Asian Journal of Psychiatry 81 (2023) 103452

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Asian Journal of Psychiatry

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Short communication

The neglected spectrum of COVID-19 pandemic - postpartum depression

among COVID-19 infected South-Indian women – a cohort study
Krithika V. Senthil Kumar a, d, *, 1, Meena Priyadharshini a, Deepika Naidu a,
Jeevithan Shanmugam b, Suganya Priyadharshini c
a
Department of Obstetrics and Gynaecology, KMCH Institute of Health Sciences and Research, Tamil Nadu, India
b
Department of Community Medicine and Biostatistics, KMCH Institute of Health Sciences and Research, Tamil Nadu, India
c
Department of Psychiatry, KMCH Institute of Health Sciences and Research, Tamil Nadu, India
d
Department of Obstetrics and Gynaecology, Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire, England, UK

A R T I C L E I N F O A B S T R A C T

Keywords: The study aims to explore the burden of postpartum depression among COVID-19-infected mothers and stressor
Postpartum depression factors. A single-centre observational cohort study was conducted in South India to evaluate postpartum
COVID-19 disease depression among 106 COVID-19-infected women who delivered from December 2020 to May 2021. Also,
stressor factors related to COVID-19 infection were figured out to analyse their role in depression. Almost half of
the COVID-19-infected mothers had a global EPDS score ≥ 10 and were at risk of depression during the
pandemic. The depressive symptoms were not confined to the immediate postpartum period, but significantly
impacted mothers until 6 months following childbirth.
Synopsis: COVID-19 infection not only affects the physical well-being but also adversely affects the mental health
of the infected persons. Postpartum mothers who require the utmost care and support, are facing social depri­
vation due to the COVID-19 pandemic. This triggers the already fragile mental state of postpartum women and
may worsen the level of depression.

1. Introduction also of utmost importance to achieve wholesome healthy living. The

The end of the second decade of the 21st century has begun with a
big bang, the coronavirus disease (COVID-19), caused by the highly
infectious Novel coronavirus SARS-CoV-2. After the emergence of the
disease in Wuhan in late December 2019, India reported the first
confirmed case of COVID-19 on 30 January 2020 (Andrews et al., 2020)
and eventually India was the second most infected country, only after
the USA.
The initial research activities focused on understanding the nature of
the disease, ways to limit the spread of infection and exploring the
possible treatment options. Two long years have elapsed since the
emergence of COVID-19 and the latest focus is on curtailing the mor­
tality rates and preventing the infection by vaccinating the community.
We have roved so far in this battle and as we are approaching the fin­
ishing line, we ought to reconcile the after-effects of COVID and that
poses a big question.
Apart from achieving physical health, addressing mental health is
same is substantiated by WHO, which defines health as a state of com­
plete physical, mental and social well-being and not merely the absence
of disease or infirmity (McCartney et al., 2019). However, the psycho­
logical impact of COVID-19 is least attended to in day-to-day clinical
practice and research activities are also limited in this regard, particu­
larly in pregnant women.
Postpartum depression is a common and serious mental health
problem, with an estimated prevalence of 6.5–20% (Shorey et al., 2018;
O’Hara and McCabe, 2013; Anokye et al., 2018). Postpartum depression
is defined by the American Psychiatric Association as a depressive
episode with onset within four weeks of delivery (DSM-5, 2013). How­
ever, for clinical practice, World Health Organisation (WHO) and the
Centers for Disease Control and Prevention (CDC) have variably defined
postpartum depression as depressive episodes that occur up to 12
months after delivery.
The postpartum period, a period of transition into motherhood due
to its biological nature itself is a risk factor for depression

* Corresponding author at: Department of Obstetrics and Gynaecology, Calderdale and Huddersfield NHS Foundation Trust, West Yorkshire, England, UK.
E-mail address: drkrithi30@gmail.com (K.V. Senthil Kumar).
1
ORCID ID: 0000–0002-1034–9850

https://doi.org/10.1016/j.ajp.2023.103452
Received 3 December 2022; Received in revised form 1 January 2023; Accepted 5 January 2023
Available online 5 January 2023
1876-2018/© 2023 Elsevier B.V. All rights reserved.
K.V. Senthil Kumar et al. Asian Journal of Psychiatry 81 (2023) 103452

