Breaking The Silence: Postpartum Anxiety and Depression Among Married Women in Pakistan

Postpartum anxiety and depression are significant yet often overlooked public health concerns affecting married women in Pakistan. This review examines the multifaceted nature of postpartum anxiety and depression, emphasizing its epidemiology, risk factors, and the profound impact of cultural norms, societal expectations, and family dynamics on maternal mental health. The global prevalence of postpartum anxiety and depression underscores its universality, but in Pakistan, unique cultural barriers, stigma, and inadequate healthcare services amplify its burden. Key risk factors include patriarchal societal structures, extended family pressures, socioeconomic challenges, and lack of spousal support. Additionally, the limited integration of mental health services within general healthcare systems and the pivotal roles of gynecologists, midwives, and other providers highlights critical areas for intervention. The findings call for a culturally sensitive, systemic approach to improving maternal mental health in Pakistan.

Frequently overlooked, maternal mental health has a vital role in women's general health, especially in the early postpartum phase. It does not indicate personal failure and is a common experience not limited to certain individuals. Reflecting on the past, there was a time when discussing cancer was taboo and treated as a family secret. Similarly, today, there is a reluctance to openly talk about AIDS. However, these barriers are slowly dissipating [1]. Pregnant women worldwide frequently experience anxiety and depression (A&D), however, thorough data from emerging countries such as Pakistan is lacking. This study aims to look into the prevalence of A&D in pregnant women and the factors that affect Pakistan's tertiary healthcare facilities. The frequency and determinants of anxiety and depression (A&D) among pregnant women attending tertiary healthcare institutions were investigated in a study in Quetta City, Pakistan. The study's 750 pregnant participants had moderate levels of anxiety and depression, according to the Hospital Anxiety and Depression Scale (HADS). The bulk of responders were urban residents between the ages of 26 and 35, without any formal education, and jobless. The results, which showed that age was a significant predictor of A&D, highlighted the significance of addressing mental health issues in prenatal treatment [2].

An agitated and markedly depressed mental state that appears during the first four weeks following childbirth and lasts up to thirty weeks postpartum is termed postpartum depression (PPD). The symptoms include sobbing fits, sleep issues, depression, tiredness, worry, and difficulty focusing. The symptoms may be mild, moderate, or severe in intensity. Several psychosocial factors might lead to PPD [3]. This review holds significant implications for public health and the well-being of mothers and infants in Pakistan. By shedding light on the prevalence and determinants of postpartum anxiety and depression, the findings of this review can inform policymakers, healthcare providers, and community stakeholders. The goal was to foster a more supportive environment for mothers during the postpartum period, contributing to improved maternal mental health outcomes. The purpose of this review was to discuss a positive impact on the development of a more encouraging atmosphere for new mothers. By addressing the factors that contribute to postpartum sadness and anxiety, interventions can be designed to enhance social support systems, reduce societal stigma, and promote a culture of understanding and empathy surrounding maternal mental health. This, in turn, can contribute to a more positive and nurturing environment for mothers and infants.

Epidemiology of Postpartum Anxiety and Depression in Pakistan

Pakistani women have one of the highest prevalence rates of postpartum depression (PPD) in Asia, with rates ranging from 28% to 63%. Beyond women, PPD has a substantial negative influence on infants and families. PPD is more common in Pakistan due to several causes, including social, cultural, and environmental effects. Additionally, Pakistani women residing in other countries face similar risks. A cross-sectional study was carried out in Sindh, Pakistan to determine the prevalence of postpartum depression (PPD) and the risk factors linked to it. The Edinburgh Postnatal Depression Scale (EPDS) indicated that 19.3% of Sindhi women had PPD, according to the study. Remarkably, 3.3% of women said they had recurring thoughts of hurting themselves [4]. In Combined Military Hospital Peshawar, Pakistan, a cross-sectional study was carried out that provided insight into the postnatal depression (PPD) landscape of this sociocultural conservative metropolis. The investigation revealed fascinating prevalence rates, with a robust response rate of 52.2% (n=402). The findings underscore the substantial impact, indicating that 27.1% of participants were categorized as low risk, 15.4% as moderate risk, and 12.9% as high risk for developing postnatal depression [5]. 

