Maternal depression refers to depressive disorders experienced by pregnant women and mothers up to 12 months after giving birth. Prenatal, postpartum, and psychotic disorders are all possible manifestations of maternal depressive illness (1). Symptoms of maternal depression are emotional and psychological changes that can affect mothers during pregnancy and after childbirth. These symptoms include distress, a depressed mood, feeling sad, and loss of interest or pleasure, and these can interfere with a mother’s responsiveness and ability to care for herself and her baby (2–4).

Malnutrition is defined as a condition where a person’s intake of energy and/or nutrients is deficient, excessive, or unbalanced. Undernutrition is a category of malnutrition that includes stunting (low height for age), wasting (low weight for height), and being underweight (low weight for age) (5). Since feeding and caring for young people are primarily the responsibility of mothers, poor maternal physical or mental health can adversely affect the nutritional, health, and psychological well-being of children (6).

Malnutrition is one of the most significant child health issues in developing countries, with approximately 19.4% and 29.9% of children aged less than 5 years being underweight and stunted, respectively (7). The rate of malnutrition among children in Ethiopia ranges from 27% to 37% (8). In a study of malnourished children, stunting (57.1%) was the most common form of malnutrition, followed by undernutrition (49.2%) and wasting (42.3%) (9). Maternal depression affects 15.6% and 19.8% of women during the antenatal and postnatal periods, respectively, in low- and middle-income countries (LMICs) (2). In sub-Saharan African countries, the rate of maternal depression ranges from 6% to 30%. Around 20% of women experience depression symptoms during pregnancy, and over 40% of the symptoms persist after delivery. Additionally, 80% of women with postpartum depression are likely to experience future depressive episodes (10). In Ethiopia, the prevalence of maternal depression ranges from 12.2% to 33.8%, and the overall prevalence of postpartum depression among mothers was 22.08% (11). Maternal depression is prevalent, affecting an estimated 14% of new mothers in the first 6 months after delivery (12). Studies from different countries have shown that the prevalence of depression was higher among mothers of children with undernutrition than among mothers of children with a normal nutritional status; the reported evidence from Uganda indicates that the prevalence of depression among mothers of malnourished children was 42%, while it was 13% among mothers in the control group (13). In Kenya, 64.1% of mothers with malnourished children experience depression, which was higher than 5.1% of mothers of children with normal weight (6). In Ethiopia, the prevalence of maternal depression among mothers of malnourished children was 22.8% (14).

Although the prevalence of child malnutrition in many regions of the world has declined in recent years, it remains one of the most significant child health problems, affecting an estimated 53% of child deaths per year (15, 16).

Malnutrition impairs physical growth, increases morbidity and mortality, and reduces both cognitive development and physical work capacity (17). Malnutrition is an underlying risk factor that increases the morbidity and mortality of many diseases in children and adults (18). Research in developing countries indicates that maternal depression is a risk factor for poor child growth in young infants (19).

Additionally, the interplay between women’s susceptibility to depression, their primary childcare responsibilities, and the high rates of maternal depression in developing countries significantly impact child development (20). Moreover, psychosocial factors, including maternal mental health status, affect breastfeeding in both high- and low-income countries (21–23). Mothers with depression symptoms also stop exclusive breastfeeding earlier than mothers without symptoms (22, 24).

Maternal mental health significantly impacts children’s nutritional status by interfering with a mother’s ability to fulfill her childcare responsibilities (25, 26). Evidence suggests a link between maternal mental health and child undernutrition in low-income countries, with an increased risk of stunting of more than 40% for children of mothers with depression symptoms (13, 27, 28). Risk factors for maternal depression include low income, education level, lack of financial support, child age, residence, maternal education, household wealth index, sex, and family size (29–32).

Even though the impact of maternal mental health on children’s emotional, cognitive, and behavioral problems has been well-studied in high-income countries, it has received less attention in LMICs, where malnutrition presents a significant additional challenge (33, 34).

Despite limited research on how child factors influence maternal depression, there is also a scarcity of studies examining the link between maternal depression and child health problems like malnutrition and illness. To address this gap, this study aimed to assess the prevalence and associated factors of maternal depression among mothers of malnourished children admitted to comprehensive specialized hospitals in Northwest Ethiopia.

