Gynecology & Obstetrics
Open Access

Buffering Effect of Perceived Social Support During Postpartum Depression: A Systematic Review

María Cantero-García^1*, Noelia Puche Escribano¹, María Rueda-Extremera¹ and y Ana Huertes-del Arco^{1,2 *}Correspondence: María Cantero-García, Universidad a Distancia de Madrid (UDIMA), Madrid, Spain, Email:

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Introduction

Depression is one of the most common mental disorders in the postpartum period, with significant repercussions for both mothers and their children. It is estimated that between 10% and 20% of women experience Post-Partum Depression (PPD) at some point after the birth of their child, although these figures may be lower than the actual prevalence due to underdiagnoses [1]. This disorder particularly affects vulnerable groups, such as first-time mothers and adolescents, who may face greater uncertainty and pressure in their new parental roles [2]. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PPD is classified under major depressive disorder with onset during the perinatal period, establishing specific diagnostic criteria that include symptoms such as depressed mood, loss of interest in previously enjoyed activities, sleep disturbances, and suicidal thoughts [3]. It is essential to distinguish PPD from maternity blues, a transitory condition characterized by brief episodes of crying and irritability that typically arise in the first few days postpartum [4]. Confusing the two can lead to a lack of recognition and appropriate treatment of PPD, resulting in a high comorbidity between subclinical depressive symptoms and anxiety. Recent studies suggest that elevated initial anxiety levels are a significant risk factor for developing PPD [5]. Moreover, endocrine disorders, such as thyroid dysfunctions, and changes in neurotransmitter function may also serve as underlying causes of postpartum depression [3].

It is essential to distinguish PPD from maternity blues, a transitory condition characterized by brief episodes of crying and irritability that typically arise in the first few days postpartum [4]. Confusing the two can lead to a lack of recognition and appropriate treatment of PPD, resulting in a high comorbidity between subclinical depressive symptoms and anxiety. Recent studies suggest that elevated initial anxiety levels are a significant risk factor for developing PPD [5]. Moreover, endocrine disorders, such as thyroid dysfunctions, and changes in neurotransmitter function may also serve as underlying causes of postpartum depression [3]. Recent research demonstrates that the symptoms of PPD are not limited to the early weeks after childbirth. Chapela found that these symptoms can persist for the first three months and, in some cases, may emerge in the first year following the birth [6]. This extension of the vulnerability period for the development of PPD highlights the importance of ongoing monitoring and support for mothers during the first year postpartum. However, many women who develop PPD do not receive adequate care, often due to a lack of communication about their issues with healthcare personnel, contributing to the condition's invisibility and the normalization of suffering [6]. The impact of PPD extends beyond the mother, affecting the child's well-being and the family unit. Affective disturbances in mothers are often not recognized as illnesses but perceived as deficiencies in their maternal capacities. This can lead to self-imposed pressure to fulfill their maternal responsibilities, sometimes unsuccessfully, resulting in significant emotional strain [6]. Mothers may feel overwhelmed by feelings of guilt and inadequacy, leading to a detrimental cycle where a lack of support and the inability to recognize PPD exacerbate symptoms [2].

