International Journal of Nursing Studies 46 (2009) 1355–1373

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International Journal of Nursing Studies

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Review

Postpartum depression in Asian cultures: A literature review

Piyanee Klainin a,*, David Gordon Arthur b
a
Alice Lee Centre for Nursing Studies, National University of Singapore, Block E3A, Level 3, 7 Engineering Drive 1, Singapore 117574, Singapore
b
Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore

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

Article history: Objectives: Postpartum depression (PPD), a major health concern, produces insidious
Received 22 July 2008 effects on new mothers, their infant, and family. This literature review aims to explore risk
Received in revised form 14 February 2009 factors for postpartum depression among women in Asian cultures, which has not been
Accepted 23 February 2009
fully elaborated.
Data sources: A literature search was undertaken by using various electronic research
Keywords: databases. Studies were eligible for this review if they (a) examined risk factors
Postpartum depression
for PPD, (b) were conducted in Asian countries using quantitative or qualitative
Risk factors
methodologies, and (c) were published in English in peer-reviewed journals between
Asian cultures
1998 and 2008. A total of 64 studies from 17 countries were reviewed, summarised,
and synthesised.
Results: The prevalence of postpartum depression in Asian countries ranged from 3.5% to
63.3% where Malaysia and Pakistan had the lowest and highest, respectively. Risk factors
for postpartum depression were clustered into five major groups: biological/physical (e.g.,
riboflavin consumption), psychological (e.g., antenatal depression), obstetric/paediatric
(e.g., unwanted pregnancy), socio-demographic (e.g., poverty), and cultural factors (e.g.,
preference of infants’ gender). Traditional postpartum rituals were not found to provide
substantial psychological benefits for the new mothers.
Conclusions: This review informs a current state of knowledge regarding risk factors for
postpartum depression and has implications for clinical practice. Health care professionals
should be aware that the phenomenon is as prevalent in Asian cultures as in European
cultures. Women should be screened for potential risk factors and depressive symptoms
during pregnancy and postpartum periods so that appropriate interventions, if needed,
can be initiated in a timely fashion.
ß 2009 Elsevier Ltd. All rights reserved.

What is already known about the topic?
 Postpartum depression (PPD) negatively affects women’s
health, their children, and relationships among family
members.
 Extensive studies examined predictors and etiological
factors associated with PPD and tested prevention
* Corresponding author. Tel.: +65 6516 7789; fax: +65 6776 7135.
E-mail address: nurpk@nus.edu.sg (P. Klainin).
interventions and treatments on women in Western
countries.
What does this paper add?
 Asian countries entail a variety of traditional postpartum
practices to facilitate recovery during a postpartum
period.
 Risk factors for PPD in Asian women encompass physical/
biological, psychological, obstetric/paediatric, socio-
demographic, and cultural factors.

