The prevalence of mental ill-health in women during pregnancy and after childbirth during the Covid-19 pandemic: a systematic review and Meta-analysis.

A systematic methodology was developed along with a relevant protocol that was peer reviewed and published in PROSPERO (CRD42021235356). The search criteria were developed based upon the research question using PubMed, Science Direct, Ovid PsycINFO and EMBASE databases. A wide search criterion was used to ensure the inclusion of all pregnant women with existing gynaecological conditions. The MeSH terms used include (COVID) OR (SARS-CoV-2) AND (SARS) AND (MERS) AND ((mental health) OR (depression) OR (anxiety) OR (PTSD) OR (psychosis) OR (unipolar) OR (bipolar)) AND ((PCOS) OR (fibroid) OR (endometriosis) OR (pre-eclampsia) OR (still birth) OR (GDM) OR (preterm birth) OR (women’s health) OR (pregnant women) OR (pregnancy)). All studies published in English were included from 20th December 2019 to 31st July 2021. Screening and data extraction were performed by two authors independently. Initially, titles and abstracts were reviewed to determine the relevance. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) diagram was completed based on the eligibility steps completed (see Fig. 1 ). Fig. 1 PRISMA Flow Chart outlining search strategy. Legend. The above PRISMA flow chart outlines the study search strategy for both the systematic review and meta-analysis PRISMA Flow Chart outlining search strategy. Legend. The above PRISMA flow chart outlines the study search strategy for both the systematic review and meta-analysis All COVID-19, SARS and MERS studies that evaluated the mental health of pregnant women with/without gynaecological conditions that were reported in English between December 2000 – July 2021 were included. All other studies were excluded from this analysis. Full texts of the included papers were reviewed to extract the following data: time and locations of the study, participants demographics, sample size, mean age, gestation, days since childbirth, prevalence of mental symptoms, data collection tools used, and cut-offs scores applied. Any disagreements were discussed and resolved by consensus between two authors. For studies with both COVID-19 and non-COVID-19 cohort, we only used data of the COVID-19 cohort and the p -value comparing them. Studies from SARS and MERS were also reviewed in full to ensure the eligibility criteria was met. Studies reporting mean (SD) or median (IQR) of the scales measuring mental symptoms instead of prevalence rates were included and a simulation method assuming normal distribution was applied to generate the corresponding prevalence