{"paper_id":"1e1b8e68-71ec-4c3a-9d43-cad729663612","body_text":"Prevalence and associated factors of antenatal depression in 1 \nrural Bangladesh 2 \nRifa Tamanna Mumu1¶, Dipak Kumar Mitra2¶  3 \n1Department of Public Health, School of Health and Life Science, North South University, 4 \nBashundhara, Dhaka, Bangladesh 5 \n2Department of Public Health, School of Health and Life Science, North South University, 6 \nBashundhara, Dhaka, Bangladesh 7 \n 8 \n*Corresponding author: 9 \nEmail: rifa.tamanna.sbmc@gmail.com (RM) 10 \n 11 \n¶These authors contributed equally to this work. 12 \n¶ Rifa Tamanna Mumu 13 \n¶ Dipak Kumar Mitra 14 \n 15 \nKeywords 16 \nAntenatal Depression, Mental Health in Pregnancy, Rural Bangladesh, Factors influencing 17 \nmaternal mental health, Prenatal depression, Prevalence, Associated Factors, Risk Factors, 18 \nDepression 19 \n 20 \nAbstract 21 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nBackground: According to the World Health Organization (WHO), approximately 322 million 22 \nindividuals globally were grappling with depressive disorders in 2015. During pregnancy, the 23 \nrisk of experiencing depression is elevated due to certain hormonal changes. Despite the 24 \npotentially severe consequences of antenatal depression for both the mother and newborn, there 25 \nhave been limited studies conducted on this issue in Bangladesh.  26 \nObjective: To find out the prevalence and associated factors of antenatal depression in a rural 27 \nsub-district in Bangladesh.  28 \nMethod: A cross-sectional study was performed in Lohagara, a rural subdistrict in Narail, 29 \nsituated in the southern part of Bangladesh between January 08 and 14, 2024. 350 subjects were 30 \nrecruited for the study, who were pregnant at various trimesters and attended antenatal check-ups 31 \nin a government health complex and a private hospital in Lohagara. The Bengali-translated 32 \nversion of the Edinburgh Postnatal Depression Scale (EPDS) and a structured questionnaire were 33 \nused for data collection. Data were analyzed in STATA version 14.  34 \nResult: The point prevalence of antenatal depression is 39% (38.86%, in 95% CI: 33.9% to 35 \n44%). Gestational week (AOR: 0.4, 95% CI: 0.2, 0.8), unintended pregnancy (AOR: 1.7, 95% 36 \nCI: 1, 3), intimate partner violence (AOR: 3.3, 95% CI: 1.1, 9.7), a history of previous diseases 37 \n(AOR: 2.4, 95% CI: 1.1, 5.2), and the history of having polygamous husbands (AOR: 13.6, 95% 38 \nCI: 1.1, 164) are found to be significantly associated with the development of depression in the 39 \nprenatal period. 40 \nConclusion: In rural Narail, high rates of antenatal depression underscore the importance of 41 \nincreased awareness among healthcare professionals and families. Strategic involvement of 42 \nstakeholders and policymakers is essential to address issues like intimate partner violence and 43 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\npolygamy. Moreover, there's a critical need for extra care and counseling for pregnant women 44 \nwith a history of health problems or facing unexpected pregnancies. 45 \n 46 \nIntroduction 47 \nGlobally, depression stands out as a prevalent mental health disorder, marked by symptoms such 48 \nas a low mood, changes in appetite and sleep patterns, loss of interest in activities, significant 49 \nweight fluctuations, feelings of hopelessness, concentration difficulties, low self-esteem, and 50 \nfrequent thoughts of mortality. It holds a prominent position among the top five causes of the 51 \nglobal disease burden (1). Projections suggest that by 2030, depressive disorders will likely 52 \nbecome one of the three leading contributors to the overall global burden of disease (2). 53 \nIn 2015, the World Health Organization (WHO) approximated that there were 322 million 54 \nindividuals globally experiencing depressive disorders and 27% of them were from the Southeast 55 \nAsian region (1). The risk of mental disorders, especially depression is more in females than in 56 \nmales (3). In pregnancy, the risk of depression is higher than general female population due to 57 \nhormonal changes (4). The global occurrence of antenatal depression ranges from 15% to 65% 58 \n(5). In high-income countries, the prevalence ranges from 5% to 30% (6, 7, 8), while in low-59 \nincome countries, it is 15.6% to 31.1% (9, 10, 11).  60 \nThe occurrence of depression during pregnancy in Bangladesh varies between 18% and 33%  61 \n(12), which is not too small. A recent study, carried out in a rural sub-district in Matlab, 62 \ninvolving pregnant women at their 34-35 weeks of pregnancy showed a 33% prevalence and the 63 \nassociated factors included an unsupportive husband or mother-in-law, domestic violence, and 64 \nmental pressure for male gender preference of the family (13). A recent cross-sectional study, 65 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nconducted in rural Sylhet highlighted male gender preference of husband, low family support, 66 \nand sexual violence as the main associated factors for developing antenatal depression (12). 67 \nThe consequences of depression in pregnancy can be devastating and it may affect both mother 68 \nand child. A pregnant woman experiencing depression may release a hormone called cortisol, 69 \nwhich can have detrimental effects on fetal growth and brain development (14). Women with 70 \nantenatal depression have a higher risk of developing Hyperemesis gravidarum, which increases 71 \nthe probability of miscarriage, low birth weight, and preterm birth (15). Not only that, the risk of 72 \nsubstance abuse, preeclampsia, hemorrhage, edema, postpartum depression, and severe 73 \nheadaches is higher in a woman with antenatal depression (16, 17). The neonatal outcomes of 74 \nantenatal depression are reported as low birth weight (LBW), low mean APGAR scores at 1 and 75 \n5 minutes following birth, and premature mortality (18, 19).  