Prevalence and associated factors of post-partum depression in Ethiopia. A systematic review and meta-analysis

Tadele Amare Zeleke; Wondale Getinet; Zemenu Tadesse Tessema; Kassahun Gebeyehu

doi:10.1371/journal.pone.0247005

. 2021 Feb 19;16(2):e0247005. doi: 10.1371/journal.pone.0247005

Prevalence and associated factors of post-partum depression in Ethiopia. A systematic review and meta-analysis

Tadele Amare Zeleke ^1,^*, Wondale Getinet ¹, Zemenu Tadesse Tessema ², Kassahun Gebeyehu ³

Editor: Marta B Rondon⁴

PMCID: PMC7894900 PMID: 33606768

Abstract

Background

Globally, post-partum depression is a major public health problem and is associated with a harmful effect on the infant, child, and mothers’ mental, physical, and social health. Although a few post-partum depression studies have been published, we still lack an accurate estimated pooled prevalence of national PPD and associated factors.

Objectives

This study aims to show the estimated pooled prevalence of PPD and associated factors in Ethiopia.

Methods

We conduct the extensive search of articles as indicated in the guideline (PRISMA), reporting systematic review and meta-analysis. Databases like MEDLINE, PubMed, psych INFO, Web of Science, EMBASE, CINAHL, Scopus, and The Cochrane Library. All publications and grey literature were addressed by using MeSH terms and keywords. The pooled estimated effect of post-partum depression and associated factors was analyzed using the random effect model meta-analysis, and 95% CI was also considered.

Protocol and registration

PROSPERO 2020 CRD42020176769 Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020176769.

Result

A total of 11 studies with 7,582 participants were included in this meta-analysis. The estimated pooled prevalence of post-partum depression (PPD) was 22.08%, with a 95% CI (17.66%, 26.49). For factors associated with post-partum depression, a random effect size model was used during meta-analysis; unplanned pregnancy [(OR = 2.84; 95% CI (2.04, 3.97)], domestic violence [OR = 3.14; 95% CI (2.59, 3.80)], and poor social support [OR = 3.57;95% CI (2.29,5.54) were positively associated factors with post-partum depression.

Conclusion and recommendation

The estimated pooled prevalence of post-partum depression was high in Ethiopia. Unplanned pregnancy, poor social support, and domestic violence were factors affecting PPD. Therefore, the Ethiopian policymakers and health personnel better give more emphasis to mothers who had a history of unplanned pregnancy, domestic violence, and poor social support

Introduction

Depression is a major public health problem that women are around twofold greater than men to experience depression during their lifetime [1–3].

Globally, depressive disorders are common, chronic, and a principal source of disability among women. In the US, approximately 12 million women experience clinical depression each year [1].

In low- and middle-income countries, the estimated prevalence of depression among women ranges from 15 to 28% in Asia and Africa [4,5].

Post-partum depression (PPD) is a mood disorder that involves the brain and affects behavior and physical health after delivery [6]. Worldwide, depression is the leading cause of disability [7], and it affects one in five women after giving birth [8]. Post-partum depression is the most common psychiatric illness, and it is the major public problem that is as twice as common in women as men during the childbearing years [9].

Globally, severe postnatal onset depression rates are three times higher than in other periods of women’s lives [9]. Parenting stress and mother-child interaction problems are common in postnatal depressive mothers [10].

In the world, depression after delivery affects women. It increases poorer self-care and maternal morbidity and negatively affects infants, children, and families as well [5,11]. The disorder is often unrecognized and untreated, despite the potentially deleterious effects of PPD on the mother, infant, and children [9,12]. Because of the stigma of depression, the mother may refuse to seek professional help [13]. Maternal PPD has short-term negative effects on young children’s emotional, cognitive, behavioral, and interpersonal development [9].

In a worldwide review, the prevalence of PPD ranges from 4.0 to 63.9% [14]. In 56 countries, the pooled prevalence of PPD was 17.7% [15]. In India, the systematic review and metanalysis of the pooled prevalence of PPD was 22% [16]. In another review, the pooled prevalence was 20% [17]. In Iran, a systematic review and meta-analysis, the pooled prevalence was 25.3% [18]. In a systematic review in Denmark, up to 15% of the mother were affected with post-partum depression [19].