rates. A risk of bias (RoB) table assessment was completed to demonstrate the risk of bias within the studies used in the systematic review and meta-analysis. The RoB is reflective of a fixed set of biases within domains of study design, conduct and reporting. This combined with the quality check allows the findings of the study to be scientifically justified, and clinically viable. The Newcastle-Ottawa-Scale (NOS) was used to assess the RoB for all systematically included studies as demonstrated within the RoB table (See Page 33, Table  1 ). Table 1 Risk of Bias for all included studies First author Symptom(s) Selection Compara bility Exposure /outcome Total Lebel C Anxiety; depression 4 0 2 6 Ayaz R Anxiety 3 0 3 6 Durankuş F Anxiety; depression 3 0 2 5 Liu X Anxiety 5 2 2 9 Mappa I Anxiety 4 0 2 6 López-Morales H Anxiety; depression 3 2 2 7 Salehi L Anxiety 3 0 2 5 Gur RE Anxiety; depression 4 2 2 8 Ng QJ Anxiety; depression; stress 5 0 2 7 Effati-Daryani F Anxiety; depression; stress 4 2 2 8 Ravaldi C Anxiety 2 0 2 4 Zhou Y Anxiety; depression; PTSD; sleep disorders 3 2 2 7 Kahyaoglu Sut H Anxiety; depression 3 2 2 7 Sinaci S Anxiety 4 1 2 7 Dong H Anxiety; depression 3 2 2 7 Hocaoglu M Anxiety; PTSD 4 0 3 7 Yue C Anxiety 4 1 2 7 Taubman-Ben-Ari O Anxiety 2 0 2 4 Maharlouei N Anxiety 2 0 2 4 Milne SJ Anxiety 1 0 1 2 Ceulemans M Anxiety; depression; stress 4 2 2 8 Yassa M Anxiety 3 0 1 4 Jiang H Anxiety; depression; stress 4 2 2 8 Mayeur A Anxiety 2 0 2 4 Lin W Anxiety; depression 4 2 2 8 Yang X Anxiety; depression 4 0 2 6 Akgor U Anxiety; depression 4 0 2 6 Preis H Anxiety; stress 3 2 2 7 Dagklis T Anxiety; depression 4 0 2 6 Esteban-Gonzalo S Anxiety 4 2 2 8 Koyucu RG Anxiety; depression; stress 3 0 2 5 Liu J Anxiety; depression 3 2 2 7 Cao Y Anxiety; depression 3 0 2 5 Mappa I Anxiety 4 0 2 6 Mehdizadehkashi A Anxiety 4 0 3 7 Yirmiya K Anxiety; depression; stress 3 2 2 7 Xie M Anxiety; depression; sleep disorders 3 0 1 4 Ge Y Anxiety 3 0 2 5 López-Morales H Anxiety; depression 3 2 2 7 Puertas-Gonzalez JA Anxiety; depression; stress 4 2 2 8 Çolak S Anxiety; depression; stress 4 0 2 6 Xu K Anxiety; depression; stress; sleep disorders 4 2 2 8 Zilver SJM Anxiety; depression; stress 4 2 2 8 Maharlouei N Anxiety; depression; stress 4 0 2 6 Harrison V Anxiety; depression 4 0 2 6 Saadati N Anxiety 4 0 2 6 Wang Q Anxiety; depression 4 2 2 8 Behmard V Anxiety 4 2 2 8 Hamzehgardeshi Z Anxiety; depression 4 2 2 8 Jelly P Anxiety 4 0 2 6 Wang Q Anxiety; depression 5 0 2 7 Zhang Y Anxiety; stress 4 1 2 7 Masjoudi M Anxiety; stress 4 1 2 7 Shangguan F Anxiety; stress 3 2 2 7 Tsakiridis I Anxiety; depression 4 0 2 6 Brik M Anxiety 