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Background: Postpartum depression (PPD) is a serious mood disorder that affects behavioural, physical and mental health of women and newborn after childbirth. Although a wide range of research have been conducted on maternal and infant health outcomes, the effect of postpartum depression on exclusive breastfeeding practices remains ambiguous, and needs addressing. The aim of this study was to assess the effect of postpartum depression on exclusive breast feeding practices in sub-Saharan African countries. Methods: PubMed, Google Scholar, Science Direct and Cochrane Library were systematically searched for relevant articles published between 2001 and 2020. STATA version 14 was used to calculate the pooled odd ratio with 95% confidence intervals (95% CI). The DerSimonian and Laird random effects meta-analysis was used to measure the effect of postpartum depression on exclusive breast feeding practices. The heterogeneity and publication bias were assessed by using I2 test statistics and Egger’s test, respectively. This review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Result: A total of 1482 published articles and gray literatures were retrieved from different databases. Additional articles were identified from the reference list of identified reports and articles. After assessment of obtained articles, studies not meeting the inclusion criteria were excluded. Twenty six studies involving 30,021 population met the inclusion criteria were included in this review. In sub Saharan Africa the overall estimated level of postpartum depression was 18.6% (95% CI: 13.8, 23.4). This review found that postpartum depression had no significant effect on exclusive breast feeding practices (OR = 0.46, 95% CI: 0.18, 1.14). Conclusion: In Sub Saharan Africa, the prevalence of postpartum depression was lower than the report of World Health Organization for developing Country in 2020. This review reveled that maternal postpartum depression has no significant effect on exclusive breast feeding practices. Thus, the investigators strongly recommend the researchers to conduct primary studies using strong study design in sub-Saharan Africa.
A three-step search strategy was used in this review. Firstly, an initial limited search of MEDLINE/PubMed was undertaken, followed by an analysis of the text words contained in the title and abstract and the index terms used to describe the articles. A second search using all identified keywords and index terms was undertaken across databases, including PubMed, Google Scholar, Science Direct, Proquest MedNar and Cochrane Library. Thirdly, the reference list of all identified reports and articles was searched for additional studies. The initial keywords were postnatal, postpartum, depression, mental disorders and exclusive breast feeding practices. These keywords were used separately and/or in combination using Boolean operators such as “OR” or “AND”. “Depression, postpartum”[All fields] AND (“africa south of the sahara”[MeSH Terms] OR and “prevalence” [Subheading] OR “(“africa south of the sahara”[MeSH Terms]” [All fields] AND “Ethiopia” [MeSH Terms] OR “africa south of the sahara”[All Fields]), “Infant breastfeeding”. Study setting: Sub-Sahara Africa. Study participants: Exclusive Breast feeding mothers. Publication condition: All published articles and gray literatures. Language: English language. Types of studies: Observational study designs. Publication date: From January 2001 to June 28, 2020, due to the lack of studies from sub Saharan Africa on the topic before 2001. Exclusion criteria: Unable to access full-texts after two email contacts of the principal investigator. This review considered studies that examined exclusive breast feeding practices in women with postpartum depression versus women without postpartum depression. Postpartum depression is defined as depression that starts within one month after childbirth and whose symptoms last more than two weeks. We can measure postnatal depression by using the Diagnostic and Statistical Manual of Mental Disorders or Edinburgh Postnatal Depression Scale and self-reporting questionnaire-20. This review excluded studies that have been conducted on mothers with preexisting psychological disorders. The outcome interest of this review was the pooled prevalence of PPD and its effect on exclusive breast feeding practices in Sub Saharan Africa. Effect size was estimated in the form of log odds ratios. This review considered studies with observational study designs: prospective, retrospective follow up studies and cross-sectional studies reporting an association between postpartum depression and exclusive breast feeding practices were considered for this review. Quality of each original study was assessed independently (DW, YT) by using Newcastle-Ottawa Scale (NOS) quality assessment tool [26]. Any disagreements were resolved by taking the mean score. Finally, studies with a scale of ≥5 out of 10 were considered as achieving high quality. Any disagreements that arise between the reviewers were resolved through discussion with a third reviewer (BS) (Table 1). Characteristics of studies included in the systematic review and meta-analysis on the effect of postpartum on exclusive breast feeding practices in Sub-Saharan Africa, 2020 Note: CES-D Centre for Epidemiologic Studies-Depression, EPHD Edinburgh Postnatal Depression, PHQ Patient Health Questionnaire, SRQ Self-reporting Questionnaire, SSQ Shona Symptom Questionnaire The standard data extraction tool was prepared in a Microsoft Excel spreadsheet. This included the specific details about the exposures, populations, study methods and outcomes of significance to the review question and specific objectives. The authors of primary studies were contacted by email in case there is incomplete information. Two reviewers (DW and YT) extracted the data independently. Any differences among reviewers were negotiated with review team members until agreement was reached. Data were analyzed using STATA version 14. Heterogeneity was assessed using the standard I2 and visual inspection of forest plots. To check publication bias, both objective and subjective (funnel plot) methods were used. Mainly, objective methods such as Eggers’ and Beggs’ tests (p-value < 0.05) were used to assess publication bias [53, 54]. The result of Eggers’ test revealed statistically significant publication bias (p-value < 0.001). Finally, Duval and Tweedie’s nonparametric trim and fill analysis was performed to account for this publication bias. The pooled prevalence and effect size was expressed as standardized mean differences and their 95% confidence intervals were calculated using the DerSimonian and Laird method. Moreover, odds ratios and their 95% confidence intervals were calculated.
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