Depressive symptoms during the postpartum period can easily be mistaken for normal adaptations to this stage of life, as they include emotional and physical changes such as mood swings, loss of interest in previously enjoyable activities, and a notable decrease in energy [2]. As symptoms progress, mothers may experience a reduction in daily activities and persistent fatigue that does not improve with rest. Insomnia and other sleep disorders are common, along with a loss of appetite. In severe cases, suicidal thoughts may arise, making early recognition and provision of adequate support imperative to ensure the health and well-being of the mother and her family [7, 8]. Among the risk factors that could contribute to the development of depressive symptoms in the postpartum period, early or extreme maternal age, unwanted pregnancy, marital difficulties, and low socioeconomic status are identified [2]. Furthermore, gynecological-obstetric pathologies, including complications during pregnancy or childbirth, may hinder physical recovery and increase emotional stress. Literature also points to the use of anesthesia during childbirth and the health of the newborn as factors that may contribute to the development of PPD [9]. Additionally, Adverse Childhood Experiences (ACEs) emerge as a critical component in the predisposition to PPD. Women who have experienced ACEs are at a higher risk of developing this condition, underscoring the need to consider the psychosocial context in the evaluation and treatment of PPD [10]. Research indicates that these adverse experiences not only predispose individuals to depression but also interfere with the mother's ability to seek and receive social support [11]. This multifactorial approach is fundamental to understanding the etiology of PPD, as its onset is influenced by a combination of biological, psychological, and social factors [2]. Regarding prevention, social support has been highlighted as a crucial protective factor. Huang et al. emphasize that a robust network of emotional, informational, and instrumental support can mitigate the impact of risk factors and reduce the prevalence of depressive symptoms. During emergency situations, such as the COVID-19 pandemic, it has been shown that social support has greater protective power, underscoring the need to promote it in vulnerable contexts [12, 13]. However, access to mental health services remains limited, implying that many women do not receive appropriate treatment for PPD [14]. The review of the literature suggests that social support and early identification of risk factors such as ACEs are essential for improving the prevention and treatment of this disorder. Increasing the visibility of PPD, along with promoting social support networks, could contribute to reducing the prevalence of this disorder and enhancing the quality of life for mothers and their families. The present work aims to conduct a systematic review of the primary studies published on the importance of social support to analyze the role of social support as a protective factor and to carry out a synthesis of the key characteristics and contents of these studies.

Methods

Review protocol

A systematic search was conducted using the most representative electronic databases in the field of study: PubMed, Web of Science (Core Collection), and ProQuest. The main interest was to find studies that relate perceived social support and postpartum depression. The document search was carried out in both Spanish and English, and publication dates were requested to be within the last five years. After eliminating duplicate studies and conducting the initial reading of titles and abstracts based on the inclusion and exclusion criteria, the full texts of the remaining articles were examined to assess their potential inclusion in the review, as shown in figure 1.

Figure 1: Sequence of search and study selection procedure.

Note: Flow diagram summarizing the different steps taken based on the Moher et al. model [15].

Selection criteria

The inclusion criteria for selecting studies were established following the PICOS format:

1. P: Participants: women in the postpartum stage with depression.

2. I: Intervention: study of the influence of social support on postpartum depression.

3. C: Comparison: women in the postpartum stage without depressive symptoms.

4. O: Outcome: quality of life and reduction of depressive symptoms.

5. S: Study: cross-sectional and longitudinal studies.

In longitudinal studies where data were collected at multiple assessment points, the measures from the first assessment point were used to make a more balanced comparison with the other studies. Regarding the exclusion criteria, studies that omitted essential methodological information in the abstract, such as the number of participants or whether they were in the postpartum stage, were excluded. Review studies, dSeptoral theses, trials, case studies, and any other qualitative works were also excluded. The criteria are outlined in table 1. With respect to the type of publications, journal articles, books, and book chapters were included, while popular newspapers, brief reports, conferences, conference proceedings, letters, and essays were discarded.

Table 1: Inclusion and exclusion criteria.

Sources of information

Several databases such as PsycINFO, Medline, and Scopus were explored. Ultimately, the ones used were Web of Science, PubMed, and ProQuest, as their article topics were more aligned with the chosen theme and offered a greater availability of open-access results.

Search strategy

The search strategy was carried out using the combination of the following terms: “Postpartum Depression” and “Social Support” and “Perceived Social Support.” To conduct the literature search by keywords, the following search string was used: ("Postpartum Depression" and "Social Support" or "Perceived Social Support"). The eligibility criteria for the analyzed studies were guided by the delineation of inclusion and exclusion criteria that allowed for a better response to the objectives. The eligibility phase took the most time, as many studies needed to be examined, first by titles and abstracts and subsequently in full text, as specified in figure 1.