In low and middle-income countries, there are large gaps in the knowledge of the long-term effects of post-partum depression in physical, psychological, and social [10] and PPD is under-recognized and under-treated [19].

In different literature reviews; factors associated with PPD were unplanned pregnancy [20–22], a having history of depression [18,23–25], perceived lack of support from husband [25], domestic violence and lack of support [16,22], poor social support from the partner [26], birth complications [27], dissatisfaction about family [28], violence from husband [29–31] and poor social support [9,23,32].

Although mothers after delivery are at a critical period for the incidence of depression, little attention is still given in terms of prevention and treatment. Showing the pooled prevalence and factors associated with PPD by systematic review and meta-analysis is very important to health policymakers to pertain attention for these vulnerable women. Therefore, the present study reviews accessible epidemiological publications on post-partum depression and related factors in Ethiopian women to help health workers and policymakers design preventive strategies and further research.

Our two purposes in this study

What is the estimated pooled prevalence of post-partum depression in Ethiopia?
What are the associated factors for post-partum depression in Ethiopia?

Intervention(s), exposed(s); postnatal mothers who considered depression as screened by depression screening tools

Comparator(s)/control; postnatal mothers who have considered no depression by depression screening tools

Materials and methods

Search process and study selection

Literature search; Our search strategy and selection of publication for the review were conducted according to the PRISMA guideline [33]. The literature on post-partum depression among Ethiopian women was retrieved through searching the scientific search engines Database like MEDLINE, PubMed, psych INFO, Web of Science, EMBASE, CINAHL Scopus, and The Cochrane Library. All publications and grey literature were addressed by using keywords that were used in PubMed. In PubMed, MeSH terms were used (incidence OR prevalence OR magnitude OR epidemiology) AND (postnatal depression OR depression OR post-partum depression OR depressive disorder OR maternal mental health OR emotional distress OR puerperal disorder OR low mood disorder OR psychological distress) AND (after childbirth OR after delivery) AND (associated factors OR risk factors OR predictors OR determinants) AND Ethiopia, January 2010 to January 2020.

For the other databases, we employed specific subject headings as advised for each database. Furthermore, to identify other related literature, we manually searched the reference lists of eligible articles.

Protocol and registration; PROSPERO 2020 CRD42020176769 Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020176769.

Eligible criteria

Inclusion criteria

Study design type-cross-sectional
Article published in the English language
Studies that reported the prevalence of post-partum depression in the health institution and in the community
A study done in Ethiopia
Publication date from 1 January 2010 to 1 January 2020
All publications which fulfilled more than 90% of the criteria were included

Exclusion criteria

Reviews, letters and international studies, and duplicated studies were excluded.

Methods for data extraction and quality assessment

Three reviewers (TAZ, WG, and ZTT) evaluated the relevant articles using the title and the abstract prior to retrieval of the full-text articles. Retrieved full-text articles were further screened according to prespecified inclusion and exclusion criteria. We resolved the arguments by a discussion with the fourth reviewer (KG).

The standardized form of the data extraction method was used for identified studies. The following information was extracted for each included study: first author, year of publication, study design, associated factors, sample size, study settings, adjusted for risk estimate (OR), and the 95% confidence interval. Data extraction from source documents was done independently by four investigators. The disagreement was resolved with discussion.

The quality of the included studies was evaluated using the Newcastle-Ottawa Scale(NOS) [34]. Sample representativeness and size, comparability between participants, ascertainment of post-partum depression, and statistical quality were the domains of NOS used to assess each study’s quality. Actual agreement and agreement beyond chance (unweighted Kappa) were used to evaluate four reviewers’ agreement. We consider the value 0 as poor agreement, 0.01 to 0.02 as slight agreement, 0.21 to 0.4 as a fair agreement, 0.41 to 0.60 as moderate agreement, 0.61 to 0.80 as substantial agreement, and 0.81 to 1.00 as almost perfect agreement [35]. In this review, the actual agreement beyond chance was ranged from 0.88 to 1 is almost perfect agreement.

Data synthesis and analysis

STATA version 14 software was used for meta-analysis. Forest plots that showed combined estimates with 95% CI. The heterogeneity was evaluated using Q and I² statistics [36]. For the variables, the random effect size (OR) model was used. The magnitude of statistical heterogeneity between studies was assessed using I² statistics and considered value 25% as low, 50% as a medium, and 75% as high [37]. In this review data, the value of the I2 statistics was 95.1% with a p-value ≤of 0.001, which showed there was high heterogeneity. Therefore, the overall pooled prevalence was estimated by the random effect model meta-analysis [36]. Meta-regression was made to explore the probable source of heterogeneity. We also carried a leave-one-out sensitivity analysis to assess the key studies that significantly impact between-study heterogeneity.

