About the Author(s)

Genesis Chorwe-Sungani Email symbol
Department of Mental Health, School of Nursing, Kamuzu University of Health Sciences, Blantyre, Malawi

Kondwani Wella symbol
Kamuzu University of Health Sciences Library, Lilongwe, Malawi

Patrick Mapulanga symbol
Kamuzu University of Health Sciences Library, Lilongwe, Malawi

Ditress Nyirongo symbol
Department of Mental Health, School of Nursing, Kamuzu University of Health Sciences, Blantyre, Malawi

Mercy Pindani symbol
Department of Mental Health, School of Nursing, Kamuzu University of Health Sciences, Lilongwe, Malawi


Chorwe-Sungani G, Wella K, Mapulanga P, Nyirongo D, Pindani M. Systematic review on the prevalence of perinatal depression in Malawi. S Afr J Psychiat. 2022;28(0), a1859. https://doi.org/10.4102/sajpsychiatry.v28i0.1859

Original Research

Systematic review on the prevalence of perinatal depression in Malawi

Genesis Chorwe-Sungani, Kondwani Wella, Patrick Mapulanga, Ditress Nyirongo, Mercy Pindani

Received: 26 Dec. 2021; Accepted: 24 June 2022; Published: 20 Oct. 2022

Copyright: © 2022. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Background: Perinatal depression causes significant burden to women and their families during the perinatal period. However, there is no reliable national prevalence data on perinatal depression in Malawi.

Aim: This systematic review aimed at establishing the pooled prevalence of perinatal depression.

Setting: The study setting is Malawi.

Methods: Two reviewers conducted the search, selection, quality evaluation and data abstraction. Appropriate terms were used to search the CINAHL, PsychINFO, PubMed and ScienceDirect databases. The relevance and the quality of the studies were assessed. The prevalence of prenatal depression was pooled using a random-effects model, which was used to synthesise the data.

Results: The review included a total of eight articles of fair and good quality. This review found a pooled prevalence of antenatal depression of 17.1% (95.0% confidence interval [CI]: 12.5–22.2) and postnatal depression of 19.8% (95.0% CI: 4.6–42.1) with an overall pooled prevalence of perinatal depression of 18.9% (95.0% CI: 14.5–23.8).

Conclusion: This systematic review provided a pooled prevalence of perinatal depression which may be used in the absence of national prevalence data on perinatal depression.

Contribution: This systematic review found a high a pooled prevalence of perinatal depression in Malawi suggesting that mental health should be a key component of maternal health programmes, policies and activities in the local setting.

Keywords: perinatal depression; antenatal depression; postnatal depression; prevalence; Malawi.


Perinatal depression is a depressive mood disorder that affects women during pregnancy or in the first 12 months after the birth of a child.1 However, perinatal depression is often underdiagnosed by clinicians in Malawi.2 There is evidence that found a pooled prevalence of perinatal depression of 11.9% in women in lower-income countries.3 In Malawi, previous studies found that depression was prevalent during pregnancy (25.8%)4 and after childbirth (10.7%).5 This is within a range of prevalence rates for antenatal depression (8.3% – 41.0%)6 and postnatal depression (16.8%) in Africa.7 Therefore, Malawi constitutes some burden of perinatal depression in Africa.

There is no routine screening for perinatal depression in primary care settings in the country.8 Primary care is crucial in detecting, treating or making appropriate referrals to mental health care for women affected with perinatal disorders.9 It is also necessary to make efforts to identify risk factors for perinatal depression to assist in prevention, identification and treatment in primary care. Risk factors for perinatal depression include life stress, history of depression, maternal anxiety, lack of social support, lower frequency of exercise, unintended pregnancy, Medicaid insurance, intimate partner violence, history of child abuse, lower income, lower education, smoking, single status and poor relationship quality.10 This is corroborated by a study that found that lower perceived social support and intimate partner violence are associated with perinatal depression.5