Publication selection

The publication selection process is graphically and succinctly presented in figure 1, a flow diagram, specifically following the PRISMA model located in the subsequent data analysis section [15]. The selection was an organized procedure carried out in several phases, which needed to be meticulously completed one by one before proceeding to the next. A personal journal of notes was a great help in this process.

Data extraction and coding

Initially, the search equation is executed in the three electronic databases, and then the inclusion and exclusion criteria provided by the search engine are applied, resulting in the following: Search equation: “postpartum depression” “perceived social support”.

1. ProQuest: A total of 28,394 results appear with this search equation. After filtering for full-text articles from scientific journals published in the last 5 years specifically related to “postpartum depression,” the number is reduced to 754 results.

2. PubMed: 2,692 results after the search. The process began by filtering for full-text articles published in the last 5 years, resulting in a total of 638 articles.

3. Web of Science: Executing the search equation yielded a total of 682 results. After filtering for fulltext articles that are open access and published in the last 5 years, 236 studies were obtained as a result. The total number of results from the three databases sums up to 1,628 studies. For subsequent management, the bibliographic manager Mendeley was used to export all the studies obtained from the three electronic databases. The authors were sorted alphabetically, and duplicate articles were eliminated one by one. After analyzing each of them, 53% were discarded, resulting in a total of 771 studies for further analysis, starting with the titles. After content analysis, studies were removed for various reasons, such as being other systematic reviews or not being available for full-text reading. Titles and abstracts of all available studies were reviewed, selecting only those that analyze the relationship between “social support” and “postpartum depression,” resulting in 129 articles. Of these, the full text was reviewed, paying special attention to the results section to assess whether social support relates to postpartum depression and, of course, whether it meets the chosen inclusion and exclusion criteria. Many of these articles were excluded because the sample was composed exclusively of pregnant women or because they studied perinatal depression during the prenatal stage and not in the postpartum period. Other studies were excluded due to insufficient sample size. Finally, 18 articles were included in the final synthesis.

Results

The number of studies included in the final synthesis was 18. All of them establish measures that evaluate the social support perceived by mothers during the postpartum stage and its relationship with depressive symptoms [16]. For a better projection of the results of the review, these are presented in table 2, which shows that all the selected studies report significant associations indicating the relationship between perceived social support and postpartum depression.

Table 2: Summary of the studies included in the present systematic review.

Sample

Most of the studies consulted have a large sample size, but not all mothers in the study exhibit depressive symptoms. The research considers many other variables, so in the same study, we may find part of the sample consisting of pregnant women and part of the sample consisting of postpartum mothers. Moreover, as mentioned, not all women in the various studies report depressive symptoms. The selected studies encompass a total of 33,708 participating women, with the average sample size of all women included in the studies of the systematic review being 1,872.6. In this review, age of the mothers, country of origin, or economic status was not used as inclusion or exclusion criteria. The 18 studies that comprise this review come from fourteen different countries. Most of the studies are from the Asian continent including two studies conducted in Turkey and one study conducted in several countries, but with the majority of the sample from Asia [9,16]. America has 3 studies in this review, as does Australia. There are 2 studies from Europe, and finally, one study from the African continent.

Risk of bias

Appendix 1 includes the AMSTAR checklist, which aims to globally assess the biases present in the studies included in the final synthesis.

Data on the evidence found

The studies included in the final review analyze the relationship between the two variables: perceived social support and depressive symptoms. When analyzing low social support, the lower the level of subjective and objective social support perceived by women, the more likely it is that depression will worsen [23]. High scores on 'unsatisfied social support' were accompanied by significant scores in Postpartum Depression (PPD) [32]. In contrast, when referring to good perceived social support; higher social support scores are related to a lower risk of postpartum depressive symptoms [27]. According to Cho et al., a greater number of women with postpartum depression were identified in groups with low social support. Other interesting variables were also studied, such as participants with multiparity (a condition in which the pregnant woman has had two or more births), previous pregnancy loss, women with obesity, and employed women, and their possible relationship with depressive symptoms [19].