Variables; post-partum depression yes/no

Independent variables were unplanned pregnancy vs. planned pregnancy, poor social support vs. strong social support, and domestic violence vs. no domestic violence.

Result

Identification of the studies

Our search strategy and selection of publication for the review was conducted in accordance with the PRISMA. In the database search, 718 articles were found. Of these, 688 articles were excluded because the title and the abstract were not fit the inclusion criteria. Eighteen articles were retrieved for full screening. However, seven studies were excluded because there was perinatal depression. Therefore, eleven studies were included in this systematic review and meta-analysis guideline (Fig 1).

Characteristics of the studies

In this systematic review and meta-analysis, 11 articles were included. The included studies were conducted from 1 January 2010 to 1 January 2020. All studies were conducted with a cross-sectional study design in Ethiopia. Post-partum depression was assessed by using EPDS (eight studies), PHQ-9 (two studies), and K-10 score (one study). Six studies were conducted in the community; the rest were in the health institution (Table 1).

Table 1. The prevalence of post-partum depression among women related to the study area in Ethiopia, 2020.

Author	Publication year	Study area	Site	Study design	PPD	sample	case	prevalence	Tool
Asaye MM. [38]	2020	Gondar town	Community	cross-sectional	YES	526	129	25	EPDS
Fantahun A. [39]	2018	Addis Ababa	Health institution	cross-sectional	YES	618	144	23.3	EPDS
Teshome H [40]	2016	Addis Ababa	Health institution	cross-sectional	YES	295	82	27.8	K-10 score.
Abadiga M. [41]	2019	Nekemte Town	Community	cross-sectional	YES	287	60	20.9	EPDS
Shewangzaw A. [42]	2018	Harar Town	Health institution	cross-sectional	YES	122	16	13.11	EPDS
Azale T [43]	2018	Sodo district	Community	cross-sectional	YES	3147	385	12.2	PHQ-9
Shitu S. [44]	2019	Ankesha district	Community	cross-sectional	YES	596	141	23.7	EPDS
Abebe A. [45]	2019	Bahir Dar Town	Health institution	cross-sectional	YES	511	113	22.1	EPDS
Kerie S. [46]	2018	Mizan Tepi Town	Health institution	cross-sectional	YES	408	138	33.8	EPDS
Toru T. [47]	2018	Mizan Aman Town	Community	cross-sectional	YES	456	102	22.4	PHQ-9
Mariam D. [48]	2016	Eastern Zone of Tigray	Community	cross-sectional	YES	616	117	19	EPDS

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Qualities of included studies

The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the studies methodologically. In the evaluation, we concluded that 11 studies satisfy the quality assessment in terms of selection, outcome measurement, and non-response bias. The risk of bias in each study was assessed by using kappa values, which range from 0.88 to 1, almost perfect (Table 2).

Table 2. The quality and agreed level of bias and level of agreement on the method qualities included articles in a meta-analysis based on sample, outcome, objective, responses rate and analysis method.

Author	Publication year	Study area	Percentage of agreement	Kappa value	Level of agreement	NOS quality(0 9)
Asaye MM.	2020	Gondar town	100	1	Almost perfect	9
Fantahun A.	2018	Addis Ababa	100	1	Almost perfect	9
Teshome H	2016	Addis Ababa	88	0.88	Almost perfect	8
Abadiga M.	2019	Nekemte Town	100	1	Almost perfect	9
Shewangzaw A.	2018	Hrarar Town	100	1	Almost perfect	9
Azale T	2018	Sodo district	100	1	Almost perfect	9
Shitu S.	2019	Ankesha district	100	1	Almost perfect	9
Abebe A.	2019	Bahir Dar Town	100	1	Almost perfect	9
Kerie S.	2018	Mizan Tepi Town	100	1	Almost perfect	9
Toru T.	2018	Mizan Aman Town	100	1	Almost perfect	9
Mariam D.	2016	Eastern Zone of Tigray	100	1	Almost perfect	9

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Publication bias

No evidence of publication bias was found by the funnel plot and Egger’s regression test of post-partum depression (Fig 2).

