The postpartum period is known as a high-risk period for the onset of different mental health problems such as postpartum blue, major depression, and postpartum psychosis (1), and depression is the most periodically happening psychiatric problem among reproductive-age women (2). The American psychiatric association (APA), defined postpartum depression as the occurrence of a major depressive episode (MDE) within 4 weeks after delivery (3) and characterized by loss of interest in usual events, sleep challenges, feelings of sadness, fatigability, problems of appetite, and difficulty in coping with daily activities (4). Globally, 10–20% of postnatal mothers suffered from depressive symptoms during their postpartum period (5). The magnitude of postpartum depression (PPD) raised by 18.4% between 2005 and 2015 years globally (6).

Different kinds of literature had shown that the prevalence of postpartum depression varies globally and it was lower among women from Europe, Australia, and the United States of America (USA) compared to women from Asia, South Africa (7) and it was about 10% in developed countries (6) and nearly 20% in developing countries (8). Evidence indicated that the magnitude of postpartum depression (PPD) in China, Japan, India, and Bangladesh was 6.7, 21, 11–16, and 39.4%, respectively (9–12). The world health organization (WHO) reported, ~20–40% of women in developing countries experienced depressive symptoms during pregnancy or after childbirth (13). African countries constitute a larger burden of postpartum depression (PPD) (14), and the prevalence of postpartum depression was 27.1% in southwestern Uganda (15), 27.5% in Egypt (16), and 35.6% in Nigeria (17). The world health organization report indicated that depression is the leading cause of disease for reproductive age group women (18), and a major public health concern in developing countries currently (6).

Postnatal depression (PND) has several maternal, neonatal, and infant health consequences such as maternal morbidity (19), social problems (20), physical damage (21), suicide (22), infant growth retardation (23), impaired child development (24), behavioral changes (25), and repeated diarrheal disease (26). Factors such as age (27), low household income (28), and preterm/low birth weight infants (29) were determinant factors of postpartum depression. Not only these, but also lack of social support, obstetric complication, previous history of depression, poor marital relationship, and unintended pregnancies also contributing factors to the development of postpartum depression (30–32). According to the report of different studies conducted in different parts of Ethiopia, the magnitude of postpartum depression ranges from 13.11% (33) to 33.82% (34).

Even if the world health organization had launched the mental health gap action program (mhGAP) intended to integrate mental health interventions with the existing maternal health services (14, 35), postpartum depression screening, diagnosis, and referral of clients for appropriate mental health services were often neglected in the health care system of several countries including Ethiopia (36). In addition, about 80% of postnatal mothers with psychological and neurological problems did not access appropriate health care services in Ethiopia and other developing countries (35). In Ethiopia, postnatal health care is majorly concerned with obstetrical/gynecological problems of the mother and newborn health, while the psychosocial well-being of the mother was given little attention even if early identification of mothers at risk of developing postpartum depression will enable us for timely referral, diagnosis, and appropriate management. In addition, little is known about the magnitude of postpartum depression and contributing factors in the current study area, and some previous studies were used a small sample size and didn't consider important potential risk factors. Therefore, this study aimed to assess the magnitude and determinant factors of postpartum depression among postnatal mothers attending their postnatal and vaccination services at public health institutions in Addis Ababa, Ethiopia.

This study aimed to assess the magnitude and determinant factors of postpartum depression among mothers attending their postnatal and vaccination services at public health institutions in Addis Ababa, Ethiopia. The study revealed that the prevalence of postpartum depression (PPD) was 19.7%. This finding was in line with the result of a study conducted in Nekemte town, Ethiopia 20.9 % (43), and Saudi Arabia 20.9 % (44). But higher than the result of the study conducted in Eritrea 7.4 % (45), and Sudan 10.9 % (46). This difference might be related to methodological differences such as sample size, sampling procedure, the timing of the postpartum period, assessment tool rating scale difference. The study conducted in Eritrea used the standard diagnostic and statistical manual of mental disorders fifth edition for diagnosis of postpartum depression (45), while the study conducted in Sudan (46) used Edinburg postnatal depression scale (EPDS) with >12 cuts of point for diagnosis of postpartum depression.