Table 1
Maternal, Obstetric and Infant Characteristics.
S.No. Parameters Overall (n = 106) EPDS < 10 (n = 54) EPDS ≥ 10 (n = 52) P value

Socio-demographic factors
1. Age ≤ 21 years 6 (5.7) 4 (7.4) 2 (3.8) 0.810
22–25 years 31 (29.2) 16 (29.6) 15 (28.8)
26–30 years 49 (46.2) 23 (42.6) 26 (50.0)
> 30 years 20 (18.9) 11 (20.4) 9 (17.3)
2. Religion Hindu 100 (94.3) 49 (90.7) 51 (98.1) 0.329
Muslim 3 (2.8) 3 (5.6) 0 (0)
Christian 3 (2.8) 2 (3.7) 1 (1.9)
3. Family type Joint 73 (68.9) 36 (66.7) 37 (71.2) 0.678
Nuclear 33 (31.1) 18 (33.3) 15 (28.8)
4. Working status Non-working 84 (79.2) 44 (81.5) 40 (76.9) 0.716
Working 22 (20.8) 10 (18.5) 12 (23.1)
5. Annual income < 1 lakh 28 (26.4) 17 (31.5) 11 (21.2) 0.386
1–5 lakhs 58 (54.7) 29 (53.7) 29 (55.8)
6–10 lakhs 15 (14.2) 7 (13.0) 8 (15.34)
> 10 lakhs 5 (4.7) 1 (1.9) 4 (7.7)
6. Educational status Illiterate/primary school 8 (7.5) 6 (11.1) 2 (3.8) 0.393
Graduate 54 (50.9) 29 (53.7) 25 (48.1)
Postgraduate 37 (34.9) 16 (29.6) 21 (40.4)
High school 7 (6.6) 3 (5.6) 4 (7.7)
Obstetric factors
7. No. of years of married life Up to 1 year 25 (23.6) 12 (22.2) 13 (25.0) 0.968
2–5 years 52 (49.1) 27 (50.0) 25 (48.1)
> 5 years 29 (27.4) 15 (27.8) 14 (26.9)
8. Order of pregnancy Primipara 64 (60.4) 35 (64.8) 29 (55.8) 0.226
Multipara 42 (39.6) 19 (35.2) 23 (44.2)
9. Duration from delivery At 1 month 10 (9.4) 5 (9.3) 5 (9.6) 0.361
2–3 months 64 (60.4) 36 (66.7) 28 (53.8)
4–6 months 32 (30.2) 13 (24.1) 19 (36.5)
10. Pregnancy complications Yes 62 (58.5) 31 (57.4) 31 (59.6) 0.846
No 44 (41.5) 23 (42.6) 21 (40.4)
11. Type of delivery Normal VD 13 (12.3) 6 (11.1)1 7 (13.5) 0.716
Instrumental VD 1 (0.9) 1 (1.9) 0 (0)
Elective LSCS 70 (66.0) 34 (63.0) 36 (69.2)
Emergency LSCS 22 (20.8) 3 (24.1) 9 (17.3)
12. Delivery complications Yes 5 (4.7) 3 (5.6) 2 (3.8) 1.000
No 101 (95.3) 51 (94.4) 50 (96.2)
Infant parameters
13. Gestation at birth Full term 94 (88.7) 48 (88.9) 46 (88.5) 0.593
Pre-term 12 (11.3) 6 (11.1) 6 (11.5)
14. NICU admission Yes 10 (9.4) 5 (9.3) 5 (9.6) 1.000
No 96 (90.6) 49 (90.7) 47 (90.4)
15. Sex of baby Male 55 (51.9) 28 (51.9) 27 (51.9) 1.000
Female 49 (46.2) 25 (46.3) 24 (46.2)
Twins 2 (1.9) 1 (1.9) 1 (1.9)
16. Sex of baby desired or not Yes 97 (91.5) 53 (98.1) 44 (84.6) 0.015*
No 9 (8.5) 1 (1.9) 8 (15.4)

