Perinatal mental health (PMH) is increasingly recognized as a significant global public health concern. The perinatal period—defined by the World Health Organization (WHO) as encompassing pregnancy and the first year after childbirth (1)—is a particularly vulnerable time for women. A 2018 systematic review estimated that ~10%−20% of women experience mental health disorders during this period (2). These disorders are concerning, not only because of their potential to affect the mother's long-term physical and mental wellbeing, but also due to their broader implications for the child, family, and society (3, 4). The impact of maternal depression and anxiety on fetal neurodevelopment (5–7), and their adverse consequences in the postnatal period (8–10) have been well documented.

A meta-analysis from high-income countries reported prevalence rates of 11% for antenatal depression, and 13% for postnatal depression (11). Another meta-analysis showed that the prevalence of maternal anxiety during pregnancy varies depending on the specific type of anxiety disorder studied, with estimates reaching up to 13% (12). The COVID-19 pandemic further intensified stressors affecting perinatal mental health. A systematic review and meta-analysis found that lockdown measures significantly increased mental health risks for pregnant and postnatal women (13), while comparative studies reported higher rates of perinatal depression during the pandemic compared to pre-pandemic periods (14–16). In Singapore, local data from the Postnatal Depression Intervention Programme similarly showed a statistically significant rise in screen-positive postnatal depression cases in 2021 (17). However, much of the existing evidence remains rooted in Western populations, with limited representation of Asian cohorts (11–13), underscoring the need for more context-specific data from diverse cultural settings.

Singapore is a multi-ethnic island city-state in Southeast Asia. As a highly developed and urbanized nation, it differs from many other Asian settings in terms of cultural practices, healthcare access, and societal norms (18). Culture plays a central role in shaping women's experiences during pregnancy and the postnatal period, influencing how emotional distress is perceived, expressed, and managed. Cultural beliefs and norms, particularly in Asian societies, can significantly affect attitudes toward mental health and influence help-seeking behaviors during this critical time. Compared to Western contexts, Asian perspectives on PMH often reflect lower awareness of the potential adverse effects of PMH conditions on both mother and child, as well as greater reluctance to seek mental health support (19, 20). Limited mental health literacy further compounds this issue and remains a key barrier to early screening and intervention (21). Despite the importance of addressing these challenges, there is a notable lack of evidence on maternal knowledge, attitudes, and help-seeking practices during the perinatal period in Asian populations.

This study aims to describe the prevalence of maternal depression and anxiety during pregnancy and the postnatal period, and to explore knowledge, attitudes, and practices related to PMH among a multicultural population of women in Singapore.

Our study found that approximately one in 10 pregnant women and one in four women within 12 weeks postnatal reported symptoms indicative of probable depression. Notably, an even greater proportion of women were identified as experiencing probable anxiety, both during pregnancy (48.4%) and in the postnatal period (56.7%).

We observed a postnatal depression prevalence of 27.3%, as screened using the EPDS (cut-off ≥13), based on data collected in 2022. This rate is significantly higher than those reported in earlier years—4.9% in 2019 and 6.5% in 2021 (16)—based on data from outpatient clinic screening programs. As expected, cohort studies tend to report higher prevalence rates, likely due to self-selection bias and increased psychological awareness among participants. For example, postnatal depression rates in local cohort studies were 10.4% in 2014 (26), 17.0% in 2018 (27), and 9.8% (28), all using the same EPDS cut-off of ≥13.

Similarly, the prevalence of antenatal depression (EPDS >15) in our study (11.9%) exceeded earlier reports—7.3% in 2016 (29) and 9.0% in 2019 (30). While prevalence estimates for perinatal depression vary widely across studies due to methodological differences, our findings appear consistent with global trends showing an increase in postnatal depression. For instance, prevalence in the US rose from 16.9% in 2019 to 18.1% in 2020 (15), while in the UK it increased from 10.3% in 2014 to 23.9% in 2020 (31). Both studies attributed this rise, at least in part, to the impact of the COVID-19 pandemic on maternal mental health. Furthermore, the overall higher prevalence of probable perinatal depression observed in this cohort compared to previous local estimates may reflect both sample characteristics and methodological factors. A relatively high proportion of participants reported adverse pregnancy outcomes, which is associated with increased psychological vulnerability during the perinatal period. Methodological differences may also have contributed. While many previous local studies administered depression screening only once, often in mid-pregnancy and at month-3 postpartum (10, 26, 28, 29), our study assessed participants at multiple time points throughout pregnancy and up to 12 weeks postpartum. This extended follow-up period may have captured late-onset antenatal symptoms and postpartum onset, resulting in a higher overall prevalence.

