Prevalence of prenatal and postpartum depression in fathers: A comprehensive meta-analysis of observational surveys

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Prevalence of prenatal and postpartum depression in fathers: a comprehensive meta-analysis of observational surveys Wen-Wang Rao PhD , Xiao-Min Zhu MD, PhD , Qian-Qian Zong BM , Qinge Zhang MD, PhD , Brian J. Hall PhD , Gabor S. Ungvari MD, PhD , Yu-Tao Xiang MD, PhD PII: DOI: Reference:

S0165-0327(19)31496-X https://doi.org/10.1016/j.jad.2019.10.030 JAD 11219

To appear in:

Journal of Affective Disorders

Received date: Revised date: Accepted date:

6 June 2019 3 October 2019 25 October 2019

Please cite this article as: Wen-Wang Rao PhD , Xiao-Min Zhu MD, PhD , Qian-Qian Zong BM , Qinge Zhang MD, PhD , Brian J. Hall PhD , Gabor S. Ungvari MD, PhD , Yu-Tao Xiang MD, PhD , Prevalence of prenatal and postpartum depression in fathers: a comprehensive meta-analysis of observational surveys, Journal of Affective Disorders (2019), doi: https://doi.org/10.1016/j.jad.2019.10.030

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Highlights



The prevalence of prenatal depression in fathers was 9.76% in the whole trimester, with 13.59% in the first, 11.31% in the second and 10.12% in the third trimester.



The prevalence of postpartum depression was 8.75% within a whole year, 8.98% within one-month, 7.82% between one- and three-months, 9.23% between three-months and six-months and 8.40% between six-months to twelve-months after childbirth.



Regular screening and effective implemented for this population.

1

interventions

should

be

urgently

Text: 2,260 words Abstract: 230 words Tables: 2 Figures: 3 Supplemental Tables: 2 Supplemental Figure: 2

Prevalence of prenatal and postpartum depression in fathers: a comprehensive meta-analysis of observational surveys Running title: Prenatal and postpartum depression in fathers 1,2#

Wen-Wang Rao, PhD Xiao-Min Zhu, MD, PhD 3# Qian-Qian Zong, BM 3# Qinge Zhang, MD, PhD 4,5 Brian J. Hall, PhD 6,7 Gabor S. Ungvari, MD, PhD 1,2 * Yu-Tao Xiang, MD, PhD 3#

1. Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao SAR, China; 2. Center for Cognition and Brain Sciences, University of Macau, Macao SAR, China; 3. Department of Psychiatry, Suzhou Guangji Hospital, Soochow University, Suzhou, Jiangsu, China; 4. The National Clinical Research Center for Mental Disorders & Beijing Key Laboratory of Mental Disorders Beijing Anding Hospital & the Advanced Innovation Center for Human Brain Protection, Capital Medical University, School of Mental Health, Beijing, China; 5. Global and Community Mental Health Research Group, Department of Psychology, University of Macau, Macao SAR, China; 6. Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 7. Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia; 8. The University of Notre Dame Australia, Fremantle, Australia #

These authors contributed equally to the work.

* Address correspondence to Dr. Yu-Tao Xiang, 3/F, Building E12, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 2

SAR, China. Fax: [email protected]

+853-2288-2314;

3

Phone:

+853-8822-4223;

E-mail:

Statement of Authorship

Role of funding The study was supported by the University of Macau (MYRG2016-00005-FHS; MYRG2019-00066-FHS), the Natural Science Foundation of Jiangsu Province (No. BK20180213), National Key Research & Development Program of China (No. 2016YFC1307200), the Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (No.ZYLX201607) and the Beijing Municipal Administration of Hospitals‟ Ascent Plan (No. DFL20151801).

Acknowledgements N/A. Conflict of interest All authors declare no conflicts of interest concerning this article.

Description of authors’ roles Study design: Wen-Wang Rao, Xiao-Min Zhu, Yu-Tao Xiang. Data collection, analysis and interpretation: Wen-Wang Rao, Xiao-Min Zhu, Qian-Qian Zong, Qinge Zhang. Drafting of the manuscript: Wen-Wang Rao, Yu-Tao Xiang. Critical revision of the manuscript: Brian J. Hall, Gabor S. Ungvari. Approval of the final version for publication: all co-authors.

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Abstract Background: Increasing attention has been paid to maternal prenatal and postpartum depressive symptoms (depression thereafter), but little is known about the prevalence of paternal prenatal and postpartum depression. To fill this gap, the current study meta-analyzed the worldwide prevalence of prenatal and postpartum depression in fathers. Methods: Studies that reported paternal depression occurring between the first trimester and the first postpartum year were identified by searching both international (PubMed, PsycINFO, Web of Science and EMBASE) and Chinese (WanFang and CNKI) databases between their inception date and July 1, 2018. A random-effects model was used to calculate pooled estimates and 95% confidence intervals. Results: Forty-seven studies with 20,728 subjects were included in the meta-analysis. The prevalence of prenatal depression in fathers was 9.76% in the whole trimester, 13.59% in the first, 11.31% in the second and 10.12% in the third trimester. The prevalence of postpartum depression was 8.75% within a whole year, 8.98% within one-month, 7.82% between one- and three months, 9.23% between three months and six months and 8.40% between six months to twelve months after child-birth. The prevalence of paternal postpartum depression was moderated by year of publication, study area, age of fathers of ≥ 18 years, quality assessment score and mean age (all P<0.05). Conclusions: This meta-analysis found that the prevalence of prenatal and postpartum depression in fathers was relatively common. Regular screening,

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effective prevention and appropriate treatment need to be implemented in this population. Key words: prenatal, postpartum, paternal, depression, meta-analysis

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1. Introduction During the period from pregnancy to postpartum parental depressive symptoms (depression thereafter) are common, and significantly associated with children's cognitive, social and behavioral development (Goodman et al., 2011; Shafer et al., 2017). Most studies focused on maternal depression, and paternal depression occurring over pregnancy to the postpartum period has been neglected although due to recent gender role shift, fathers are frequently involved in childcare. Compared to maternal depression, paternal depression usually has a longer duration and slower remission or recovery (Escribe-Aguir et al., 2008; van den Berg et al., 2009). Prenatal and postpartum paternal depression could lead to personal suffering, impaired functional outcomes and lower quality of life (Field, 2018) and it could even increase the risk of children‟s emotional and behavioral problems