0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.02.012
1356 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
 Cultural factors may play a unique role in the occurrence
of PPD in Asian cultures.
1. Introduction
Postpartum depression (PPD) is considered a debilitat-
ing mental disorder with prevalence rates of 0.5–60.8%
around the world depending on the definitions used
(Halbreich and Karkun, 2006). Definitions of PPD are
provided by two existing diagnostic systems; the Diag-
nostic and Statistical Manual of Mental Disorders (DSM IV-
TR; APA, 2000) and the International Statistical Classifica-
tion of Diseases and Related Health Problems (ICD-10;
WHO, 2007). The DSM IV-TR recognises PPD as a major
depressive disorder with postpartum onset and indicates
that depressive symptoms begin within 4 weeks post-
partum. According to the ICD-10, PPD is a mild mental and
behavioural disorder commencing within 6 weeks of
delivery. Clinical manifestations of PPD may enlist
depressed mood, markedly diminished pleasure in almost
all activities, insomnia or hyper insomnia, significant
weight loss or weight gain, psychomotor agitation or
retardation, loss of energy, feelings of worthlessness and
excessive guilt, reduced self-esteem and self-confidence,
difficulty in concentration, and suicidal ideation (APA,
2000; WHO, 2007).
Evidence suggests that maternal depression has dele-
terious effects on new mothers, their infants, and family
relationships (Leiferman, 2002). Depressed mothers
express more negative emotions (such as sadness, anxiety,
nervousness, and aggression), perceive more difficult
relationships with their family members including their
parents (Righette-Veltema et al., 2002), and report a higher
level of sexual dissatisfaction than non-depressed counter-
parts (Morof et al., 2003). They have little verbal
communication with their infants, express fewer positive
facial emotions and verbal expression, and show less
physical affection (Righette-Veltema et al., 2002). Maternal
depression is associated with poorer adoption of pre-
ventive measures (such as the use of baby’s car seat,
electrical plug covers, and smoke detectors) and decreased
utilization of preventive services for the infants (such as
age appropriate well-child visits and vaccination) (McLen-
nan and Kotelchuck, 2000; Minkovitz et al., 2005).
Additionally, infants of depressed mothers show impaired
maternal–child interactions, including visual and vocal
interactions (Righette-Veltema et al., 2002), poorer phy-
sical growth (Rahman et al., 2004), lower cognitive
development, more behavioural problems (Beck, 1998),
and a higher risk of psychiatric disorders during adolescent
years than those of non-depressed mothers (Pawlby et al.,
2008).
Explanatory models for the aetiology of PPD have been
proposed from biological and psychological perspectives
(Groer and Morgan, 2007). The biological viewpoint
addresses various physiological changes during preg-
nancy/postpartum periods and assumes that the disabling
depressive disorder results from (a) nutritional deficien-
cies and/or metabolic imbalance, (b) iron-deficiency
anaemia, (c) hormonal changes and fluctuations, (d)
abnormality in biopterin or neopterin levels, (e) alterations
in hypothalamic–pituitary–adenocortical mechanism, and
(f) alterations in neurotransmitter levels (such as seroto-
nin) (Groer and Morgan, 2007). The psychological models
relevant to the aetiology of PPD include cognitive,
behavioural, learned helplessness, and self-control models
(O’Hara, 1995). The cognitive model postulates that
depressed women have negative views of themselves,
the world, and their future (Beck, 1970). The behavioural
model hypothesises that diminished levels of response-
contingent positive reinforcements predispose the depres-
sive symptoms (Lewinsohn et al., 1979). The learned
helplessness model posits that past or present negative
events lead to expectations of future failure and help-
lessness and thus contribute to depressive symptomatol-
ogy (Abramson et al., 1978). Finally, the self-control model
proposes that depression results from disturbances in self-
control processes including self-monitoring, self-evalua-
tion, and self-reinforcement (Rehm, 1977).
Given that depressive women are less likely to seek
professional help, the most effective ways of dealing with
PPD are prevention interventions and early detection of the
depressive symptoms. Identifying risk factors of PPD
enables early recognition of high-risk populations and
provision of timely prevention interventions. Beck (2001)
conducted a meta analysis on 84 existing studies to
determine the magnitude of the relationships between
PPD and its risk factors. Thirteen significant risk factors
were identified; 10 of which had moderate effect sizes and
3 had small effect sizes. The former included factors such
as prenatal depression, low self-esteem, poor marital
relationship, history of previous depression, infant’s
difficult temperament, and maternity blues. The latter
encompassed low socioeconomic status, being a single
parent, and unplanned/unwanted pregnancy. Further-
more, Raid and Meadows-Oliver (2007) reviewed 12
research articles examining postpartum depression in
adolescent mothers and reported that family conflict,
fewer social support, and low self-esteem were significant
risk factors.
Asia, the world’s largest and most populous continent,
contains 29.4% of the earth’s land area with almost four
billion people (Wikipedia, 2008). This continent can be
categorised into six distinct regions; central (such as
Uzbekistan, Kazakhstan), eastern (such as China, Hong
Kong, Japan), northern (Russia), southern (such as India,
Nepal, Pakistan, Maldives), south-eastern (such as Thailand,
Singapore, East Timor, Vietnam), and western Asia (such as
Turkey, Israel, Unites Arab Emirates) (Wikipedia, 2008).
Asian countries encompass a wide variety of languages,
socio-economic environments, cultural backgrounds, reli-
gious practices, and perceptions of mental health that may
play important roles in the postpartum period (Wikipedia,
2008). Some cultures dictate traditional rituals and
supportive mechanisms that are believed to protect
women from the crippling symptoms of depression
(Halbreich and Karkun, 2006). A literature review of 143
research studies undertaken in 40 countries around the
world demonstrated that the prevalence of PPD (as mostly
measured by the Edinburgh Postpartum Depression Scale;
EPDS; Cox et al., 1987) in Asian countries ranged from
11.0% to 60.8% (Halbreich and Karkun, 2006).
 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
While Western women express their depressive symp-
toms overtly, new mothers in Asian cultures tend to
manifest their emotional problems through somatic
complaints (Kim and Buist, 2005). Chinese women express
exhaustion of their hearts and feelings of being squeezed
and weighed down (Bashiri and Spielvogel, 1999). Korean
women who experience Sanhupung (postpartum disorder)
exhibit such symptoms as polyarthragia (disabling muscle
soreness and fatigue), joint pain, chill, headache, numb-
ness, sleep disturbance, dizziness, and anxiety (Kim and
Buist, 2005). Furthermore, those who suffer from Hwa-
byung (anger disorder) manifest somatic symptoms
encompassing headache, blurred vision, palpitation, dis-
comfort in the chest, and stomach rumbles (Kim and Buist,
2005). Somatisation may be a socially exceptionable
avenue of expressing psychological problems in Asian
cultures where an ability to suppress negative emotions
reflects higher level of education, maturity, and decent
family background (Kim and Buist, 2005).
Some meta-analyses and literature reviews regarding
risk factors for PPD have been recently published to
summarise the current state of knowledge (Beck, 1998,
2001; Raid and Meadows-Oliver, 2007). Nonetheless, those
publications primarily included research conducted on
Western populations and overlooked many studies under-
taken in Asian countries. Hence, important issues pertinent
to socio-cultural contexts in Asia were not succinctly
elaborated. Given that Asian and Western countries
considerably differ in terms of philosophical traditions,
cultural practices, religions, belief systems, and attitudes
toward psychological problems, findings from the afore-
mentioned meta-analyses might not generalise to Asian
populations. This current literature review aims to
summarise and synthesise the current state of knowledge
of studies conducted in Asian countries taking socio-
cultural contexts into account. This will therefore enhance
an understanding of the PPD phenomena. The central
question here is what are the risk factors for PPD among
women in Asian cultures?
2. Methods
2.1. Search strategies
A literature search was conducted using the following
electronic databases: CINAHL, MEDLINE, Pubmed, Scien-
ceDirect, PsyINFO, Ovid, Scopus, and the Cochrane library.
Such terms as postnatal depression, postpartum depres-
sion, perinatal depression, puerperal depression, Asian
countries, factors, risk factors, predisposing factors, and
Asian women were entered separately and in combination
during the search. Additional articles were retrieved by
using reference lists of published journal articles.
2.2. Inclusion and exclusion criteria
Studies were included in this review if they (a)
examined and identified risk factors for PPD among Asian
women, (b) were conducted in Asian countries using
quantitative and qualitative methodologies, and (c) were
published in English peer-reviewed journals between 1998
1357
and 2008. Studies conducted outside Asian countries were
excluded. Although these studies recruited Asian mino-
rities as part of their samples, the findings might be
questionable as they were possibly influenced and
complicated by other cultural and environmental contexts.
The primary goals of this literature review are to
provide updated description, possible relationships
among study variables, scope of existing studies, and
comprehensive understanding of the phenomena of
interest in Asian cultures. Integration of findings from
both qualitative and quantitative perspectives, which
provides a much broader summary of the literature (Evan,
2007), has the potential to accomplish the goals. In
particular, quantitative studies illustrate possible links
between PPD and its pertinent variables whereas quali-
tative research elaborates descriptive experiences of
study participants in their socio-cultural contexts.
Furthermore, studies undertaken within a 10-year period
were included as they are more likely to reflect the current
state of knowledge concerning PPD.
It is common practice for systematic reviews and meta-
analytic studies to assess quality of all studies prior to
inclusion in the reviews (Evan, 2007). This process aims to
prevent inclusion of poor-quality research, which may
distort conclusion of research findings (Evan, 2007). In this
literature review, the authors examined each individual
research and provided an overall critique of the existing
studies in terms of knowledge gaps and methodological
limitations in Sections 3 and 4. All available studies were
included in this review regardless of their quality due to
two major reasons. First, given that limited research has
been conducted in each Asian country, omitting all poor-
quality studies might discard meaningful and insightful
information. Secondly, the inclusion of qualitative and
quantitative research in this review requires different sets
of criteria for each type of research. This may increase
complexity of the appraisal process (Evan, 2007) and
produce difficulties in determining and comparing quality
across studies.
3. Results
Our search strategy resulted in 173 abstracts relating to
PPD among Asian women. Subsequently, 109 studies were
excluded because they did not fulfil the inclusion criteria.
Forty-three studies did not examine predictors or risk
factors of PPD, 34 mainly validated psychometric proper-
ties of research instruments, 10 were published in the
researchers’ native languages (not in English), 9 were not
research-based articles (such as literature reviews and
systematic reviews), 8 were undertaken among Asian
women who migrated to countries outside Asia, and 5
were conducted to test the effectiveness of interventions
for PPD.
Sixty-four research articles conducted in 17 Asian
countries were identified and included in this literature
review (Table 1). These studies were undertaken in China
(3.1%; n = 2), Hong Kong (12.5%; n = 8), India (4.7%; n = 3),
Indonesia (3.1%; n = 2), Iran (1.6%; n = 1), Israel (7.8%;
n = 5), Japan (15.6%; n = 10), Lebanon (1.6%; n = 1),
Malaysia (6.3%; n = 4), Nepal (1.6%; n = 1), Pakistan
 1358
Table 1
Factors associated with postpartum depression in Asian cultures.

Author Design Sampling design Sample size Settings Measures Time Frame Prevalence Factors associated with PPD
of PPD (postnatally) of PPD (%)

China
Xie et al. (2007) Part of prospective Convenience 300 4 hospitals EDPS 6 weeks 17.3 Infant’s gender (girl)
cohort study (cut-off >13) Dissatisfaction with living
conditions parity (multiparae)

Wang et al. (2003) Cross-sectional, Convenience 512 Not mentioned BDI 6 weeks Taiwanese 44.3 Stress
comparative (cut-off > 10) Aborigines 59.6 Poor social support
Chinese 25.0 Low self-esteem, Low level

P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373

of education
Low level of education

Hong Kong
Chung and Yue (1999) Cross-sectional Convenience 36 Not mentioned EPDS Not mentioned NA Tangible support
correlational Affectionate support
Emotional information support
Positive social interaction
Number of confidants

Lee et al. (2000) Prospective, Convenience T1: 220 Hospital BDI T1: 2 days – Temporary housing
correlational T2: 145 T2: 6 weeks Previous-induced abortions
Past history of depression
Past psychiatric history
Depression during pregnancy
Neuroticism
Spouse disappointment with
baby’s gender

Leung et al. (2002) Prospective Convenience 838 Hospital EPDS T1: 2–3 days – Domestic violence
cohort T2: >3 days
T3: 6 weeks