Maternal depression might contribute to undernutrition in children, and consequently, can negatively impact their interpersonal behavior and impair social functioning, leading mothers to be less responsive to their children’s needs. Additionally, depression can reduce a mother’s interest in her child, making it difficult to cope with the demands of motherhood and hindering her involvement in essential caregiving tasks. This lack of engagement ultimately hinders the child’s physical growth.

In this study, the prevalence of maternal depression and its possible associated factors were assessed. The findings indicated that a high number of mothers suffered from maternal depression.

This study showed that 36.4% (95% CI = 32%–41%) of mothers with undernourished children had depression. This is in line with other studies done in Botswana, which found a prevalence of 33.3% (50). However, it was lower than in studies done in Kenya (64.1%), Uganda (42%), and Sudan (41.5%) (10, 51, 52). Variations in the results may be due to differences in the screening tools and cut-off points used across studies. The previous study in Uganda employed the Mini-International Neuropsychiatric Interview (M.I.N.I.), while studies in Kenya and Sudan utilized the PHQ-9, similar to the current study. However, the Kenyan study used a different cut-off point, with a score of ≥5 on the PHQ-9 (51). However, in the current study, the PHQ-9 score was equal to or greater than 10.

In contrast, the current study found a higher prevalence compared to previous studies conducted in North Ethiopia (22.8%) (14), northern Ghana (27.8%) (53), Kenya (27.1%) (54), and Brazil (17.9%) (55).

The possible variation in results may be due to differences in study settings, screening tools, study designs, and sample sizes. For instance, the previous Ethiopian study was community-based, whereas the current study involved a hospital setting focused on severely malnourished children, where maternal depression is likely to be more prevalent. This hospital environment itself could be a contributing factor to emotional distress in mothers. There is another possible explanation: the studies used different screening tools. The previous study employed the Edinburgh Postnatal Depression Scale (EPDS), whereas the present study used the PHQ-9 score (14). In addition, a plausible explanation for the difference could be the difference in sample size between the current study and previous studies.

The current study employed the PHQ-9, a more sensitive screening tool compared to those used in prior studies conducted in northern Ghana, Kenya, and Brazil. These previous studies utilized the Centre for Epidemiological Studies Depression Screening Scale (CES-D) in northern Ghana, the Beck Depression Inventory (BDI) in Kenya, and EPDS in Brazil (53–55).

There are discrepancies in maternal depression rates between our current study and the Brazilian study. The use of the PHQ-9 in our study might have overestimated the prevalence of depression compared to the tool used in Brazil. The other plausible explanation for the discrepancy in the prevalence rate between our current study and the study done in Brazil may lie in the type of research design employed, particularly the cohort used in the Brazilian study (55). In this regard, this study design was performed for a long study period, which may lead participants to develop resilience to adverse conditions of child malnutrition over the longer course of the study period. The current study’s cross-sectional design, with its limited timeframe, offered a minimal opportunity to assess how coping and resilience change over time and influence current depression levels. This one-time survey approach might therefore overestimate the prevalence of depression. Other possible explanations include the socioeconomic status of the participants, maternal education level, and the availability of healthcare facilities in the developing countries. Women in low-income settings, like Ethiopia, often face limited access to quality healthcare and are more susceptible to stress, which can directly or indirectly contribute to the development of maternal depression (56).

Regarding factors associated with maternal depression, mothers with children who did not attend formal education were 2.9 times more likely to experience maternal depression compared to mothers with higher levels of education. This finding supported previous studies conducted in Ethiopia, Saudi Arabia, Iran, and Japan (57–59). Poor readers may experience emotional and behavioral issues that can lead to heightened vulnerability to depression and challenges in managing it (60). Mothers who lack literacy skills suffer from low self-esteem, a lack of confidence, and an inability to make independent decisions, and they are held responsible for every unfavorable event; this leads to negative feelings among mothers. A low education level is a key indicator of poor economic status, being linked to more stressors and a higher risk of developing symptoms of depression (61).