(Weitzman

et

al.,

2011)

and

later

psychiatric

morbidity

(Gutierrez-Galve et al., 2019; Ramchandani et al., 2008). Further, fathers‟ depression could negatively affect children‟s development (Ramchandani et al., 2005), and lead to conflicts in marital (Ramchandani et al., 2011) and offspring relationships (Kouros et al., 2014). In the past decades some studies examined the epidemiology of paternal prenatal and postpartum depression, but the findings were mixed; the prevalence varied from 3% to 36% during the pregnancy period and from 1% to 42% during the postnatal period (Abbasi et al., 2014; Deater-Deckard et al., 1998; Wynter et al., 2013). A meta-analysis of paternal prenatal and postpartum depression found the overall prevalence of paternal depression was 10.4% (95% 7

CI: 8.5%-12.7%), while the prevalence of depression during the 3- to 6-month postpartum was 25.6% (95% CI: 17.3%-36.1%) (Paulson and Bazemore, 2010). Another meta-analysis of Chinese studies found that the overall prevalence of paternal postpartum depression was 13.6% (95% CI = 8.7%-21.3%) (Wang et al., 2016). A systematic review found that the prevalence of paternal depression during the first year postpartum ranged from 10.1% to 28.6% (Goodman, 2004). However, there are common limitations in these meta-analyses and reviews. First, various scales with different psychometric properties were used across studies, therefore the findings should not have been pooled. Second, either only English (Goodman, 2004; Paulson and Bazemore, 2010) or Chinese databases (Wang et al., 2016) were searched, thus studies were omitted. In addition, the Wang et al. (Wang et al., 2016) and Goodman (Goodman, 2004) reviews only focused on the postpartum period, but did not include prenatal depression. During the past decades several instruments have been used to assess prenatal and postpartum depression, such as the Postpartum Depression Screening Scale (PDSS) (Beck and Gable, 2000), the Beck Depression Inventory-II (BDI-II) (Beck et al., 1996), the Center for Epidemiological Studies Depression Scale (CES-D)(Radloff, 1977) and Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001). However, most scales are not specifically developed for prenatal and postpartum depression, therefore they may not be sensitive enough to detect the presence of depressive symptoms. In contrast, the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987) is a self-report tool specific for prenatal and postpartum depression and has been used widely in 8

research (Gibson et al., 2009), including to assess paternal prenatal and postpartum depression (Lai et al., 2010; Massoudi et al., 2013; Matthey, 2008; Tran et al., 2012). Hence, a meta-analysis of epidemiological studies was performed using the EPDS to examine the prevalence of paternal prenatal and postpartum depression.

2. Methods 2.1. Literature search The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline was followed and the study protocol was registered in the International

Prospective

Register

of

Systematic

Reviews

(PROSPERO:

CRD42018115468). A systematic literature search was conducted in both international and Chinese bibliographic databases, including PubMed, EMBASE, Web of Science, PsycINFO, CNKI, and WANFANG from their inception date to July 1, 2018. Two authors (WWR and XMZ) independently searched the literature using the following search words: (paternal OR father OR husband OR dad) AND (depressive symptoms OR depression OR depressive disorders OR depressi*) AND (postpartum OR perinatal OR antenatal) AND (prevalence OR epidemiology OR rate OR percentage).

2.2. Inclusion and exclusion criteria

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Two authors (WWR and XMZ) independently assessed publications for eligibility with the following inclusion criteria: (1) studies with data on prevalence of prenatal or postpartum depression in fathers, or relevant information that could generate prevalence of prenatal or postpartum depression in fathers as measured by the Edinburgh Postnatal Depression Scale (EPDS); (2) assessment was conducted during the period from the first trimester to the 12-month postpartum; (3) papers published in English or Chinese. Studies conducted in special populations, such as the military or adolescents (younger than 18 years), were excluded. If multiple papers used a same dataset, only the paper with the most complete information was included.

2.3. Study selection and data extraction After removing duplicates, titles and abstracts of identified publications were independently screened, and then the full texts were read by two authors (WWR and XMZ). Furthermore, the reference lists of relevant reviews (Goodman, 2004; Paulson and Bazemore, 2010; Wang et al., 2016) were checked to identify additional studies. Any disagreements about literature search was resolved by consensus or a discussion with a senior author (YTX). The study search is shown in Figure 1. Two authors (WWR and ZXM) independently extracted relevant data for analyses, including literature information (such as the first author and publication language and year), study characteristics (such as study year and site, country and continent according to the WHO region classification (World Health 10

Organization, 2018)), depression definition and sample size), and sample information (such as mean age). Disagreements were resolved by consensus. The inter-rater reliability between the two authors needed to be greater than 0.75 (kappa value for categorical variables; intra-class correlation coefficients (ICC) for continuous variables) in the data extraction. Otherwise, the data extraction had to be repeated, until the agreement reached the required level of 0.75.

2.4. Quality assessment As recommended by the Agency of Healthcare Research and Quality (AHRQ), the Methodology Checklist for Cross-sectional studies (Rostom A et al., 2004) was used to assess study quality independently by two authors (WWR and QQZ). The AHRQ consists of 11 items, including (1) information source; (2) study criteria; (3) study period; (4) sampling; (5) interview method; (6) instrument validation; (7) exclusion reasons; (8) measure of confounding effects; (9) process of missing values; (10) response rate; (11) use of follow-up. Each item was rated as either „yes‟, „no‟ or „unclear‟. The total score ranged from 0 to 11, with 0-3, 4-7 and 8-11 defined as “low quality”, “moderate quality” and “high quality”, respectively (Chen et al., 2014; Hu et al., 2015; Jing et al., 2018).

2.5. Data synthesis The program R, version 3.3.0 and R Studio, version 0.99.903 were used to perform data analyses. The pooled prevalence of depressive symptoms was 11

calculated as effect size (ES) and its 95% confidence intervals (CIs) using the Freeman-Tukey double arcsine transformation (Freeman and Tukey, 1950) by “metaprop” command in the “meta” package (Barendregt et al., 2013). The DerSimonian and Laird random-effects model using the inverse variance method was applied to synthesize the overall prevalence of prenatal and postpartum depression and also by different timeframes, including (1) the first trimester of pregnancy; (2) second trimester of pregnancy; (3) third trimester of pregnancy; (4) one month postpartum; (5) three-month postpartum; (6) six-month postpartum; (7) twelve-month postpartum. Heterogeneity between studies was measured using the Cochran‟s Q test and I2 statistic. Funnel plot and Begg‟s tests were used to publication bias. Publication bias was examined when there were at least 10 studies in the meta-analysis (Dalton et al., 2016). Subgroup analyses based on the Hierarchical concept were carried out in order to find the sources of heterogeneity according to the following variables: study site, continents, EPDS cutoff value, quality assessment, year of publication and sample size (dichotomized using median spitting method). In addition, meta-regression analyses with the “metareg” command in the “metafor” package (Viechtbauer, 2010) were performed to examine continuous moderating variables, such as mean age and its SD, sample size, year of publication and quality assessment score. Significance level was set at 0.05 (two-tailed).

