Risk Factors for Depression in Pregnancy: Scoping Review

Antenatal depression has become a common and serious problem that can affect the health of both mother and baby. This study aims to review the latest obstetric scientific evidence on the risk factors for depression in pregnancy. This research is a Scoping review using the Arkshey & O'Malley Framework and the PRISMA-ScR Checklist. The literature search used 3 databases, namely Pubmed, Science Direct, and Wiley Online Library. The keywords used were pregnant women, risk factors, and pregnancy depression. The inclusion criteria were original articles; published in 2018 to 2022, in English, open access and full text, and a focus on risk factors for pregnancy depression. Article quality assessment uses the Joanna Briggs Institute (JBI) Checklist. 13 articles were quantitative studies conducted in hospitals and clinics, and came from 8 different countries. Mapping themes from the results of the article analysis are the prevalence of depression in pregnancy, risk factors based demographics including age, education level, marital status and occupation, risk factors based on obstetric characteristics including the number of pregnancies, history of abortion, unwanted pregnancies and diseases in pregnancy, as well as risk factors based on psychosocial including husband support, family, domestic violence, and harmful habits. Information on recognizing risk factors for depression in pregnancy is important for health workers to detect depression on time and implement relevant psychosocial interventions to reduce the incidence of depression during pregnancy


INTRODUCTION
Antenatal depression has become a common and serious problem that significantly affects the health of the mother and fetus. However, evaluation and intervention methods for pregnant women and midwifery clinics are inadequate (Guo et al., 2021). One in three to one in five women in developing countries and around one in ten women in developed countries have mental health problems during pregnancy and after childbirth. High levels of mental health problems in pregnant women and mothers have been reported in many African countries such as Ethiopia, Nigeria, Senegal, South Africa, Uganda, Zimbabwe, and many others (World Health Organization, 2016).
A study in Ethiopia stated that the overall prevalence of general mental disorders in pregnant women was 37.5%. The intimate partner violence, parity, gestational age, history of abortion, and the absence of follow-up antenatal care were significantly associated with general mental disorders during pregnancy (Tamiru et al., 2022). Women with a history of mental health disorders have a worse pregnancy course. Psychiatric illness increases the risk of having a baby (Sudziute et al., 2020). The results of the meta-analysis showed that multigravida pregnant women, in the first and third trimesters of pregnancy, are more prone to experiencing mental health disorders than other pregnant women (Yan et al., 2020).
Social determinants are the main cause of mental health problems in pregnant women and mothers. Women living in developing countries are more vulnerable to risk factors that increase their vulnerability to mental health problems. Some of these include poor socioeconomic status, undervalued social roles and status, unwanted pregnancies, and genderbased violence. The rate of mental health problems in women exposed to intimate partner violence is at least 3 to 5 times higher. After the rape, nearly 1 in 3 women develop post-traumatic stress disorder compared to 1 in 20 nonvictims. Pre-existing psychological disorders often present as depression, substance abuse, or suicide attempts, especially when it is combined with an unwanted pregnancy (WHO, 2022).
A woman's mental health not only impacts the mother but also influences the developing baby. Depressive conditions in pregnant women can reduce appetite and lack of self-care behavior. They will tend not to have routine pregnancy checks which can endanger the baby and the mother (Yayasan Project HOPE, 2022). Maternal depression is directly related to lower birth weight, higher rates of malnutrition and stunting, higher rates of diarrheal disease, communicable diseases and hospitalization, and reduced completion of the recommended immunization schedule for children. It also adversely affects the physical, cognitive, social, behavioral, and emotional development of children (World Health Organization, 2016). A study stated that positive maternal mental health during pregnancy can bring mental health benefits to children (Tuovinen et al., 2021) (Lahdepuro et al., 2022). The purpose of this scoping review study is to review the latest obstetric scientific evidence on risk factors for depression in pregnancy.