In addition, this result was higher than the results of three studies conducted in different parts of Ethiopia such as Harar (33), Debre Berhan (47), and eastern Ethiopia (48) which reported the prevalence of PPD as 13.11, 15.6, and 16.3%, respectively. Moreover, the prevalence of postpartum depression in this study was lower than the result of a study conducted in southwestern Uganda 27.1% (15), Egypt 27.5% (16), Pakistan 31% (49), Vientiane Capital 31.8% (41), Nigeria 35.6% (17), and Bangladesh 39.4% (12). This variation might be associated with socio-cultural differences, assessment tools, the difference in the cut of point of EPDS, the difference in the sampling procedure, and included study participants. The study conducted in southwestern Uganda (15) used the diagnostic and statistical manual of mental disorders V for diagnosis of postpartum depression while Edinburg postnatal depression scale (EPDS) was used in our study. Edinburg postnatal depression scale (EPDS) with ≥10 thresholds were used in a study conducted in Bangladesh (12) and Vientiane Capital (41), while minimum Edinburg postnatal depression scale (EPDS) ≥13 thresholds were considered for the diagnosis of postpartum depression in our study. Besides, the prevalence of postpartum depression (PPD) in this study was lower than the report of three studies conducted in different regions of Ethiopia such as Addis Ababa (50), Gondar (37), and southeast Ethiopia (34) showing the prevalence of postpartum depression (PPD) 23, 25, and 33%, respectively. This discrepancy might be associated with the methodological and socio-demographic differences of included study participants.

Unemployed postnatal mothers were over 3 times more likely to develop postpartum depression compared to employed postnatal mothers. This finding was in line with the result of a study conducted in Sudan, Qatar, Lebanon, and the USA (46, 51–53). This could be related to the lack of adequate income among unemployed postnatal mothers which could be the driving cause for the onset of a different psychosocial stressor and postpartum depression. Again, delivery and postpartum periods are known as stressful moments, and unemployment is the main relapsing factor of previous stress, exposing unemployed postnatal mothers to develop postpartum depression (54). But, this finding was different from the result of the study conducted in Eritrea 2020 (45), which indicated that housewives were less likely to develop postpartum depression compared to those employed postnatal mothers.

Those unmarried postnatal mothers were almost 3 times more likely to develop postpartum depression. This finding was in line with the result of the study conducted in Addis Ababa Ethiopia (55), and Uganda (56). Pregnancy and delivery in the absence of marriage have stigma and discrimination in the community of most African countries. Handling these stressful events alone and the absence of support those postnatal mothers could have gotten from their partners might initiate the development of postpartum depression (PPD). Besides, evidence indicated that lack of partner support was a risk factor for the development of postpartum depression (45). Postnatal mothers who had difficulty in managing their income were almost 4 times more likely to have postpartum depression than those who had no problems managing their income. This result was in line with the results of two studies conducted in Ethiopia [Addis Ababa (55) and at the national level in Ethiopia (57)], Eritrea (45), Qatar (51), Taiwan (58), and western Iran (59). The possible explanation is that those postnatal mothers who were of low economic status or had a problem managing their finance might have faced the inability to fulfill all the necessary needs for raising their newborns, which might have caused postpartum depression.

Postnatal mothers who delivered a baby with undesired sex were about 5 times more likely to have postpartum depression than their counterparts. This finding was consistent with the report of the study conducted in Harar, Ethiopia (33) and Uganda (56). Probably, the absence of support from the family members for postnatal mothers because of the delivery of a baby with undesired sex, especially in a family where there were sex preferences, might have stressed the mother to develop postpartum depression. Study participants who had a history of child death were seven times more likely to develop postpartum depression compared to their counterparts. This finding was in line with the results of studies conducted in Mizan-Tepi University teaching hospital, Ethiopia (34) and a systematic review and meta-analysis, Ethiopia (60). The loss of an infant has several negative impacts on maternal life, and mothers who had lost a child before could fear they might lose their newborn as well again, which might have stressed the mother for the development of postpartum depression. Besides, unplanned pregnancy increased the odds of postpartum depression about 3 times. This finding was in line with the reports of two systematic reviews and meta-analyses in Ethiopia (57, 60), Bangladesh (12), and developing countries (61). Probably, those postnatal mothers with unplanned pregnancies might have not fully prepared for pregnancy, childbirth, and child nursing events, which might have stressed the postnatal mothers in turn to develop postpartum depression.