3. Results 3.1. Study characteristics 12

The literature search is shown in Figure 1. A total of 2,942 initial hits were found and finally 47 studies published in English (n=40) or Chinese (n=7) with 20,728 subjects were included in the meta-analysis (Figure 1). One study (Thorpe et al., 1992) reported data from Greece and Britain separately, hence the data were analyzed as two samples. Fifteen studies included 10,247 subjects during pregnancy and 41 included 17,980 subjects during the first year after child-birth. Studies were conducted in Europe (n=22), Western Pacific (n=19), Americas (n=4), Eastern Mediterranean (n=1), Africa (n=1) and South-East Asia (n=1). Detailed data are presented in Table 1 and Supplemental Table 1.

3.2. Quality assessment and publication bias The mean AHRQ score was 6.23, ranging from 4 to 8. Forty studies were rated as „moderate quality‟ and 8 studies was rated as „high quality.‟ Supplemental Figure 1 shows the funnel plot of 15 studies with data on prenatal depressive symptoms, while Begg‟s test (Z=0.15, P=0.88) did not find publication bias. Begg‟s test found publication bias in prevalence of postpartum depression (overall prevalence: Supplemental Figure 2, Z=0.282, P=0.778; one-month prevalence: Z=-0.701, P=0.484; three-month prevalence: Z=-0.136, P=0.892; six-month prevalence: Z=1.635, P=0.102).

3.3. Prevalence of prenatal depressive symptoms The overall prevalence of depressive symptoms during pregnancy (including all 13

the 3 trimesters) was 9.76% (95% CI: 5.69%-14.74%; I2=97.5%; Figure 2), while the prevalence was 13.59% (n=4; 95%CI: 1.94%-33.03%; I2=98.6%) in the first, 11.31% (n=8; 95%CI: 3.57%-22.46%; I2=98.6%) in the second, and 10.12% (n=9; 95%CI: 4.50%-17.59%; I2=97.4%) in the third trimester. In subgroup

analyses

and

meta-regression

no

moderating

variables

were

significantly associated with prevalence of prenatal depressive symptoms (all P>0.05; Table 2 and Supplemental Table 2).

3.4. prevalence of postpartum depression The

overall

prevalence

of

postpartum

depression

was

8.75%

(95%

CI=6.68%-11.07%; I2=95.6%; Figure 3), while the one-month prevalence was 8.98% (n=11; 95%CI=6.34%-12.01%; I2=82.4%), three-month prevalence was 7.82% (n=31; 95%CI=5.60%-10.36%; I2=96.0%), six-month prevalence was

9.23%

(n=11;

95%CI=4.84%-14.77%;

I2=92.9%), and

12-month

prevalence was 8.40% (n=3; 95%CI=0.50%-23.17%; I2=92.3%). Subgroup analyses found that studies published before 2014, living in the European region and studies without data on father‟s age were associated with lower prevalence of postpartum depression (all P<0.05; Table 2). Furthermore, meta-regression analyses revealed negative associations between the prevalence of postpartum depression and the quality assessment score (β=−0.04, P=0.043) and mean age (β=-0.025, P=0.01), and positive association between the prevalence of postpartum depression and SD of age (β=0.059, P=0.009).

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4. Discussion This meta-analysis found that the prevalence of paternal prenatal (9.76%) and postpartum depression was common (8.75%). The United Nations reported that there were approximately 140.46 million births globally in 2016 (The United Nations International Children's Emergency Fund, 2017), which would equate to 13.71 million fathers with prenatal depression and 12.29 million with postpartum depression according to the findings in this meta-analysis. Common paternal prenatal and postpartum depression could be due to several reasons. First, fathers, especially those previously without children, usually face challenges associated with newborns, such as sleepless nights, diaper changes, feeding problems, and endless demands (Gay et al., 2004; Kim and Swain, 2007). Second, a sizeable minority of mothers suffer from mood problems, which could in turn affect fathers‟ mental health (Goodman, 2004; Paulson and Bazemore, 2010). Third, growing expenses and heavy economic burden associated with newborns may be associated with increased risk of mood disorders, such as anxiety and depression (Doran and Kinchin, 2017). As expected, the prevalence of postpartum depression was highest in the Western Pacific (10.06%), followed by the Americas (9.43%) and Europe (5.52%). The relatively poorer social support, economic and living conditions in many Western Pacific countries may be associated with increased depression. We found that fathers aged ≥18 was associated with higher prevalence of paternal postpartum depression. We speculate that when fathers are older than 18 years, other family members, such as grandparents, are less likely to help care for 15

newborns and their mothers in the postpartum period, which could increase the risk of fathers‟ stress and depression in this period. In addition, fathers‟ age was negatively associated with the prevalence of postpartum depression. A possible reason could be that younger people are less likely affluent. When their child is born, growing stress related to the economic burden could increase the risk of paternal depression. A positive association between the quality assessment score and the prevalence of postpartum depression was found. In high quality studies, depressed subjects are more likely to be identified. The strengths of this meta-analysis include the large number of studies across countries, the large sample size and the homogeneity of the instrument used to assess depressive symptoms. However, there are several limitations to this study. First, included studies (prenatal: 15; postpartum: 42) covered 21 countries, which limits the generalizability of the findings to all countries of the world. Second, similar to other meta-analyses of epidemiology (Mata et al., 2015), heterogeneity was impossible to avoid, even if subgroup analyses have been conducted and only studies using the EPDS were included. Heterogeneity could stem from different severity of depression, social support, physical health, and other sample characteristics. Third, important variables related to prenatal and postpartum depression, such as economic status, place of residence, reasons for hospitalization, ethnicity of participants, the rate of attrition in the sample and major medical conditions, were not reported in most studies. In addition, the original minimum and maximum agreements on the extracted demographic data between the two authors and the average reliability figures were not recorded. 16

In conclusion, this meta-analysis found that paternal depression was common, affecting 7.82%-13.59% of the fathers in different stages of their partners‟ pregnancy. Health authorities and professionals should pay more attention to the early identification of prenatal and postpartum paternal depression and implement effective treatment.

