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Postpartum Hemorrhage To Reveal Increased Risk For Postpartum Depression

Postpartum Hemorrhage To Reveal Increased Risk For Postpartum Depression

Postpartum hemorrhage (PPH) affects 14 million women annually and is the leading cause of maternal deaths worldwide, accounting for 30% of maternal mortality. Despite declining death rates, complications and prevalence of PPH have increased, along with associated mental health issues like postpartum depression (PPD). The World Health Organization’s 2022 guidelines emphasize integrating perinatal mental health services. PPD significantly impacts mother-infant bonding and maternal well-being, with symptoms sometimes persisting long-term and escalating to severe psychiatric conditions. Identifying risk factors, especially the link between severe PPH and PPD, is essential for early intervention. This review and meta-analysis examine whether severe PPH is a risk factor for PPD to improve screening and treatment. 



The incidence of postpartum hemorrhage (PPH) remains a significant concern in maternal health, with approximately 14 million women experiencing it annually, leading to around 70,000 maternal deaths worldwide [1]. PPH stands as a leading cause of maternal morbidity and mortality, contributing to about 30% of maternal deaths globally [2]. Despite efforts to reduce maternal mortality rates, epidemiological data indicate a gradual increase in PPH prevalence over recent decades [3]. Beyond immediate health risks, PPH can trigger secondary complications such as post-traumatic stress disorder, renal failure, and respiratory distress syndrome [4,5]. While maternal mortality attributed to PPH has decreased, the incidence of serious complications has risen, emphasizing the need for effective prevention and management strategies [2].

In response to the growing recognition of perinatal mental health challenges, including those stemming from childbirth-triggered psychiatric illnesses, such as postpartum depression (PPD), initiatives have emerged to integrate mental health services into maternal and child healthcare frameworks [6,7]. PPD, characterized by symptoms like sadness, insomnia, and decreased productivity, poses a significant threat to maternal-infant bonding and overall mental health [8,9]. Although many women experience symptom improvement within 3-6 months postpartum, a notable proportion continue to struggle with depression for extended periods, heightening the risk of severe psychiatric complications, including suicide and infanticide [10,11]. Given these complexities, identifying risk factors for PPD, including potential associations with severe PPH, is crucial for early detection and intervention efforts aimed at minimizing the impact on maternal and child health outcomes.

This study presents a systematic review and meta-analysis aiming to investigate the relationship between severe PPH and the development of PPD in women. By synthesizing existing evidence, the research seeks to shed light on whether severe PPH serves as a risk factor for PPD onset. Such insights promise to inform targeted screening and treatment approaches, ultimately contributing to improved maternal and child health outcomes. 



The systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and were registered in the International Prospective Register of Systematic Reviews (PROSPERO) database. A comprehensive literature search spanned PubMed, Embase, the Cochrane Library, and Web of Science, augmented by previous meta-analyses. Two independent reviewers evaluated study eligibility, focusing on cases of postpartum hemorrhage (PPH) and subsequent postpartum depression (PPD) while excluding studies solely examining postpartum post-traumatic stress disorder and PPH.

PPH was defined based on established criteria, distinguishing between primary occurrences (within 24 hours) and secondary occurrences (24 hours to 12 weeks post-birth). PPD symptoms were assessed using the Edinburgh Postnatal Depression Scale. Data extraction encompassed publication details, participant demographics, PPH definitions, and PPD assessment methods. The study’s methodological quality was assessed using a modified Newcastle-Ottawa scale.

The primary outcome revolved around the odds ratio (OR) for PPD symptoms or diagnosis in women with PPH compared to those without, with meta-regression analyses exploring the influence of maternal factors. The attributable risk (AR) was also calculated to estimate the proportion of PPD attributable to PPH exposure within a single population. 



The statistical analysis used both random-effects and common-effect models to account for differences in study populations and assessment methods. The primary outcome’s odds ratio (OR) was calculated for dichotomous variables with 95% confidence intervals (CI). The researchers assessed the effects of various clinical factors on postpartum depression (PPD) with meta-regression analysis.


The meta-analysis used the “metagen” package in R version 3.5.1. Meta-regression analysis, sensitivity analysis, funnel plots, and Egger’s test were done using the “metaphor” package. Studies were considered heterogeneous if the I2 statistic was greater than 50% and the p-value was less than 0.1. The DerSimonian–Laird method estimated the heterogeneity variance (τ2). The I2 statistic was calculated to show the proportion of variance due to heterogeneity. A p-value of less than 0.05 was considered statistically significant.



Study Selection

–  Total Studies Retrieved: 354

–  After screening, 16 full-text articles were assessed, and seven studies were included.

Study Characteristics

– Total Participants: 540,558

   – With P.P.H.: 46,511

   – Without P.P.H.: 494,017

– Study Designs: 6 cohort studies, one case-control study

– Incidence of PPD:

  – PPH Group: 3.28%

  – Non-PPH Group: 2.49%

Risk of Bias

– Quality: 4 high-quality, three moderate-quality studies

– Publication Bias: No signs of bias detected

Primary Outcome

– Odds Ratio (OR) for PPD:

  – Common-effect Model: OR = 1.10 (95% CI 1.03–1.16)

  – Random-effects Model: OR = 1.10 (95% CI 1.03–1.18)

– Heterogeneity: Low (I2 = 0.23, τ2 = 0.0007, p = 0.25)

– Attributable Risk: 24%

Women with postpartum hemorrhage (PPH) are at a slightly higher risk of developing postpartum depression (PPD) compared to those without PPH. The low heterogeneity indicates consistent findings across the studies. The attributable risk shows that 24% of PPD cases in women with PPH could be attributed to the PPH itself.