METHODS
This study is a scoping review. The reference sources used vary from several articles. Scoping review is a method of identifying comprehensive and in-depth literature from various sources related to the research topic (Munn et al., 2018). The preparation and report in this study used PRISMA-ScR through 5 steps according to Arksey and O'Malley: 1. Identifying research questions; 2. Identifying relevant articles; 3. Selecting articles; 4. Mapping data; 5. Aggregating data, summarizing and presenting results (Tricco et al., 2018).

STEP 1. Identifying Research Question
The PEO (Population, Exposure, and Outcome) framework in this study is to help find articles, determine inclusion and exclusion criteria, and identify suitable articles. The review question in this scoping review was "What is the latest obstetric scientific evidence on risk factors related to depression in pregnancy?"

STEP 2. Identifying Relevant Articles
In determining the articles that match the questions and research objectives, the researchers identified the inclusion and exclusion criteria as follows: In searching for articles, the researchers used several strategies, namely using keywords, using medical subject headings (MesH), using truncation, using Boolean operators (OR, AND, and NOT), and paying attention to the use of keywords in British English and American English. This scoping review used three databases, namely Pubmed, Science Direct, and Wiley Online Library. The keywords are as follows:

STEP 3. Article Selection
The next step is searching for articles from the selected database, which is shown in the PRISMA flowchart as follows: Based on searching articles using keywords in databases and search engines, 784 articles were found. Then, all articles were included in Rayyan and 14 articles were deleted through duplication checks. Furthermore, the researchers screened the titles and abstracts. 752 articles were excluded because they did not meet the inclusion and exclusion criteria. After that, 20 articles were screened as a whole. 3 articles were excluded because they did not find results that fit the purpose, and 4 others were excluded because of a literature review. Article extraction and article quality assessment were carried out on 13 articles that met the requirements.

STEP 4. Charting Data
The charting data used was adopted from the Joana Briggs Institute including author data, article title, year, country, aims, research type, data collecting technique, number of participants/samples, and research results (Peters et al., 2020). Then, the mapping through discussion was carried out with the second author.  (Raghavan et al., 2021) India To estimate the prevalence of perinatal depression and identify social risk factors It was a cross-sectional study in a rural area of Bihar. All perinatal women were screened through a door-todoor survey and recruited after approval. A semi-structured proforma was used to collect socio-demographic characteristics and familyrelated variables. 564 perinatal women were recruited into the study.
The estimated prevalence of PND was 23.9%. Multivariate analysis showed perinatal depression was associated with physical illness in the mother, a history of prior abortion, poor financial status, and poor treatment by in-laws.

A3
Prevalence Complete data were available for 575 women. The mean EPDS score was 10.5 (SD 5.5). The prevalence of depression was 26.8%. The mean anxiety score was 38.4 (SD 11.4) and the mean anxiety score was 38.2 (SD 9.5). The prevalence of anxiety using the state-anxiety scale was 23.6% while using the trait scale was 23.9%. The risk was higher among unemployed women with a history of miscarriages and unplanned pregnancies. The prevalence of antenatal depression using EPDS was 19%. The main risk factors were being distressed by anxiety or depression for more than 2 weeks during this pregnancy, feeling that the relationship with the partner was not an emotionally supportive one, having experienced great stress, change, or loss during this pregnancy, feeling that the father criticized him growing up and a having history of feeling miserable or depressed for ≥ 2 weeks before pregnancy.
10 10 10 7 Were the outcomes measured in a valid and reliable way? 10 10 10 8 Was the follow up time reported and sufficient to be long enough for outcomes to occur? 10 10 10 9 Was follow up complete, and if not, were the reasons to loss to follow up described and explored?
10 10 10 10 Were strategies to address incomplete follow up utilized? 7,5 7,5 5 11 Was appropriate statistical analysis used? 10 10 7,5 TOTAL SCORE/GRADE 9,5/A 9,5/A 8,8/B Were the groups comparable other than the presence of disease in cases or the absence of disease in controls? 10 2 Were cases and controls matched appropriately? 10 3 Were the same criteria used for identification of cases and controls? 10 4 Was exposure measured in a standard, valid and reliable way? 10 5 Was exposure measured in the same way for cases and controls? 10 6 Were confounding factors identified? 10 7 Were strategies to deal with confounding factors stated? 10 8 Were outcomes assessed in a standard, valid and reliable way for cases and controls? 10 9 Was the exposure period of interest long enough to be meaningful? 7,5 10 Was appropriate statistical analysis used? 10 TOTAL SCORE/GRADE 9,7/A