76 \nAntenatal depression poses a significant challenge for expectant mothers, particularly in 77 \nBangladesh. Research on this topic is predominantly limited to rural areas, with scant urban-78 \nbased studies available. Moreover, there is a notable dearth of information regarding the 79 \nprevalence of depression during different trimesters of pregnancy in Bangladesh. This gap in 80 \nresearch underscores the need for a more comprehensive understanding of antenatal depression 81 \nacross diverse geographic and demographic settings in the country. The absence of research on 82 \nantenatal depression in Narail, a southern district in Bangladesh, underscores the significance of 83 \nthis study. By shedding light on the current status of antenatal depression at the sub-district level 84 \nin Narail, this research aims to provide a crucial snapshot of the situation. The findings from this 85 \nstudy can play a pivotal role in identifying necessary interventions, informing policy-making 86 \ndecisions, and structuring health education programs. The ultimate goal is to enhance awareness 87 \nand establish effective measures for controlling antenatal depression in the future. 88 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\n 89 \nMethod 90 \nStudy Design and Setting 91 \nA cross-sectional study was performed between January 08 and 14, 2024 in Upazila Health 92 \nComplex, Lohagara, a government hospital, and Khan General Hospital, Lahuria, a private 93 \nhospital in Lohagara, a rural sub-district in Narail, situated in the southern part of Bangladesh. 94 \nStudy Participants 95 \nThe target population was pregnant mothers of any trimester in the Lohagara sub-district and the 96 \nsample population was pregnant mothers of any trimesters attending the ANC Corner of Upazila 97 \nHealth Complex, Lohagara, Narail, and Khan General Hospital, Lahuria for antenatal checkups. 98 \nSample Size and Sampling Technique 99 \nConsidering the prevalence of antenatal depression in Bangladesh is 33% according to a study 100 \nconducted in a rural sub-district in Matlab (13), 95% confidence interval, and with 5% margin of 101 \nerror, calculated sample size, /g1866/g3404 /g4666 1.96 /g4667 /g2870 /g1499\n/g2868./g2871/g2871 /g4666 /g2869/g2879/g2868./g2871/g2871 /g4667\n/g4666 /g2868./g2868/g2873 /g4667 /g3118/g3404 340  102 \nThe sampling technique was systematic sampling. Every third patient attending ANC Corner for 103 \nantenatal checkups in both government and private hospitals was selected as a participant in the 104 \ninterview for data collection. 105 \nData Collection Tools 106 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nThe presence of depression was assessed by the Bengali-translated version of the Edinburgh 107 \nPostnatal Depression Scale (EPDS). This questionnaire consists of 10 questions scoring from 0 108 \nto 30. A score of 10 or higher on the assessment indicates probable antenatal depression.  109 \nAnother structured questionnaire, which was also translated into Bengali, was used to collect 110 \ndata on the sociodemographic, obstetric, psychosocial, psychological, and disease and treatment-111 \nrelated factors of patients. The questionnaire was tested on some target population rather than the 112 \nstudy participants and the necessary changes were made before the data collection. 113 \nData Management & Analysis Plan 114 \nThe data for the study was analyzed by STATA version 14. Pearson’s chi-square test was 115 \nperformed to find out the possible association of sociodemographic, obstetric, psychosocial, 116 \ndisease, and treatment-related factors with prenatal depression.  A binary logistic regression was 117 \nalso performed to find out the crude odds ratio of variables. To adjust the confounding factors, a 118 \nmultivariate analysis using multivariate logistic regression was performed. Adjusted and 119 \nunadjusted odds ratio and their 95% CI were used as indicators strength of the association. 120 \nEthical Considerations 121 \nEthical permission was taken from the Institutional Ethics Committee of North South University 122 \nbefore data collection (Approval Number: 2023/OR-NSU/IRB/1224). Permission letters from 123 \nUpazila Health Complex, Lohagara, and Khan General Hospital, Lahuria were also obtained. 124 \nInformed written consent was obtained from pregnant mothers of 18 years or more and guardians 125 \nof pregnant women aged below 18 years before data collection. The respondents were assured of 126 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nthe confidentiality of information and also informed about the purpose, advantages, and potential 127 \nrisks of the study. 128 \n 129 \nResult 130 \nSocio-demographic Characteristics of Pregnant Mothers 131 \nIn this research involving 350 women in any trimester of gestation, with a high response rate of 132 \n98.5%, several demographic characteristics were examined. The median Edinburgh Postnatal 133 \nDepression Scale (EPDS) score was 8, with an interquartile range of 4 to 12. The respondents 134 \nhad a median age of 23 years, falling within an interquartile range of 20 to 27 years. Among the 135 \nrespondents, 5.7% (20) were below 18 years old, while a majority of 83.7% were in the age 136 \nbracket of 18 to 30 years. The rest 10.6% were over their thirties.  