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References Abbasi, M., van den Akker, O., Bewley, C., 2014. Persian couples' experiences of depressive symptoms and health-related quality of life in the pre- and perinatal period. Journal of Psychosomatic Obstetrics and Gynecology 35, 16-21. Anding, J., Rohrle, B., Grieshop, M., Schucking, B., Christiansen, H., 2015. Early detection of postpartum depressive symptoms in mothers and fathers and its relation to midwives' evaluation and service provision: a community-based study. Frontiers in Pediatrics 3, 62. Ballard, C.G., Davis, R., Cullen, P.C., Mohan, R.N., Dean, C., 1994. Prevalence of postnatal psychiatric morbidity in mothers and fathers. British Journal of Psychiatry 164, 782-788. Barendregt, J.J., Doi, S.A., Lee, Y.Y., Norman, R.E., Vos, T., 2013. Meta-analysis of prevalence. Journal of epidemiology and community health 67, 974-978. Beck, A.T., Steer, R.A., Brown, G.K., 1996. Beck depression inventory-II. San Antonio 78, 490-498. Beck, C.T., Gable, R.K., 2000. Postpartum Depression Screening Scale: development and psychometric testing. Nursing research 49, 272-282. Bielawska-Batorowicz, E., Kossakowska-Petrycka, K., 2006. Depressive mood in men after the birth of their offspring in relation to a partner's depression, social support, fathers' personality and prenatal expectations. Journal of reproductive and infant psychology 24, 21-29. Chen, X., Li, L., Zhou, T., Li, Z., 2014. Prevalence of hypertension in rural areas of china: a meta-analysis of published studies. PloS one 9, e115462. Clavenna, A., Seletti, E., Cartabia, M., Didoni, A., Fortinguerra, F., Sciascia, T., Brivio, L., Malnis, D., Bonati, M., 2017. Postnatal depression screening in a paediatric primary care setting in Italy. BMC psychiatry 17, 42. Condon, J.T., Boyce, P., Corkindale, C.J., 2004. The First-Time Fathers Study: a prospective study of the mental health and wellbeing of men during the transition to parenthood. The Australian and New Zealand journal of psychiatry 38, 56-64. Cox, J.L., Holden, J.M., Sagovsky, R., 1987. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry 150, 782-786. Da Costa, D., Zelkowitz, P., Dasgupta, K., Sewitch, M., Lowensteyn, I., Cruz, R., Hennegan, K., Khalife, S., 2017. Dads Get Sad Too: Depressive Symptoms and Associated Factors in Expectant First-Time Fathers. American journal of men's health 11, 1376-1384. Dalton, J.E., Bolen, S.D., Mascha, E.J., 2016. Publication Bias: The Elephant in the Review. Anesth Analg 123, 812-813. Dave, S., Nazareth, I., Sherr, L., Senior, R., 2005. The association of paternal mood and infant temperament: A pilot study. British Journal of Developmental Psychology 23, 609-621. Deater-Deckard, K., Pickering, K., Dunn, J.F., Golding, J., 1998. Family structure and depressive symptoms in men preceding and following the birth of a child. The American journal of psychiatry 155, 818-823. Doran, C.M., Kinchin, I., 2017. A review of the economic impact of mental illness. Australian Health Review 43, 43-48. Dudley, M., Roy, K., Kelk, N., Bernard, D., 2001. Psychological correlates of depression in fathers and mothers in the first postnatal year. Journal of reproductive and infant psychology 19, 187-202. Edhborg, M., 2008. Comparisons of different instruments to measure blues and to predict depressive symptoms 2 months postpartum: a study of new mothers and fathers. Scandinavian journal of caring sciences 22, 186-195. Escribe-Aguir, V., Gonzalez-Galarzo, M.C., Barona-Vilar, C., Artazcoz, L., 2008. Factors related to depression during pregnancy: are there gender differences? Journal of epidemiology and community health 62, 410-414. Field, T., 2018. Paternal Prenatal, Perinatal and Postpartum Depression: A Narrative Review. J Anxiety Depress 1, 102. Figueiredo, B., Conde, A., 2011. Anxiety and depression in women and men from early pregnancy to 3-months postpartum. Archives of women's mental health 14, 247-255. 18

Freeman, M.F., Tukey, J.W., 1950. Transformations related to the angular and the square root. The Annals of Mathematical Statistics, 607-611. Gao, L.L., Chan, S.W., Mao, Q., 2009. Depression, perceived stress, and social support among first-time Chinese mothers and fathers in the postpartum period. Research in nursing & health 32, 50-58. Gawlik, S., Muller, M., Hoffmann, L., Dienes, A., Wallwiener, M., Sohn, C., Schlehe, B., Reck, C., 2014. Prevalence of paternal perinatal depressiveness and its link to partnership satisfaction and birth concerns. Archives of women's mental health 17, 49-56. Gay, C.L., Lee, K.A., Lee, S.-Y., 2004. Sleep patterns and fatigue in new mothers and fathers. Biological research for nursing 5, 311-318. Gibson, J., McKenzie-McHarg, K., Shakespeare, J., Price, J., Gray, R., 2009. A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta psychiatrica Scandinavica 119, 350-364. Goodman, J.H., 2004. Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of advanced nursing 45, 26-35. Goodman, J.H., 2008. Influences of maternal postpartum depression on fathers and on father-infant interaction. Infant mental health journal 29, 624-643. Goodman, S.H., Rouse, M.H., Connell, A.M., Broth, M.R., Hall, C.M., Heyward, D., 2011. Maternal depression and child psychopathology: a meta-analytic review. Clinical child and family psychology review 14, 1-27. Goyal, K., Purbiya, P., Lal, S.N., Kaur, J., Anthwal, P., Puliyel, J.M., 2017. Correlation of Infant Gender with Postpartum Maternal and Paternal Depression and Exclusive Breastfeeding Rates. Breastfeeding medicine 12, 279-282. Gutierrez-Galve, L., Stein, A., Hanington, L., Heron, J., Lewis, G., O’Farrelly, C., Ramchandani, P.G., 2019. Association of Maternal and Paternal Depression in the Postnatal Period With Offspring Depression at Age 18 Years. JAMA psychiatry 76, 290-296. Hu, J., Dong, Y., Chen, X., Liu, Y., Ma, D., Liu, X., Zheng, R., Mao, X., Chen, T., He, W., 2015. Prevalence of suicide attempts among Chinese adolescents: A meta-analysis of cross-sectional studies. Comprehensive psychiatry 61, 78-89. Jing, X., Chen, J., Dong, Y., Han, D., Zhao, H., Wang, X., Gao, F., Li, C., Cui, Z., Liu, Y., Ma, J., 2018. Related factors of quality of life of type 2 diabetes patients: a systematic review and meta-analysis. Health and Quality of Life Outcomes 16, 189. Karukivi, M., Tolvanen, M., Karlsson, H., Karlsson, L., 2015. Alexithymia and postpartum anxiety and depression symptoms: a follow-up study in a pregnancy cohort. Journal of psychosomatic obstetrics and gynaecology 36, 142-147. Kerstis, B., Aarts, C., Tillman, C., Persson, H., Engstrom, G., Edlund, B., Ohrvik, J., Sylven, S., Skalkidou, A., 2016. Association between parental depressive symptoms and impaired bonding with the infant. Archives of women's mental health 19, 87-94. Kerstis, B., Engstrom, G., Sundquist, K., Widarsson, M., Rosenblad, A., 2012. The association between perceived relationship discord at childbirth and parental postpartum depressive symptoms: a comparison of mothers and fathers in Sweden. Upsala journal of medical sciences 117, 430-438. Kim, P., Swain, J.E., 2007. Sad dads: paternal postpartum depression. Psychiatry 4, 35-47. Koh, Y.W., Chui, C.Y., Tang, C.S., Lee, A.M., 2014. The Prevalence and Risk Factors of Paternal Depression from the Antenatal to the Postpartum Period and the Relationships between Antenatal and Postpartum Depression among Fathers in Hong Kong. Depression research and treatment 2014, Article ID 127632. Kouros, C.D., Papp, L.M., Goeke-Morey, M.C., Cummings, E.M., 2014. Spillover between marital quality and parent– child relationship quality: Parental depressive symptoms as moderators. Journal of Family Psychology 28, 315. Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine 16, 606-613. Lai, B.P., Tang, A.K., Lee, D.T., Yip, A.S., Chung, T.K., 2010. Detecting postnatal depression in Chinese men: a comparison 19