Postpartum Depression (PPD) is a major concern in the Rawalpindi, Pakistan, metropolitan area, according to a cross-sectional study carried out at the Fauji Foundation Hospital's Gynecology and Obstetrics Department. The study comprised screening for PPD in 252 female patients using the Patients Health Questionnaire (PHQ 9) throughout six months from January to June 2022. The findings disclose that 34.5% of the participants experienced PPD, highlighting the prevalence of this condition among new mothers in the city, while the remaining 65.5% showed no signs of PPD [6]. In a cross-sectional comparative study, the researchers investigated how nursing moms who were depressed and those who were not at Bolan Medical Complex Hospital Quetta perceived their breast milk to be insufficient. The researchers screened moms and gathered information on demographics, nursing behaviors, and prenatal details using self-reporting questionnaires, the Edinburgh Postnatal Depression Scale (EPDS), and the Perception of Insufficient Milk (PIM) questionnaire. Findings revealed that 84% of mothers received antenatal care, with 26% having proper information about breastfeeding. The majority were multigravida (73%), and 41% of depressed mothers scored greaterthan 12 on EPDS, while 59% of non-depressed mothers scored similarly. The study underscored the significant impact of perceived insufficient milk on breastfeeding interruptions among postnatal depressive lactating mothers [7].

Comparative Analysis: Urban Vs Rural Prevalence

Several studies have reported varying prevalence rates of postpartum depression (PPD) across urban and rural settings, suggesting that socio-environmental factors play a significant role in these disparities. Research conducted in Sindh, Pakistan, revealed a PPD prevalence rate of 19.3% in urban settings, with 3.3% of women reporting persistent thoughts of self-harm [4]. While another study in Lahore found the prevalence to be 29.8% [8]. PPD was shown to be prevalent overall in Pakistan, according to a meta-analysis of research, with greater rates recorded in rural than in urban areas [9]. These findings indicate a moderate level of PPD in urban areas, where access to healthcare may be relatively better. 

However, the situation in rural areas paints a more concerning picture. According to a study, PPD prevalence in Southeast Asia ranges from 18- 30% in urban areas but escalates to 28-36% in rural regions. This disparity reflects broader socio-economic challenges in rural areas, including poverty, limited healthcare access, and fewer mental health resources. Addressing this overlooked condition is crucial, as it can lead to severe complications, emphasizing the need to prioritize public health initiatives [10]. In contrast, urban women might benefit from better healthcare infrastructure, mental health awareness, and more readily available support services, contributing to relatively lower PPD rates. This urban-rural divide underscores the need for targeted interventions in rural areas, addressing the socio-economic barriers to maternal mental health care. Increasing healthcare access, raising awareness, and building community-based support systems are essential strategies to mitigate the higher prevalence of PPD in rural populations.

Global Prevalence of Postpartum Anxiety and Depression

Globally, postpartum depression (PPD) has been recognized as a significant public health concern, with varying prevalence rates depending on region and socio-economic factors. The postpartum period presents enhanced challenges for mothers, with depression episodes doubling compared to other life stages. Postpartum depression (PPD) affects women in different ways around the world; rates range from 0.5% to 60.8%. After giving birth, PPD may affect 30% of women, with severity varying from mild to moderate in 50-80% of cases; in contrast, less than 1% of women experience intense psychosis [11]. In a comprehensive examination of postpartum depression (PPD) prevalence across 40 countries. Their research analysis of 143 showed a significant diversity, with a reported prevalence ranging from nearly 0% to nearly 60%, in contrast to the frequently stated estimate of 10-15% [12]. Notably, rare reports of PPD or postpartum depression symptoms were found in Singapore, Malta, Malaysia, Austria, and Denmark; on the other hand, large incidence rates were found in Brazil, Guyana, Costa Rica, Italy, Chile, South Africa, Taiwan, and Korea [13].