137 \nRegarding educational background, 26 participants (7.4%) did not have a minimum primary 138 \nlevel education. All participants were married, with the majority being housewives. However, a 139 \nsmall percentage (4%) were employed. In terms of monthly family income, 26% of women (91) 140 \nhad an income below 10,000 tk, 58% (203) had an income between 10,000 to 20,000 tk, and the 141 \nremaining 16% (56) had an earning per month exceeding 20,000 tk. 142 \nReligiously, the participants belonged to two communities, with 96.3% (337) identifying as 143 \nMuslim and 3.71% (13) as Hindu. These demographic details provide a comprehensive snapshot 144 \nof the participants in the study, offering insights into their socioeconomic and cultural 145 \nbackgrounds. 146 \nObstetric History of Pregnant Mothers 147 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nA large percentage (53.4%) of respondents were in their second trimesters. 107 women (30.6%) 148 \nwere in the third trimester, and the rest 16% (56) were passing the first trimester. In this study, 149 \nthe median age of marriage was found to be 18 years, with an interquartile range spanning from 150 \n16 to 19 years. Significantly, almost half of the participants (48.6%) reported a history of getting 151 \nmarried before the age of 18. Regarding pregnancy status, 38.6% (135) of the total expectant 152 \nmothers were experiencing pregnancy for the first time. 153 \nAmong the multiparous women, 51% (105) had undergone at least one cesarean section (46.6% 154 \nonly caesarian section, 4.4 % had both vaginal delivery and caesarian section), and 30.6% (63) 155 \nfaced complications during their previous deliveries. Additionally, 21.5% (75) of the women 156 \nreported a history of abortion, stillbirth, or intrauterine fetal death. These findings provide 157 \nimportant contextual information about the participants' marital and reproductive histories, 158 \ncontributing to a more comprehensive understanding of the factors influencing antenatal 159 \ndepression in this population. 160 \nPsychosocial Criteria of Pregnant Mothers 161 \nIn the study, 74% of the women (259) reported that their current pregnancies were planned, 162 \nwhile 26% (91) indicated the opposite. Regarding satisfaction with their husbands' behavior, the 163 \nmajority of women (50.3%) expressed moderate satisfaction, while a small proportion (4.8%) 164 \nreported poor relationship status. 165 \nConcerning relationships with in-laws, the majority (77.8%) reported good relationships, and 166 \n15.7% (55) described their relationships as moderate. However, 6% (21) of women had a history 167 \nof poor relationship status, with 1.43% (5) being separated from or having deceased parents-in-168 \nlaw. 169 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nThe study also highlighted instances of violence. Approximately 5.14% of women (19) reported 170 \nbeing victims of domestic violence, and 5.43% (18) reported experiencing sexual violence. 171 \nNotably, 10% of women (35) had faced sexual violations during the current pregnancy. 172 \nAdditionally, family dynamics played a role, with 18.6% of women (65) reporting that their 173 \nhusbands preferred male children, and 18% (63) mentioned specific demands from their in-laws 174 \nfor a male child. These findings provide insights into the social and familial factors that may 175 \ncontribute to antenatal depression in the study population. 176 \nDisease and Treatment-related History of Pregnant Mothers 177 \nAmong the 350 women, 37 (10.57%) were suffering from diseases like Diabetes Mellitus, 178 \nHypertension, Bronchial Asthma, and Thyroid disorders, while 49 (14%) had a history of at least 179 \none previous surgery other than caesarian section. 180 \nPsychological Factors of Pregnant Mothers 181 \nIn the study, a small percentage of women reported certain marital challenges. Specifically, 182 \n2.57% (9) of the women mentioned that their husbands had other wives, and a couple of women 183 \n(0.6%) indicated a history of their husbands having extra-marital relationships with other 184 \nwomen. However, none of the participants reported having such relationships themselves. These 185 \nfindings offer insights into the complex dynamics within marital relationships and potential 186 \nfactors that may contribute to antenatal depression in the studied population. 187 \nPrevalence of Depression among Pregnant Mothers           188 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nIn the study, the scores from the 30 questions of the Edinburgh Postnatal Depression Scale 189 \n(EPDS) were summed up, creating a new variable ranging from 0 to 30. The findings revealed 190 \nthat 150 (42.9%) women had none or minimal depression, and 141 women (40.29%) had mild 191 \ndepression, scoring between 7 to 13 on the EPDS. Another 43 women (12.29%) scored between 192 \n14 to 19, indicating moderate depression. Additionally, 16 women (4.57%) had severe 193 \ndepression, with scores exceeding 19. Table 1 194 \nTable 1. Extent of Depression among pregnant women in Lohagara 195 \n 196 \n 197 \n 198 \n 199 \n 200 \n 201 \nTo simplify the interpretation, the scores were further categorized into two classes: \"Having 202 \nDepression\" and \"No Depression.