Literature suggests that perinatal depression has a substantial impact on women during pregnancy5 and the first year after delivery. It is one of the major causes of disability among women during the perinatal period11 and can have serious long-term adverse effects on the well-being of women, their partners and infants.10,12,13 For instance, a systematic review found that some women who committed neonaticide, infanticide or filicide had mental health concerns.14 This may be the case in South Africa, where rates of neonaticide (19.6 per 100 000 live births) and infanticide (28.4 per 100 000 live births) are high.15 Furthermore, perinatal depression is linked to poor uptake of antenatal services,16 premature birth, intrauterine growth restriction, low birth weight,17 fatigue, poor concentration and feelings of hopelessness in a pregnant woman.18 Additionally, perinatal depression may affect mothers’ ability to provide sufficient nutritional care resulting in compromised infant growth and development.19,20

Perinatal depression may increase the risk of anxiety, depression, attention deficit hyperactivity disorder and conduct disorder in a child.21 Additionally, perinatal depression and human immunodeficiency virus (HIV) infection are linked in a vicious cycle, in which the symptoms of one disease exacerbate the other’s condition.22 Women who have co-morbid perinatal depression and HIV infection are less likely to adhere to antiretroviral medication, which is essential for their survival and the prevention of HIV transmission to their babies.23 This demonstrates the clinical and public health importance of perinatal depression22,23,24,25 in low-resource settings where the condition is highly prevalent.24 Although prevalence is often useful as it indicates the burden of a condition in a particular population,26 there is no reliable national prevalence data on perinatal depression in Malawi. Therefore, this systematic review aimed at establishing the pooled prevalence of perinatal depression in Malawi.


The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to conduct the systematic review27 to address the review question.

Search process

To find relevant terms in the title, abstract and subject descriptors, a limited search of PubMed and ScienceDirect was conducted. After that, search phrases and synonyms were identified for use in searching various databases for prevalence studies conducted in Malawi. No date limits were set, in anticipation that a wider period to be searched from the inception of each database will yield many relevant studies for possible inclusion in this systematic review. However, the search focused on articles that were written in English only. Search terms that were used are presented in Table 1.

TABLE 1: Search terms.

Using all identified search terms, electronic databases were searched for primary studies (PubMed, CINAHL, PsychINFO and ScienceDirect), and the results were imported into EndNote. Reference lists of key articles identified were hand-searched to identify additional articles. Manual searches of indexes and ‘grey’ literature databases were not carried out. The preliminary searches were conducted between July and August 2020, and the final search was done in October 2021.

Data Collection

Upon completion of the search, duplicates and irrelevant articles (abstracts, conferences, congresses, editorials, commentaries, reviews, news and irrelevant records) were removed from the EndNote database, and later the search data was exported into Excel. The selection of articles for review was then conducted in three phases.

Abstract screening

This first phase involved reviewers independently scrutinising the titles and abstracts and indicating which articles were relevant in Excel. When the abstract did not provide enough information or the reviewers were undecided, the full-text articles were evaluated, and a consensus was reached between the reviewers on whether the article should be included or excluded. To determine the level of agreement for eligibility for inclusion at this step, a kappa statistic was calculated.

Screening based on participant, intervention, comparison, outcome and setting criteria

In the second phase of the selection process, articles were independently reviewed by two reviewers by applying and extracting the participant, intervention, comparison, outcome and setting (PICOS) criteria as follows: Participants (P) (pregnant women and mother of infants ≤ 12 months), Intervention (I) (any studies reporting the prevalence of perinatal depression), Outcome measures (O) (the measured prevalence of perinatal depression) and study setting (S) (Malawi). In addition, all primary quantitative studies that measured the prevalence of perinatal depression were considered for inclusion in the systematic review. Studies conducted outside Malawi were excluded.

