Depression in these women has a complex etiology involving factors as diverse as poverty, marital conflict, domestic violence and lack of control over economic resources.50 However, recent studies suggest that depression can be affordably treated in developing countries.51 Varied interventions, such as social support, group therapy or home visits, which are often delivered by lay community workers, have led to a reduction in maternal depressive symptoms in a range of countries, including China, Jamaica, Pakistan, South Africa and Uganda.52–57 Interventions aimed at improving parenting and the mother–infant relationship have been effective in reducing depressive symptoms in postpartum women,55–57 which suggests that maternal depression is modifiable. Our findings indicate that a reduction in the incidence of maternal depressive symptoms in developing countries would not only have a beneficial effect on mothers, but would also improve child growth substantially, and this could in turn influence the children’s future health, development and socioeconomic status.7–12

Acknowledgements

The authors thank Laurence Magder, Bryan Shaw, Yan Wang and Virginia Tedrow for their assistance with this project.

Competing interests:

None declared.

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