\" A cut-off score of 10 or more was used to indicate the 203 \npresence of depression. The results showed that nearly one in three women (38.86%, with a 95% 204 \nconfidence interval ranging from 33.9% to 44%) exhibited symptoms of depression during 205 \npregnancy. These figures highlight the prevalence and varying degrees of depression among the 206 \nstudy participants Error! Reference source not found.. 207 \nExtent of Antenatal Depression \nClass EPDS score n % \nNone or minimal Depression 0-6 150 42.9 \nMild Depression 7-13 141 40.3 \nModerate Depression 14-19 47 13.4 \nSevere depression 20-30 12 3.4 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nTable 2. Prevalence of Antenatal Depression in Lohagara 208 \nPrevalence of Antenatal Depression \nDepression EPDS score n % \nYes 10-30 136 38.86 \nNo 0-9 214 61.14 \n 209 \nFactors associated with Antenatal Depression 210 \nSociodemographic, Obstetric, Psychosocial, Psychological, and Disease and treatment-related 211 \nfactors were used to identify the factors that were significantly associated with the development 212 \nof depression in pregnancy. Among the variables, gestational week, number of pregnancies, type 213 \nof pregnancy, relationship with husband as well as in-laws, history of domestic and sexual 214 \nviolence, having a husband with multiple marriages, and history of previous disease were found 215 \nstatistically significant with a p-value <0.05 in the chi-square test Table 3.  216 \nTable 3. Factors associated with antenatal depression in women visiting for antenatal 217 \ncheck-ups in UHC, Lohagara, and Khan General Hospital, Lahuria from July to August 218 \n2023 (bivariate analysis by chi-squared test). 219 \nVariables Category \nNo \nDepression \nMild \nDepression \nModerate \ndepression \nSevere \nDepression \nChi2 p-\nvalue \nGestational \nweek \n<12 weeks \n14 \n 9.3% \n30  \n21.3% \n10 \n 21.3% \n2 \n 16.7% \n0.026 \n12-28 weeks \n92  \n61.3% \n74  \n52.5% \n15 \n 31.9% \n6 \n 50% \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\n29-40 weeks \n44 \n 29.3% \n37  \n26.2% \n22  \n46.8% \n4 \n 33.3% \nPara \nNulliparous \n68  \n45.3% \n48 \n 34.4% \n16 \n 34.4% \n3 \n 25% \n0.005 \nMultiparous \n82  \n54.7% \n93 \n 66% \n31 \n 66% \n9 \n 75% \nType of \npregnancy \nPlanned \n123  \n82% \n97  \n68.8% \n35 \n \n 72.3% \n4 \n 33.3% \n0.002 \nUnplanned \n27  \n18% \n44 \n 21.2% \n12 \n 27.7% \n8 \n 66.7% \nRelationship \nwith \nhusband \nGood \n72  \n48% \n60 \n 42.6% \n22  \n46.8% \n3 \n 25% \n0.017 Moderate \n73 \n 48.7% \n78 \n 55.3% \n20  \n42.6% \n5 \n 41.7% \nPoor \n5 \n 3.3% \n3 \n 2.1% \n5 \n 10.6% \n4 \n 33.3% \nRelationship \nwith in-laws \nGood \n128 \n85.3% \n110 \n 78% \n28 \n 79.6% \n3 \n 25% \n0.001 \nModerate \n16  \n10.7% \n24 \n 17% \n12 \n 25.5% \n3 \n 25% \nPoor \n5  \n3.3% \n4  \n2.8% \n7  \n14.9% \n5 \n 41.7% \nDead/Separated \n1 \n0.7% \n3 \n 2% 0 \n1 \n 8.3% \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nDomestic \nviolence \nYes \n5 \n 3.3% \n7 \n5% \n4  \n8.5% \n2  \n16.7% \n0.047 \nNo \n145  \n96.7% \n134  \n95% \n43 \n 91.5% \n10 \n 83.3% \nSexual \nviolence \nYes \n4  \n2.7% \n9  \n6.4% \n3  \n6.4% \n3 \n25% \n0.007 \nNo \n146  \n97.3% \n132  \n93.6% \n44  \n93.6% \n9  \n 75% \nPolygamous \nhusband \nYes \n1 \n \n0.7% \n4  \n2.8% \n1  \n2% \n3 \n 25% \n0.002 \nNo \n149  \n99.3% \n137  \n97.2% \n46 \n 97.9% \n9  \n75% \nPrevious \ndisease \nYes \n9 \n 6% \n18 \n 12.8% \n7 \n 14.9% \n3 \n 25% \n0.007 \nNo \n141 \n 94% \n123  \n87.2% \n40 \n 85% \n9  \n75% \n 220 \nA binary logistic regression was also performed to find out the odds ratio of variables Table 4. 221 \nThese covariates were then considered for the multiple logistic regression analysis. 222 \nTable 4. Factors associated with prenatal depression among women attending antenatal 223 \ncare in UHC, Lohagara and Khan General Hospital, Lahuria from June to August 2023 224 \n(after bivariate and multivariate regression analysis). 225 \nVariables Category Depression No COR AOR  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nDepression  (95% CI) (95% CI) \nGestational \nweek \n<12 weeks 30  26 1 1 \n12-28 weeks 63  124 \n0.4 (0.2, \n0.8) \n0.4 (0 .2,0 .8) \n29-40 weeks 43  64 \n0.6 (0.3, \n1.1) \n0.6 (0.3, 1.2) \nPara \nNulliparous 40  95 \n0.5 (0.3, \n0.8) \n0.9 (0.5,1.5) \nMultiparous 96  119 1 1 \nType of \npregnancy \nPlanned 88  171 1 1 \nUnplanned 48  43 \n2.2 (1.4, \n3.6) \n1.8 (1, 3.1) \nRelationship \nwith husband \nGood 55  102 1 1 \nModerate 69  107 \n1.2 (0.8, \n1.9) \n1.2(0.7, 1.9) \nPoor 12  5 \n4.5 (1.3, \n13.3) \n1.6 (0.3, 8.9) \nRelationship \nwith in-laws \nGood 91\n 178 \n0.3 (0.06, \n2.08) \n2.6 (0.2, 38.7) \nModerate 27  28 0.6 (0.1, 4) 4.7 (0.3, 71.7) \nPoor 15  6 \n1.7 (0.2, \n12.6) \n11.2 (0.6, 194) \nDead/ 3  2 1 1 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nSeparated \nDomestic \nviolence \nYes 11  7 2.6 (1, 6.9) 1.2 (0.3, 5.7) \nNo 125  207 1 1 \nSexual violence \nYes 13  6 \n3.7 (1.4, \n9.9) \n3.3 (1.1, 9.6) \nNo 123  208 1 1 \nPolygamous \nhusband \nYes 8  1 \n13.3 (1.6, \n107.7) \n13.6 (1.1,163) \nNo 128  213 1 1 \nPrevious \ndisease \nYes 22  15 \n2.6 (1.3, \n5.1) \n2.4 (1.1, 5.3) \nNo 114  199 1 1 \n 226 \nGestational weeks, intimate partner violence, unwanted pregnancy, a history of previous disease, 227 \nand multiple married husbands were found to be significantly associated with the development of 228 \ndepression in pregnancy. Those who were in their 2nd trimester of pregnancy had 60% less 229 \nchance of developing antenatal depression than those who were in the first trimester. (AOR: 0.4, 230 \n95% CI: 0.2, 0.8) Table 5.  