1 0 1 2 Effati-Daryani F Anxiety; depression; stress 4 0 2 6 Lubián López DM Anxiety 4 0 2 6 Maleki A Anxiety 4 0 2 6 Khoury JE Anxiety; depression; stress; sleep disorders 4 2 2 8 Suárez-Rico BV Anxiety 3 0 2 5 Obata S Anxiety; depression 3 2 2 7 Mo PKH Anxiety; depression 4 2 2 8 Wu F Anxiety; depression 4 2 2 8 Ding W Anxiety 4 0 2 6 Mirzaei N Anxiety; depression 4 0 2 6 Ramirez Biermann C Anxiety; depression 1 0 1 2 Palalioglu RM Anxiety 3 0 2 5 Molgora S Anxiety; depression 4 0 2 6 Patabendige M Anxiety; depression 4 0 1 5 Zeng X Anxiety; depression; sleep disorders 4 2 2 8 Nurrizka RH Anxiety 2 0 2 4 Wu Y Depression 4 2 3 9 Wang Y Depression; PTSD 3 1 2 6 Medina-Jimenez V Depression; stress 4 0 2 6 Matsushima M Depression 4 0 2 6 Gildner TE Depression 4 0 2 6 Shayganfard M Depression; stress 4 0 2 6 Silverman ME Depression 3 0 3 6 Muhaidat N Depression 3 0 2 5 Thayer ZM Depression 4 2 2 8 Zhang CJP Depression; PTSD 4 2 2 8 Khamees RE Depression 4 0 2 6 Silverman ME Depression 3 0 2 5 Shahid A Depression; sleep disorders 4 0 1 5 Ionio C Depression 4 0 2 6 Overbeck G Depression 3 2 2 7 Kachi Y Depression 3 2 2 7 Smith CL Depression; stress 2 2 2 6 King LS Depression 2 2 1 5 Korukcu O Depression 4 0 2 6 Zhou Y Depression 4 2 2 8 Chaves C Depression 4 0 2 6 Davis JA Stress 4 2 3 9 Ionio C PTSD 4 0 2 6 Basu A PTSD 4 2 2 8 Kara P PTSD 4 0 2 6 Wang J Sleep disorders 4 2 2 8 The above table outlined the risk of bias results for all studies included within this paper. Firth author and symptoms of mental health are displayed. Four outcome measures assessing risk of bias are also shown Risk of Bias for all included studies The above table outlined the risk of bias results for all studies included within this paper. Firth author and symptoms of mental health are displayed. Four outcome measures assessing risk of bias are also shown Random effects model with restricted maximum-likelihood estimation method was applied for the meta-analysis and I-square statistic was used to evaluate heterogeneity across studies. The pooled prevalence rates of symptoms of anxiety, depression, PTSD, stress, and sleep disorders with 95% confidence interval (CI) were computed. Subgroup analysis was conducted based on pregnancy trimester. Sensitivity analysis was performed to assess the robustness of the results. Potential publication bias was assessed with funnel plot and Egger’s test. Analyses were conducted with the R studio (version 1.4.17.17) and STATA 16.1.