Around 500,000 US women face mental health issues during pregnancy. The general causes can involve maternal illness, social and financial support, illiteracy, and mortality. If these causes are prolonged, they might affect the mother in various stages of her life. Despite these facts, many studies focus on depression, but there are very few studies that focus on anxiety alone in pregnancy which let this overview shed light on this crucial aspect of maternal mental health [14]. Another study reported varying rates of postpartum depression (PPD) across Asian countries. Malaysia demonstrated one of the lowest rates at 3.5%, whereas, Pakistan exhibited one of the highest rates at 63.3%. These findings underline the diversity in PPD prevalence within cultural contexts [15]. Moreover, another comprehensive research was conducted, analyzing 565 studies from 80 countries. With study size and country development as major factors, they discovered that 17.22% of the world's population suffers from postpartum depression. The biggest regional variance was observed in Southern Africa (39.96%), while wealthy nations had a substantially lower percentage. With 39.96% of women reporting postpartum depression, Southern Africa had the highest frequency, followed by Southern Asia (22.32%) and South America (21.71%). Other noteworthy rates were seen in Western Asia (19.83%), Northern Africa (18.75%), and Eastern Asia (17.39%). At 11.11%, Oceania had the lowest prevalence [16].

Influence of Cultural Norms and Traditional Practices in Pakistan on Mental Health

In Pakistan, cultural norms often discourage open discussions about mental health, especially for women. The stigma associated with mental illnesses, particularly postpartum depression (PPD), leads to underreporting and a lack of adequate care. Traditional societal expectations in Pakistan demand that women take on multiple roles as mothers, wives, and caretakers which exacerbates stress and mental health challenges during the postpartum period. These cultural pressures make it difficult for women to seek help or acknowledge the emotional difficulties they face after childbirth. According to a study, women in Pakistan often experience exacerbated postpartum depression symptoms due to the lack of spousal and familial emotional support. The traditional expectations that women endure postpartum challenges in silence without seeking external help contribute to these higher levels of depression. Postpartum depression is largely influenced by the lack of social support, interpersonal interactions, self-neuroticism, and anxiety. In the context of Pakistani culture, women are frequently blamed for giving birth to female children. When the spouse and in-laws find out that a girl has been born, the attitudes of many families change. The woman experiences more sadness and disturbance as a result of her partner's and in-laws' lack of support, which eventually triggers postpartum depression symptoms [17].

Pregnancy has been linked to several mental health conditions, the most common of which is depression. According to a study, pregnancy was formerly believed to be a period for emotional well-being and "protecting" women against mental health issues. Researchers have become interested in these concerns since intimate partner abuse and violence during pregnancy have long-lasting impacts on the mental health and welfare of both the mother and her child [18]. Additionally, a study found that low family support, particularly from spouses, is a significant predictor of postpartum depression, underscoring the cultural norms that expect women to bear emotional hardship without external assistance [19]. In South Punjab, Pakistan, 100 women between the ages of 24 and 33 were studied, according to the results, 88% of the individuals had postpartum depression, and 70% of them expressed pregnancy-related worries. Moreover, 50% of the subjects reported being economically disadvantaged, 70% mentioned that their husbands did not support them, and 76% mentioned that they had bad social relationships. The study found that psychological distress accounts for around 84% of the symptoms of postpartum depression, while domestic violence accounts for 65% of the symptoms [20].

Healthcare Access and Cultural Barriers

Cultural norms surrounding mental health play a pivotal role in shaping healthcare access in Pakistan, particularly in rural areas. Many women are discouraged from seeking mental health services due to societal perceptions that label postpartum depression as a natural part of motherhood, rather than a condition requiring medical intervention. This cultural barrier restricts women's ability to access timely and adequate healthcare for postpartum mental health disorders. Cultural resistance to mental health interventions in Pakistan is a prominent challenge. Many families perceive postpartum mental health issues as natural trials that women must endure without seeking professional help. This perception is reinforced by the strong societal belief in self-reliance and the role of family, rather than medical professionals, in managing emotional and mental health challenges. In addition, a study discovered that women, particularly in rural areas, often rely on traditional healers and religious figures for emotional and mental support during the postpartum period, delaying or avoiding professional treatment for postpartum depression. The widespread belief in traditional remedies reflects the deep-rooted cultural practices that prioritize non-medical interventions over clinical treatment [21].