It is undoubtedly interesting to analyze how mothers perceive their quality of life during the postpartum period and how social support determines life satisfaction and the rediscovery of a sense of community belonging among women in the postpartum period [30]. Similarly, the lack of social support contributes to a low health-related quality of life for postpartum women [24].

Defining social support as a unique and closed concept does not seem to be an accurate idea. Certain studies divide social support into global social support, family social support, friend social support, and social support from other loved ones [17, 20, 22, 25, 26, 31, 33]. The role of support from spouses is highlighted in several studies finding a significant relationship between marital dissatisfaction and postpartum depression [17, 25]. Mothers with marital dissatisfaction scored higher on the Edinburgh Postnatal Depression Scale (EPDS) [25]. Mothers who do not have social support from their partner or other significant individuals have reported a high risk of postpartum depression [33]. According to the latter study by Yamada et al., the concept of social support contains various classifications, and the results study how each of them correlates with depressive symptoms: having a spouse and social support from others is not the same as not having a spouse but receiving social support from others, or, for example, having support from a spouse but not from others, or ultimately, having no social support from either a spouse or others [33].

Undoubtedly, social support stands as a crucial protective factor. Therefore, the practical implications of this research reflect the understanding of social support as a significant predictor of depression in the postpartum period, as well as the need to integrate the social component into the support and assistance system for pregnant women and mothers. This implies attention that goes beyond social policies, advocating for the inclusion of support not only from close relatives and loved ones but also from broader social structures [17].

Research analyzing the losses of social support during the COVID-19 pandemic showed that both emotional and instrumental support were essential to protect against the risk of PPD [31]. Emotional support and what is termed informational support, characteristic of assistance systems, have a partial mediating effect on the relationship between perceived stress and prenatal depressive symptoms [18]. A significant negative relationship was evidenced between instrumental support, which consists of tangible help and services available when needed, and postpartum distress for mothers whose preferred language was Spanish, suggesting how culture may interfere with the perception of social support [20].

The postpartum period cannot be considered a specific moment in a mother’s life but rather a broader period or interval of time. For this reason, different studies examine postpartum experiences over various time intervals. Among the findings, it can be noted that regardless of the time elapsed postpartum, total and family social support scores were negatively associated with postpartum depression [26]. Another relevant aspect of the study was the collection of maternal measures at several key moments. These measurements were taken at baseline, nine weeks after randomization (which was selected for the current analysis), as well as at six, nine, and twenty-four months after childbirth. This approach allowed for the capture of potential changes that may occur during a period of up to two years postpartum [28].