Our initial search identified a total of 1603 papers and 523 studies were excluded after screening by titles and abstracts. After full-text evaluation, 217 were included in the systematic review and 99 studies were included in the meta-analysis. The PRISMA flowchart was illustrated in Fig.  1 . A total of 217 COVID-19 studies were included and 99 studies were meta-analysed. These studies were reported from various parts of the world, as indicated in the characteristics (See page 35 for Tables  2 and 3 ). We did not identify SARS and MERS studies that were suitably aligned to the eligibility criteria of our study. Table 2 Outline of all studies in the systematic review and meta-analysis ID Authors Publication Year Country Sample size p -value 1 Wu Y [ 9. ] 2020 China 1285 0.01 2 Durankuş F [ 10. ] 2020 Turkey 260 N/A 3 Moyer CA [ 11. ] 2020 United States 2740 p  < 0.001 4 Zanardo V [ 12. ] 2020 Italy 91 p  < 0.001 5 López-Morales H [ 13. ] 2021 Argentina 43 N/A 6 Salehi L [ 14. ] 2020 Iran 220 N/A 7 Pariente G [ 15. ] 2020 Israel 223 0.002 8 Ostacoli L [ 16. ] 2020 Italy 163 N/A 9 Ravaldi C [ 17. ] 2021 Italy 200 p  < 0.001 10 Zhou Y [ 18. ] 2020 China 544 N/A 11 Kahyaoglu Sut H [ 19. ] 2021 Turkey 403 N/A 12 Hui PW [ 20. ] 2021 Hong Kong (China) 925 p  < 0.05 13 Oskovi-Kaplan ZA [ 21. ] 2021 Turkey 223 N/A 14 Sinaci S [ 22. ] 2020 Turkey 246 N/A 15 Dong H [ 23. ] 2021 China 156 N/A 16 Hocaoglu M [ 24. ] 2020 Turkey 283 p  = 0.01 17 Liang P [ 25. ] 2020 China 845 N/A 18 Preis H [ 26. ] 2020 US 4451 N/A 19 Yue C [ 27. ] 2021 China 308 N/A 20 Maharlouei N [ 28. ] 2020 Iran 540 N/A 21 Medina-Jimenez V [ 29. ] 2020 Mexico 503 N/A 22 Ceulemans M [ 30. ] 2020 Belgium 3445 N/A 23 Milne SJ [ 30. ] 2020 Ireland 70 N/A 24 Matsushima M [ 31. ] 2020 Japan 1777 N/A 25 Ceulemans M [ 32. ] 2021 Ireland, Norway, Switzerland, the Netherlands, and the UK 3545 N/A 26 Gildner TE [ 33. ] 2020 US 1856 N/A 27 Shayganfard M [ 34. ] 2020 Iran 103 N/A 28 Yassa M [ 35. ] 2020 Turkey 203 N/A 29 Silverman ME [ 36. ] 2020 US 516 p  < 0.001 30 Muhaidat N [ 37. ] 2020 Jordan 944 N/A 31 Thayer ZM [ 38. ] 2021 US 2099 N/A 32 Jiang H [ 39. ] 2021 China 1873 N/A 33 Zhang Y [ 40. ] 2021 China 560 N/A 34 Mayeur A [ 41. ] 2020 France 88 N/A 35 Lin W [ 42. ] 2021 China 751 N/A 36 Zhang CJP [ 43. ] 2020 China 1901 N/A 37 Yang X [ 44. ] 2021 Chinese 19,515 N/A 38 Khamees RE [ 45. ] 2021 Egypt 120 p  < 0.001 39 Lorentz MS [ 46. ] 2021 Brazil 50 p  = 0.004 (comparing scores) p  = 0.062 (comparing prevalence) 40 Silverman ME [ 47. ] 2020 US 485 N/A 41 Akgor U [ 48. ] 2021 Turkey 297 N/A 42 Shahid A [ 49. ] 2020 Pakistan 552 N/A 43 Preis H [ 50. ] 2020 US 788 N/A 44 Dagklis T [ 51. ] 2020 Greece 269 p < 0.001 45 Ionio C [ 52. ] 2021 Italy 40 N/A 46 Esteban-Gonzalo S [ 53. ] 2021 Spain 353 N/A 47 Koyucu RG [ 54. ] 2021 Turkey 729 N/A 48 Overbeck G [ 55. ] 2021 