Postpartum Depression & Omega-3 Polyunsaturated Fatty Acids in Low and Middle-Income Countries
Pregnancy is a life-changing event accompanied by major social, hormonal, and psychological changes.
Postpartum depression, a mental health disorder that occurs in the mother after childbirth, affects around 10–15% of women globally, whilst more than half of cases go undetected.
It is estimated that nearly half of all cases go undetected. It hinders early mother-child relationships which can result in great detriment to the mother’s life, work, and relationships and also the child’s social and psychological development. Recent studies looking into the prevalence of omega-3 polyunsaturated fats in the diets of pregnant women and the relationship between this macronutrient and postpartum depression.
Existing Research
When looking at postpartum depression varies globally and especially between low and middle-income countries and high-income countries. The prevalence of postpartum depression among women in high-income countries is 10–12% and in low-income countries, it is close to 20%. This is in part due to the fact that women in lower-income countries are met with more hardships and less support which exacerbates mental health issues. Additionally, lower and middle-income countries receive very little mental health support through aid because most of the focus of aid lies on decreasing mortality and morbidity in those countries. These are some of the things we need to keep in mind when comparing the research done with omega-3 PUFA supplementation in high-income countries and low and middle-income countries.
When looking at the broader relationship between omega-3 PUFAs and postpartum depression, we find that higher dietary consumption of omega-3 PUFAs are inversely related to depressive symptoms in high-income countries. A cohort study done in Norway where fatty acid status in red blood cells was assessed in the 28th gestation week. Participants were then tested for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) 3 months after delivery. This study investigates the correlation between a low omega-3 index in pregnancy and whether that correlates with the possible risk factor for postpartum depression. This study found that the omega-3 index was inversely correlated with the EPDS score which allows for the conclusion that a low omega-3 index in late pregnancy is associated with higher depression (Markhus et al.).
Similarly, women in an Austrian sample with and without PPD had their diets compared in this study in respect to the foods and supplements they had that were nutritionally beneficial to nervous system health.
It was found that depression was less prevalent in subjects who consumed more oily fish and offal and those with vegetarian diets.
The majority of subjects with depression had inadequate nutritional support during pregnancy (Hoggs-Kollars etal.). As mentioned before, these findings of a strong correlation are only true for high-income countries.
When we look at low and middle-income countries, we find something very different. A randomized placebo-controlled study on omega-3 supplementation was done in Rio de Janeiro, Brazil using fish oil capsules. Supplementation started at 22–24 weeks of gestation and went on for 16 weeks. There was no difference found between the intervention and control groups. Although the women in the fish oil group with previous history had a higher reduction of depression from the second to third trimester than the control group, this study also found that the daily supplementation of omega-3 PUFAs did not prevent maternal depressive symptoms (Juliana dos Santos Vaz, et al.).
A study in Ghana in which lipid-based nutrient supplements were given to women with less than 20 weeks of gestation resulted in no differences in the number of women with postpartum depression at six months postpartum (Okronipa et al.). A similar study in Malawi studying women with less than 20 weeks of gestation found that LNS fortification of maternal diets was not a viable strategy for reducing postpartum depression (Robert C. Stewart et al.). Another study looked at the association of fish intake and depression from seven low and middle-income countries. The main component of omega-3 PUFAs is fish oil which makes this study closely related to our focus on omega-3 PUFAs and postpartum depression. In this study pre-existing data was used and two diagnostic criteria for late-life depression to assess the association between categories of weekly fish consumption and depression was applied. The countries the researchers looked at were Cuba, Dominican Republic, Venezuela, Peru, Mexico, China, and India. Associations between fish consumption and depression were found positive in India, inverse in Peru, Cuba, and China, and not significant everywhere else. This shows how inconsistent the data is for the effect of omega-3 PUFAs in low and middle-income countries. It similarly shows how little data is found regarding n-3 PUFA supplementation in these countries as there was really only one study [I found] that specifically looked at n-3 PUFA supplementation in the context of postpartum depression in a low or middle-income country.
Some of the weaknesses of the studies done in the LMICs include relatively small sample sizes and possibly weak analysis. The scales used for measuring postpartum depression, usually the Edinburgh Postnatal Depression Scale (EPDS), may also be ineffective in these countries as they were developed with women usually residing in HICs in mind. These scales may need adjustment based on the regions and cultures of the LMICs they are used in or a new standard should be investigated. Women in LMICs also usually have a myriad of things to worry about besides their children and have many more stressors in their environments which should be taken into consideration. A study done in Ethiopia on postpartum depressive symptoms found that social adversity and threats to reproductive health correlated with poorer mental health postpartum (Telake Azale, et al.). There are many factors at play when it comes to women’s mental health postpartum in LMICs and that need to be identified and considered in these studies. It is clear that further and more focused research needs to be done in LMICs into the relationship between n-3 PUFAs and postpartum depression.