Stigma and Mental Health Seeking Behavior

A major factor contributing to the underreporting and undertreatment of postpartum depression in Pakistan is the stigma associated with mental health disorders. According to a study, the pervasive stigma around mental illness in Pakistani society prevents women from seeking help, as they fear being labeled as “mad” or “unfit” for motherhood. This stigma not only discourages women from discussing their mental health struggles openly but also leads to isolation and shame, further aggravating their condition [22]. Another study noted that the societal expectation for women to be strong and endure emotional hardships in silence creates a barrier to accessing mental health services. This societal pressure is particularly intense during the postpartum period when women are expected to transition into motherhood seamlessly. The fear of being judged as an inadequate mother contributes to the hesitance in seeking professional help for postpartum depression and anxiety. While pregnancy is typically viewed as a natural phase, it represents a sensitive time for women due to exposure to various physical, mental, and social challenges. Identifying and addressing these conditions promptly enhances the likelihood of minimizing their impact. Managing psychological distress during the perinatal period positively influences the mother's and her baby's well-being within their living contexts [23].

The stigma associated with mental health in Pakistan has a profound impact on the treatment and management of postpartum depression. A study concluded that cultural stigma leads to delayed or neglected treatment for mental health conditions in postpartum women, exacerbating symptoms. Women in the current study who expressed concerns about being labeled as “mentally ill” were significantly less likely to seek help from healthcare professionals, which mirrors findings from similar studies in the region. The social repercussions of being diagnosed with a mental health disorder also play a critical role in preventing women from seeking help. According to a study, the fear of being ostracized by the community or being seen as unfit mothers leads many women to suppress their symptoms. This fear was echoed by participants in the current study, many of whom felt that disclosing their mental health struggles would lead to judgment or ridicule from family members and friends [24]. Addressing the stigma surrounding mental health is crucial to improving postpartum care in Pakistan. This review also highlights the need for interventions that not only treat the symptoms of postpartum depression but also address the cultural and societal stigmas that prevent women from seeking treatment in the first place.

Role of Family Dynamics and Societal Expectations of Married Women and Socioeconomic Challenges

In Pakistan, socioeconomic factors such as poverty and illiteracy significantly influence maternal mental health outcomes. The prevalence of postpartum depression is exacerbated by limited access to healthcare services, particularly in rural areas. In South Punjab, Pakistan, 100 women between the ages of 24 and 33 were studied in a 2016 study by Zia A. According to the results, 88% of the individuals had postpartum depression, and 70% of them expressed pregnancy-related worries. Moreover, 50% of the subjects reported being economically disadvantaged, 70% mentioned that their husbands did not support them, and 76% mentioned that they had bad social relationships. According to the study, psychological distress accounts for around 84% of the symptoms of postpartum depression, while domestic violence accounts for 65% of the symptoms [20]. Income distribution shows that nearly half of the participants are in the lower-middle-income category. Post-hoc analysis using the Games-Howell test showed that lower-middle-income participants had significantly higher EPDS scores compared to the affluent group. This suggests that women in the lower-middle-income bracket are more likely to experience severe postpartum depression due to economic status. Moreover, financial instability can lead to increased stress and anxiety, further exacerbating mental health issues during the postpartum period [25].

A study found that married people with low levels of education, many of whom were housewives, made up the bulk of the sample. Findings showed that over one-third of the women had a significant risk of developing postpartum depression (PPD), which frequently starts in the first week following delivery but is first diagnosed as a psychological issue later on. The relationship between social support and postpartum depression was examined in a study conducted in the hospital environment in Rawalpindi, Islamabad, Pakistan. Social support and postpartum depression were found to be significantly correlated in this cross-sectional study, which included 310 postpartum mothers [20]. The Edinburgh Postpartum Depression measure (EPDS) and a multidimensional perceived social support measure were used in the study. The results demonstrated a critical connection between postpartum depression development and insufficient assistance from family members and significant people. Remarkably, there was no significant correlation found between postpartum depression and variables such as the mother's age, the style of delivery, the baby's feeding habits, and history of sickness during pregnancy [26].