Chan and Levy (2004) Cross-sectional, Purposive 35 Postpartum clinic EPDS 6 weeks NA Uncaring husband
descriptive and hospital (cut-off >10) Controlling and powerful
in-laws

Lee et al. (2004) Prospective Convenience 959 Hospital EPDS 6 months 12.7 Depression during the 3rd
Ethnoepidemiology (cuff-off >9) trimester
Poor relationship with
mother-in-law
Marital dissatisfaction
Past history of depression

Leung et al. (2005a,b) Phenomenological Purposive 11 Community EDPS 6 months NA Perceived stress in five themes:
(Home visit) (cut-off >13) Parenting competence
The expectation-experience gap
The baby-minder arrangements
Childcare demands
Conflict with culture and
tradition
 Leung et al. (2005a,b) Prospective Convenience T1: 385 5 hospitals EPDS 6 weeks 19.8 Antenatal depression
correlational (antenatal) (cut-off 13) Perceived stress
T2: 269 Childcare stress

Lee et al. (2007) Prospective Convenience T1: 335 Regional hospital EPDS 6 weeks 24.2 Antenatal depression
correlational T2: 335 (cut-off 13) Antenatal anxiety
T3: 335
(antenatal)
T4: 244

India
Chandran et al. (2002) Cross-sectional, Convenience 359 Antenatal clinics CIS-R 6–12 weeks 19.8 Antenatal depression
correlational Low income

P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373

Dissatisfaction with infant’s
gender.
Relationship difficulties with
mother-in-law and parents
Adverse life events in previous
years
Lack of physical help after
delivery

Rodrigeus et al. (2003) Qualitative Purposive 39 Hospital EPDS 6–8 weeks NA Physical problems
(>11) Domestic violence
in-depth The lack of support from
interview husband Relationship problems
Husband unemployment
Economic difficulties
Infant’s gender (girl)

Patel et al. (2002) Prospective, Convenience 252 Hospital EPDS T1: 6–8 weeks T1 = 23.0 Antenatal psychological
correlation (cut-off 12) problems
T2: 6 months T2 = 22.0 Economic deprivation
Being hungry in the past month
Poor marital relationships
Marital violence
Infant’s gender (girl)

Indonesia
Edwards et al. (2006) Prospective, Random sample 434 3 hospitals EPDS (>10) T1: 1 week 22.35% Low income
comparative T2: 2 weeks
T3: 4 weeks

Andajani-sutjahjo Qualitative Convenience T1: 488 (antenatal) Community EPDS T2: 6 weeks 14.96 Inadequate economic resources
et al. (2007) (Home visit) (cut-off 13) T3: 6 months Unwanted pregnancy
T2: 274 Infant’s health problems
T3: 41 Feeling of physical restraint

Iran
Iranfar et al. (2005) Cross-sectional, Convenience 163 Antenatal BDI 1–12 months – Unintended pregnancy
comparative care clinics

1359
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Table 1 (Continued )
Author Design Sampling design Sample size Settings Measures Time Frame Prevalence Factors associated with PPD
of PPD (postnatally) of PPD (%)

Israel
Glasser et al. (1998) Cross-sectional, Random sample 288 Community BDI 6 weeks 34.0% (BDI) Antenatal depression
comparative (prenatal care (cut-off 10)
centre) EPDS 22.6% (EPDS) Being an immigrant
(cut-off 10)

Glasser et al. (2000) Prospective, Random sample T1: 344 Prenatal clinic EPDS 6 weeks 22.6% Lack of social support
cohort (antenatal) (cut-off 10) Marital disharmony

P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373

T2: 288 Antenatal psychological
symptoms
History of emotional problems
Prolonged infant health’s
problems

Dankner et al. (2000). Prospective, Convenience T1: 400 Hospitals EPDS T1: 1–3 days – Religiosity (being a secular)
comparative T2: 327 (cut-off 9) T2: 6–10 weeks Psychiatric history
Mood symptoms during
immediate postpartum

Eilat-Tsanani et al. (2006) Prospective, Convenience T1: 723, T2: 527 Medical centre EPDS 2 months T2: Jewish 5.5% Being a homemaker
comparative (cut-off = 13)
FSD T2: Arab 24.7% Being an immigrant
Hard pregnancy course
Previous history of depression
(EPDS was used Unplanned pregnancy
during T2 only) Poor physical health

Bloch et al. (2005) Prospective, Convenience T1: 1800 Medical centre SCID 6–8 weeks – Premenstrual dysphoric disorder
comparative (antenatal) History of depression
T2: 242 Mood symptoms during the
first 2–4 days postpartum
Mood symptoms during
3rd trimester

Japan
Kitamura et al. (2006) Prospective Convenience 280 5 University Structured T1: 1 month 5.0% Poor accommodation
epidemiological hospitals interview T2: 3 months Negative attitude toward
(DSV-III) pregnancy
T3: 12 months Dissatisfaction with infant’s
gender
Antenatal depression

Yamachita et al. (2000) Prospective Convenience 88 University SADS EDPS T1: 3 weeks T1 = 15.0% Maternity blues
survey hospital (cut-off >8) T2: 3 months T2 = 17.0%

Yoshida et al. (2001) Cross-sectional, Convenience 186 Japan and England EPDS T1: 3 weeks 17.0% Traditional postpartum practice
comparative (cut-off >9) (Japanese sample)
SADS T2: 1 months
T3: 3 months
 Ueda et al. (2006) Cross-sectional, Convenience 70 Community EPDS 12 months 27.0% Paediatric illnesses
comparative (Home visit) (cut-off >9)
(a pilot study) SCID-IV

Sagami et al. (2004) Cross-sectional, Stratified 215 Community-based EPDS 0–12 months 17.7% Support from husband
correlational random setting (cut-off 9) Negative & passive attitude
sampling toward the mother role

Miyake et al. (2006a) Prospective Convenience 865 Community-based EPDS 2–9 months 14.0% Low level of dietary GI
cohort setting (cut-off >9)

Miyake et al. (2006b) Prospective, Convenience T1: 1002 Community-based EPDS 2–9 months – Low level of docosahexaenoic
cohort (antenatal) setting (cut-off 9) acid (DHA)
T2: 865

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Noriko et al. (2007) Cross-sectional, Convenience 206 Municipal health EPDS 4 months NA Negative evaluation of birth
descriptive centres experience
Infants requiring medical
interventions
Relocation
Past psychiatric illness

Sekizuka et al. (2006) Prospective, Expedient T1: 60 (antenatal) Obstetric facilities Postpartum 3–5 days NA Secretary immunoglobulin
correlational sampling T2: 60 Depression A (S-IGA)
Scale

Murakami et al. (2008) Prospective Convenience 865 Community-based EPDS 2–9 months 14.0% Low riboflavin consumption
cohort setting (cut-off >9)

Lebanon
Chaaya et al. (2002) Prospective, Convenience 396 Hospitals EPDS T1: 7 days 21.0% Poor social support
correlational Community (cut-off 12) T2: 4–5 months Antenatal depression
Chronic health problems
Stressful life events
Vaginal delivery
Low education
Unemployment

Malaysia
Mahmud et al. (2002) Two-stage Convenience 174 Health centre 30-item GHQ 6–8 weeks 9.8% Low income
population CIS Marital problems
survey The absence of breastfeeding

Grace et al. (2001) Cross-sectional, Convenience 154 Hospital EPDS 6 weeks 3.9 Traditional postpartum practice
correlational (cut-off >9)
Koo et al. (2003) Retrospective Convenience 255 University hospital EPDS 6 weeks 22.0 Emergency delivery
comparative (cut-off 13)