Denmark 330 0.2209 49 Kachi Y [ 56. ] 2021 Japan 270 N/A 50 Mariño-Narvaez C [ 57. ] 2021 Spain 75 p  = 0.038 51 Liu J [ 58. ] 2021 US 715 N/A 52 Smith CL [ 59. ] 2021 USA 83 N/A 53 Cao Y [ 60. ] 2021 China 298 N/A 54 Mappa I [ 61. ] 2021 Italy 161 p  < 0.0001 55 Mehdizadehkashi A [ 62. ] 2021 Iran 300 N/A 56 Yirmiya K [ 63. ] 2021 Israel 1114 N/A 57 Xie M [ 64. ] 2021 China 689 p  = 0.03 58 Ge Y [ 65. ] 2021 China 446 N/A 59 López-Morales H [ 66. ] 2021 Argentina 102 N/A 60 Puertas-Gonzalez JA [ 67. ] 2021 Spain 100 p  = 0.025 61 Çolak S [ 68. ] 2021 Turkey 149 N/A 62 Xu K [ 69. ] 2021 China 274 N/A 63 Zilver SJM [ 70. ] 2021 Netherlands 1102 p  = 0.14(comparing prevalence)/ p  = 0.03(comparing score) 64 Maharlouei N [ 71. ] 2021 Iran 540 N/A 65 Harrison V [ 72. ] 2021 UK 205 N/A 66 Saadati N [ 73. ] 2021 Iran 300 N/A 67 Wang Q [ 74. ] 2021 China 15,428 N/A 68 Behmard V [ 75. ] 2021 Iran 801 N/A 69 King LS [ 76. ] 2021 US 725 p  < 0.001 70 Nurrizka RH [ 77. ] 2021 Indonesia 120 N/A 71 Jelly P [ 78. ] 2021 India 333 N/A 72 Wang Q [ 79. ] 2021 China 19,515 N/A 73 Zhang Y [ 80. ] 2021 China 1794 N/A 74 Masjoudi M [ 81. ] 2021 Iran 215 N/A 75 Shangguan F [ 82. ] 2021 China 2120 N/A 76 Tsakiridis I [ 83. ] 2021 Greece 505 N/A 77 Brik M [ 84. ] 2021 Spain 164 N/A 78 Effati-Daryani F [ 85. ] 2021 Iran 437 N/A 79 Boekhorst MGBM [ 86. ] 2021 Netherlands 265 N/A 80 An R [ 87. ] 2021 China 209 N/A 81 Lubián López DM [ 88. ] 2021 Spain 514 N/A 82 Maleki A [ 89. ] 2021 Iran 2336 N/A 83 Khoury JE [ 90. ] 2021 Canada 304 N/A 84 Suárez-Rico BV [ 91. ] 2021 Mexico 293 N/A 85 Korukcu O [ 92. ] 2021 Turkey 497 p  < 0.0001 86 Obata S [ 93. ] 2021 Japan 4798 N/A 87 Sakalidis VS [ 94. ] 2021 Australia and New Zealand 233 N/A 88 Basu A [ 95. ] 2021 64 countries 6894 N/A 89 Kara P [ 96. ] 2021 Turkey 445 N/A 90 Fallon V [ 97. ] 2021 UK 614 p < 0.001 91 Mo PKH [ 98. ] 2021 China 4087 N/A 92 Wu F [ 99. ] 2021 Shenzhen 3434 N/A 93 Ding W [ 100. ] 2021 Wuhan 817 N/A 94 Chrzan-Dętkoś M [ 101. ] 2021 Poland 78 p  = 0.025 95 Janevic T [ 102. ] 2021 New York 228 N/A 96 Thompson KA [ 103. ] 2021 US 232 N/A 97 Mirzaei N [ 104. ] 2021 Iran 200 N/A 98 Hiiragi K [ 105. ] 2021 Japan 279 p  = 0.17 99 McFarland MJ [ 106. ] 2021 US 2402 N/A 100 Zhou Y [ 107. ] 2021 China 1266 N/A 101 Gluska H [ 108. ] 2021 Israel 421 N/A 102 Liu CH [ 109. ] 2021 US 628 p  < 0.01 103 Ramirez Biermann C [ 110. ] 2021 US 162 N/A 104 Palalioglu RM [ 111. ] 2021 Turkey 526 N/A 105 Molgora S [ 112. ] 2020 Italian 389 N/A 106 Patabendige M [ 113. ] 2020 Sri Lanka 257 N/A 107 Mollard E [ 114. ] 2021 US 885 N/A 108 Wang J [ 115. ] 2021 China 2235 N/A 109 Zeng X [ 116. ] 2020 China 625 N/A 