Healthcare System and Mental Health Services in Pakistan

The healthcare system in Pakistan is characterized by disparities in access and quality, particularly in maternal care. The maternal mortality rate remains unacceptably high, with inadequate access to skilled healthcare providers and facilities being major contributing factors. The public healthcare system is often overburdened and under-resourced, especially in rural areas, limiting women's access to essential maternal health services. Unhealthy infants, a larger percentage of female children, cesarean delivery, poor family ties, and a lack of social support were all significant predictors of postpartum depression (PPD). Nearly half of the moms who had cesarean deliveries also experienced postpartum depression. Postpartum depression symptoms were less evident in women who had assistance from their spouses and relatives than in those who did not. PPD was more common than in industrialized nations, where it was marked by a high birth rate, limited social security, and poor health care. The study found that prenatal sadness, morbidity, and chronic illnesses are frequently the causes of postpartum depression in the community. Mental health services for postpartum women in Pakistan are significantly lacking, particularly in rural areas where access to specialized care is limited. This scarcity results in many women not receiving the necessary support during a critical period of their lives. The current state of maternal mental health services in Pakistan is inadequate, with only a fraction of women being able to access appropriate care. According to a report by the World Health Organization, the country has one psychiatrist for every 400,000 people, highlighting a severe shortage of mental health professionals available for postpartum women [27].

Role of General Healthcare Providers, Gynecologists, and Midwives in Addressing Postpartum Mental Health

Healthcare providers, including gynecologists and midwives, play a crucial role in identifying and addressing postpartum mental health issues. They are often the first point of contact for new mothers, and their ability to recognize signs of postpartum depression can significantly influence treatment outcomes. A study emphasizes the need for training healthcare providers to recognize and manage postpartum mental health conditions. Gynecologists and midwives should be equipped with the necessary skills to screen for anxiety and depression, facilitating timely referrals for women who require further support. Moreover, the involvement of general healthcare providers in mental health discussions during routine check-ups can enhance awareness and encourage postpartum women to seek help when needed [28].

A study investigated the relationship between postpartum depression (PPD) and a range of demographic and health-related characteristics among women. The findings showed a substantial correlation between PPD and the following variables: mode of delivery, age of the last child born, bad obstetric history, education level, socioeconomic class, postpartum phase, and postpartum problems. Furthermore, the number of boys and PPD ratings were found to be negatively correlated. The results highlight how crucial it is to identify and manage these sociodemographic and health-related risk factors for postpartum depression to enable prompt screening, diagnosis, and treatment for those who are impacted. In obstetric settings, collaboration with psychologists and psychiatrists is advised to successfully address these contributing variables [29].

Risk Factors for Postpartum Anxiety and Depression in Pakistan

Various factors can be involved in causing postpartum anxiety and depression in Pakistani women. Some of these factors are discussed in this review. 

Influence of Extended Family Pressure and Patriarchal Societal Structures

The social dynamics and family pressures within Pakistan, particularly in the context of extended families and patriarchal expectations, often place a considerable psychological burden on postpartum women. Research indicates that these traditional structures can sometimes lead to increased anxiety and depressive symptoms postpartum. For example, studies in similar settings have shown that the obligations and expectations placed on new mothers such as caring for extended family members and adhering to traditional roles can exacerbate mental health challenges, creating a “perceived lack of autonomy and intensified emotional strain”. Additionally, the findings show that the kind of family and family structure—especially the extended joint family system—is important in supporting the postpartum period. Extended family expectations can also impact women’s ability to seek mental health care, as discussing psychological distress may be stigmatized or minimized in favor of maintaining familial harmony. According to a study, the prevalence of postpartum depression is higher among women who feel an acute sense of responsibility to satisfy extended family expectations, highlighting a need for culturally sensitive support mechanisms in mental health services. Additionally, societal expectations of women as primary caregivers often lead to neglect of their well-being, further compounding mental health concerns [30].