Kadir et al. (2005) Prospective, Random T1: 377 Maternal & child EPDS T2: 1 week T2: 22.8 Depressive symptoms during
correlational sampling T2: 377 health clinic (cut-off 12) T3: 4–6 weeks T3: 20.7 late pregnancy
T3: 377

1361
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Table 1 (Continued )
Author Design Sampling design Sample size Settings Measures Time Frame Prevalence Factors associated with PPD
of PPD (postnatally) of PPD (%)

Nepal
Ho-yen et al. (2007) Cross-sectional, Convenience 426 Hospital & EPDS 5–10 weeks 4.9 Husband’s alcoholism
correlational Community (cut-off 12) Polygamy
History of depression
Antenatal of depression
Being a Smoker
Number of children  4
Stressful life events

P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373

Body Mass Index (BMI)
< 20 kg/m2

Pakistan
Kalyani et al. (2001) Prospective Convenience T1: 120 Community EPDS T1: 2 weeks 63.3 Unwanted pregnancy
comparative T2: 76 (Home visit) (cut-off >10) T2: 2–4 weeks Parity (Premiparae)
Living with extended family
Marital difficulties
Early loss of mother

Husain et al. (2006) Prospective, Convenience T1: 175 Community-based EPDS T2: 3 months 36.0 Domestic violence
correlational (antenatal) settings (cut-off 12) Low social support from
significant others, friends,
and family
T2: 149 Antenatal psychological
problems

Rahman and Creed Prospective Convenience T1: 701 Community-based SCAN T2: 3 months T4: 56.0 Antenatal psychological
(2007) correlational (antenatal) settings symptoms
T3: 6 months Poverty
T2: 632 T4: 12 moths Number of children 5
T3: 160 Uneducated husband
T4: 129 Lack of confidants or friends

Singapore
Chen et al. (2004) Cross-sectional, Convenience 487 Hospital CES-D Not mentioned 21.0 Antenatal depression
correlational (cut-off >4) History of medical problems
Having a domestic maid

Chee et al. (2005) Prospective Convenience 278 Hospital EPDS 6 weeks 6.8 Past history of depression
cohort (cut-off = 7)
SCID-IV Negative confinement
experience
The lack of instrumental
support
Poor marital relationship

Chee et al. (2007) Prospective Convenience 471 Hospital EPDS 6–12 months NA Frequent non-routine visits
cohort (cut-off >12) to physician
SCID-IV
Taiwan
Huang and Mather Cross-sectional, Convenience 50 Hospitals in EDPS 0–3 months 19.0 (Taiwan) Poor relationship with partners
(2001) comparative Taiwan and UK (cut-off >12) Low self-confidence
Feeling of anxiousness
Stress regarding child care
Insufficient sleep

Heh et al. (2004) Cross-sectional, Convenience 280 Hospital ESDS Not mentioned 21.0 The lack of family support
survey (cut-off 10) Dissatisfaction with parents’
support
Dissatisfaction with in-law’s
support

Chien et al. (2006) Cross-sectional, Convenience 202 2 Hospitals CES-D 4–6 weeks 30.2 Traditional practice

P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373

correlational Postpartum (cut-off  = 15) Location of traditional practice
care centres Low education
Parity (premiparae)
Breastfeeding

Wang and Chen (2006) Cross-sectional, Convenience 83 Private medical BDI 6 weeks 36.6 Perceived stress
correlational centre (cut-off 10) Poor social support

Thailand
Limlomwongse and Prospective, Convenience T1: 610 University ESDS 6–8 weeks 16.8 Religion (non-Buddhist)
Liabsuetrakul (2006) cohort study (antenatal) hospital (cut-off >10) Premenstrual symptoms
T2: 525 Perception of pregnancy
complication
Negative attitude toward
pregnancy

Liabsuetrakul et al. Prospective, Convenience T1: 400 University PDRS 6–8 weeks NA Anxiety
(2007) cohort study (antenatal) hospital (cut-off 33)
T2: 400 Poor social support

Turkey
Danaci et al. (2002) Cross-sectional, Random 257 Primary care EPDS 0–6 months 14.0 Number of living children
correlational sampling centres (cut-off 12) Living in a shanty
Being an immigrant
Baby’s serious health problem
Mother’s previous psychiatric
disorder
Spouse’s psychiatric disorders
Relationship problems with
in-laws

Inandi et al. (2002) Cross-sectional Cluster 2514 Five Eastern ESDS 1–12 months 27.2 Unemployment
correlational sampling provinces (cut-off 13) Low education
Poverty
Poor family relationships
Lack of medical services
Mental health problems

Alkar and Gençöz Cross-sectional, Convenience 151 Hospital EPDS Initial days of 50.7 Negative Affect
(2005) correlational (cut-off = 13) postpartum Marital maladjustment

1363
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Table 1 (Continued )
Author Design Sampling design Sample size Settings Measures Time Frame Prevalence Factors associated with PPD
of PPD (postnatally) of PPD (%)

Aydin et al. (2005) Cross-sectional, Simple 728 7 primary care EPDS 1–12 months 40.1 Past psychiatric history
correlational Random units (Cut-off = 13) Psychiatric disorders during
sampling pregnancy
Lack of husband support
Unemployed husband
Temperamentally difficult child
Infant’s illness
Premenstrual symptoms

P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373

Ekuklu et al. (2004) Cross-sectional, Convenience 178 Community-Home ESDS 6 weeks 40.4% Unemployed husband
correlational visit (cut-off 12) Low education
Living in a rented home
History of psychological
problems
Baby’s gender (girl)
Unwanted pregnancy
Problems during previous
pregnancy

Gulseren et al. (2006) Prospective Convenience 125 Primary health ESDS T1: 5–8 weeks T1: 16.8 Antenatal depression
cohort study center (cut-off 10)
Home visit T2: 10–14 weeks T2: 14.4 Low income
T3: 20–26 weeks T3: 9.6 Adverse life events
Poor relationships with
husband

Ayvaz et al. (2006) Prospective Convenience T1: 192 Hospitals Clinic ESDS T2: 6–8 weeks T2: 29.6 Antenatal psychological
correlational (antenatal) (cut-off 12) problems
T2: 152 T3: 6 months T3: 11.4 History of depression in the
T3: 132 previous pregnancy

Sabuncuoğlu and Cross-sectional, Convenience 80 Health care ESDS 2–18 months 30.0 Insecure attachment style
Berkem (2006) correlational centres (cut-off 11) Avoidant attachment style
Anxious/ambivalent
attachment style

Sayil et al. (2006) Prospective Convenience T1: 200 2 Hospitals BDI 6–8 months – Antenatal anxiety
correlational (antenatal) 3 Clinics Negative attitude toward
employment
T2: 182 Dissatisfaction with paternal
support

Kuscu et al. (2007) Cross-sectional, Convenience 100 University ESDS 7–10 days – Ambivalent attachment style
correlational hospital (cut-off 12) State anxiety
Family support
Presence of social network
(friends and neighbours)
 Dinder and Erdogan Cross-sectional, Random 679 Public health ESDS 1–12 months 25.6 History of psychiatric illness
(2007) correlational sampling centres (cut-off 12) Smoking
Low socioeconomic status
Relationships problems with
husband and mother-in-law
Dissatisfaction with social
relationships
Previous loss of baby
Infant’s gender (girl)

Ege et al. (2008) Cross-sectional, Convenience 364 Community EPDS 6–48 weeks 33.2 Social support
correlational (Home visit) (cut-off >13) Vaginal delivery
Low education

P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373

Uneducated spouse
Unplanned pregnancy
Lack of knowledge regarding
child care
Lack of confidants
Previous psychiatric history

Kara et al. (2008) Cross-sectional, Convenience 326 Well-baby clinic BDI 1–3 months 17 Premenstrual syndrome
comparative (cut-off 17) History of depression