of three instruments. Psychiatry research 180, 80-85. Lai, M.H., WEn, X., Li, W.S., Jiang, M., Li, Z., 2015. Incidence and its influencing factors of paternal postpartum depression (in Chinese). Chinese Journal of Nursing 50, 546-551. Lane, A., Keville, R., Morris, M., Kinsella, A., Turner, M., Barry, S., 1997. Postnatal depression and elation among mothers and their partners: prevalence and predictors. The British Journal of Psychiatry 171, 550-555. Luo, G., 2018. Relationship between social support, marital quality and maternal spouse postpartum depression (in Chinese). Chinese Journal of New Clinical Medicine 11, 497-500. Luo, L.B., Wang, P.H., Deng, L.L., Mei, L.Y., Li, H.Z., 2017. Prevalence and risk factors of postnatal depression in fathers (in chinese). Journal of Nursing Science 32, 84-87. Madsen, S.A., Juhl, T., 2007. Paternal depression in the postnatal period assessed with traditional and male depression scales. Journal of Men's Health and Gender 4, 26-31. Mao, Q., Zhu, L.X., Su, X.Y., 2011. A comparison of postnatal depression and related factors between Chinese new mothers and fathers. Journal of clinical nursing 20, 645-652. Massoudi, P., Hwang, C.P., Wickberg, B., 2013. How well does the Edinburgh Postnatal Depression Scale identify depression and anxiety in fathers? A validation study in a population based Swedish sample. Journal of affective disorders 149, 67-74. Massoudi, P., Hwang, C.P., Wickberg, B., 2016. Fathers' depressive symptoms in the postnatal period: Prevalence and correlates in a population-based Swedish study. Scandinavian journal of public health 44, 688-694. Mata, D.A., Ramos, M.A., Bansal, N., Khan, R., Guille, C., Di Angelantonio, E., Sen, S., 2015. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. Jama 314, 2373-2383. Matthey, S., 2008. Using the Edinburgh Postnatal Depression Scale to screen for anxiety disorders. Depression and anxiety 25, 926-931. Morse, C.A., Buist, A., Durkin, S., 2000. First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers. Journal of Psychosomatic Obstetrics & Gynecology 21, 109-120. Nasreen, H.E., Rahman, J.A., Rus, R.M., Kartiwi, M., Sutan, R., Edhborg, M., 2018. Prevalence and determinants of antepartum depressive and anxiety symptoms in expectant mothers and fathers: results from a perinatal psychiatric morbidity cohort study in the east and west coasts of Malaysia. BMC psychiatry 18, 195. Nishimura, A., Fujita, Y., Katsuta, M., Ishihara, A., Ohashi, K., 2015. Paternal postnatal depression in Japan: an investigation of correlated factors including relationship with a partner. BMC pregnancy and childbirth 15, 128. Nishimura, A., Ohashi, K., 2010. Risk factors of paternal depression in the early postnatal period in Japan. Nursing & health sciences 12, 170-176. Paulson, J.F., Bazemore, S.D., 2010. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. Jama 303, 1961-1969. Philpott, L.F., Corcoran, P., 2018. Paternal postnatal depression in Ireland: Prevalence and associated factors. Midwifery 56, 121-127. Pinto, T.M., Samorinha, C., Tendais, I., Silva, S., Figueiredo, B., 2018. Antenatal paternal adjustment and paternal attitudes after infertility treatment. Human Reproduction 33, 109-115. Radloff, L.S., 1977. The CES-D scale: A self-report depression scale for research in the general population. Applied psychological measurement 1, 385-401. Ramchandani, P., Stein, A., Evans, J., O'Connor, T.G., Team, A.S., 2005. Paternal depression in the postnatal period and child development: a prospective population study. The Lancet 365, 2201-2205. Ramchandani, P.G., Psychogiou, L., Vlachos, H., Iles, J., Sethna, V., Netsi, E., Lodder, A., 2011. Paternal depression: an examination of its links with father, child and family functioning in the postnatal period. Depression and anxiety 28, 471-477. Ramchandani, P.G., Stein, A., O'Connor, T.G., Heron, J., Murray, L., Evans, J., 2008. Depression in men in the postnatal 20

period and later child psychopathology: a population cohort study. Journal of the American Academy of Child and Adolescent Psychiatry 47, 390-398. Rogers, C.N., 2015. Postpartum depression in fathers: Role strain, stress, and lack of social support. Capella University, US. Rostom A, Dubé C, Cranney A, Saloojee N, Sy R, Garritty C, Sampson M, Zhang L, Yazdi F, Mamaladze V, Pan I, McNeil J, Moher D, Mack D, D., P., 2004. Celiac Disease. Evidence Report/Technology Assessment No. 104. (Prepared by the University of Ottawa Evidence-based Practice Center, under Contract No. 290-02-0021.) AHRQ Publication No. 04-E029-2.