Sensitivity analysis

In the sensitivity analysis, there is no single study that is influencing the overall meta-analysis estimate (Fig 3)

The result of estimated a pooled meta-analysis

Prevalence of post-partum depression

A total of 11 studies with 7,582 participants were included in this meta-analysis. In Ethiopia, the prevalence of post-partum depression was ranged from 12.2% to 33.8% (Table 1). The random-effect model was used to combine the 11 articles to show the estimated pooled prevalence of post-partum depression. The estimated pooled prevalence of post-partum depression (PPD) among mothers was 22.08%, with 95% CI (17.66%, 26.49). The studies’ heterogeneity was significant (I² = 95.1%; Q = 204.06 df = 10 and p≤0.001) (Fig 4).

Subgroup analysis by assessment tools

Around eight articles were conducted with EPDS, two articles were with PHQ-9, and one study was conducted with a K-10 score. The prevalence of PPD by using EPDS, PHQ-9, and K-10 Score was 27.76% with 95% CI (19.46, 26.05), 17.13% with 95% CI (7.14, 27.12), and 27.80% with 95% CI (22.69, 32.91) respectively. The heterogeneity of each tool, EPDS, and PHQ-9, was significant (I² = 82.7, Q = 40.38, df = 7, p≤0.001), and (I² = 96.0, Q = 25.06, df = 1, p≤0.001) respectively. In all assessment tools; the prevalence of PDD were similar. Since the study conducted by the K-10 assessment tool was a single study, there was no heterogeneity test (Fig 5).

Unplanned pregnancy and post-partum depression

From (Fig 6) a total of seven articles were included in the analysis. There was a significant association between unplanned pregnancy and post-partum depression. Mothers who had a history of unplanned pregnancy were about 3(OR = 2.84; 85% CI 2.04 to 3.97) times more likely to have depression when compared to a planned pregnancy.

Social support and post-partum depression

Three studies were carried out in this meta-analysis. The pooled odds ratio (OR) demonstrated that the odds of PPD were significantly higher in mothers who had poor social support than mothers’ who had strong social support (OR = 3.57; 95% CI 2.29 to 5.54) (Fig 7).

Domestic violence and post-partum depression

In (Fig 8) a total of five articles were comprised in this analysis. There was a significant association between domestic violence and post-partum depression. Having domestic violence was about 3 (OR = 3.14; 95% CI 2.59, 3.80) times more likely to have post-partum depression than not having domestic violence.

Discussion

The pooled prevalence of post-partum depression in Ethiopia in our meta-analysis was 22.08%, with a 95% CI (17.66%, 26.49). Post-partum depression is strongly linked to life stress events (socio-economic factors), physical and emotional demands of childbearing and caring for new babies, and change in hormones after delivery [49]. In low and middle-income countries, post-partum depression is even more prevalent; the reason might be biological factors like (illness, and biological predisposition); psychosocial aspects (greater exposer to violence, the difficulty of living conditions, childhood maltreatment, social exclusion, and unplanned pregnancy), and economical (poverty and food insecurity) [10]. Another study showed that individuals who are living in low-income countries experienced more stressors associated with depression and anxiety than high-income countries [50].

This finding was consistent with other systematic findings. A systematic review of studies in 56 countries showed that the pooled prevalence of PPD was 17.7% [15]. In India, the systematic review and metanalysis, the pooled prevalence of PPD was 22% [16]; in another review, the pooled prevalence was 20% [17]. In Iran, a systematic review and meta-analysis, the pooled prevalence was 25.3% [18]. These estimates in low income and middle-income countries are similar to this finding, and taken together; they support a disagreement for placing more importance on maternal post-partum depression as part of overall efforts to maternal, infant, and child health. However, the current finding was significantly higher than the prevalence of 15% derived from a systematic review of studies from Denmark [19]. The discrepancy might be due to the absence of an awareness of PPD by health experts; there are issues that may be barriers to early recognition and management of post-partum depression [51–53].

Article review revealed that the following factors affect post-partum depression: unplanned pregnancy, social support, and domestic violence.