RESULT AND DISCUSSION
Articles Characteristics The research articles used in this scoping review come from several countries, such as African continents, namely South Africa, Ethiopia, and Kenya; Asian continents, namely India, China, and Saudi Arabia; American continents, namely Brazil; and Europe namely Sweden. Based on the research design used, there were 13 articles. 9 articles were cross-sectional articles, 3 articles were cohort articles, and 1 article was a case-control article. Based on the critical assessment conducted on the 13 articles in this study, there were 11 articles with quality A and 2 articles with quality B. Articles with quality A had good value because they were appropriate and provided clear information regarding the aims, methods, and results of the study. Articles with quality B had a moderate value because they did not explain the criteria and limitations of sample inclusion in the study setting.

Prevalence depression in pregnancy
Many women experience changes in mental health during the perinatal period. Poor mental health can have a negative impact on women's health and the well-being of their babies and families. Likewise, poor health or difficult circumstances in the life of women, babies and families can negatively impact women's mental health (WHO, 2022).
Perinatal anxiety and depression are common, affecting around 1 in 10 women in high-income countries and one in five in low-and middle-income countries (WHO, 2022). Mental health and mental disorders are generally shaped by various social, economic and physical environments (WHO, 2014). Perinatal depression affects 21-50% of women in South Africa and poses significant health risks to both mother and child, depressive symptoms will decrease after delivery (A1). The highest intensity of depressive symptoms in the second trimester is related to unmarried status, Article characteristic based on quality A B unplanned pregnancies, gestational diabetes, and headaches (Lau et al., 2018). Teenage pregnancy is associated with various adverse outcomes for these young mothers such as depression, substance abuse, and post-traumatic stress disorder (43.1%) (Tele et al., 2022). The prevalence of perinatal depression in India (23.9%) is in rural areas (A2). In Brazil, antenatal depression was common (11.4%) associated with a vulnerable sociodemographic (A4). The prevalence of depression in Saudi Arabia is 26.8% higher among unemployed women with a history of miscarriage and unplanned pregnancy (A9). Pregnant women who are depressed have one or more psychological symptoms, including fatigue, irritability, anxiety, and problems with sleeping and concentration (A10). Prevalence of antenatal depression in pregnant women during the COVID-19 pandemic was 34.1% depression and COVID-19 during the pandemic (Sewnet Amare et al., 2022).

Demographic risk factors for depression in pregnancy
Perinatal depression was one of the most common mental disorders in women during the perinatal period. In India, the prevalence of perinatal depression was 23.9%. Weak financial status with or without debt resulting in poverty and stress was a strong risk factor for perinatal depression (A2, A6). Malnutrition during pregnancy due to low family income was a risk factor for pregnancy depression (Madeghe et al., 2021). A study stated that the mental health of pregnant women was related to the growth of fetal head circumference (Handayani et al., 2020).
Based on the factors related to antenatal depression was that antenatal depression was significantly higher among women in divorced marital status. Divorced women were 7.52 times more likely to experience pregnancy depression than married women (A3). Being an unmarried mother was considered a shame or a stigma not only for herself but also for the whole family. In some cases, the family rejected and left the unmarried mothers. It could create pressure and guilt, then, led to depressive symptoms (A12).
Antenatal depression was 4.05 times higher among women whose husbands cannot read and write, whereas women whose husbands can read and write without formal education were 2.39 times more likely to experience antenatal depression (A3). It was in line with the results of research in Iran that partner work and education had a statistically significant relationship with antenatal depression (Alipour et al., 2018). Thus in Brazil, antenatal depression was common and associated with vulnerable socio-demographics, including mothers with primary school education, non-white skin color, and living alone (A4). In Kenya, perinatal depression often occurred in teenage pregnancies with a prevalence of around 11-18%, teenage pregnancies result in dropouts which can lead to perinatal depression (A11).

