Prevalence and Factors Associated with Postpartum Depression during the COVID-19 Pandemic among Women in Jeddah, Saudi Arabia: A Cross-Sectional Study

Background: Postpartum depression is the most common psychological health problem among females; it begins after the birth of the child and can occur at any time during the first year of delivery. The COVID-19 pandemic is a novel virus that is highly infectious and has several negative psychological impacts on individuals globally. Aim: Coronavirus disease 2019 (COVID-19) has been reported to increase the incidence rate of depression. We investigated the prevalence rate and associated factors of postpartum depression (PPD) among women in Jeddah, Saudi Arabia, during the COVID-19 period, thereby attempting to determine whether and how COVID-19 affected PPD. Methods: This is a cross-sectional study that was conducted on women at one week to six months postpartum using an online questionnaire. SPSS program was used for analyzing data. Results: This study included 150 participated women; 49.3% were in the age range of 25 - 34 years old. There were 30.7% reported being primigravida. 0.03). Conclusion: There was a high prevalence of PPD among women during the COVID-19 period, and it was higher than the prevalence of PPD before the COVID-19 period.


Introduction
Postpartum depression (PPD) is a non-cyclic depression that begins after childbirth in the postpartum period, and it can occur at any time during the first year after delivery [1]. PPD is the most common psychological health issue among females, affecting 10% -15% of females globally [2]. The main characteristics of PPD including emotional stress, anxiety, loss of appetite, tearfulness, guilt feelings, sleep disorders, suicidal thoughts, memory problems, concentration problems, irritability, feeling of weakness, and exhaustion [3] [4] [5].
The international prevalence of PPD was reported to be 13%; however, the prevalence rates are based on the screening period, the country of the study and the screening method and tool used [3].
A study investigated the prevalence of PPD in Saudi Arabia reported that there was 33.2% of participants showed PPD symptom risk, with anemia and low hemoglobin being the risk factors for PPD [7]. A study from Riyadh reported that the prevalence of PPD among 174 females was 38.5%, and there were significant associations between PPD and each of the unsupportive husband and recent stressful events [8]. The prevalence of PPD among postpartum mothers in Jeddah was reported according to the EPDS score, and it was 12.7 with a range of zero to 30. The prevalence of PPD was associated with maternal age, education, occupation, medical problems, monthly income, previous psychological problems, and planning pregnancy [9].
On January 30 th , the world health organization (WHO) announced the outbreak of the novel coronavirus (COVID-19) as a public health emergency of international concern [10]. COVID-19 is a highly infectious disease that has posed a global health threat [11]. The authorities in Saudi Arabia were monitoring the COVID-19 situation from the time it was first detected, and plans were established to prepare for the potential spread of the disease in the kingdom [12]. However, on March 2 nd , the first COVID-19 case in Saudi Arabia was confirmed in a traveler returning from Iran through Bahrain with no declaration of his traveling history to Iran [13]. Umrah was completely pended, the two holy mosques in Makkah and Madinah were put for daily closure for cleaning and disinfection, and the schools and universities were depending on remote learning [13].

A. I. Tarabay et al. Open Journal of Obstetrics and Gynecology
The COVID-19 resulted in significant negative psychological impacts on individuals globally. These impacts include stress, fair, pandemic, anxiety, depression, sleep disorders, insomnia, panic, and impaired quality of life [14]. These effects are close to the effects caused by PPD, so the presence of COVID-19 may enhance the occurrence of PPD. Although there were studies reported on the prevalence of PPD in Saudi Arabia, there was no study that investigated its prevalence during the COVID-19 period, so this study was conducted to assess the prevalence of PPD during the COVID-19 period.

Subjects and Study Design
This is a cross-sectional study; it was performed during the period from March 2020 to August 2020 using an anonymous online questionnaire. The study included women from one week to 6 months postpartum. The Arabic version of the Edinburgh Postnatal Depression Scale and a questionnaire regarding associated factors were administered to all participants. Approval for the study was obtained before the beginning of the study with an IRB registration number with KACST, KSA: H-02-J-002.

Statistical Analysis
SPSS program version 22 was used to analyze the data; numbers and percents were used to represented qualitative variables. Multivariate logistic regression was used to determine factors that were significantly associated with PPD. P-value at ≤0.05 was considered significant.
There were 124 (82.7%) reported university education, whereas 26 (17.3%) had less than university education. Regarding the job, there 71 (47.3%) housewives, 63 (42%) employees, and 16 (10.7%) students. The highest monthly income of more than ten thousand was reported by 43 (28.7%) of participants. More than half of women, 77 (51.3%), reported two to four times of pregnancy, whereas 46 (30.7%) reported being primigravida, and 27 (18%) reported more than four times of pregnancy. Table 1 shows the demographics and characteristics of the participated women.
We used the Arabic version of the Edinburgh Postnatal Depression Scale, so the depression score was calculated according to that scale. The maximum score of the scale is 30, the depression is predicted at ten scores and more. There were 91 (60.7%) of participants scored ≥ ten scores, whereas 59 (39.3%) scored less than ten scores, Figure 1.    The factors associated with depression during the COVID-19 period were investigated, and they are shown in Table 3

Discussion
This is the first Saudi study to investigate the postpartum depression during the  126 females, there was 12% only having the risk for PPD [14]. The Turkish study also used the EDP scale as we used; however, the prevalence rate in our study still higher among the studies conducted in other countries.
The prevalence of PPD in Saudi Arabia, as reported in several studies before the pandemic, ranged from 17.8% to 38.5% [9] [15]. Our findings showed a high elevation in the prevalence rate of PPD in Saudi Arabia. These findings were in agreement with the Canadian study that reported that there was a significant elevation in depression and anxiety symptoms compared to similar pre-pandemic among pregnant women, with 37% showed depression symptoms, and 57% showed anxiety symptoms [16].
This study did not examine the prevalence rate of PPD before COVID-19 pandemic and thus we cannot conclude that COVID-19 actually increased the incidence of PPD. However, previous data on the incidence of PPD in Saudi Arabia was much lower than that obtained here. Thus, we believe that the Other factors associated with PPD during the pandemic period were reported from a study from China, and they included immigrant women, persistent fever, poor social support, concerns about contracting COVID-19, and certain precautionary measures [11]. A study from Turkey reported low income, higher education levels, previous psychiatric illness, and having newborn needs NICUS were associated significantly with PPD [14]. In agreement with our study, the high level of education was associated with PPD.
Demographic factors associated with PPD didn't change before and after the pandemic and seemed to have the same impact enhancing the occurrence of PPD, where it was reported to form a study from Central Nepal that the education level was associated with the prevalence of PPD. This study from Central Nepal was conducted from 2017 to 2018 and published in 2019 before the pandemic [18].

Conclusion
There was a high prevalence of PPD among women during the COVID-19 period. Compared with the period before the COVID-19 pandemic, the prevalence during the COVID-19 was higher than before the pandemic. The factors associated with the prevalence of PPD included demographic factors such as education, family history. However, the pandemic COVID-19 increased the prevalence of PPD by some factors, including the quarantine due to the pandemic and A. I. Tarabay et al.