Meta-Regression Analyses

 – Significant Factor: Maternal smoking

– Non-significant Factors: Maternal age, marital status, preterm labor, education, preeclampsia, anemia, cesarean section

Maternal smoking was found to significantly affect the risk of PPD, while other factors did not show a significant impact.

Sensitivity Analyses

– Excluding One Study: Reduced I2 to 0%, OR = 1.09 (95% CI 1.03–1.16), low heterogeneity (τ2 = 0.0006)

The robustness of the results was confirmed by excluding one study, which showed consistent findings and reduced heterogeneity.



The systematic review and meta-analysis conducted by Sheng et al. reveal a heightened risk of postpartum depression (PPD) in women who experience postpartum hemorrhage (PPH), with a 10% increased risk compared to those without PPH [1]. Furthermore, women with PPH exhibit a 24% higher attributable risk percentage of PPD than their counterparts without PPH, surpassing the previously reported incidence among healthy mothers [1].

Perinatal mental health research confronts ethical challenges associated with studying vulnerable populations, potentially contributing to the observed elevation in PPD risk among women with PPH [1]. The disparity in enrollment numbers between studies focusing on PPH and those on non-pregnant women with depression may impede a comprehensive understanding of the true incidence of PPD, underscoring the need for increased attention [1].

The etiology of PPD involves mental and psychological changes influenced by hormonal fluctuations during pregnancy, particularly estrogen, progesterone, thyroid hormone, and 5-hydroxytryptamine [1]. Notably, a significant correlation between PPD and premenstrual syndrome is observed, likely attributable to hormonal fluctuations [1].

Moreover, severe PPH can compromise blood supply to the pituitary gland, potentially leading to Sheehan syndrome, which has been linked to psychosis in some cases [1]. The severity of intraoperative bleeding during childbirth significantly affects the likelihood of PPD, with hormone fluctuations emerging as a critical factor [1].

In meta-regression analyses, maternal smoking emerges as a significant factor impacting the risk of PPD. In contrast, other variables such as maternal age, marital status, and preterm labor show no significant effects [1]. Sensitivity analyses indicate that excluding specific studies reduces heterogeneity, suggesting their potential contribution to variability [1].

Compared to previous meta-analyses, the study’s low heterogeneity (I^2 = 23%) underscores the importance of excluding low-quality studies to enhance result credibility [1]. Including high-quality studies with proper matching and a large sample size of nearly 50,000 women provides robust findings regarding postpartum outcomes [1]. Random and common-effect models were employed to ensure a comprehensive analysis [1]. Assessment for publication bias through funnel plots and Egger’s test reveals no significant bias, further bolstering confidence in the findings [1]. 



  1. Potential Confounding Factors:

   – Complete exclusion of confounding factors in several studies remains to be determined.

   – Variances in study designs and methodologies may have impacted overall outcomes.

  1. Observational Nature of Studies:

   – Despite low heterogeneity in primary outcomes, the observational nature of studies leaves room for confounding effects.

   – Lack of control over variables may have influenced the validity of results.

  1. Data Availability on Risk Factors:

   – Insufficient or incomplete reporting of data on risk factors for postpartum depression (PPD) in most included studies.

   – Limited data availability hindered the conduct of a comprehensive meta-regression analysis.

   – Restriction in obtaining more detailed insights into the relationship between PPD and associated risk factors.

These limitations underscore the need for cautious interpretation of the study results and emphasize the importance of addressing these gaps in future research endeavors.



The study concludes that women experiencing postpartum hemorrhage (PPH) face a higher risk of postpartum depression (PPD) compared to those without PPH, emphasizing the need for enhanced screening tools, like those recommended by the American College of Obstetricians and Gynecologists, to identify better and support at-risk women. Close monitoring of women with PPH is crucial for early recognition and management, leading to improved treatment outcomes and maternal-infant well-being. Additionally, the study suggests that the risk of PPD in women with PPH may be exacerbated by a history of maternal smoking, urging further investigation through large-scale trials to understand this relationship better and develop more effective interventions for maternal mental health care. 



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  7. [7] World Health Organization. Guide for Integrating Perinatal Mental Health in Maternal and Child Health Services[R]. World Health Organization; 2022.
  8. [8] Koutra K, Vassilaki M, Georgiou V, et al. Pregnancy, perinatal and postpartum complications as determinants of postpartum depression: the Rhea mother-child cohort in Crete, Greece. Epidemiol Psychiatr Sci. 2018;27:244-255. (
  9. [9] Dagher RK, McGovern PM, Dowd BE, Gjerdingen DK. Postpartum depression and health services expenditures among employed women. J Occup Environ Med. 2012;54:210-215. (
  10. [10] Woolhouse H, Gartland D, Mensah F, Brown SJ. Maternal depression from early pregnancy to 4 years postpartum in a prospective pregnancy cohort study: implications for primary health care. BJOG. 2015;122:312-321. (
  11. [11] Tronick E, Reck C. Infants of depressed mothers. Harv Rev Psychiatry. 2009;17:147-156. (
  12. [1] Sheng B, Jiang G, Ni J. Association between postpartum depression and postpartum hemorrhage: A systematic review and meta-analysis. Acta Obstet Gynecol Scand.  2024;00:1-8. (






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