Postnatal mothers who had poor social support were about 4 [OR = 3.57; 95% CI (2.29,5.54)] times more likely to have depression when compared to mothers who had strong social support. Poor social support refers to perceived lack of support from husband [25], poor social support from the partner [26], poor social support [9,23,32], lack of support from the family [16,22] and dissatisfaction from family [28]. The reason might be that living with a supportive person halves stress. Social support is significant for maintaining good mental and physical health, and it related to resilience [54]. Good social support has been shown to be a consistent protective factor for mothers with high distress. The mothers who reported consistent opportunities to interact and talk with people were more likely to report a reduction in distress [55].

Mothers who had a history of domestic violence were about 3 [OR = 3.14; 95% CI (2.59,3.80)] times more likely to have depression than their counterparts. Other studies revealed that mothers who had a history of violence and abuse from husband [29–31] and domestic violence from the family members [16,22] were associated with post-partum depression. Violence has a negative effect on mental health. Mothers who are violent had feelings of helplessness and then had depression; they are also high risk for suicide to end their life [56].

Women whose pregnancy was unplanned were 3[(OR = 2.84; 95% CI (2.04, 3.97)] times more likely to have depression when compared with mothers who gave birth after a planned pregnancy. Having unplanned pregnancy, unwanted delivery, and unwanted pregnancy were factors affecting post-partum depression [20–22]. The reason might be during the conception period; psychological preparedness is very important to the mother, otherwise there will be mental health problems. Unplanned pregnancy leads the mother to feel unhappy and have negative thoughts, consequently depression develops [57]. Mothers e with unplanned pregnancy had the earliest parenting stress [58]. The mother also perceived poor social support and less satisfaction with marriage life [59].

Strengths and limitations

In this study, the authors used different databases to search the articles to minimize reviewers’ bias and quality evaluation by four reviewers. Showing estimated pooled prevalence and pooled associated factors and conducting subgroup analysis based on assessment tools.

Limitation

In this study, only English language articles were included. A disproportional number of studies were included in the subgroup analysis of screening tools that minimize the estimated value’s precision.

Implication of this finding

The finding has implications for the future researcher, clinicians, and policymakers; for the future researcher, the prevalence of post-partum depression is increasing in the current finding. Therefore, it needs further investigation to know the reason why PPD is increasing and better management. Clinicians should screen the mother for depression when they present in the institution and the community. Our study should assist policymakersin design prevention and treatment strategies both in the community and in health institution.

Conclusion

Postpartum depression was high in Ethiopia. Unplanned pregnancy, poor social support, and domestic violence were factors affecting PPD. Therefore, the Ethiopian policymakers and health personnel better emphasize mothers who had a history of unplanned pregnancy, domestic violence, and poor social support.

Supporting information

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Acknowledgments

The authors would like to thank all authors of the research paper included in this systematic review and meta-analysis.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0247005.r001

Decision Letter 0

Vanessa Carels

27 Oct 2020

PONE-D-20-11869

Prevalence and associated factors of postpartum depression in Ethiopia. A systematic review and meta-analysis, 2020

PLOS ONE

Dear Dr. Zeleke,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

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Reviewer #1: Title: Prevalence and associated factors of postpartum depression in Ethiopia. A systematic review and meta-analysis, 2020

Dear editor,

Thank you for giving me the opportunity to review this paper.

In this study, the authors conducted a systematic review and meta-analysis of the Prevalence and associated factors of postpartum depression in Ethiopia. This is an important area of research. The paper will be a useful addition to the literature and hopefully further research. Meanwhile, there are a lot of minor issues that need to be addressed for publication. I have briefly summarized them below

1. The review lacks detaildnesss in most of the contents of the reach, most importantly the results and discussion. Please elaborate on the results, discussion, methods, and other components.

2. Could you please remove 2020 from the title

3. Could you please revise the background section of the abstract in more convincing and succinct ways?

4. In the result section of the abstract, please indicated the analysis method used and highlight whether the factors are based on the meta-analysis results.

5. In the conclusion section of the abstract, just focus on the findings of the current study and it is advised to remove the sentence regarding the general population prevalence since you did not measure it.

6. In the introduction section, could you please revise the sentence regarding the definition of PPD, is that serious mental illness?

7. In the first paragraph of the introduction, could you please indicate the global epidemiology first and then go to PPD. Also, avoid repeated use of the word globe.