United Arab Emires

Green et al. (2006) Prospective, Convenience T1: 125 Hospitals EPDS T1: Few days T2 = 22.1 The absence of breast feeding
Correlational T2: 86 Community (cut-off13) T2: 3 months T3 = 12.5 Premiparae
T3: 56 T3: 6 months Poor self-image
Marriage at older age
Poor relationships with
mother-in-law

Vietnam
Fisher et al. (2004) Cross-sectional, Convenience 506 Hospital and EPDS 6 weeks 33 Unwanted pregnancy
survey Health centre (cut-off >12) Lack of a permanent job
Less than 30 days of complete
rest after childbirth
Unsettled baby
Being given special foods
Avoiding proscribed foods
Unable to confide with
husband

CES-D = Centre of Epidemiologic Study-Depression, EPDS = Edinburgh Postpartum Depression Scale, SCID-IV = Structure Clinical Interview for DSM-IV, SCAN = The Schedule for Clinical Assessment in
Neuropsychiatry, CIS = Clinical Interview Schedule, CIS-R = The revised Clinical Interview Schedule, GHQ = General Health Questionnaire, SRQ = The Self-reported Questionnaire, PSE = The Present State
Examination, SADS = The Schedule for Affective Disorders and Schizophrenia (SADS), BDI = Beck Depression Inventory, FSD = Froom Survey questions for depression, PDRS = Postpartum Depression Risk Scale.