110 Miranda AR MD [ 117. ] 2021 Argentina 305 N/A 111 Nomura R [ 118. ] 2021 Brazil 1662 N/A 112 Davis JA [ 119. ] 2021 US 31 N/A 113 Provenzi L [ 120. ] 2021 Italy 163 N/A 114 Kotabagi P [ 121. ] 2020 UK 11 N/A 115 Berthelot N [ 122. ] 2020 Canada 1258 0.001 116 Corbett GA [ 123. ] 2020 NA 71 N/A 117 Farrell T [ 124. ] 2020 Qatar 288 N/A 118 Stepowicz A [ 125. ] 2020 Poland 210 N/A 119 Mayopoulos GA [ 126. ] 2021 United States 637 0.008 120 Liu CH [ 127. ] 2021 United States 1123 N/A 121 Farewell CV [ 128. ] 2020 United States 27 N/A 122 Haruna M [ 129. ] 2020 Japan 2872 N/A 123 Bender WR [ 130. ] 2020 United States 318 N/A 124 Aksoy Derya Y [ 131. ] 2021 Turkey 48 N/A 125 Nodoushan RJ [ 132. ] 2020 Iran 560 N/A 126 Mortazavi F [ 133. ] 2021 Iran 484 N/A 127 Chasson M [ 134. ] 2021 Israel 233 N/A 128 Taubman-Ben-Ari O [ 135. ] 2020 Israel 233 N/A 129 Moyer CA [ 136. ] 2021 Ghana 71 N/A 130 Dib S [ 137. ] 2020 UK 1329 N/A 131 Qi M [ 138. ] 2020 China 298 N/A 132 Kassaw C [ 139. ] 2020 Ethiopia 178 N/A 133 Zheng QX [ 140. ] 2020 China 331 N/A 134 Machado MMT [ 141. ] 2021 Brazil 1041 N/A 135 Perzow SED [ 142. ] 2021 US 135 p  < 0.001 136 Pope J [ 143. ] 2021 US,Ireland,UK 573 N/A 137 Kotabagi P [ 144. ] 2020 UK 14 p  = 0.9 138 Naurin E [ 145. ] 2021 Sweden 0 N/A 139 Bo HX [ 146. ] 2021 China 1309 N/A 140 Barbosa-Leiker C [ 147. ] 2021 US 162 N/A 141 Stampini V [ 148. ] 2021 Italy 600 N/A 142 Li C [ 149. ] 2021 China 2201 N/A 143 Bradfield Z [ 150. ] 2021 Australia 2840 N/A 144 Kinser PA [ 151. ] 2021 US 524 N/A 145 Özkan Şat S [ 152. ] 2021 Turkey 376 N/A 146 Kawamura H [ 153. ] 2021 Japan 297 N/A 147 Silverio SA [ 154. ] 2021 UK 710 N/A 148 Ahlers-Schmidt CR [ 155. ] 2020 US 114 N/A 149 de Arriba-García M [ 156. ] 2021 Spain 754 N/A 150 Chaves C [ 157. ] 2021 Spain 724 N/A 151 Wdowiak A [ 158. ] 2021 Poland 50 N/A 152 Ravaldi C [ 159. ] 2020 Italy 2448 N/A 153 Wyszynski DF [ 160. ] 2021 64 countries 7185 N/A 154 Sbrilli MD [ 161. ] 2021 US 199 N/A 155 Davenport MH [ 162. ] 2020 Canada 900 p  < 0.01 156 Di Mascio D [ 163. ] 2020 China, Saudia Arabia, South Korea, United Arab, Jordan, Canada, USA 19 157 Juan J [ 164. ] 2020 USA, Iran, China, Italy, Spain, Peru, Sweden, Turkey, Korea, Australia, Canada and France 24 158 Amaral WND [ 165. ] 2020 China, France, US, Iran, Italy, Spain, EUA, Peru, UK, Switzerland, Netherlands, Ireland, Sweden, Canada, Korea 1457 159 Di Mascio D [ 166. ] 2020 Argentina, Australia, Belgium, Brazil, Colombia, Czech Republic, Finland, Germany, Greece, Israel, Italy, North Macedonia, Peru, Portugal, Republic of Kosovo, Romania, Russia, Serbia, Slovenia, Spain, Turkey, US 388 160 Sentilhes L [ 167. ] 