8. Generally, the introduction needs to be more capitalized and the justification section also needs to be included.

9. Please elaborate on the method section.

10. Please move the sentence regarding the results of publication bias from the method section to the result sections.

11. In the result section, please elaborate on the search process, and also include the detailed description of the characterizes of the included studies.

12. In the results of meta-analysis, specify whether a fixed or random-effect meta-analysis was used.

13. In table 1, please revise the author's name accordingly.

14. In the results section could you please included results of publication bias and sensitivity analysis (if heterogeneity exists).

15. Please more elaborate on the discussion. Also, include reasons for higher prevalence rates of depression in postpartum periods.

16. Please indicate the implication of the findings in the discussion section.

17. Elaborate on the strength and limitations of the study.

18. Revised conclusion section. Also, remove sentence regarding the general population prevalence, focus on your findings.

Reviewer #2: 1. Abstract:

Line 2: most common complication

2. Introduction

Para 1: revise language

3. Para 3: separate low and middle income countries from high income countries. I respectfully suggest

4. Page 5, para 2: globally? LMIC? HIC? Clarify please

Methods

6. Independent variables: You mention as factors associated with postpartum depression “D were unplanned pregnancy(16-18), a having history of depression(10, 19-21) , perceived lack of support from husband(21), domestic violence and lack of support(8, 18), poor social support from the partner(22), birth complication(23), dissatisfaction about family(24), violence from husband(25-27) and poor social support(4, 19, 28).”. However you only examine poor v strong social support, pregnancy intendedness and exposure to violence. These turn out to significant associations. I suggest you test and report all the previously mentioned factors, and report the negative results (if that should be the case)

Results:

7. Features of the studies, “comprised” maybe “carried out”?

Discussion:

8. The reason there is a difference between pooled postpartum depression in LMIC and HIC may also be related to factors such as social exclusion, poverty, food insecurity, greater exposure to violence etc. I suggest you look at Herba et al (Lancet Psychiatry 2016 Oct;3(10):983-992.) doi: 10.1016/S2215-0366(16)30148-1. Epub 2016 Sep 17 and other recent literature to iMprove this part of the discussion.

9. Please elaborate on the effect of social support on maternal mental health. “The reason might be due to individuals who has stress, share their stress to another person, stress reduced by half.” Is not enough

10. Please elaborate on the untoward impact of violence on mental health (via chronic stress, for instance) there is a lot of literature on this topic.

11. please elaborate on the potential mechanism of unwanted pregnancy as a risk factor for postpartum depression.

11. English needs some revision by a native or near native speaker.

**********

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Reviewer #1: Yes: Getinet Ayano

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2021 Feb 19;16(2):e0247005. doi: 10.1371/journal.pone.0247005.r002

Author response to Decision Letter 0

24 Nov 2020

Response to Reviewers’

Dear Reviewer1

Thank you for your valuable comments and questions. Authors tried to amend the comments and answering questions accordingly. The detailed is in the “manuscript track change”

Sincerely,

Tadele Amare

1. The review lacks detailedness in most of the contents of the reach, most importantly the results and discussion. Please elaborate on the results, discussion, methods, and other components.

Response: it is elaborated in each section accordingly.

2. Could you please remove 2020 from the title

Response: it is removed page1 line 2

3. Could you please revise the background section of the abstract in more convincing and succinct ways?

Response: the background is revised as convincing page 24 to 27

4. In the result section of the abstract, please indicated the analysis method used and highlight whether the factors are based on the meta-analysis results.

Response: random effect size model was used and factors were analyzed in meta-analysis. Page2 line 43 to 44

Response: it is removed. Page3 line 48 to 49

6. In the introduction section, could you please revise the sentence regarding the definition of PPD, is that serious mental illness?

Response: it is modified as “Postpartum depression (PPD) is a mental illness that involves the brain and affects behavior and physical health after delivery” Page 5 line 103 to 104

7. In the first paragraph of the introduction, could you please indicate the global epidemiology first and then go to PPD. Also, avoid repeated use of the word globe.

Response: it is modified in page 5 line 96 to102

8. Generally, the introduction needs to be more capitalized and the justification section also needs to be included.

Response: the introduction section is modified and justification section is also added page 4 to 7 and line 65 to 138

9. Please elaborate on the method section.

Response: it is elaborated page 8 to 11 line 151 to 228

10. Please move the sentence regarding the results of publication bias from the method section to the result sections.

Response: it is moved from method section to result section page 15 line 274 to 276

11. In the result section, please elaborate on the search process, and also include the detailed description of the characterizes of the included studies.