231 \nTable 5. Multivariate logistic regression of possible factors associated with antenatal 232 \ndepression in women visiting for antenatal check-ups in UHC, Lohagara, and Khan 233 \nGeneral Hospital, Lahuria from July to August 2023. 234 \nVariables Category Reference Odds P>|z| \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nCategory ratio \nGestational week \n13-28 \n<13 \n0.40967 0.008 \n>28 0.59227 0.15 \nPara Nulliparous Multiparous 0.88095 0.633 \nType of pregnancy Unplanned Planned 1.81135 0.027 \nRelationship with husband \nModerate \nGood \n1.15832 0.562 \nPoor 1.59752 0.593 \nRelationship with in-laws \nGood \nDead/ Separated \n1.85478 0.653 \nModerate 3.57372 0.363 \nPoor 8.56358 0.098 \nDomestic violence Yes No 1.2175 0.803 \nSexual violence Yes No 3.09672 0.03 \nPolygamous husband Yes No 13.6921 0.04 \nHistory of previous diseases Yes No 2.56009 0.025 \n 235 \nAmong the pregnant women suffering from depression, 53.6% (30) were in the first trimester. 236 \n33.7% (60) of prenatally depressed women were between 13 to 28 weeks of gestation. 40% (43) 237 \nwere passing their 3rd trimester of pregnancies. 238 \nThe odds ratio revealed three times increase in expectant women who had a history of 239 \nexperiencing intimate partner violence than those who did not have (AOR: 3.3, 95% CI: 1.1, 240 \n9.7). 241 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nWomen facing intimate partner violence showed elevated levels of various forms of antenatal 242 \ndepression. Roughly 21% (4) of pregnant women with a background of intimate partner violence 243 \ndid not experience depression or had minimal symptoms, 47.4% (9) had mild depression, 15.8% 244 \n(3) had moderate depression, and another 15.8% (3) dealt with severe depression. 245 \nType of pregnancy was also an important contributing factor as the odds ratio raised about two 246 \ntimes in cases of unplanned pregnancy (AOR: 1.8, 95% CI: 1, 3).  247 \nwomen had a history of unplanned pregnancy. Among them, 52.8% (48) were experiencing 248 \nprenatal depression. 34% (98) of the total 259 expectant mothers having a history of intended 249 \npregnancies, were suffering from antenatal depression.  250 \nThe incidence of moderate depression was nearly identical in both intended and unintended 251 \npregnancies, ranging from 13.2% to 13.5%. However, in the case of unwanted pregnancies, the 252 \nrates of mild and severe depression were higher (mild depression: 48.4%, severe depression: 253 \n8.8%). Out of the 91 women with a history of unintended pregnancies, 48.4% (44) reported mild 254 \ndepression, 13.2% (12) experienced moderate depression, and 8.8% (8) had severe depression. 255 \nAdditionally, 29.7% (27) showed no or minimal signs of depression. 256 \nIn contrast, among the total of 259 women with planned pregnancies, 37.5% (97) were dealing 257 \nwith mild depression, 13.5% (35) reported moderate depression, and 1.5% (4) experienced 258 \nsevere depression. Moreover, 47.5% (123) exhibited no or minimal signs of depression. 259 \nWomen suffering from a disease from the past showed a 2 times escalated odds ratio than those 260 \nwho were free from any medical condition (AOR: 2.4, 95% CI: 1.1, 5.2).  261 \nOut of the pregnant women undergoing prenatal depression, 59.5% (22) had a history of prior 262 \ndiseases or illnesses. Within this group, 48.7% (18) were dealing with mild depression, 19% (7) 263 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nwith moderate depression, and 8.1% (3) with severe depression. Additionally, 24% (9) showed 264 \nno or minimal signs of depression. 265 \nOn the other hand, pregnant women married to husbands who have multiple wives unveiled a 13 266 \ntimes higher odds ratio than those having single-married husbands (AOR: 13.6, 95% CI: 1.1, 267 \n164). 268 \nApproximately 89% (8) of women with a history of multiple-married husbands were grappling 269 \nwith prenatal depression. Within this group, approximately 55.6% (5) were undergoing mild to 270 \nmoderate depression, while the remaining 33.3% (3) were dealing with severe depression during 271 \npregnancy. The rest 11.1% did not experience depression or had minimal symptoms. 272 \n 273 \nDiscussion 274 \nThis study aimed to assess the prevalence and evaluate the sociodemographic, obstetric, 275 \npsychosocial, psychological, and disease and treatment-related determinants associated with the 276 \ndevelopment of antenatal depression in a rural subdistrict in Narail. The point prevalence of 277 \nantenatal depression accounted for 39% (38.86%, 95% confidence interval: 33.9% to 44%) in 278 \nthis study. The elevated odds ratio of Antenatal Depression Syndrome (ADS) is attributed to 279 \nseveral significant social determinants, including sexual violence, and unplanned pregnancy. 280 \nAdditionally, having a polygamous husband is identified as a crucial psychological factor, while 281 \na history of previous disease serves as a notable disease and treatment-related factor contributing 282 \nto the increased odds of ADS. Gestational week is an important obstetric factor associated with 283 \ndepression in pregnancy. 284 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nThe obtained prevalence of depression in pregnancy in this study is in agreement with the 285 \nprevalence in lower (34.0%, 95% Confidence Interval: 33.1%-34.9%)  and middle-income 286 \ncountries ( 22.7%, 95% Confidence Interval: 20.1%-25.2%) (20). The result of this study also 287 \naligns with the study conducted by Gausia et al. (33%, 95% CI, 27.6–37.5) (13), and Tasnim et 288 \nal. (36.2% in patients with GDM) (21), and that is perhaps because of similar locations. 