Socioeconomic Stressors, Including Financial Constraints and Healthcare Access

Income distribution shows that nearly half of the participants are in the lower-middle-income category, while 32.0% are classified as affluent. In comparisons, significant differences were observed through ANOVA. Post-hoc analysis using the Games-Howell test showed that lower-middle-income participants had significantly higher EPDS scores compared to the affluent group and the middle-income group. This suggests that women in the lower-middle-income bracket are more likely to experience severe postpartum depression compared to those in higher-income brackets. Furthermore, low-income women are at higher risk for postpartum depression (PPD) due to barriers such as inadequate access to care and untreated mental health issues. In another study, it was found that poverty significantly influences postpartum depression (PPD), with higher rates observed in low- and middle-income countries. In Southeast Asia, PPD prevalence ranges from 18-30% in urban areas and 28-36% in rural areas, highlighting the impact of low income on mental health [31].

Lack of Spousal Support and Its Role in Mental Health Outcomes

Family support during or after childbirth is diverse, and those who reported 'Never' having support had significantly higher EPDS scores compared to those who reported 'Often' having support. This indicates that a lack of family support is associated with higher levels of postpartum depression. A similar study found that low family support increases the risk of postpartum depression (PPD). Lack of support, particularly from spouses, is a significant predictor of PPD. The role of spousal support was underscored as essential in managing postpartum mental health symptoms. The lack of adequate spousal involvement is associated with increased depressive symptoms among new mothers, indicating that a supportive marital relationship can significantly buffer against postpartum mood disturbances. Insufficient support from spouses during the postpartum period is a recurrent factor in the increased prevalence of depressive symptoms among mothers, especially in conservative societal structures where family dynamics heavily influence maternal responsibilities. This dynamic often places an unequal mental burden on new mothers, highlighting spousal support as a critical element in reducing PPD symptoms [32].

The International Classification of Diseases (ICD-10) defines postpartum depression (PPD) as the onset of depressive symptoms within six weeks of childbirth. PPD can cause emotions of helplessness, exhaustion, unjustified guilt, and humiliation in new moms. These symptoms are frequently accompanied by disturbed sleep and decreased appetite. Maternal and fetal outcomes are also influenced by low social status and limited access to healthcare. Furthermore, untreated postpartum depression has been associated with long-term issues like weight problems, substance abuse, domestic challenges, and breastfeeding difficulties. Pregnancy is associated with several physiological changes in addition to psychosocial risk factors. These changes include changes in neuroendocrine function, neuroinflammation, neurotransmitter levels, circuit malfunction, and the influence of genetics and epigenetics. Together, these elements play a major role in the emergence of postpartum depression. Postpartum depression is largely influenced by the lack of social support, interpersonal interactions, self-neuroticism, and anxiety [33]. In the context of Pakistani culture, women are frequently blamed for giving birth to female children. When the spouse and in-laws find out that a girl has been born, the attitudes of many families change. The woman experiences more sadness and disturbance as a result of her partner's and in-laws' lack of support, which eventually triggers postpartum depression symptoms.

Recommendations

To address postpartum anxiety and depression among married women in Pakistan, it is crucial to enhance awareness and education through public health campaigns that destigmatize mental health and encourage early help-seeking behavior, while also providing families with the tools to recognize and support affected women. Healthcare systems must be strengthened by training gynecologists, midwives, and general practitioners to identify and manage postpartum anxiety and depression, and by integrating maternal mental health services into primary care settings. Policy interventions should include mandatory mental health screenings during prenatal and postnatal care, alongside increased resource allocation for mental health programs, particularly in rural areas. Community-based support systems and culturally sensitive counseling services can foster an environment of shared experiences and guidance, while workshops for husbands and extended families can promote supportive behaviors and address underlying gender dynamics and financial stressors that exacerbate maternal mental health challenges. By prioritizing these actions, Pakistan can create a more supportive framework for addressing postpartum anxiety and depression.

Postpartum anxiety and depression remain critical yet under-addressed challenges for married women in Pakistan. The interplay of cultural norms, family dynamics, and systemic gaps exacerbates the condition, leading to profound consequences for mothers, children, and families. This review highlights the urgent need for comprehensive, culturally informed strategies to address these barriers. Strengthening healthcare infrastructure, fostering awareness, and engaging families is essential to breaking the silence surrounding postpartum anxiety and depression. By prioritizing maternal mental health, Pakistan can improve not only the well-being of mothers but also broader societal outcomes.

Funding

No funding agencies supported our work and does not have any grants.

Conflicts of Interest

None.