2020 Europe, Sub-Saharan Africa, North Africa 38 161 Sahin D [ 168. ] 2021 Turkey 533 162 Kayem G [ 169. ] 2020 France 617 163 Adhikari EH [ 170. ] 2020 Texas, US 252 164 Garcia Rodriguez A [ 171. ] 2020 N/A 1 165 Islam MM [ 172. ] 2020 N/A 235 166 Hansen JN [ 173. ] 2021 N/A 1 167 Oltean I [ 174. ] 2021 N/A 315 168 Wei SQ [ 175. ] 2021 N/A 438,548 169 Singh V [ 176. ] 2021 India 132 170 Della Gatta AN [ 177. ] 2021 China 51 171 Di Toro F [ 178. ] 2021 N/A 1104 172 Bellos I [ 179. ] 2021 China 158 173 Abou Ghayda R [ 180. ] 2020 China,Italy,Iran 104 174 Remaeus K [ 181. ] 2020 Sweden 67 175 Mullins E [ 182. ] 2020 N/A 1606 176 Zaigham M [ 183. ] 2020 China, Sweden, US, Korea, Honduras 108 177 Yu N [ 184. ] 2020 China 7 178 Galang RR [ 185. ] 2020 N/A 12 179 Capobianco G [ 186. ] 2020 N/A 44 180 Berthelot N [ 122. ] 2020 Canada 1258 181 Mappa I [ 187. ] 2020 Italy 178 182 Ayaz R [ 188. ] 2020 N/A 63 183 Dubey P [ 189. ] 2020 N/A 790 184 Pierce-Williams RAM [ 190. ] 2020 USA 44 185 Gao YJ [ 191. ] 2020 N/A 236 186 Yang R [ 192. ] 2020 China 65 187 Yee J [ 193. ] 2020 N/A 9032 188 Liu X [ 194. ] 2020 China 1947 189 Novoa RH [ 195. ] 2020 N/A 322 190 Matar R [ 196. ] 2020 China, US, Republic of Korea, Honduras 136 191 Gur RE [ 197. ] 2020 America 787 192 Sakowicz A [ 198. ] 2020 America 1317 193 Taubman-Ben-Ari O [ 199. ] 2020 Israel 336 194 Ng QJ [ 200. ] 2020 Singapore 324 195 Hamzehgardeshi Z [ 201. ] 2020 Iran 318 196 Ozsurmeli M [ 202. ] 2020 Turkey 24 197 Makvandi S [ 203. ] 2020 N/A 68 198 Guo Y [ 204. ] 2020 China 20 199 Karimi L [ 205. ] 2020 N/A 571 200 Waratani M [ 206. ] 2020 Japan 1 201 Savasi VM [ 207. ] 2020 Italy 11 202 Effati-Daryani F [ 208. ] 2020 Iran 205 203 Smith V [ 209. ] 2020 N/A 92 204 Chen H [ 210. ] 2020 China 9 205 Wang Y [ 211. ] 2020 China 72 206 Janevic T [ 212. ] 2021 USA 3731 207 Cao D [ 213. ] 2020 China 10 208 Lebel C [ 214. ] 2020 Canada 1764/1757 209 Marín Gabriel MA [ 215. ] 2020 Spain 11 210 Lokken EM [ 216. ] 2020 America 155 211 Ashraf MA [ 217. ] 2020 N/A 90 212 de Vasconcelos Gaspar A [ 218. ] 2021 Portugal 7 213 Huntley BJF [ 219. ] 2020 N/A 538 214 Khoury R [ 220. ] 2020 USA 241 215 Diriba K [ 221. ] 2020 N/A 1316 216 Assiri A [ 222. ] 2016 N/A 5 217 Malik A [ 223. ] 2016 N/A 1 This table outlines the first author, year of publication, and geographical locations for all studies. Sample size has been recorded and p-value has been included where appropriate Table 3 Studies selected for the meta-analysis Authors Country Sample Size Publication Year Symptoms Measure Name Lebel C [ 214. ] Canada 1757/ 1764 2020 Anxiety,Depression PROMIS,EPDS Ayaz R [ 188. ] Turkey 63 2020 Anxiety BAI