289 \nHowever, this is higher than the study of Nasreen et al. (18.3%, 95% CI:15.9%-20.7%) (22). 290 \nThat is probably because of the differences in the research methodology like sample size and 291 \nstudy area. This study was conducted in Narail, which is a district of Khulna division, while the 292 \nstudy conducted by Nasreen et al. was in the Mymensingh division, and there was a significant 293 \ngap between the period of conduction of both studies. The sample sizes are also different from 294 \neach other. Another study was conducted in a rural district in Sylhet which showed a higher 295 \nprevalence (56.6%, 95.5% CI 50.0–63.0%) of ADS than the prevalence obtained from this study. 296 \nThe reason behind this distinction can be the difference in the location and number of 297 \nparticipants involved. A majority of women in the Khulna division, specifically 88.6%, have no 298 \nmore than a primary education. 61% of mothers are unaware of the presence of Maternal Health 299 \nClinics (MHC) in this area, and 36% of them are receivers of any form of antenatal care (ANC) 300 \nonly. Additionally, ANC services from government healthcare facilities are sought by 47% of 301 \nexpectant mothers. Regardless of potential complications and warning signs, 95% of births 302 \nusually take place at home that are assisted by untrained birth attendants. Merely, postnatal care 303 \n(PNC) is provided among 19.75% of mothers and 12.3% of infants. Multiple factors contribute 304 \nto the limited utilization of Maternal Health Clinic (MHC) services, including poor 305 \ncommunication, insufficient awareness of MHC services, limited financial resources, decision-306 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nmaking processes, and the absence of a companion for accessing healthcare services (23). On the 307 \nother hand, variations in the sample sizes are also an influencing factor for the differences. 308 \nViolence is a common problem in Bangladesh and it is one of the countries having the highest 309 \nrecords of violence (24). Intimate partner violence was revealed as a significant contributing 310 \nfactor in many studies which include domestic and sexual violence. It encompasses various 311 \nforms of abusive behavior, including physical violence that occurs at any point in the 312 \nrelationship, instances of forced sexual activity, and physical violence specifically during 313 \npregnancy. (25). 37% of women living in cities and half of the village women are sufferers of 314 \nlifetime sexual violence. Causes include the history of physical abuse of mothers-in-law by 315 \nfathers-in-law, The degree of husband's controlling conduct, and the occurrence of forced or 316 \ncoerced initial sexual activity. In rural areas, the likelihood of this violence increased when 317 \nwomen were between the ages of 20-24 as opposed to 15-19 and when there was a dowry 318 \ndemand during marriage (26). In Bangladesh, a percentage of women believe, their husbands 319 \nhave the right to raise their hands on them. Some women, who have been seeing their mothers 320 \nbecome dominated and being hit by their fathers for a long time, take it easy to believe that their 321 \nhusbands can not only dominate them but also bear the right to beat them. These two groups of 322 \nwomen are more likely to be the victims of intimate partner violence (27). This study found 323 \nintimate partner violence as a significant contributing factor to antenatal depression which is 324 \nsimilar to the study conducted by Peltzer et al. in Thailand and Insan et al. in Bangladesh (12, 325 \n28). 326 \nThis study obtained unplanned pregnancy as a responsible factor for antenatal depression. 327 \nBrazilian women who have experienced unplanned pregnancies face a 2.5 times higher risk of 328 \nexperiencing depression during both pregnancy and the postpartum period compared to their 329 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\ncounterparts who have had planned pregnancies (29). Postnatal depressive symptoms among 330 \nsocio-economically disadvantaged rural Bangladeshi women are notably linked to the perception 331 \nof paternal pregnancy unwantedness and couple pregnancy discordance. Additionally, maternal 332 \nintentions and pregnancy discordance are associated with prenatal depressive symptoms in this 333 \npopulation (30). A study conducted by Surkan et al. in northwestern Bangladesh and another 334 \nstudy conducted by Gausia et. al in eastern Bangladesh showed that unwanted pregnancy is a 335 \nsignificantly associated factor of antenatal depression which is similar to this study (13, 30). 336 \nWithin the realm of obstetric factors, the gestational week emerges as a notable element 337 \ninfluencing the onset of prenatal depression. The study reveals a substantial decrease in the 338 \nlikelihood of developing depression, amounting to a 60% reduction during the second trimester 339 \ncompared to the first trimester. This aligns with findings from a systematic review and meta-340 \nanalysis conducted by Okagbue et al., encompassing 26 articles, which underscores that the 341 \nprevalence of antenatal depression tends to be lower between the 13th and 28th weeks of 342 \ngestation (31). 