Response: it is elaborated and characterized page 12 to 14 line 239 to 273

12. In the results of meta-analysis, specify whether a fixed or random-effect meta-analysis was used.

Response: the random effect model was used and corrected in page 15 line 291 to 292

13. In table 1, please revise the author's name accordingly.

Response: Tabel1 and Table2 the author’s name is corrected Table1 page 13, line 261 to 262 and Table2 page 14 line 272 to 273.

14. In the results section could you please included results of publication bias and sensitivity analysis (if heterogeneity exists).

Response: publication bias and sensitivity analysis is included. Publication bias page 15 line 274 to 276 (see also Fig2 in figure section) and sensitivity test page15 line 279 to 281

15. Please more elaborate on the discussion. Also, include reasons for higher prevalence rates of depression in postpartum periods.

Response: the discussion section is modified page 18 to 21 line 340 to 410

16. Please indicate the implication of the findings in the discussion section.

Response: implication of the finding is stated in page 21 line 420 to 426

17. Elaborate on the strength and limitations of the study.

Response: it is elaborated in page 21 line 412 to 418

18. Revised conclusion section. Also, remove sentence regarding the general population prevalence, focus on your findings.

Response: it is revised and removed “general population”. Page 21 to 22 line 427 to 431

Dear Reviewer2,

Thank you for your valuable comments and questions. Authors tried to amend the comments and answering questions accordingly. The detailed is in the “ manuscript track change”

Sincerely,

Tadele Amare

Reviewer #2: 1. Abstract:

Line 2: most common complication

Response: it is modified page 2 line 24 to 27

2. Introduction

Para 1: revise language

Response: it is totally modified page 5 line 103 to 104

3. Para 3: separate low- and middle-income countries from high income countries. I respectfully suggest

Response: it is separated in page5 line 96 to 102 and again in page 6 line 118 to 126

4. Page 5, para 2: globally? LMIC? HIC? Clarify please

Response: para2. This is the global study page6 line 108.

Methods

6. Independent variables: You mention as factors associated with postpartum depression“ were unplanned pregnancy(16-18), a having history of depression(10, 19-21) , perceived lack of support from husband(21), domestic violence and lack of support(8, 18), poor social support from the partner(22), birth complication(23), dissatisfaction about family(24), violence from husband(25-27) and poor social support(4, 19, 28).”. However, you only examine poor vs strong social support, pregnancy intendedness and exposure to violence. These turn out to significant associations. I suggest you test and report all the previously mentioned factors, and report the negative results (if that should be the case)

Response: These all factors were found in the literature review in different countries other than Ethiopia. The factors that were included in meta-analysis were conducted in Ethiopia.

Results:

7. Features of the studies, “comprised” maybe “carried out”?

Response: it is rewrite page12 line 251 to 256

Discussion:

8. The reason there is a difference between pooled postpartum depression in LMIC and HIC may also be related to factors such as social exclusion, poverty, food insecurity, greater exposure to violence etc. I suggest you look at Herba et al (Lancet Psychiatry 2016 Oct;3(10):983-992.). Epub 2016 Sep 17 and other recent literature to iMprove this part of the discussion.

Response: it is added in page 18 line 342 to 351

Response: other justifications are added page 19 and 20 line 383 to 387

10. Please elaborate on the untoward impact of violence on mental health (via chronic stress, for instance) there is a lot of literature on this topic.

Response: it is elaborated page 20 line 388 to 398

11. please elaborate on the potential mechanism of unwanted pregnancy as a risk factor for postpartum depression.

Response: it is elaborated in page 20 and 21 line 399 to 410

11. English needs some revision by a native or near native speaker.

Response: the English language is edited by the English language experts at Department of English language and literature, College of Social Science and Humanities, University of Gondar.

PLoS One. doi: 10.1371/journal.pone.0247005.r003

Decision Letter 1

Marta B Rondon

25 Jan 2021

PONE-D-20-11869R1

Prevalence and associated factors of postpartum depression in Ethiopia. A systematic review and meta-analysis

PLOS ONE

Dear Dr. Zeleke,

==============================

I see that you have introduced the changes and answered the queries, and I thank you for your dedicated review of the language. However it is still not ready, Please look at the attached Word version with some amends and accept them, so that we may go on with this process.