Unemployed mothers were 2.6 times more likely to develop maternal depression than mothers who had been employed. This finding was in line with studies done in Sudan, Kenya, and Saudi Arabia (59, 62, 63). Unemployed mothers often experience psychological distress and anxiety due to concerns about finding work, financial strain, and insufficient income. This lack of employment can further contribute to depression by limiting social interaction and amplifying financial pressures. For mothers in the postpartum period, already a vulnerable time, unemployment can exacerbate existing stress and significantly increase the risk of depression (64).

Mothers with poor social support were 2.2 times more likely to have maternal depression than mothers who had strong social support. These findings are in line with previous studies done in Ethiopia (65–67), Sudan, Pakistan, and Japan (68–70). One possible reason is that mothers who lack social support are more likely to experience stress, loneliness, hopelessness, low self-esteem, and psychological distress (71). Mothers with good social support throughout the postpartum period are better able to handle their responsibilities at home, address challenges and problems, and minimize the risk of major stressors that contribute to depression.

Mothers who had perceived stigma due to being mothers of undernourished children were about 2.24 times more likely to develop maternal depression when compared to those who did not. These findings are in line with previous studies done in Ethiopia (72). Perceived stigma influences self-reported maternal depression or the association between the two. Experienced perceived stigma is a person’s perception of being stigmatized by others because their children are undernourished, which may or may not accurately reflect network members’ behavior and feelings. Internalized perceived stigma is a person’s negative feelings, such as shame and deviance, about their undernourished children (73). The possible justification is the perception of stigma, the belief that people will devalue and discriminate against individuals whose mothers were undernourished. The findings of the current study align well with previous research, which has shown that perceived stigma can negatively impact social support and lead to self-isolation, low self-esteem, and increased vulnerability to stress (74, 75). Perceived stigma predicts higher mental health conditions like depression and social anxiety (76). Mothers of undernourished children are easily subjected to shame, ignorance, feelings of isolation from social situations, and feelings of guilt because their neighbors typically hold them accountable for their children’s undernourishment (72).

Mothers with stunted children were more than two times more likely to have maternal depression than mothers whose children were not stunted. This finding was supported by previous studies done in Kenya, Uganda, Botswana, India, and Pakistan (29, 32, 51, 77, 78). Mothers of stunted children are more vulnerable to stressors related to their child’s health and physical status. This vulnerability stems from feelings of helplessness, sadness, and low self-esteem.

The symptoms of depression were evaluated using maternal recall data from the 2 weeks before the survey; this method may have led to under- or over-reporting of symptoms and could introduce recall bias.

The data were collected through face-to-face interviews, which led to social desirability bias.

We excluded data from mothers whose children had a comorbid developmental disorder.

This study found a higher prevalence of maternal depression among mothers of undernourished children compared to most previous studies. This suggests that maternal depression is a significant burden for mothers caring for undernourished children. The distribution of maternal depression among undernourished children was high among mothers with a lack of education, unemployment, poor social support, perceived stigma, and stunting in children with undernutrition. Therefore, early screening and detection of maternal depression are necessary and can provide educational opportunities, reduce unemployment, strengthen social support, and alleviate perceived stigma among mothers with undernourished children.

Researchers are advised to conduct longitudinal studies to determine the cause-and-effect relationships between maternal depression and children with undernutrition.

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

The studies involving humans were approved by Institutional review board of University of Gonder. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

BY: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing, Investigation, Project administration, Resources, Software, Supervision, Validation, Visualization. BG: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing, Funding acquisition, Investigation, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft. GoN: Conceptualization, Data curation, Methodology, Supervision, Visualization, Writing – review & editing, Formal analysis, Funding acquisition, Investigation, Project administration, Resources, Software, Validation, Writing – original draft. GiN: Investigation, Methodology, Visualization, Writing – review & editing, Conceptualization, Data curation, Formal analysis, Funding acquisition, Project administration, Resources, Software, Supervision, Validation, Writing – original draft. AM: Data curation, Formal analysis, Visualization, Writing – review & editing, Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft. DM: Data curation, Formal analysis, Writing – review & editing, Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft. MN: Data curation, Formal analysis, Resources, Writing – review & editing, Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft.