Association between anemia and maternal depression: A systematic review and meta-analysis

Abstract

Previous observational epidemiological studies have reported inconsistent findings regarding the association between anemia and the risk of maternal depression. In the present study, we investigated the relationship between anemia and the risk of maternal depression using a meta-analysis. We searched PubMed, EMBASE, and the bibliographies of relevant articles in May 2019. Three evaluators independently reviewed and selected the eligible studies based on the predetermined selection criteria. A random-effects model was employed to calculate meta-estimates of the association between anemia and maternal depression. Of the 1305 articles, 15 observational epidemiological studies (five case-control studies and 10 cohort studies) were included in the final analysis. A total of 32,792,378 women were included. Anemia was significantly associated with an increased risk of maternal depression in the random-effects meta-analysis of 15 studies (OR/RR: 1.53, 95% CI: 1.32–1.78). The association was consistent in both antepartum (OR/RR: 1.36, 95% CI: 1.07–1.72) and postpartum depression (OR/RR: 1.53, 95% CI: 1.32–1.78). Subgroup meta-analyses based on definition of anemia, definition of depression, and methodological quality reported consistent findings. The current meta-analysis showed that anemia was associated with an increased risk of maternal depression.

Introduction

Maternal depression is a serious mental illness that has a detrimental impact on both mother and child (Brummelte and Galea, 2016). Recent studies have reported that the prevalence of antepartum and postpartum depression is approximately 16% and 12%, respectively, although this varies depending on the diagnostic criteria of depression (Okagbue et al., 2019; Shorey et al., 2018). Maternal depression is more common in low and middle income countries: the prevalence of antepartum and postpartum depression in these countries is 25.3% and 19.0%, respectively. (Gelaye et al., 2016). In pregnant women, depression is associated with harmful health behaviors, such as alcohol and substance abuse, smoking, and poor nutrition, which lead to insufficient weight gain and inadequate prenatal care (Zuckerman et al., 1989). Moreover, depression may cause suboptimal fetal outcomes, such as preterm birth, low birth weight, and fetal growth restriction (Jarde et al., 2016; Lewis et al., 2016). Furthermore, depressive symptoms may continue in affected mothers after childbirth, causing impaired mother-child interaction and low cognitive function in the child (Kingsbury et al., 2015; McManus and Poehlmann, 2012a, 2012b).

Several risk factors of maternal depression have been proposed such as hormonal changes (fluctuations in estradiol levels, sustained high levels of glucocorticoids), psychosocial issues (stress, lack of social support), and nutritional factors (low level of serum vitamin D, magnesium, and zinc) (Brummelte and Galea, 2016; Etebary et al., 2010; Glynn et al., 2013; Razurel et al., 2013; Trujillo et al., 2018). In addition to these risk factors, some epidemiological studies have reported anemia as a potential risk factor (Albacar et al., 2011; Goshtasebi et al., 2013; Xu et al., 2018). In one study, the odds of postpartum depression were more than 4-fold higher among women with anemia (Goshtasebi et al., 2013). However, several studies have found no significant relationship between anemia and the risk of maternal depression (Chandrasekaran et al., 2018; Lukose et al., 2014). As inconsistent findings exist for the association between anemia and maternal depression, it is worthwhile determining whether anemia is a risk factor for maternal depression.

To our knowledge, no quantitative meta-analysis has been published on this topic. Thus, we investigated the association between anemia and the risk of maternal depression by carrying out a meta-analysis of observational epidemiological studies.