Rockville,

MD:

Agency

for

Healthcare

Research

and

Quality

Available:

http://www.ncbi.nlm.nih.Gov/books/NBK35156/ Accessed 2018 October 20. Roubinov, D.S., Luecken, L.J., Crnic, K.A., Gonzales, N.A., 2014. Postnatal depression in Mexican American fathers: Demographic, cultural, and familial predictors. Journal of affective disorders 152-154, 360-368. Serhan, N., Ege, E., Ayranci, U., Kosgeroglu, N., 2013. Prevalence of postpartum depression in mothers and fathers and its correlates. Journal of clinical nursing 22, 279-284. Shafer, K., Fielding, B., Wendt, D., 2017. Similarities and differences in the influence of paternal and maternal depression on adolescent well-being. Social Work Research 41, 85-96. Stein, D.J., Koen, N., Donald, K.A., Adnams, C.M., Koopowitz, S., Lund, C., Marais, A., Myers, B., Roos, A., Sorsdahl, K., Stern, M., Tomlinson, M., van der Westhuizen, C., Vythilingum, B., Myer, L., Barnett, W., Brittain, K., Zar, H.J., 2015. Investigating the psychosocial determinants of child health in Africa: The Drakenstein Child Health Study. Journal of neuroscience methods 252, 27-35. Suto, M., Isogai, E., Mizutani, F., Kakee, N., Misago, C., Takehara, K., 2016. Prevalence and Factors Associated With Postpartum Depression in Fathers: A Regional, Longitudinal Study in Japan. Research in nursing & health 39, 253-262. The United Nations International Children's Emergency Fund, 2017. The 2017 State of the World’s Children Report. available from https://data.unicef.org/wp-content/uploads/2018/03/SOWC-2017-statistical-tables.pdf. Thorpe, K.J., Dragonas, T., Golding, J., 1992. The effects of psychosocial factors on the mother's emotional well-being during early parenthood: a cross-cultural study of Britain and Greece. Journal of reproductive and infant psychology 10, 205-217. Top, E.D., Cetisli, N.E., Guclu, S., Zengin, E.B., 2016. Paternal Depression Rates in Prenatal and Postpartum Periods and Affecting Factors. Archives of Psychiatric Nursing 30, 747-752. Tran, T.D., Tran, T., Fisher, J., 2012. Validation of three psychometric instruments for screening for perinatal common mental disorders in men in the north of Vietnam. Journal of affective disorders 136, 104-109. van den Berg, M.P., van der Ende, J., Crijnen, A.A., Jaddoe, V.W., Moll, H.A., Mackenbach, J.P., Hofman, A., Hengeveld, M.W., Tiemeier, H., Verhulst, F.C., 2009. Paternal depressive symptoms during pregnancy are related to excessive infant crying. Pediatrics 124, e96-103. Viechtbauer, W., 2010. Conducting meta-analyses in R with the metafor package. Journal of statistical software 36, 1-48. Wang, J.N., Yang, L., 2015. Analysis of the Social Demographic Factors of the Depression of the Spouses of the Pregnant Women (in Chinese). medical information 28, 11-12. Wang, T.T., Xu, Y., Li, Z.Z., Chen, L.Z., 2016. Prevalence of paternal postpartum depression in China and its association with maternal postpartum depression: A Meta-analysis (in Chinese). Journal of Central South University (Medical Science) 41, 1082-1089. Weitzman, M., Rosenthal, D.G., Liu, Y.-H., 2011. Paternal depressive symptoms and child behavioral or emotional problems in the United States. Pediatrics 128, 1126-1134. Weng, T.T., Yang, S.Q., Wang, Q.Y., Tao, L.L., Cao, H., Huang, K., 2018. Correlation between parental postpartum depression and infant temperament (in Chinese). Chinese Journal of Woman and Child Health Research 29, 254-258. World Health Organization, 2018. Quantifying environmental health impacts. Country groupings. available from 21

http://www.who.int/quantifying_ehimpacts/global/ebdcountgroup/en/

Accessed 2018 October 20.

Wynter, K., Rowe, H., Fisher, J., 2013. Common mental disorders in women and men in the first six months after the birth of their first infant: a community study in Victoria, Australia. Journal of affective disorders 151, 980-985. Xu, W.Q., Chen, C., Tang, Y.P., Pang, G.P., An, H., 2014. Depressive level and the related factors in perinatal maternal and their spouses (in Chinese). Zhejiang medical education 13, 51-52+60. Zhang, Y.P., Zhang, L.L., Wei, H.H., Zhang, Y., Zhang, C.L., Porr, C., 2016. Post partum depression and the psychosocial predictors in first-time fathers from northwestern China. Midwifery 35, 47-52. Zhou, Y., 2017. Correlation between family cohesion and adaptability and maternal spouse's puerperium depression (in Chinese). Chinese Journal of Rural Medicine and Pharmacy 24, 10-11.

22

Table 1. Characteristics of the studies included in the meta-analysis

Screening No.

First Author

Language of

Study

Sample

Age

publication

year

size

range

Mean age of fathers (Mean ± SD)

Study site

measure for Country

Continent

DP scale

Quality of

Mother aged

Father aged

First-time

First-time

≥18

≥18

mother

father

Yes

Yes

NR

NR

8

(Abbasi et al., 2014)

Yes

NR

NR

NR

7

(Anding et al., 2015)

NR

NR

NR

NR

6

(Ballard et al., 1994)

NR

6

(Bielawska-Batorowicz and Kossakowska-Petrycka, 2006)

cut-off

assessmen

References

t

≥10 1

Abbasi, M.

E

2010-2011

513

20-46

32.26±5.23

H

Iran

EMR

EDPS ≥13

2

Anding, J.

E

2010-2012

276

NR

32.18±6.21

C

German

EUR

EDPS

3

Ballard, C. G.

E

NR

178

NR

27.7± NR

H

England

EUR

EDPS

≥11 ≥10 ≥13

4

EUR

EDPS

≥13

Yes

Yes

NR

Italy

EUR

EDPS

≥12

NR

NR

NR

NR

5

(Clavenna et al., 2017)

Australia

WPR

EDPS

≥13

NR

NR

NR

Yes

8

(Condon et al., 2004)

Canada

AMR

EDPS

≥10

NR

Yes

NR

Yes

8

(Da Costa et al., 2017)

UK

EUR

EDPS

≥13

NR

Yes

NR

NR

9

(Dave et al., 2005)

NR

6

(Deater-Deckard et al., 1998)

No

8

(Dudley et al., 2001)

Yes

6

Bielawska, B. E.

E

2002

80

24-37

31.18± NR

H

Poland

5

Clavenna, A.

E

2012

1,420

NR

36.3±5.8

H

6

Condon, J. T.

E

NR

312

NR

29±5

H

7

Da Costa, D.

E

NR

622

22-52

34.3±5

H

8

Dave, S.