Characteristics of obstetric risk factors for depression in pregnancy
Pregnancy was a very vulnerable time for women, as income potential and health declined, and childcare needed to increase. Antenatal depression was common in women who had three or more children (A6). Physical illness in the mother increased the risk of perinatal depression eightfold, as did gestational diabetes and HIV AIDS (A11). Headache was a significant factor in antenatal depressive symptoms, which might occur due to changes in cortisol secretion (A12). History of miscarriage was not only associated with perinatal depression, but also with other psychiatric disorders such as anxiety and post-traumatic stress disorder. Abortion caused grief as well as deteriorating physical health which could increase the risk of perinatal depression (A2, A9). It was in line with the meta-analysis studies which showed a history of abortion and a history of previous pregnancy complications were risk factors for antenatal depression (Zegeye, 2018).
Women with unplanned pregnancies had an increased risk of antenatal depressive symptoms. Unplanned pregnancies were associated with delays in attending prenatal classes, and were less likely to discuss pregnancy problems with their friends and relatives, consequently, unplanned pregnancies could contribute to the risk of antenatal depressive symptoms due to lack of proper support and treatment (A12). An unplanned pregnancy would make women think that their pregnancy would harm their lives (A9). A systematic review study reported that maternal age, marital status, income, occupation, history of previous psychiatric disorders, antenatal follow-up, unplanned pregnancies, complications during pregnancy, and social support were associated with antenatal depression (Getinet et al., 2018).

Psikosocial risk factors for depression in pregnancy
The perinatal period was a sensitive period for the occurrence of depressive symptoms due to profound physiological and psychosocial changes. Women whose partners had a negative attitude toward pregnancy had higher rates of depression than women whose partners had a positive attitude. Women who had got intimate partner violence had higher depression scores than women who had not (A5). Domestic violence was a global public health problem and a potential risk factor for adverse pregnancy and fetuses. Women who experienced psychological violence had a significant impact on prenatal depression and adverse birth outcomes (Yu et al., 2018) (Pasaribu, 2021).
Poverty, poor social support, abuse by in-laws, and poor access to health services could contribute to women's health (A2). Women who often smoked (A7) and lived with drinkers/alcohol or illegal drug users had a higher rate of depression than those who did not (A5). Feeling of depression during pregnancy and a history of depression were risk factors for antenatal depression (A13). Marital conflict was found to be a significant factor associated with antenatal depression. Women who experienced marital conflict were six times more likely to get antenatal depression than women who did not. Women who had social support were 79% less likely to get antenatal depression than women with low support. Social support from husband, family, and friends during pregnancy would help a woman deal with stressful life events during pregnancy (A8, A10). The husband's support during the antenatal period included physical support, psychological support, and informational support (Halim & Kurniawan, 2018). It was in line with the results of research which showed that the husband's support affected the anxiety of third-trimester pregnant women (Alza & Ismarwati, 2018) which was strongly associated with perinatal depression (Bernard et al., 2018).

LIMITATION OF THE STUDY
The limitation of this study is that data was not collected directly, because it only analyzed previous articles.

CONCLUSIONS AND SUGGESTIONS
Based on the 13 articles used, it was found that depression in pregnancy can be caused by sociodemographic factors including relatively young age, low education level, unemployed mothers, and families with low incomes. Based on obstetric characteristics, depression in pregnancy can occur in women with more than 3 pregnancies, a history of miscarriages, unwanted pregnancies, and pregnant women with the disease. Meanwhile, from the psikososio factor, antenatal depression can occur due to a lack of support from husband and family, domestic violence, and harmful habits such as smoking and drinking in the family. Information on risk factors for antenatal depression is important for health workers to detect depression on time and implement relevant psychosocial interventions to reduce the incidence of antenatal depression.
maternal mental health during pregnancy and mental and behavioral disorders in children: A prospective pregnancy cohort study. Journal of Child Psychology and Psychiatry and Allied Disciplines. https://doi.org/10.1111/jcpp.13625