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1366 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
(4.7%; n = 3), Singapore (4.7%; n = 3), Taiwan (6.3%; n = 4),
Thailand (3.1%; n = 2), Turkey (20.3%; n = 13), United Arab
Emires (1.6%; n = 1), and Vietnam (1.6%; n = 1). Sixty-one
studies (95.3%) utilised a quantitative approach while 3
studies (4.7%) used a qualitative method. The majority of
studies collected data cross-sectionally (n = 34; 53.1%) and
used a convenience or purposive sampling (n = 55; 85.9%)
with sample sizes ranging from 11 to 2514. Most
participants were recruited from hospitals/medical cen-
tres/antenatal clinics (n = 35; 54.7%), followed by commu-
nity-based settings such as primary care centres and
participants’ homes (n = 21; 32.8%), combined settings
(such as hospital and community) (n = 6; 9.4%). Two
studies did not mention the recruitment setting (n = 2;
3.1%).
3.1. Measurement of postpartum depression
Several measurements were used to determine PPD in
Asian women (Table 1). The self-reported EPDS (Cox et al.,
1987) was most frequently used (68.8%; n = 44) followed
by the Beck Depression Inventory (BDI; Beck et al., 1961)
(7.8%; n = 5), the revised version of Clinical Interview
Schedule (CIS-R; Lewis et al., 1992) (1.6%; n = 1), the
Schedule for Clinical Assessment in Neuropsychiatry
(SCAN; WHO, 1994) (1.6%; n = 1), the Structured Clinical
Interview for DSM-IV (SCID-IV; First et al., 1994) (1.6%;
n = 1), the Structured Clinical Interview based on DSM-III
(Kitamura et al., 2006) (1.6%; n = 1), the Centre of
Epidemiologic Study-Depression (CES-D; Radloff, 1977)
(1.6%; n = 1), the Postpartum Depression Risk Schedule
(PDRS; Liabsuetrakul et al., 2007) (1.6%; n = 1), and the
Postpartum Depression Scale (Ikemoto et al., 1986) (1.6%;
n = 1). Furthermore, eight studies (12.8%) utilised a
combination of PPD instruments.
Methodological limitations in the existing literature
need to be addressed. In particular, all questionnaires were
originally developed in English and psychometric proper-
ties (such as validity, reliability, sensitivity, and specificity)
were tested with Western samples. They were later
translated into the native languages of the relevant Asian
countries. However, the majority of the studies did not
provide sufficient evidence of psychometric properties of
the translated versions on their samples, leading to
questionable research findings. Moreover, time frames
for measuring PPD varied considerably ranging from 3
weeks to 12 months. Only 23 studies (35.9%) used the time
frame specified by the DSM-IV (4 weeks) or the ICD-10 (6
weeks) diagnostic criteria.
The EPDS (Cox et al., 1987) is a uni-dimensional self-
reported checklist designed for use as a screening tool (i.e.,
not a diagnostic tool) for identifying mothers at risk for
PPD in community settings. Respondents are asked to rate
their symptoms in the past 7 days on one of four response
categories ranging from ‘‘0’’ = ‘‘not at all’’ to ‘‘3’’ = ‘‘most of
the time/quite often.’’ The possible scores, after reversing
all positive-worded items, range from 0 to 30 with a higher
score reflecting a higher risk for PPD. Cox et al. (1987)
validated the EPDS on 84 mothers living in England and
suggested that women who scored above 13 are more
likely to suffer from a depressive illness and thus need
further assessment in order to confirm the diagnosis (Cox
et al., 1987). Additional methodological limitations
emerged when the majority of existing research utilised
the EPDS without confirming the diagnosis with the DSM
or ICD systems. Furthermore, different cut-off scores
ranging from 7 to 13 were used to determine the
prevalence of PPD (Table 1), leading to difficulties in
comparing research findings across studies.
3.2. Prevalence of postpartum depression in Asian cultures
The prevalence of PPD in Asian countries displayed a
wide range from 3.5% to 63.3%, where Malaysia and
Pakistan had the lowest and highest prevalence, respec-
tively (Table 1). PPD among Emirari women (n = 125)
was categorised into three groups based on EPDS scores:
no depression (EPDS < 9), borderline depression
(10  EPDS  12), and depression (EPDS  13) (Green
et al., 2006). Depressed mothers in Indonesia (Andajani-
sutjahjo et al. (2007)) described their depressive symp-
toms during 6 weeks postpartum in a Javanese language as
nelongso (self-pity), kepekiran (worrisome), tertekan
(emotionally repressed), gelo (regretful), sumpek (over-
whelmed feeling of being in trouble), and krisis mental
(mental crisis). In Hong Kong, respondents of a descriptive
study (n = 35) reported a unique phenomenon called
‘‘phantom crying’’, where the new mothers heard their
baby crying and found that the baby was actually sleeping
when they went to check (Chan and Levy, 2004). During
the study, these mothers were not adequately assessed
and/or referred to a psychiatrist and therefore a possibility
of dreaming or auditory hallucinations (i.e., an indication
of postpartum psychosis) were not ruled out. Indian
women in a qualitative study (n = 39) indicated that
postpartum depression negatively affected their relation-
ships with family members and performance of household
tasks (Rodrigeus et al., 2003).
3.3. Risk factors for postpartum depression in Asian cultures
Postpartum depression among Asian women was
associated with numerous factors which can be cate-
gorised into five majors groups; physical/biological,
psychological, obstetric/paediatric, socio-demographic,
and cultural factors (Fig. 1).
3.3.1. Physical/biological factors
Twelve studies documented an association between
physical/biological factors and PPD (Fig. 1). Depressive
mothers reported a history of medical conditions and
premenstrual symptoms (Aydin et al., 2005; Chen et al.,
2004), poor physical health (Eilat-Tsanani et al., 2006), and
difficulties in carrying out daily activities (Rahman and
Creed, 2007). There is an increased risk of developing PPD
among Nepalese women with a body mass index (BMI)
below a normal range (<20 kg/m2) (Ho-yen et al., 2007).
Low BMI probably reflects women’s poor nutritional
status, which in turn serves as a proxy measure for low
socioeconomic status (Ho-yen et al., 2007).
A prospective survey of 527 Israeli women indicated
that depressed mothers tended to be highly sensitive to
 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
Fig. 1. Number of studies examining risk factors for PPD in Asian cultures.
Note: (a) 1 = Physical/biological, 2 = psychological, 3 = obstetric/
paediatric, 4 = socio-demographic, and 5 = cultural factors. (b) Total
number of studies = 64; some studies investigated multiple categories of
risk factors.
their emerging physical symptoms after delivery (Eilat-
Tsanani et al., 2006). They made non-routine visits to
family physicians and gynaecologists seeking treatment
1.5–4 times more frequently than their non-depressed
counterparts (Eilat-Tsanani et al., 2006). Conversely,
Indian women perceived the physical problems as minor
natural consequences of childbirth or as a result of
performing household chores. Hence, they hesitated to
consult physicians and usually seek traditional remedies
such as oil massage for pain management and cassia (a
mixture of ginger and holy Indian basil) for cold symptoms
(Rodrigeus et al., 2003).
Additionally, a prospective cohort study in Japan
(n = 865) suggested that consuming food with a higher
level of riboflavin (vitamin B2), higher level of docasahex-
aenoic acid (DHA) and high dietary glycemic index
(carbohydrates that break down rapidly and raise blood
sugar quickly) during pregnancy were associated with a
decreased risk of PPD (Miyake et al., 2006a,b; Murakami
et al., 2008). DHA, highly concentrated in brain cell
membranes and synaptic terminals, plays an important
role in neurochemical transmission which has a positive
impact on women’s emotion (Miyake et al., 2006b). Food
with high glycemic index is believed to escalate insulin
secretion and thus facilitate tryptophan transport, a
precursor of serotonin, in the brain. As the level of
serotonin elevates, depressive symptoms are believed to
subsequently abate (Miyake et al., 2006a).
3.3.2. Psychological factors
The effects of psychological factors on PPD were
investigated in 43 studies. Depressive symptoms during
pregnancy, antenatal anxiety, past psychiatric history,
premenstrual dysphoric disorder, stressful life events,
child care stress, negative affect, low self-esteem, poor self-
image, insecure attachment style, and negative attitude
toward employment were strong risk factors (Table 1). In
Japan, women who exhibited maternity blues in the first 5
days after delivery were 33 times more likely to suffer from
PPD at 3 weeks and 20 times more likely to be depressed at
1367
the third month postnatally (Yamachita et al., 2000). In a
Hong Kong phenomenological study, depressed women
(n = 11) identified stressful situations that might contri-
bute to their PPD including (a) feelings of incompetence
regarding child care, (b) difficulties in identifying a
trustworthy baby-minder with reasonable service charges,
(c) conflicts between the reality of experiences and
expectation, and (d) conflicts with Chinese traditional
rituals (Leung et al., 2005a,b).
3.3.3. Obstetric/paediatric factors
Twenty-two studies examined the role of obstetric/
paediatric factors. Problems during pregnancy, previous
abortion, previous loss of a baby, unplanned pregnancy,
unintended pregnancy, negative attitude toward preg-
nancy, negative attitude toward mother roles, the lack of
childcare knowledge, and the absence of breastfeeding
were major risk factors (Table 1). In United Arab Emirate
(UAE), people’s ways of living are primarily influenced and
shaped by Islamic values (Green et al., 2006). According to
the Koran (the holy book of Islam), it is essential that
Muslim women breastfeed their infants for at least 2 years
(Green et al., 2006). Women who are unable to follow such
religious expectation may experience internal guilt, which
may contribute to tremendous stress and thus increase a
possibility of depressive symptoms (Green et al., 2006).
Emergency delivery was defined as an unplanned
delivery performed after the onset of labour carried out
for maternal reasons (such as cephalopelvic disproportion)
or foetal factors (such as foetal distress) (Koo et al., 2003).
Malaysian women who reported having had an emergency
delivery (including caesarean section, vacuum delivery,
and forceps intervention) had about two times increased
risk of PPD than those who had non-emergency delivery
(Koo et al., 2003). Elective caesarean section (ECS)
appeared to be a protective factor against PPD among
Lebanese women (n = 396) (Chaaya et al., 2002). The
stronger protective effect of ECS was found among women
dwelling in Beirut, a capital city of Lebanon, than those
who lived in other cities. One of the possible explanations
is that women in Beirut, who were more modernised and
had higher socioeconomic status, perceived vaginal
delivery as a source of fear, stress, and traumatic
experience whereas women residing in a more traditional