E

2002

48

26-45

NR

H

9

Deater-Deckard, K.

E

1991-1992

6028

NR

NR

C

England

EUR

EDPS

≥13

NR

NR

NR

10

Dudley, M.

E

NR

93

NR

33.2± NR

H

Australia

WPR

EDPS

≥13

NR

NR

No

11

Edhborg, M.

E

2002

133

NR

33.8±5.4

H

Sweden

EUR

EDPS

≥10

NR

NR

Yes

12

Escribe-Aguir, V.

E

2005

664

NR

NR

H

Spain

13

Figueiredo, B.

E

NR

260

NR

NR

H

Portugal

EUR

EDPS

≥11

NR

NR

NR

NR

7

EUR

EDPS

≥10

NR

NR

NR

NR

6

23

(Edhborg, 2008) (Escribe-Aguir et al., 2008) (Figueiredo and Conde, 2011)

14

Gao, L. L.

E

2006-2007

130

24-43

31.92±3.15

H

China

WPR

EDPS

15

Gawlik, S.

E

2010-2011

102

23-55

35.82±5.95

C

Germany

EUR

EDPS

≥13

Yes

Yes

Yes

Yes

7

(Gao et al., 2009)

≥9

NR

Yes

NR

NR

6

(Gawlik et al., 2014)

Yes

NR

NR

NR

6

(Goodman, 2008)

≥10 16

Goodman, J. H.

E

NR

128

NR

NR

H

USA

AMR

EDPS ≥13

17

Goyal, K.

E

2014-2015

479

NR

NR

H

India

SEAR

EDPS

≥11

NR

NR

No

No

6

(Goyal et al., 2017)

18

Karukivi, M.

E

2010

65

NR

32±5.6

C

Finland

EUR

EDPS

≥10

NR

NR

No

NR

5

(Karukivi et al., 2015)

19

Kerstis, B.

E

2006-2007

727

NR

NR

H

Sweden

EUR

EDPS

≥10

NR

NR

No

NR

8

(Kerstis et al., 2016)

20

Kerstis, B.

E

2004-2006

252

NR

32.96±5.6

H

Sweden

EUR

EDPS

≥10

NR

NR

No

No

7

(Kerstis et al., 2012)

21

Koh, Y. W.

E

NR

451

19-55

34.19±5.21

H

China

WPR

EDPS

≥13

NR

Yes

NR

NR

8

(Koh et al., 2014)

22

Lane, A.

E

NR

181

NR

NR

H

Ireland

EUR

EDPS

≥13

NR

NR

No

NR

6

(Lane et al., 1997)

23

Madsen, S. A.

E

2004-2005

542

22-57

32± NR

H

Denmark

EUR

EDPS

≥10

NR

Yes

NR

No

7

(Madsen and Juhl, 2007)

24

Mao, Q.

E

2007-2008

376

22-39

27.09± 4.46

H

China

WPR

EDPS

≥13

Yes

Yes

Yes

Yes

8

(Mao et al., 2011)

25

Massoudi, P.

E

NR

885

20-51

32.6± NR

C

Sweden

EUR

EDPS

≥12

NR

Yes

No

No

6

(Massoudi et al., 2016)

26

Morse, C. A.

E

1995-1998

251

21-45

NR

H

Australia

WPR

EDPS

≥10

Yes

Yes

Yes

Yes

6

(Morse et al., 2000)

27

Nasreen, H. E.

E

2016-2017

583

NR

31.76±5.94

H

Malaysia

WPR

EDPS

NR

NR

NR

NR

6

(Nasreen et al., 2018)

≥10 ≥16

(Nishimura et al., 2015) (Nishimura and Ohashi, 2010)

28

Nishimura, A.

E

2013

807

NR

33.4±5.7

C

Japan

WPR

EDPS

≥8

NR

NR

No

No

6

29

Nishimura, A.

E

2007

143

NR

32.3±5.3

H

Japan

WPR

EDPS

≥8

NR

NR

NR

No

5

NR

Yes

NR

NR

5

(Philpott and Corcoran, 2018) (Pinto et al., 2018)

≥9 30

Philpott, L. F.

E

NR

77

24-50

NR

C

Ireland

EUR

EDPS ≥12

NR

C

Portugal

EUR

EDPS

≥10

NR

Yes

NR

Yes

4

NR

NR

C

USA

AMR

EDPS

≥10

NR

Yes

NR

Yes

7

(Rogers, 2015)

NR

31.3±7.5

C

USA

AMR

EDPS

≥10

NR

Yes

No

No

5

(Roubinov et al., 2014)

Pinto, T. M.

E

NR

126

18-46

32

Rogers, C. N.

E

NR

76

33

Roubinov, D. S.

E

NR

92

31

24

34

Serhan, N.

E

NR

110

NR

31.9±5.02

C

Turkey

EUR

EDPS

≥13

NR

NR

Yes

NR

6

(Serhan et al., 2013)

35

Stein, D. J.

E

2012

75

NR

NR

H

South Africa

AFR

EDPS

≥13

Yes

NR

NR

NR

4

(Stein et al., 2015)

36

Suto, M.

E

2012-2013

207

NR

32±4.9

C

Japan

WPR

EDPS

≥8

NR

NR

NR

No

7

(Suto et al., 2016)

NR

157

NR

NR

Greece

EUR

EDPS NR

NR

NR

NR

6

(Thorpe et al., 1992)

≥10 ≥13 37

Thorpe, K. J.

E

H ≥10

NR

110

NR

NR

Britain

EUR

EDPS ≥13

38

Top, E. D.

E

2014-2015

92

23-52

33.72±5.13

H

Turkey

EUR

EDPS

≥12

Yes

Yes

No

NR

7

(Top et al., 2016)

39

Wynter, K.

E

2006-2007

172

NR

32.8±5.6

C

Australia

WPR

EDPS

≥10

Yes

NR

Yes

Yes

5

(Wynter et al., 2013)

40

Zhang, Y. P.

E

2013

166

NR

29.49±2.9

H

China

WPR

EDPS

≥10

NR

NR

Yes

Yes

5

(Zhang et al., 2016)

NR

Yes

Yes

No

5

(Lai et al., 2015)

Yes

Yes

NR

No

6

(Luo, 2018)

Yes

Yes

Yes

No

5

(Luo et al., 2017)

NR

Yes

Yes

NR

6

(Wang and Yang, 2015)

≥9 41

Lai, M.H.

C

2013-2014

501

20-50

30.84±4.47

H

China

WPR

EDPS ≥13

≥10 42

Luo, G.