*P < 0.05, statistically significant

(Kołomańska-Bogucka, 2019). Previous pandemic reports have shown
that the vulnerability of pregnant women to psycho-emotional distur­
bances due to catastrophic events is more when compared to their
non-pregnant counterparts. Hence, there is a growing need to under­
stand the psychological impact of COVID-19, particularly in vulnerable
groups like postpartum mothers, to prevent serious mental illness in
both mother and newborn in the long run.
2. Materials and methods
It was an observational cohort study conducted from June 2021 to
September 2021 in the department of Obstetrics and Gynaecology,
KMCH Institute of Health Sciences and Research, a tertiary care hospital
in South India. Institutional Ethics Committee approval was obtained
before the start of the study (02/IHEC/2021).
All pregnant women who were admitted for delivery in our institute
during the COVID-19 pandemic were universally tested for COVID-19
infection by either Reverse Transcriptase – Polymerase Chain Reaction
(RT-PCR) or Gene Xpert depending on the availability of the test. All
COVID-19-positive women who delivered from December 2020 to May
2021 were listed from the delivery registry maintained in our centre.
Women aged more than 18 years, whose mother tongue is Tamil and not
on anti-psychiatric medications were selected from the list. High-risk
pregnancies such as multiple pregnancy, foetal growth restriction, and
pre-existing autoimmune, cardiac, renal and neurological diseases were
excluded from the study. Eligible postpartum mothers from 4 weeks to 6
months after delivery were contacted over the telephone and explained
in detail the nature and purpose of the study in the native language
(Tamil). Women willing to participate in the study were sent a Google
link with information sheet, consent form for the study and Google
survey form with an e-questionnaire assessing the following parameters.
(1) Basic socio-demographic parameters like age, residence – rural or
urban, mother tongue, religion, educational and employment
status, perceived annual income, family type and marital
relationship
(2) Pregnancy details including order of pregnancy, number of chil­
dren, duration of pregnancy at delivery, mode of delivery, ob­
stetric complications, sex of the baby and Neonatal ICU (NICU)
stay
(3) Concerns of COVID-19 like job loss and family income insuffi­
ciency, fear of contracting the infection, threat to own life and