culture outside Beirut valued natural childbirth (Chaaya
et al., 2002).
Women, whose infant had serious or long-term medical
problems, had unsettled crying, and was temperamentally
difficult, were likely to experience PPD (Ueda et al., 2006;
Fisher et al., 2004). Once depressed, the mothers may react
to their infant’s illness in different ways. The depressed
mother may overlook the baby’s illness and may not seek
professional help until the problem become elevated.
Conversely, they may be overly nervous in response to the
baby’s minor health problems and seek medical attention
more frequently (Chee et al., 2007). A prospective cohort
study in Singapore (n = 471) supports the latter specula-
tion by documenting the significant association between
maternal depression and frequent non-routine visits with
physicians concerning the baby’s medical problems (Chee
et al., 2007).
1368 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
There is contradictory evidence concerning the link
between parity and PPD. In Nepal where many families
were socially and financially disadvantaged, having an
additional child may result in financial burden and
therefore enhance family stress (Ho-yen et al., 2007). A
cross-sectional, correlational study indicated an increased
risk of PPD among Nepalese women (n = 426) who had
more than four children (Ho-yen et al., 2007). Conversely,
in UAE where women’s status in extended families is
elevated after each childbirth, premiparous women were
more likely to develop PPD at 3 and 6 months postpartum
than multiparous mothers (Green et al., 2006). Multiparity
did not link to substantially increased workload and stress
levels in UAE. This is because the majority of women
employed maids to help with household chores and also
received additional support from extended family mem-
bers (Green et al., 2006).
3.3.4. Socio-demographic factors
Forty-two studies investigated the links between socio-
demographic factors and PPD. Economic difficulties, being
hungry in the past month, being a homemaker, being an
immigrant, having unemployed or uneducated husband,
having a husband with a history of psychiatric disorder,
polygamy, domestic violence, dissatisfaction with living
conditions, a lack of emotional support (e.g., confidant and
friends), and dissatisfaction with support from husband,
parents, and parent-in-law were reported as potential risk
factors (Table 1). Having a domestic helper was signifi-
cantly associated with PPD among Singaporean women
(Chen et al., 2004). Possible explanations for this unex-
pected finding could be (a) women perceived additional
stress in managing a helper who is a stranger to their
families and/or (b) they employed a helper because they
experienced depressive symptoms (Chen et al., 2004).
Women in Hong Kong, Turkey, and India who had
relationship problems with their husband and mother-in-
law tended to suffer from PPD (Table 1). In UAE, women
traditionally reside in their husbands’ family after mar-
riage and the husbands usually have a strong connection
with their family of origins (Green et al., 2006). Mother-in-
laws often have power over their sons’ and daughters-in-
laws’ life (Green et al., 2006). Having a poor relationship
with the mother-in-laws may contribute to marital conflict
and thus enhance the risk for PPD (Green et al., 2006). A
descriptive study in Hong Kong (Chan and Levy, 2004)
suggested that some depressed women experienced
maltreatment by their uncaring husband and controlling
mother-in-laws. These women felt so severely trapped in
their situations that they had thought of violent alter-
natives such as suicide, infanticide, and homicide (Chan
and Levy, 2004).
3.3.5. Cultural factors
While postpartum practices in modern Western cul-
tures are considered individualistic, new mothers in Asian
cultures rely on practical and emotional support from
family members such as the mother, mother-in-law,
relatives, and husband. Given that women are physiolo-
gically vulnerable after childbirth, a certain convalescence
period, prescribed diets, and specific activities are encour-
aged in most Asian cultures to facilitate recovery and
restore physical equilibrium. Such cultural practices are
regarded as protective factors against postpartum depres-
sion (Halbreich and Karkun, 2006).
A traditional postpartum ritual called ‘‘Satogaeribun-
ben’’ is considered typical in Japan (Bhugra and Bahl, 1999).
Women of 32–35 weeks gestation return to their family
homes to deliver and stay there until approximately 2
months postpartum. They will receive support regarding
domestic housework and child care from their family of
origin, especially their mothers, and thus have physical
rest (Bhugra and Bahl, 1999). Furthermore, knowledge and
skills regarding childcare are also passed on to the new
mothers.
Traditional Chinese medicine posits that two opposing
forces ‘‘Yin’’ (hot air or positive energy) and ‘‘Yang’’ (cold
air or negative energy) regulate the entire universe and
exist within the human body. After childbirth, the
harmony and balance of such two forces are believed to
be impaired, leading to a physiologically vulnerable state.
Therefore, women in China, Taiwan, Hong Kong, Singapore,
and Vietnam are encouraged to participate in a postpartum
convalescence period commonly known as ‘‘doing the
month’’ for 30 days after childbirth. Women will rest
preferably in bed and receive support from their own
mother or mother-in-law regarding child care, cooking,
and other domestic work (Holroyd et al., 1997). Certain
activities (such as taking a bath, washing one’s hair, going
out of the house, and being blown by the wind) are to be
avoided in order to prevent the women from possible
medical problems. Prescribed diets are provided to restore
the Yin and Yang equilibrium. Additionally, Vietnamese
women are prohibited from expressing negative emotions,
complaining, crying, or showing facial wrinkling, which are
considered weaknesses of the mind (Degotardi, 1995). The
status of Vietnamese woman may be raised after the
childbirth, particularly when she delivers a male offspring.
A special cerebration called ‘‘Day Thang’’ is held by the
family when a baby becomes 1-month-old. Many relatives
join the event and bring gifts for the baby and food for the
new mother.
In Arab cultures, family connotes a centre of honour,
loyalty, and reputation with a large extended family is
greatly appreciated. Women are traditionally subordinate
to male relatives; however, they receive the recognition of
honour and substantial social support during a 40-day
postpartum period (Stuchbery et al., 1998). In Turkey,
women and their baby are not left alone during the 40-day
postpartum period and must be accompanied by their
mother, mother-in-law, or female relatives at all times.
This cultural practice is believed to protect the new
mothers and their babies from the ‘‘Jinni’’ (evil spirit).
Many people visit and congratulate the child birth. On the
twenty-first day, the new mothers together with their
family are permitted to leave their home for a day to visit
close relatives.
Thai women receive care and support provided by
family members and may participate a traditional practice
of ‘‘Yu Fai’’ for 30 days postnatally. The new mother wear
warm clothes, cover with warm blanket, and lie down on a
wooden bed over a fire source (Dennis et al., 2008). This
 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
ritual helps eliminate retained blood and placenta, aid
involution of uterus, facilitate recovery, and prevent
potential physical illnesses. Some Thai women in rural
area avoid household duties, heavy physical activities,
travelling long distances, and consuming certain food (e.g.,
durian, beef, internal organs, and spicy food) during the
postpartum period (Thrakul et al., 2007).
Women in Rajasthan and other rural regions of India are
ornamented with henna (artistic body and feet paintings)
and receive 40-day homecare after delivery (Jones, 2002).
To preserve the beauty of the henna pastes, the new
mothers are discouraged from performing any hard work
such as household chores. Friends and relatives take care of
older children and complete all household chores, allowing
sufficient time for the woman to recuperate and establish
meaningful bonding with the baby (Jones, 2002). In
Malaysia, a newborn baby is envisioned as a carrier of
light and therefore a bright light is burned day and night
during the 40-day confinement period called ‘‘Pantang’’
(Kanagaratnarn, 1995). Women consume a prescribed
warm diet, wear warm clothes, bind warmed rocks around
their abdomen, or stay in a heating room in order to restore
their body’s balance (Grace et al., 2001) and to protect
themselves from being harmed by evil spirits (Mahmud
et al., 2002). Malaysian women receive daily care from a
traditional midwife including full-body massages, ther-
apeutic baths, and milk-producing ‘‘jamu’’ (a blended drink
of herbs and egg yolk) (Kanagaratnarn, 1995).
Although postpartum rituals in Asian cultures are
envisioned as supportive mechanisms for new mothers
and the baby, a paucity of research has been conducted to
test such postulations. Furthermore, there is mixed
evidence concerning the impact of postpartum rituals on
PPD. A cross-sectional study in Taiwan (n = 202) suggested
that women who adhered to doing-the-month practice
were less likely to exhibit physical symptoms and suffer
from PPD at 4–6 weeks postpartum (Chien et al., 2006).
Nevertheless, a comparative study of 186 Japanese women
who live in Japan and England did not support that the
Japanese postpartum ritual ‘‘Satogaeribunben’’ protected
the respondents from PPD (Yoshida et al., 2001). Similarly,
Vietnam women in a cross-sectional survey (n = 506)
reported depressive symptoms despite their adherence to
traditional practices (Fisher et al., 2004). Additionally, a
cross-sectional correlational study of 154 Malaysia women
suggested that respondents who practised postnatal
Pantang actually had significantly higher scores on the
Beck Depression scale than those who did not (Grace et al.,
2001).
In Singapore, a prospective cohort study (n = 278)
revealed that approximately one-third of the participants
faced negative experiences during the confinement period,
which turned out to be a significant contributing factor for
their depressive episode (Chee et al., 2005). A phenom-
enological study in Hong Kong reported that the majority
of respondents preferred a Western style to the Chinese
traditional rituals, which they believed to be out-dated and
not feasible (Leung et al., 2005a,b). Some women felt bored
and trapped inside a small place guarded from leaving the
house by others (such as mother-in-laws). They had
difficulties following proscriptions of the ritual and had
1369
conflicts with their own mothers and/or mother-in-laws
regarding childcare (Leung et al., 2005a,b).
The association between infants’ gender and postpar-
tum depression was investigated in seven studies
(Table 1). Delivery of a baby girl posed a substantial threat