Discussion

Following the analysis of the results obtained from various studies, it is evident that there is a significant relationship between perceived social support and depressive symptoms in the postpartum period. To continue researching this field with greater precision, it would be crucial to reach a consensus on the definition of what is understood by the postpartum period [3]. According to the American Psychiatric Association this period encompasses the first four weeks after childbirth, while the International Classification of Diseases (ICD-10) states that it begins at six weeks post-delivery [34]. Other authors suggest a broader timeframe, as indicated by some studies included in this review [26]. The lack of diagnosis and consequently the absence of adequate treatment can inevitably lead to chronic postpartum depression, with symptoms that persist, change, or intensify over time. Such depression can be especially detrimental not only to the mother but also to the newborn. The mother-baby bond can be severely affected, which may have significant consequences for the baby's emotional and cognitive development. In fact, sometimes the mother's diagnosis is made indirectly through the child's behavior or development, underscoring the importance of identifying and addressing postpartum depression early and effectively. Undoubtedly, breaking down and dissecting the concept of social support may be the most appropriate approach, as emotional support is not valued the same as instrumental support, or, for example, the support provided by friends compared to that from a spouse. Ultimately, deconstructing the experience of support and understanding the specific type of assistance referred to helps us identify which aspects are most suitable for reinforcement, prevention, and even highlighting as concrete tools to implement in the treatments indicated for managing depressive symptoms during the postpartum period. When we analyze the influence of spousal social support on postpartum depression symptoms, studies such as that of González-González et al. found that conflictual marital relationships represent one of the risk factors [2]. Psychosocial aspects, which include social support and marital relationships, are crucial elements in the mental health of mothers during the postpartum period. Attention to these areas is fundamental in the psychological realm and can make a significant difference in the prevention and treatment of postpartum depression. Therefore, developing interventions and programs designed to promote and maintain these protective factors is essential to providing effective support to mothers and their families. Such interventions may include educational and support programs that encourage communication and conflict resolution in marital relationships, as well as social support networks that provide mothers with emotional and practical support during the postpartum period. By investing in strengthening these psychosocial aspects, we can lay the groundwork for better maternal and family mental health in the long term. Moreover, by recognizing the importance of these factors for the well-being of both mother and child, we can advocate more effectively for public policies that support and promote social support and marital relationships as integral components of maternal and family health care. The prevalence of postpartum depression indicated by the results of the various studies is highly variable due to the great heterogeneity in the evaluation methodologies used. The main difficulty in comparing the results of the studies lies in the fact that they do not use the same measurement instrument for social support or even for depressive symptoms. Several of them indeed utilize the Edinburgh Postnatal Depression Scale or the Multidimensional Scale of Perceived Social Support (MSPSS) [8, 19, 21, 25, 33]. Additionally, the different studies show how each one defines the concept of social support differently, ranging from establishing it as a single term to breaking it down into various concepts, further specifying the meaning of each. Furthermore, we find results that, depending on how social support is conceptualized, correlate more or less with depressive symptoms. When the term social support refers to who provides the support, the focus shifts to the more direct emotional social support that the mother receives in the postpartum period, where most studies consider it to be the spouse. Lastly, it is also necessary to highlight the time interval considered when referring to "postpartum" because it varies from study to study; while some collect their data within the first six weeks after childbirth, others gather data up to six months postpartum, leaving a substantial gap between the two measures. As limitations, it can be indicated that this work has presented issues with the imprecision of the measures and the variety used in the studies, as mentioned earlier, since the measurement instruments were diverse, and it is not straightforward to examine the results as equitably as possible. As a line of future research, it is proposed to redefine the concept of perceived social support, observing how the individual providing support influences this and simultaneously exploring it across countries to determine whether culture conditions the perception or support provided. Redefining the concept of social support would not mean establishing a concrete and unanimous definition for all mothers, but rather specifying what type of social support may need to protect mothers according to their cultural background and the social policies available to them. In the field of perinatal psychology, there is a pressing need to continue researching with the aim of reducing the phenomenon where women confuse depressive symptoms during the postpartum period with the normal adaptation to this stage of life, whether due to shame or fear of not meeting the socially established norms [2]. The establishment of perinatal mental health programs in all public maternity wards, as well as follow-up programs for pregnancy from primary care, is essential to better implement available resources for prevention, protecting the well-being of women, babies, and society in general during the pregnancy and postpartum stages. In fact, there is still no practical guideline or established care protocol for the diagnosis and treatment of such disorders. Training and interdisciplinary collaboration among health professionals are essential for implementing a national perinatal mental health plan.

Conclusion

In conclusion, social support emerges as a key protective factor for women experiencing depressive symptoms during the postpartum period. However, it is fundamental to establish a clearer and more consensual definition of what mothers perceive as effective social support, as its efficacy will largely depend on whether such support aligns with the needs and expectations of women during this stage. Actively promoting social support during the perinatal period is crucial not only for preventing the onset of depressive symptoms but also for mitigating their impact on those women who already present them. This support, combined with other factors such as access to mental health resources and a supportive family environment, can significantly contribute to reducing depressive symptoms and improving the overall well-being of mothers.

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