C

2015-2016

200

23-40

30.76±3.67

H

China

WPR

EDPS ≥13 ≥9

43

Luo, L. B.

C

2014-2015

187

22-53

29.83±3.87

H

China

WPR

EDPS ≥12

44

Wang, J. N.

C

2014

153

45

Weng, T. T.

C

2013-2014

1007

46

Xu, W. Q.

C

2012-2013

349

Zhou, Y.

C

2016

142

NR

47

21-38

28.0±1.9

H

China

WPR

EDPS

≥10

NR

NR

H

China

WPR

EDPS

≥10

NR

NR

NR

NR

5

(Weng et al., 2018)

23-39

26.5±2.9

H

China

WPR

EDPS

≥13

Yes

Yes

NR

NR

6

(Xu et al., 2014)

28.4±4.8

H

China

WPR

EDPS

≥10

NR

NR

Yes

Yes

6

(Zhou, 2017)

NR=Not Reported; DP=Depression; E=English; C=Chinese; H=Hospital; C=Community; EUR=Europe; EMR=Eastern Mediterranean; AFR=Africa; AMR=Americas; SEAR=South-East Asia; WPR=Western Pacific

25

Table 2 Subgroup analyses

Subgroups

Sample I2 size (%)

Categories (Number of studies)

N

ES

Hospital (11) Community (4) ≥2014 (9) < 2014 (6) ≥260 (8) <260 (7) EUR (7) WPR (5) Others (3) ≥13 (5) ≥9~≤12 (10) Good (4) Midian (11) Yes (5) Not report (10) Yes (8) Not report* (7) Yes (2) No (2) Not report (11) Yes (5) Not report (10)

482 205 378 309 599 88 281 124 282 234 453 301 386 247 440 352 335 44 13 630 152 535

10.56 7.38 11.41 7.47 9.43 10.11 7.20 7.37 21.32 5.99 11.55 12.36 8.66 14.81 7.47 11.06 7.95 11.52 8.31 9.72 9.53 9.93

5.84 2.62 5.19 4.13 4.07 7.53 4.07 4.42 7.24 3.22 6.46 2.31 5.63 4.74 4.70 4.47 4.71 8.47 1.31 4.97 6.23 4.55

16.42 14.12 19.56 11.65 16.68 13.00 11.10 10.99 40.15 9.52 17.83 28.63 12.24 28.98 10.79 20.01 11.93 14.96 19.80 15.79 13.43 17.01

3953 6321 2629 7645 9433 841 7337 1727 1210 6996 3278 1898 8376 1061 9213 2287 7987 381 157 9736 1441 8833

96.5 88.5 96.8 94.1 98.7 38.2 90.9 84.5 97.7 88.6 95.9 98.8 92.6 96.4 94.4 97.0 93.7 0.0 76.8 98.1 79.2 98.2

Hospital (30) Community (12) ≥2014 (23) < 2014 (19) English (35) Chinese (7) >179.5 (21) <179.5 (21) EUR (20) WPR (17) AMR (3) Others (2) ≥13 (11) ≥12 (3) ≥11 (2) ≥10 (19) ≥9 (4) ≥8 (3) Good (7) Midian (35) Yes (11) Not report (31) Yes (18) Not report* (24) Yes (10) No (10) Not report (22) Yes (8) No (12) Not report (22)

858 432 871 419 1,019 271 1,050 240 487 535 30 238 347 86 77 550 85 145 290 1,000 387 903 552 738 186 323 781 124 416 750

9.41 7.13 10.75 6.45 8.30 10.90 8.40 9.17 6.29 9.61 9.85 26.26 7.48 4.40 8.93 9.20 12.11 11.69 10.58 8.35 12.51 7.49 11.96 6.70 7.80 8.25 9.48 7.11 9.57 8.89

6.71 4.15 7.48 4.42 5.99 8.79 5.68 6.25 4.61 7.34 6.32 4.09 4.20 1.09 2.99 5.61 5.33 8.81 2.68 6.48 6.17 5.74 7.79 4.77 4.56 5.82 6.15 2.89 7.46 5.69

12.49 10.78 14.51 8.81 10.93 13.20 11.58 12.56 8.19 12.15 14.01 58.54 11.56 9.59 17.53 13.54 21.06 14.92 22.58 10.43 20.62 9.44 16.85 8.92 11.78 11.04 13.42 12.88 11.90 12.69

9084 8896 8605 9375 15441 2539 15562 2418 11714 5075 296 895 7905 2389 755 4904 867 1160 2123 15857 2374 15606 4461 13519 2046 3665 12269 1447 4391 12142

95.3 94.7 96.2 90.3 96.0 63.0 97.4 85.8 90.0 87.3 17.5 99.0 93.9 94.5 91.6 95.4 90.1 48.4 98.1 93.8 96.4 93.3 95.1 94.3 88.6 85.3 97.1 92.3 82.2 97.0

95%CI

Q

P across subgroup

0.55

0.457

1.05

0.306

0.07

0.785

3.64

0.162

3.08

0.080

0.28

0.600

1.64

0.200

0.54

0.463

0.54

0.763

0.01

0.903

0.95

0.329

4.26

0.039

2.13

0.144

0.23

0.634

8.03

0.045

7.33

0.197

0.20

0.656

2.04

0.153

4.98

0.026

0.47

0.791

0.67

0.716

Paternal prenatal depression Study site Year of publication Sample Size Area Cut-off value Quality score Mother aged ≥ 18 Father aged ≥ 18 First time mother First time father Paternal postpartum depression Study site Year of publication Language of publication Sample Size

Area

Cut-off value

Quality score Mother aged ≥ 18 Father aged ≥ 18 First time mother

First time father

N= Number of fathers with depression; ES: effect size; EUR=Europe; WPR=Western Pacific; AMR=Americas * Participants were adults although their mean age was not reported.

26

Records identified through database search (n = 2,942 )

Additional records identified through other sources (n = 17)

Records after duplicates removed (n =2,761)

Records screened (n =2,761)

Full-text articles assessed for eligibility (n = 181)

Records excluded (n =2,580)

Full-text articles excluded (n = 134): -Duplicate publications (n=115) -Incomplete assessment tool (n=1) -No assessment time (n=2) -Fathers and/or mothers age < 18 years (n=7) - No use of the EPDS (n=4) -No relevant data (n=5)

Studies included in qualitative synthesis (n =47)

Studies included in quantitative synthesis of prevalence data (meta-analysis) (n = 47)

Figure 1. Flowchart of study selection

27

Figure 2. Forest plot of prevalence of prenatal depression based on 15 studies

28

Figure 3. Forest plot of prevalence of postpartum depression based on 42 studies

29