343 \nWhile some studies have identified family support and a preference for the male gender within 344 \nfamilies as significant contributing factors to prenatal depression (12, 13), this particular study 345 \ndid not observe such associations. It suggests that with the progression of time, contemporary 346 \nfamily members may be more attentive and supportive of pregnant mothers than in the past. 347 \nAdditionally, the inclination toward preferring male children within families appears to be less 348 \nprevalent today compared to historical trends. This study specifically noted that 18.5% (65) of 349 \nwomen reported a history of male baby preference from their husbands, and 18% (63) from their 350 \nfamilies. However, a substantial majority, around 82%, did not report any history of a preference 351 \nfor male children from either their husbands or family members. 352 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nHowever, unlike other studies, this study identified noteworthy connections between a previous 353 \nhistory of any disease and having a polygamous husband with depression during pregnancy. In a 354 \nstudy carried out by Nasreen et al. in rural sub-districts of Mymensingh, a significant correlation 355 \nwas identified between a previous history of depression and prenatal depression (22). This 356 \nresearch revealed that women with a previous mental health condition, as well as those with a 357 \nhistory of other ailments such as Diabetes mellitus, Hypertension, and Thyroid disorders, are 358 \nprone to experiencing depression during pregnancy. 359 \nLimitations 360 \nIn summary, this study faced limitations primarily stemming from a small and constrained 361 \nsample size due to time and resource limitations. The study was carried out with women 362 \nattending antenatal check-ups at a particular government and private hospital in Lohagara. 363 \nNevertheless, there could be a subset of women who do not seek medical attention throughout 364 \ntheir entire pregnancy unless they experience extreme physical challenges. In many instances, 365 \nthese women opt for home deliveries assisted by unskilled birth attendants, bypassing hospitals 366 \nduring childbirth. For this reason, the findings may not fully capture the diversity of the entire 367 \ncommunity population, limiting the generalizability of obtained results.  368 \n 369 \nConclusion 370 \nIn conclusion, the prevalence and associated factors of antenatal depression in rural Bangladesh 371 \nhighlight a critical public health concern with far-reaching consequences for both mothers and 372 \nnewborns. Antenatal depression is frequently observed in the rural areas of Bangladesh, 373 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nemphasizing the importance of increasing awareness among healthcare professionals and family 374 \nmembers. This awareness is crucial to offer additional mental support to pregnant women, 375 \nespecially in their first and third trimesters of gestation. Furthermore, formulating strategic plans 376 \nand policies is essential to reduce intimate partner violence and discourage polygamy. The 377 \nsituation also underscores the necessity of providing extra care to mothers with a history of 378 \nhealth-related issues and offering additional counseling to those who find themselves 379 \nunexpectedly pregnant. 380 \nTo effectively tackle this issue, it is imperative for the government, stakeholders, and 381 \npolicymakers to collaborate on comprehensive national programs and health education 382 \ncampaigns. Resource allocation and the formulation of definitive policies are crucial steps 383 \ntoward raising awareness and destigmatizing mental health concerns in rural communities. By 384 \naddressing the root causes and promoting a proactive approach to mental health, we can work 385 \ntowards reducing the prevalence of antenatal depression and ultimately safeguarding the well-386 \nbeing of both mothers and newborns in rural Bangladesh. 387 \n 388 \nSupporting Information 389 \nS1 File. Dataset. 390 \nhttps://doi.org/10.6084/m9.figshare.24994110 (xlsx) 391 \nAcknowledgement 392 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\nI am profoundly thankful to the Almighty for granting me the opportunity to pursue MPH 393 \n(Epidemiology) at North South University. I am also grateful to North South University for 394 \nallowing me to do the research for the partial fulfillment of my MPH degree. My gratitude 395 \nextends to my supervisor, Dr. Dipak Kumar Mitra, Ph.D., MPH, MBBS, the current chairman of 396 \nthe Department of Public Health at North South University, for his kind advice and guidance. I 397 \nam greatly thankful to Dr.S M Mashud, UH&FPO, Upazila Health Complex, Lohagara, for his 398 \nwonderful guidance and unwavering support to carry out the study.  399 \n 400 \nReferences 401 \n1. World Health Organization. Depression and other common mental disorders: global health 402 \nestimates. 2017. 403 \n2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. 404 \nPLoS medicine. 2006;3(11):e442. 405 \n3. Kuehner C. Gender differences in unipolar depression: an update of epidemiological findings and 406 \npossible explanations. Acta Psychiatrica Scandinavica. 2003;108(3):163-74. 407 \n4. Osman NN, Bahri AI. Impact of altered hormonal and neurochemical levels on depression 408 \nsymptoms in women during pregnancy and postpartum period. Journal of Biochemical Technology. 409 \n2019;10(1):16. 410 \n5. Dadi AF, Miller ER, Bisetegn TA, Mwanri L. Global burden of antenatal depression and its 411 \nassociation with adverse birth outcomes: an umbrella review. BMC public health. 2020;20:1-16. 412 \n6. Mukherjee S, Trepka MJ, Pierre-Victor D, Bahelah R, Avent T. Racial/ethnic disparities in 413 \nantenatal depression in the United States: A systematic review. Maternal and child health journal. 