to women’s mental health and thus increased a greater risk
for PPD among Indian, Turkish, Chinese, and Japanese
women (Chandran et al., 2002; Patel et al., 2002; Rodrigeus
et al., 2003; Xie et al., 2007). New mothers were blamed for
having a girl and experienced antipathy, criticism, and
hostility from their husbands and mother-in-laws (Lee
et al., 2000; Leung et al., 2005a,b).
Culturally, the gender preference in favour of boys has
been deeply ingrained in some societies such as Arab
countries, Turkey, India, China, Japan, Taiwan, Korea, Hong
Kong, and Vietnam. Indian culture believes that male
children contribute economically to the family, provide
old-age support for the parents, and earn a daughter-in-
law upon their marriage, together with economic reward
by dowry payment (Rodrigeus et al., 2003). Conversely,
female children are considered a financial drain to the
family as they will pose monetary penalty through dowry
charges. Similar cultural beliefs are also noted in China
where the preference for a first offspring is a boy. While
female children belong to the grooms’ family after
marriage and cannot contribute financially to the family
of origin, male children take over the family business,
provide economic security, support elderly parents, and
carry on the family’s bloodline (Xie et al., 2007).
4. Discussion
The primary goals of this literature review are to
provide updated description, possible relationships among
study variables, scope of existing studies, and compre-
hensive understanding of PPD in Asian cultures. Sixty-four
studies conducted in 17 Asian countries were reviewed
and summarised. The wide variation of PPD (3.5–63.3%)
may reflect the actual prevalence across countries or
perhaps result from methodological limitations across
studies. These limitations encompass the use of (a)
different screening tools/diagnostic tools (such as a self-
reported questionnaire or standardised clinical interview);
(b) different cut-off points on EPDS scores to determine
PPD cases; (c) varying time periods postnatally for
collecting data regarding depressive symptoms; (d) small
sample sizes and convenience sampling which may
impede generalisability and representativeness of the
research findings; and (e) using translated versions of
measurements (i.e., from English to native languages)
without adequately demonstrating their psychometric
properties. Hence, there was insufficient supporting
evidence to substantiate that the measurements really
capture the concept of depression in Asian cultures.
Additionally, Halbreich and Karkun (2006) asserted that
the standardised Western screening tool may not be
culturally sensitive to signs and symptoms of depressive
illness expressed in Asian countries. As previously noted,
some Asian respondents (e.g., Chinese women) tended to
exhibit depression through more somatic symptoms such
as head numbness, wind inside the head, or wind illness
1370 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
(Lee et al., 2000) whereas Western women tended to
express emotional symptoms.
According to this review, factors associated with PPD in
Asian women were clustered into five major groups:
psychological, obstetric/paediatric, socio-demographic,
physical/biological, and cultural factors. The first three
clusters were consistent with results from other meta-
analytic studies-based primarily on Western populations.
Specifically, significant predictors of PPD in those studies
included prenatal depression, history of depression,
psychiatric disturbances during pregnancy, maternity
blues, childcare stress, stressful live events, low self-
esteem, low social support, low marital satisfaction,
unplanned/unwanted pregnancy, difficult infant tempera-
ment, and low socioeconomic status (Beck, 1998, 2001;
O’Hara and Swain, 1996; Raid and Meadows-Oliver, 2007).
Knowledge gaps in the existing literature can be
identified. Particularly, studies exploring the effects of
cultural and physical/biological factors on PPD are quite
limited. Most research conducted in Asian cultures
primarily emphasised psychological and socio-demo-
graphic variables. The etiological roles of nutrition
deficiencies/metabolic imbalance, hormonal changes, neu-
rotransmitter levels, hypothalamic–pituitary–adenocorti-
cal mechanism, and iron-deficiency anaemia have not been
fully explored. Moreover, the question of how traditional
rituals and other cultural practices interplay or interact
with postpartum situations in Asian countries remains
unanswered. Unless the relationships among variables
surrounding PPD are well-understood, the development of
effective culturally sensitive interventions may not be
easily achieved.
Cultural variables may play a unique role in the
occurrence of PPD among Asian women. Asian cultures
adopt a variety of postpartum rituals including the
prescribed confinement periods ranging from 30 to 40
days, restricted activities and diets, and practical/emo-
tional support from family members—mother, mother-in-
law, traditional birth attendant, or female relatives. Such
cultural practices may be perceived as a double-edged
sword which offers physical comfort on the one hand but
serves as major sources of interpersonal conflicts and
emotional frustration on the other. Existing studies
suggested that postpartum rituals in Japan, Vietnam,
Malaysia, Hong Kong, and Singapore did not provide
significant psychological benefits for the new mothers.
At least four possible explanations can be proposed for
such unexpected findings. First, the women may not have
practiced the rituals by choice but have had to comply with
their caregivers’ (e.g., mother-in-laws) suggestions in
order to avoid unnecessary interpersonal conflicts. Second,
the pre-existing relationships between the new mothers
and their caregivers may not be satisfactory, leading to
difficulties in forming the caring relationship during the
confinement period. Third, some aspects of postpartum
rituals, especially restricted activities, may generate stress,
tension, and frustration. Finally, other challenges sur-
rounding the postpartum situation may interact with the
traditional practice and affect women’s mental health.
Such challenges may include cultural issues (such as
gender preference in favour of a boy baby); infants’ health
conditions and temperament; new mothers’ physical/
psychological symptoms; and family’s socioeconomic
status (such as poverty and poor living conditions). In
many cases, women who have been exposed to higher level
of education and other cultures may rebel against their
own traditional practices.
Issues concerning internal validity (i.e., ability to draw
accurate interrelationships among concepts of interest) of
the existing studies should be treated with caution. Most
nursing phenomena operate in complicated nomological
frameworks which include multiple constructs. The fact
that the existing studies examined a bivariate relationship
between study variables without examining or controlling
extraneous variables may not represent realistic situa-
tions. Furthermore, the use of cross-sectional, non-
experimental research in most studies may limit an ability
to draw conclusions regarding causal relationships among
study concepts. This issue awaits future longitudinal
investigations.
4.1. Limitations
Limitations concerning this literature review need to be
addressed. First of all, all studies examined in this review
were published in English, peer-reviewed journals. Pub-
lications in Asian languages, which may contain useful and
insightful information, were excluded, leading to limited
generalisability of the findings. Secondly, only reports from
17 Asian countries are available in the existing literature.
Factors related to PPD in other countries and other cultural
subgroups remain unknown. Thirdly, integrating findings
from both qualitative and quantitative methodologies,
which differ in their philosophical stances, may compro-
mise an ability to draw accurate conclusions across
studies. Finally, given that all available research under-
taken in Asian cultures was included regardless of their
quality, internal validity of the research findings may be
questionable.
5. Implications for clinical practice
It is well-established that postpartum depression is
prevalent in some Asian countries and is probably as
prevalent as in Western countries despite the existence of
traditional postpartum rituals and strong social supportive
mechanisms. It is of great importance that health care
professionals become aware of this phenomenon and
provide effective interventions in a timely fashion. As there
may be a lack of mental health staff in some countries,
provision of training for midwives and community nurses
to screen and deal with PPD is pivotal to PPD care.
Strategies such as primary, secondary, and tertiary
prevention interventions (Neuman, 1995) may be applied.
Primary prevention interventions include indentifying risk
factors associated with PPD in the target populations and
delivering appropriate preventive measures. As an exam-
ple, family planning and counselling services may decrease
unwanted/unplanned pregnancy (Ekuklu et al., 2004).
Secondary prevention interventions encompass early
detection and treatments of the disabling depressive
symptoms. Routine screening for PPD by using a self-
 P. Klainin, D.G. Arthur / International Journal of Nursing Studies 46 (2009) 1355–1373
reported questionnaire during pregnancy and postpartum
periods are strongly encouraged. It is important to note
that WHO principles of early disease detection (Wilson and
Jungner, 1968) should be taken into consideration during
the PPD screening process. Women whose scores exceed a
cut-off point should be immediately referred to mental
health staff to confirm the diagnosis. Appropriate treat-
ments (e.g., psychoeducation, culturally sensitive counsel-
ling, and antidepressants) should be subsequently
provided. Finally, tertiary prevention interventions entail
preventing relapses of depressive symptoms. Routine
follow-up and home health visits during the pregnancy
and postpartum periods are strongly recommended.
6. Recommendation for future research
To overcome the aforementioned knowledge gaps and
methodological shortcomings in the existing literature,
PPD studies in Asian countries should further explore the
role of physical/biological and cultural factors. Constructs
related to PPD should be observed within nomological
frameworks of well-established theories where multiple
variables operate together in naturally occurring settings.
Longitudinal studies utilising representative and large
samples undertaken in both clinical and community
settings are encouraged. More qualitative data are also
needed to elaborate women’s lived experiences during
postpartum period. Additionally, randomised-controlled
trails are required to test the effectiveness of culturally
sensitive interventions developed for women with PPD in
Asian cultures. Internationally collaborative studies are
strongly recommended.
Conflict of interest: None declare.
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