This paper will be a useful addition to the literature on perinatal depression, particularly for practitioners and policymakers in LMIC. Please make a last effort.

==============================

Please submit your revised manuscript by January 27 at the latest.. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Marta B Rondon, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

thank you for your dedicated review of English. However, it is not ready yet,

Please look at the amended Word files I am enclosing.

[Note: HTML markup is below. Please do not edit.]

Attachment

Submitted filename: PONE-D-20-11869R1 MBR CLEAN.docx

Click here for additional data file.^{(86.5KB, docx)}

Attachment

Submitted filename: PONE-D-20-11869R1 MBR track changes.docx

Click here for additional data file.^{(88.4KB, docx)}

PLoS One. 2021 Feb 19;16(2):e0247005. doi: 10.1371/journal.pone.0247005.r004

Author response to Decision Letter 1

26 Jan 2021

Response for reviewers’

Thank you for your commitment in reviewing of the manuscript. Based on the given comments, the English language is edited point by point.

Sincerely,

Tadele Amare

PLoS One. doi: 10.1371/journal.pone.0247005.r005

Decision Letter 2

Marta B Rondon

1 Feb 2021

Prevalence and associated factors of postpartum depression in Ethiopia. A systematic review and meta-analysis

PONE-D-20-11869R2

Dear Dr. Zeleke,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Marta B Rondon, M.D.

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

You have answered our queries and have satisfied our observation. Pleased to see this accepted and even more pleased when I see this in print. Kudos.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

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PLoS One. doi: 10.1371/journal.pone.0247005.r006

Acceptance letter

Marta B Rondon

3 Feb 2021

PONE-D-20-11869R2

Prevalence and associated factors of post-partum depression in Ethiopia. A systematic review and meta-analysis.

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PERMALINK

Prevalence and associated factors of post-partum depression in Ethiopia. A systematic review and meta-analysis

Tadele Amare Zeleke

Wondale Getinet

Zemenu Tadesse Tessema

Kassahun Gebeyehu

Roles

Abstract

Background

Objectives

Methods

Protocol and registration

Result

Conclusion and recommendation

Introduction

Our two purposes in this study

Materials and methods

Search process and study selection

Eligible criteria

Exclusion criteria

Methods for data extraction and quality assessment

Data synthesis and analysis

Variables; post-partum depression yes/no

Result

Identification of the studies

Fig 1. Flow chart showing how was the research articles were searched, 2020.

Characteristics of the studies

Table 1. The prevalence of post-partum depression among women related to the study area in Ethiopia, 2020.

Qualities of included studies

Table 2. The quality and agreed level of bias and level of agreement on the method qualities included articles in a meta-analysis based on sample, outcome, objective, responses rate and analysis method.

Publication bias

Fig 2. Forest plot presenting of publication bias of post-partum depression among after child giving mothers, Ethiopia, 2020.

Sensitivity analysis

Fig 3. Forest plot presenting to show not having a single study influences the overall meta-analysis estimated of post-partum depression among after child giving mothers, Ethiopia, 2020.

The result of estimated a pooled meta-analysis

Prevalence of post-partum depression

Fig 4. The estimated pooled prevalence of post-partum depression among mothers after giving birth in Ethiopia, 2020.

Subgroup analysis by assessment tools

Fig 5. Forest plot presenting of subgroup analysis of the pooled estimated prevalence of post-partum depression based on tools in Ethiopia, 2020.

Unplanned pregnancy and post-partum depression

Fig 6. Forest plot pooled random effect size (OR) of unplanned pregnancy-related to planned pregnancy in post-partum depression among mothers in Ethiopia, 2020.

Social support and post-partum depression

Fig 7. Forest plot pooled random effect size (OR) of poor social support related to strong social support in post-partum depression among mothers in Ethiopia, 2020.

Domestic violence and post-partum depression

Fig 8. Forest plot pooled random effect size (OR) of domestic violence related to no domestic violence in post-partum depression among mothers in Ethiopia, 2020.

Discussion

Strengths and limitations

Limitation

Implication of this finding

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Vanessa Carels

Roles

Author response to Decision Letter 0

Decision Letter 1

Marta B Rondon

Roles

Author response to Decision Letter 1

Decision Letter 2

Marta B Rondon

Roles

Acceptance letter

Marta B Rondon

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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