We also found higher rates of probable perinatal anxiety (antenatal: 48.4%; postnatal: 56.7%), as assessed using the EPDS-3A (25), compared to a 2018 meta-analysis that reported pooled rates of 15.2% during pregnancy and 15.0% postnatal (32). In Singapore, earlier studies using the State-Trait Anxiety Inventory (STAI) reported lower antenatal anxiety rates of 17–19% in 2016 (8) and 29.5% in 2018 (33). A meta-analysis conducted during the COVID-19 pandemic found that anxiety symptoms in pregnant women exceeded rates of depression, with a pooled antenatal anxiety prevalence of 40% across 26 studies, primarily from Asia (34). Our findings of 48.4% are consistent with this upward trend and further supported by other studies linking heightened anxiety to the pandemic context (34–36).

An increase in antenatal depression from the first to the third trimester was also observed, with both depression and anxiety peaking in the third trimester. This aligns with prior systematic reviews and meta-analyses suggesting higher rates in the second and third trimesters (37, 38). However, not all studies observed similar trends. In Kenya (39), the highest depression prevalence occurred during the early second trimester, while in Bangladesh (40), depressive symptoms declined as pregnancy progressed. These differences may stem from variations in EPDS cut-offs > 12 in Kenya and > 10 in Bangladesh—vs. > 15 in our study. Unlike depression, trends in antenatal anxiety were less consistent across trimesters, possibly due to the lack of standardized diagnostic criteria. A review found pooled anxiety rates of 18.2% (first trimester), 19.1% (second), and 24.6% (third) (32), with other studies showing mixed trimester trends (39, 41).

Despite high overall awareness of perinatal mental health (PMH) disorders (96.8%), fewer women were aware of the adverse effects on pregnancy outcomes and child development (77.4%). Additionally, only 63.8% could recognize symptoms of PMH disorders—comparable to the 68.2% found in a Chinese study on postnatal literacy (42). A systematic review of studies in Western countries similarly highlighted poor symptom recognition among postnatal women (19). Since awareness and recognition are critical for timely help-seeking (43), the discrepancy is noteworthy.

Our findings show that women were more likely to seek support from their spouse (57%) than from healthcare professionals (15.5%). This pattern is consistent with both Western (21) and Chinese studies (42), which found a general preference for informal sources of help. For example, Gong et al. reported only 9.3% of women preferred seeking help from professionals (44), while Huang et al. noted that “knowledge and beliefs about professional help” scored lowest among literacy items (42). Cultural beliefs play a significant role in shaping attitudes toward mental health and help-seeking behaviors in Singapore (45). Among Chinese individuals, the concept of “face” and the perception of mental health struggles as a moral failing may contribute to stronger stigma and less social tolerance (46, 47). In contrast, while some Malay Muslim participants attributed mental health issues to spiritual possession—potentially delaying access to appropriate care—they also demonstrated greater acceptance of persons with mental health issues, possibly due to Islamic teachings that emphasize compassion, acceptance, and the divine purpose behind human suffering (48). Thus, our findings of low help-seeking from healthcare professionals align with existing evidence that stigma—rooted in conservative values, shame, loss of “face,” and cultural reluctance to discuss psychological distress—remains a major barrier to mental health care in Asian societies compared to Western populations (49).

Healthcare provider support for PMH also appears suboptimal. A recent local survey of 55 doctors found that 83.7% lacked confidence in managing PMH concerns, and 65.5% did not routinely screen for them (50). Similar patterns were reported in India, where 89% of providers did not screen for perinatal depression and less than half were familiar with the appropriate tools (51). A systematic review across 43 studies in Western countries also revealed only moderate PMH literacy among healthcare providers, with limited knowledge of symptoms and screening tools (52). This deficiency, observed among both women and providers (50, 52), poses a major barrier to delivering adequate PMH care. Encouragingly, 85% of women in our study endorsed the benefits of education and screening, and 94.5% agreed that PMH guidelines would be helpful.

In conclusion, our study highlights high rates of perinatal depression and anxiety, alongside suboptimal mental health literacy among women. These findings, together with insights from a recent survey of healthcare professionals (50), informed the development of the Singapore Perinatal Mental Health Guidelines on Depression and Anxiety (17). In parallel, initiatives have been introduced to strengthen public education and outreach, as well as to enhance training within primary healthcare settings.