Those postnatal mothers who have faced negative life events during their pregnancy were over 2 times more likely to develop postpartum depression. This finding was similar to the results of the study conducted in Bahir dar town, Ethiopia (62), Egypt (16), Qatar (51), and Saudi Arabia (44). Stressful life events were the major risk factors for the onset of different psychosocial stressors and literature has indicated that exposure to negative life events can cause postpartum depression (63–65). Substance utilization during pregnancy was about six times risky for the development of postpartum depression. This finding was similar to the reports of studies conducted in Addis Ababa, Ethiopia (55), Mizan Aman town, Ethiopia (66), and Nekemte town, Ethiopia (43). According to some evidence, postpartum depressive symptoms were prevalent among postpartum substance users (67) and those with a substance utilization history (29).

Those postnatal mothers who had a previous history of depression were 5 times more likely to develop postpartum depression (PPD) than those who did not have a previous history of depression. This finding was consistent with the results of the study conducted in Egypt (16), Saudi Arabia (44), systematic review and meta-analysis in Ethiopia (60), and the study conducted in developing countries (61). Most of the risk factors for the development of disease either mental or non-mental are recurrent and hormonal imbalance during pregnancy and postpartum might have caused the relapse of the previous depression. Lastly, those study participants who were unsatisfied with their marriage were over 6 times more likely to develop postpartum depression compared to their counterparts. This finding was in line with the results of a systematic review and meta-analysis in Ethiopia (60), Mizan Aman town, Ethiopia (66), and a study conducted in developing countries (61). Probably, this was related to the absence of sharing of burdens such as child caring, household activities, and social responsibilities among couples with poor marital relationships, which could have stressed those postnatal mothers.

Our study was carried out during the global pandemic of COVID-19, which might have increased the prevalence of postpartum depression in Ethiopia. Data about the risk factors of PPD were collected from postnatal women's recall, which leads to under or over-reporting of symptoms of depression. Kansas Marital Satisfaction Scale and 3-item Oslo Social Support Scale were not used to assess the level of marital satisfaction and level of social support, respectively. The cause and effect relationship of the independent with dependent variable was not determined because of the cross-sectional nature of the design. The correlates of postpartum depression explored in this study were not exhaustive and the use of objective measures to assess some of the plausible correlates of postpartum depression was lacking.

The prevalence of postpartum depression in our study is high and it was an alarming finding which necessitates more attention to be given to maternal mental health problems during the postpartum period. Occupational status, marital status, income management, sex of baby, history of child death, unplanned pregnancy, negative life event, substance use during pregnancy, history of depression, and marital satisfaction were determinant factors of postpartum depression. The ministry of health should integrate mental health services with existing maternal health care services. It would be better if all healthcare professionals working in the maternal and child health care unit will routinely screen postpartum depressive symptoms and link them to mental health services giving special consideration to those postnatal mothers who were unemployed, unmarried, unsatisfied with their marriage, and for those postnatal mothers who had low monthly family income/problem of finance management, undesired sex of a baby, history of child death, unplanned pregnancy, negative life event during last pregnancy, substance use during their pregnancy and previous history of mental health problems.

All data sets used for this study are available from the corresponding author on request.

GW, GF, and BA: conceptualization. MT and ST: methodology. GF, BA, and ST: software and supervision. GW, MT, ST, and BA: formal analysis. GF, MT, and ST: data curation. GW and MT: writing—original draft preparation. GW, GF, BA, MT, and ST: writing—review and editing. GW: visualization. GW, GF, and MT: funding acquisition. All authors have read and approved the final version of the manuscript to be published.

Debre Berhan University had covered the costs for data collection instruments, data collectors, and supervisors. Ethical clearance was obtained from the Institutional Health Research Review Committee Board (Ref. No. IHRRCB-019/04/2020) of the Institute of Medicine and Health Science College of Debre Berhan University. But the funder had no role in the decision to publish.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.