Article review

Reviewers independently scrutinised full texts selected to confirm their inclusion by checking if an article reported the prevalence of perinatal depression in Malawi. Eligibility for full article review, assessment of study characteristics and relevant data extraction were assessed using a standard tool in Excel, and data were entered into a database. For each eligible study, the reviewers extracted information about the author, year of publication, title, setting, study design sample, assessment tool and prevalence rate of depression. Prevalence, measured based on a diagnostic assessment tool (Mini International Neuropsychiatric Interview [MINI] or Structured Clinical Interview for DSM [SCID]), was extracted from an article that reported multiple prevalence rates. All results were subject to double data entry.

Assessment of methodological quality of studies

The critical appraisal tool for scoring methodological rigour of studies28 was used to assess the methodological quality of the included studies. However, the reliability and the validity of the tool are not documented in Malawi. The critical appraisal tool for scoring methodological rigour of studies was used in this systematic review to assess the quality of included studies.28 The tool has nine items that each assess the quality of a study on a scale as: very poor (1), poor (2), fair (3) and good (4). The tool has a minimum score of 9 and a maximum score of 36, and it allowed each reviewer to grade the included studies independently. Full texts of the included studies were retrieved and double-blind assessed for methodological quality by the two reviewers (P.M. and K.W.). The average score achieved by each study on the tool was used to determine its quality.

Data analysis

Quantitative data analysis was conducted using MedCalc software.29 The calculated I2 Statistic (I2 = 91.9%, 95.0% confidence interval [CI]: 86.4–95.2) showed that the included studies were statistically homogeneous. However, because of clinical and methodological heterogeneity within and between studies,30 a random-effects model was utilised to calculate the pooled prevalence and 95% CIs. Pooling of prevalence and subgroup analysis by groups (antenatal depression and postnatal depression) were performed.

Review process and results

The electronic search yielded 1829 published records from PubMed, CINAHL, PsychINFO and ScienceDirect (Figure 1). A total of 23 duplicates were removed, resulting in 1806 records that were scrutinised. A further 1778 records were removed because they were irrelevant (conferences, congresses, editorials, commentaries, reviews and news). The remaining 28 articles were assessed for relevancy by the reviewers using the PICOS criteria, excluding a further 18 articles, leaving 10 articles. The reviewers’ ratings for inclusion or exclusion of studies agreed with a kappa = 0.94. Of the 10 articles that remained, two were excluded31,32 because they did not report the prevalence of perinatal depression, resulting in eight studies that were included in this systematic review.

FIGURE 1: Study flow diagram based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

The methodological quality of reviewed studies

All the eight included articles were rated for quality independently by G.C. and K.W. Overall, the quality was satisfactory with four articles4,33,34,35 rated as good, and four articles5,20,36,37 were fair (Table 2).

TABLE 2: Methodological quality of studies.
Findings from studies for inclusion in the review (n = 8)

Of the eight articles that were included in this systematic review, seven articles were published in medical journals and one in a nursing journal, and their years of publication ranged from 2010 to 2021 (Table 1). Most of the articles were for cross-sectional studies (n = 6).

Instruments that were used to measure perinatal depression

The systematic review revealed that various instruments were used to assess for perinatal depression in Malawi (Table 3). The most-used instrument of the articles was Edinburgh Postnatal Depression Scale (n = 4), whose cut-off points ranged from ≥ 6 to >12. The second most-used instrument was SCID (n = 2), followed by the Self-Reporting Questionnaire 20 (n = 1), with a cut-off point ≥ 8, and the MINI (n = 1) (Table 3).

TABLE 3: Results for included studies (n = 8).
Prevalence of perinatal depression in Malawi

The systematic review found that pooled prevalence of antenatal depression (17.1% [95.0% CI: 12.5–22.2]) (Table 4), postnatal depression (19.8% [95% CI: 4.6–42.1]) (Table 5) and the overall pooled prevalence of perinatal depression (18.9% [95.0% CI: 14.5–23.8]) (Table 6) were comparable. However, the pooled prevalence of postnatal depression was higher than the overall pooled prevalence.

TABLE 4: Pooled prevalence of antenatal depression in Malawi.
TABLE 5: Pooled prevalence of postnatal depression in Malawi.
TABLE 6: Overall pooled prevalence of perinatal depression in Malawi.


Depression is the most common mental health condition that affects women worldwide during the perinatal period.9,10,38,39,40 It is necessary that women are screened for perinatal depression for early detection and treatment.4 However, the studies and instruments that are used to measure perinatal depression globally vary,3,7,41,42 leading to clinical heterogeneity. Clinical heterogeneity refers to variability in study population characteristics, interventions and outcomes across studies, while statistical heterogeneity includes methodological heterogeneity, biases and random error.43 This systematic review showed that the included primary studies had substantial clinical heterogeneity regarding study designs, sample sizes, sample characteristics and assessment tools. This might have affected the magnitude of the overall pooled prevalence that was generated in this study. As indicated by Kriston and colleagues, reviewers’ beliefs on the role of heterogeneity on the pooled prevalence found in this systematic review must be reflected.44

This systematic review suggests that the prevalence of perinatal depression in Malawi is high with an overall pooled prevalence of 18.9%. This pooled prevalence for perinatal depression in Malawi is lower compared to the one that was found in Ethiopia (25.8%).45 However, contrary evidence showed that the pooled prevalence of perinatal depression in Malawi is higher than that of women in lower-income countries (11.9%).3 This may be explained by literature which indicated that women encounter numerous risk factors during the perinatal period in Malawi.4,5,46 However, the need for conducting a proper national epidemiological study for perinatal depression still remains in the country. Epidemiological data will help in the implementation of targeted evidence-based interventions to protect the public47 and perinatal women in particular.

Literature suggests that violence, anxiety, life stress, prior depression and lack of social support are some of the risk factors for perinatal depression.48 Furthermore, prenatal depression is a risk factor for postnatal depression,49 so that pregnant women with untreated depression are more likely to suffer from postpartum depression and suicidality.50 This may be the case in Malawi, where this systematic review found that pooled prevalence for postnatal depression (19.8%) was higher than the pooled prevalence for antenatal depression (17.1%). Nonetheless, this result is contrary to the evidence that showed that pooled prevalence for postnatal depression (16.8%)7 was lower than the pooled prevalence of antenatal depression (26.3%)42 in Africa. Despite the variations, this review agrees with existing evidence that the prevalence of perinatal depression is high in Africa and Malawi in particular.

Study limitations

This systematic review is limited in that there is a shortage of studies in Malawi to produce generalisability evidence. There is also a difference in the depression assessment tools, which may also have contributed to the detected heterogeneity in this review. Hence, caution should be taken during the interpretation of the results.


This systematic review generated a pooled prevalence of perinatal depression for Malawi, which may be used by clinicians, researchers and policymakers in the absence of national prevalence data on perinatal depression. The review suggests that perinatal depression is highly prevalent in Malawi, based on a few published studies with inherently heterogeneous estimates. Based on this review, maternal health programme policies and activities should incorporate maternal mental health as a core component to promote early detection of perinatal depression and prompt interventions that would save the mother and her baby from different forms of morbidity and mortality.


The authors acknowledge all colleagues who offered guidance and technical support to the project and drafting of this manuscript.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

G.C.-S. drafted the manuscript with support from K.W., P.M., M.P. and D.N. G.C.-S. designed the study, and searches for records were performed by K.W. and P.M. Data extraction was carried out by G.C.-S. and K.W. All authors participated in the review and revision of the manuscript and have approved the final manuscript to be published.

Ethical considerations

This systematic review was registered in the PROSPERO international prospective register of systemic reviews (ref. no.: CRD42019142723).

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.


The views and opinions expressed in this article are those of authors and do not necessarily reflect the official policy or position of any affiliated agency of the author.


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