414 \n2016;20:1780-97. 415 \n7. Chatillon O, Even C. La dépression de l’antepartum: prévalence, diagnostic, traitement. 416 \nL'Encéphale. 2010;36(6):443-51. 417 \n8. Mitchell-Jones N, Gallos I, Farren J, Tobias A, Bottomley C, Bourne T. Psychological morbidity 418 \nassociated with hyperemesis gravidarum: a systematic review and meta-analysis. BJOG: An International 419 \nJournal of Obstetrics & Gynaecology. 2017;124(1):20-30. 420 \n9. Biaggi A, Conroy S, Pawlby S, Pariante CM. Identifying the women at risk of antenatal anxiety 421 \nand depression: a systematic review. Journal of affective disorders. 2016;191:62-77. 422 \n10. Minamoto VB, Suzuki KP, Bremner SN, Lieber RL, Ward SR. Dramatic changes in muscle 423 \ncontractile and structural properties after 2 botulinum toxin injections. Muscle & nerve. 2015;52(4):649-424 \n57. 425 \n11. Woody C, Ferrari A, Siskind D, Whiteford H, Harris M. A systematic review and meta-regression 426 \nof the prevalence and incidence of perinatal depression. Journal of affective disorders. 2017;219:86-92. 427 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\n12. Insan N, Forrest S, Jaigirdar A, Islam R, Rankin J. Social Determinants and Prevalence of 428 \nAntenatal Depression among Women in Rural Bangladesh: A Cross-Sectional Study. International Journal 429 \nof Environmental Research and Public Health. 2023;20(3):2364. 430 \n13. Gausia K, Fisher C, Ali M, Oosthuizen J. Antenatal depression and suicidal ideation among rural 431 \nBangladeshi women: a community-based study. Archives of women's mental health. 2009;12:351-8. 432 \n14. Franke K, Bergh Bvd, de Rooij SR, Roseboom TJ, Nathanielsz PW, Witte OW, et al. Effects of 433 \nprenatal stress on structural brain development and aging in humans. bioRxiv. 2017:148916. 434 \n15. Hoirisch-Clapauch S, Brenner B, Nardi AE. Adverse obstetric and neonatal outcomes in women 435 \nwith mental disorders. Thrombosis Research. 2015;135:S60-S3. 436 \n16. Horrigan TJ, Schroeder AV, Schaffer RM. The triad of substance abuse, violence, and depression 437 \nare interrelated in pregnancy. Journal of substance abuse treatment. 2000;18(1):55-8. 438 \n17. Bitew T, Hanlon C, Kebede E, Honikman S, Fekadu A. Antenatal depressive symptoms and 439 \nperinatal complications: a prospective study in rural Ethiopia. BMC psychiatry. 2017;17:1-12. 440 \n18. Yedid Sion M, Harlev A, Weintraub AY, Sergienko R, Sheiner E. Is antenatal depression 441 \nassociated with adverse obstetric and perinatal outcomes? The Journal of Maternal-Fetal & Neonatal 442 \nMedicine. 2016;29(6):863-7. 443 \n19. Imran N, Haider II. Screening of antenatal depression in Pakistan: risk factors and effects on 444 \nobstetric and neonatal outcomes. Asia-Pacific Psychiatry. 2010;2(1):26-32. 445 \n20. Fekadu Dadi A, Miller ER, Mwanri LJPo. Antenatal depression and its association with adverse 446 \nbirth outcomes in low and middle-income countries: a systematic review and meta-analysis. 447 \n2020;15(1):e0227323. 448 \n21. Tasnim Sd, Auny FM, Hassan Y, Yesmin R, Ara I, Mohiuddin MS, et al. Antenatal depression 449 \namong women with gestational diabetes mellitus: a pilot study. Reproductive Health. 2022;19(1):71. 450 \n22. Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Prevalence and associated factors of depressive and 451 \nanxiety symptoms during pregnancy: a population based study in rural Bangladesh. BMC women's 452 \nhealth. 2011;11(1):1-9. 453 \n23. Haque MA, Dash SK, Chowdhury MABJBph. Maternal health care seeking behavior: the case of 454 \nHaor (wetland) in Bangladesh. 2016;16(1):1-9. 455 \n24. García-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts C. WHO multi-country study on 456 \nwomen’s health and domestic violence against women: World Health Organization; 2005. 457 \n25. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CHJTl. Prevalence of intimate partner 458 \nviolence: findings from the WHO multi-country study on women's health and domestic violence. 459 \n2006;368(9543):1260-9. 460 \n26. Naved RTJAosb. Sexual violence towards married women in Bangladesh. 2013;42:595-602. 461 \n27. Islam TM, Tareque MI, Sugawa M, Kawahara KJJofv. Correlates of intimate partner violence 462 \nagainst women in Bangladesh. 2015;30:433-44. 463 \n28. Peltzer K, Pengpid S. Associations between intimate partner violence, depression, and suicidal 464 \nbehavior among women attending antenatal and general outpatients hospital services in Thailand. 465 \nNigerian journal of clinical practice. 2017;20(7):892-9. 466 \n29. Faisal-Cury A, Menezes PR, Quayle J, Matijasevich A. Unplanned pregnancy and risk of maternal 467 \ndepression: secondary data analysis from a prospective pregnancy cohort. Psychology, health & 468 \nmedicine. 2017;22(1):65-74. 469 \n30. Surkan PJ, Strobino DM, Mehra S, Shamim AA, Rashid M, Wu LS-F, et al. Unintended pregnancy 470 \nis a risk factor for depressive symptoms among socio-economically disadvantaged women in rural 471 \nBangladesh. BMC pregnancy and childbirth. 2018;18:1-13. 472 \n31. Okagbue HI, Adamu PI, Bishop SA, Oguntunde PE, Opanuga AA, Akhmetshin EM. Systematic 473 \nreview of prevalence of antepartum depression during the trimesters of pregnancy. Open access 474 \nMacedonian journal of medical sciences. 2019;7(9):1555. 475 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint \n\n 476 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted May 31, 2024. ; https://doi.org/10.1101/2024.05.30.24308225doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}