Interventions for Women with PPD
Existing interventions for women experiencing postpartum depression in both HICs and LMICs include psychoeducational and psychotherapeutic ones. Interventions using n-3 PUFAs are usually done through the distribution of supplements. Although it is sometimes recommended that women take n-3 PUFA supplements, there is not enough research-based evidence supporting this as a form of treatment yet. While the existing interventions are proven to be useful and beneficial to women experiencing postpartum depression, it is safe to assume that women in LMICs are more often than not unable to seek out help through the existing interventions. Therefore it is evident that more research must be done into finding the kinds of interventions that are most effective and accessible for women in LMICs.
An intervention I can propose using what I have learned is community-based monitoring of women at risk of postpartum depression along with the community-based supplementation of omega-3 PUFAs to these women in LMICs. This would allow more focused research into the relationship between n-3 PUFAs and postpartum depression while ensuring communal support for women during their perinatal period. This intervention would require strong community bonds, especially among women, and diligent care for women at risk of postpartum depression. This intervention would be looking at things at the community scale while also being implemented in several communities throughout LMICs. Data collected would include rates of postpartum depression in women in control communities and from intervention communities and then analyzed to evaluate the effectiveness of the intervention. This intervention is limited as the community based approach itself may have an impact on rates of postpartum depression in those communities as women may feel less stressed and maybe overall less prone to symptoms of postpartum depression as a result. Although this is beneficial for the wellbeing of the women and their children, this may interfere with the correlative data between postpartum depression and n-3 PUFA supplementation. This intervention may prove to be beneficial regardless as it would be a step forward for research on postpartum depression and n-3 PUFAs.
In conclusion, while the effects of omega-3 polyunsaturated fatty acid supplementation may show significant correlations in the reduction of postpartum depression, much research is left to be done in LMICs in the same regard. The data available now is inconclusive due to how much inconsistency there is and also how little research has been done in this specific area of study. Therefore more research must be done in order to create substantial plans for future interventions in LMICs.
Works Cited
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Thomas L, Gandhi S, Parel JT (2018) Interventions for Mothers with Postpartum Depression: A Systematic Review. Int J Depress Anxiety 1:002. doi.org/10.23937/ijda-2017/1710002
Okronipa, Harriet et al. “Maternal supplementation with small-quantity lipid-based nutrient supplements during pregnancy and lactation does not reduce depressive symptoms at 6 months postpartum in Ghanaian women: a randomized controlled trial.” Archives of women’s mental health vol. 21,1 (2018): 55–63. doi:10.1007/s00737–017–0752–7
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Azale, T., Fekadu, A. & Hanlon, C. Postpartum depressive symptoms in the context of high social adversity and reproductive health threats: a population-based study. Int J Ment Health Syst 12, 42 (2018). https://doi.org/10.1186/s13033-018-0219-x
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Albanese E, Lombardo FL, Dangour AD, Guerra M, Acosta D, et al. (2012) No Association between Fish Intake and Depression in over 15,000 Older Adults from Seven Low and Middle Income Countries–The 10/66 Study. PLOS ONE 7(6): e38879. https://doi.org/10.1371/journal.pone.0038879
Vaz, J.d., Farias, D.R., Adegboye, A.R.A. et al. Omega-3 supplementation from pregnancy to postpartum to prevent depressive symptoms: a randomized placebo-controlled trial. BMC Pregnancy Childbirth 17, 180 (2017). https://doi.org/10.1186/s12884-017-1365-x
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Stewart RC, Ashorn P, Umar E, Dewey KG, Ashorn U, Creed F, Rahman A, Tomenson B, Prado EL, Maleta K. The impact of maternal diet fortification with lipid-based nutrient supplements on postpartum depression in rural Malawi: a randomised-controlled trial. Matern Child Nutr. 2017 Apr;13(2):e12299. doi: 10.1111/mcn.12299. Epub 2016 Apr 5. PMID: 27060705; PMCID: PMC6866218.
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Markhus, Maria Wik et al. “Low omega-3 index in pregnancy is a possible biological risk factor for postpartum depression.” PloS one vol. 8,7 e67617. 3 Jul. 2013, doi:10.1371/journal.pone.0067617
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