2
K.V. Senthil Kumar et al.
Fig. 1. COVID-19 stressors.
neonate’s health, the likelihood of other family members con­
tracting infection, concern about inadequate care in hospital,
hospital visitor restriction policy, quiet and isolated ward
(4) Precautionary measures against COVID-19 like social isolation,
frequent hand washing, avoidance of sharing food, wearing a
mask and following respiratory etiquette
(5) Edinburgh postnatal depression scale (EPDS), a self-validated
questionnaire was designed and translated into the local lan­
guage (Tamil) for current research. This scale consists of 10 items
rated from 0 to 3. The lowest possible score can be 0, whereas the
highest is 30. Women scoring 10 or more were considered at risk
of developing depression.
Study participants were requested to respond to the survey form in
48 h and complete responses were recorded in an Excel spreadsheet. The
data collected were analysed using SPSS software version 27. Descrip­
tive statistics were expressed as mean/SD or frequency/percentages as
appropriate. The normality of distribution was assessed by the
Kolmogorov-Smirnov test. Multivariate analysis was performed to
identify the underlying factors. For all parameters, a P value < 0.05 was
considered statistically significant. The study flow chart is outlined in
Supplementary Figure 1.
3. Results and discussion
A total of 106 postpartum mothers participated in our study. The
mean age of the mothers included in the study was 27.34 ± 3.82 years.
The study subjects were divided into two groups based on the EPDS
score. Almost half of the COVID-infected mothers (n = 52/106, 49%)
showed high EPDS scores (≥10). As they were at risk of depression, there
were referred to a psychiatrist for evaluation and further help. Table 1
shows that the socio-demographic parameters were not significantly
3
Asian Journal of Psychiatry 81 (2023) 103452
different between mothers who had normal and high EPDS scores.
Similar findings were obtained from various other studies across the
globe and they signify that the impact of COVID on mental health is
beyond the racial disparities. An Italian study has shown that 26% of
women delivered during the time of the COVID-19 lockdown had a
global depression score above 12 (Zanardo et al., 2020). Another study
from Italy has reported that depression rates and Post Traumatic Stress
Symptoms (PTSS) rates were 44.2% and 42.9% respectively during the
pandemic (Ostacoli et al., 2020). Around 35% of Turkish pregnant
women had EPDS scores higher than 13 (Durankuş and Aksu, 2020). A
study from Canada has reported symptoms of depression in 37% and
anxiety in 57% of pregnant females during the pandemic (Lebel et al.,
2020). A study conducted in eastern India established anxiety in 20.4%
of population who attended the COVID-19 screening facility (Sahu et al.,
2021) and this further denotes the exorbitant level of anxiety among the
pregnant women compared to the general population.
The mothers who were at risk of depression did not differ in terms of
obstetric characteristics and duration from delivery (Table 1). In a study
by Patel et al. (2012), the risk of developing depression was 5.7% in the
second month after childbirth, while it was 5.6% in the sixth month
postpartum. In our study, it was evident that one-third of mothers who
were experiencing depressive symptoms delivered 4–6 months back.
This proclaims the fact that the infected mothers were more depressive
not only during the early months but for an extended period following
delivery. Such a considerable number of mothers experiencing psycho­
logical insults due to COVID-19 is alarming. Hence in the weaning phase
of the COVID-19 pandemic, it is imperative to actively follow up with
the mothers delivered during the active pandemic and emphasize the
aftermath of COVID-19 on their long-term mental health. Furthermore,
the importance of periodically screening the children born to
COVID-19-infected mothers for neurodevelopmental disorders and
schizophrenia has also been emphasized (Chatterjee and Kar, 2022). As
K.V. Senthil Kumar et al.
the COVID-19 pandemic exposed a lot of weaknesses in the healthcare
system across the globe (Tandon, 2021), it is prudent to handle the
long-term effects of the COVID-19 in a better organised manner.
Even though 11% of infants were born pre-term and 9.4% had NICU
admission with an average duration of stay of 1.9 days, these did not
significantly affect the EPDS score. However, the mothers with high
EPDS scores reported dissatisfaction with the sex of the baby (Table 1).
Several studies have looked into the causative factors specific to the
unforeseen COVID-19 pandemic, which aggravated depression (Lebel
et al., 2020; Liang et al., 2020). We dwelled further to analyse how
stressor factors specific to COVID-19 influenced the level of depression.
The major distressing factor for the expectant mothers was loneliness
during hospitalisation, leaving the women deserted to handle the
frightening disease all alone (Fig. 1). Thanks to the advancements in
telecommunication, they were solaced to a certain extent by video chats
over mobile on-demand.
Motherhood is selfless and a mother always worries about her chil­
dren and family members. Hence, the other considerable factors are not
astonishing. Eight out of ten mothers were worried about the threat to
new born health due to COVID-19 and just about three-fourths were
concerned about other family members contracting the COVID-19
infection (Fig. 1). Social quarantine policies and compromised family
income were the least bothering and this signifies that compromised
family structure was impacting the mothers much more than the social
curtailments. The effect of specific stressor factors on postnatal depres­
sion score is further elaborated in Supplementary Table 1.
Presumably, this is the first study of its kind to evaluate the magni­
tude of postpartum depression among COVID-19-infected mothers till 6
months after delivery. The study population included mothers from all
cadres, thereby negating the influence of demographic parameters on
the findings. We recognise several limitations to this study. The major
drawbacks are single centred study and a small sample size. However,
considering the significant level of depression, the findings cannot be
overlooked.
Our study concluded that the COVID-19 infection adversely dis­
tressed new mothers and it was not confined to the immediate post­
partum period, but significantly impacted mothers until 6 months
following childbirth. Hence, long-term follow-up of COVID-19-infected
mothers is crucial to recognise depression and to offer timely psycho­
logical support.
Financial disclosure
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Authors’ contributions
Meena Priyadharshini, Krithika V Senthil Kumar and Suganya
Priyadharshini conceived the study. Material preparation and data
collection were performed by Krithika V Senthil Kumar and Deepika
Asian Journal of Psychiatry 81 (2023) 103452
Naidu. Analysis was performed by Jeevithan Shanmugam and Krithika V
Senthil Kumar. The manuscript was first drafted by Krithika V Senthil
Kumar and all authors commented on previous versions of the manu­
script. All authors read and approved the final manuscript.
Conflict of interest
The authors have no relevant financial or non-financial interests to
disclose. Authors have full control of all primary data.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.ajp.2023.103452.
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