Durankuş F [ 10. ] Turkey 260 2020 Anxiety,Depression BAI,EPDS Liu X [ 194. ] China 1947 2020 Anxiety SAS Mappa I [ 187. ] Italy 178 2020 Anxiety STAI-T,STAI-S López-Morales H [ 66. ] Argentina 72 2021 Anxiety,Depression STAI-S,BDI-II Salehi L [ 14. ] Iran 220 2020 Anxiety CDAS Gur RE [ 197. ] United States 787 2020 Anxiety,Depression GAD-7,PHQ-2 Ng QJ [ 200. ] Singapore 324 2020 Anxiety,Depression,Stress DASS21-A, DASS21-D, DASS21-S Effati-Daryani F [ 208. ] Iran 205 2020 Anxiety,Depression,Stress DASS21-A, DASS21-D, DASS21-S Ravaldi C [ 17. ] Italy 200 2021 Anxiety COVID-ASSESS questionnaire Zhou Y [ 18. ] China 544 2020 Anxiety,Depression,PTSD,Sleep orders GAD-7,PHQ-9,PCL-5,ISI Kahyaoglu Sut H [ 19. ] Turkey 403 2021 Anxiety,Depression HADS-A, HADS-D Sinaci S [ 22. ] Turkey 200 2020 Anxiety STAI-T,STAI-S Dong H [ 23. ] China 156 2021 Anxiety,Depression SAS,SDS Hocaoglu M [ 24. ] Turkey 283 2020 Anxiety,PTSD STAI-T,STAI-S/IES-R Yue C [ 27. ] China 308 2021 Anxiety SAS Taubman-Ben-Ari O [ 199. ] Israel 336 2020 Anxiety self-designed questionnaire Maharlouei N [ 28. ] Iran 540 2020 Anxiety self-designed questionnaire Milne SJ [ 30. ] Ireland 70 2020 Anxiety N/A Ceulemans M [ 32. ] Ireland, Norway, Switzerland, the Netherlands, and the UK 3545 2021 Anxiety,Depression,Stress GAD-7,EDS, PSS-10 Yassa M [ 35. ] Turkey 203 2020 Anxiety STAI-S,STAI-T Jiang H [ 39. ] China 1873 2021 Anxiety,Depression,Stress SAS,EDS, CPSS-14 Mayeur A [ 41. ] France 88 2020 Anxiety self-designed questionnaire Lin W [ 42. ] China 751 2021 Anxiety,Depression SAS,PHQ-9 Yang X [ 44. ] Chinese 19,515 2021 Anxiety,Depression GAD-7,PHQ-9 Akgor U [ 48. ] Turkey 297 2021 Anxiety,Depression HADS-A, HADS-D Preis H [ 50. ] US 788/4451 2020 Anxiety,Stress GAD-7,PREPS Dagklis T [ 51. ] Greece 269/215 2020 Anxiety,Depression STAI-S,STAI-T/EPDS Esteban-Gonzalo S [ 53. ] Spain 353 2021 Anxiety STAI-S Koyucu RG [ 54. ] Turkey 729 2021 Anxiety,Depression,Stress DASS21-A, DASS21-D, DASS21-S Liu J [ 58. ] US 715 2021 Anxiety,Depression GAD-7,EPDS Cao Y [ 60. ] China 298 2021 Anxiety,Depression N/A Mappa I [ 61. ] Italy 161 2021 Anxiety STAI-T,STAI-S Mehdizadehkashi A [ 62. ] Iran 300 2021 Anxiety self-designed questionnaire Yirmiya K [ 63. ] Israel 1114 2021 Anxiety,Depression,Stress GAD-7,PHQ-2,PREPS Xie M [ 64. ] China 689 2021 Anxiety,Depression,Sleep disorders SCL90-R,PSQI Ge Y [ 65. ] China 446 2021 Anxiety SAS López-Morales H [ 66. ] Argentina 102 2021 Anxiety,Depression STAI-S,BDI-II Puertas-Gonzalez JA [ 67. ] Spain 100 2021 Anxiety,Depression,Stress SCL-90-R,PSS-14 Çolak S [ 68. ] Turkey 149 2021 Anxiety,Depression,Stress BAI,BDI,PSQI Xu K [ 69. ] China 274 2021 Anxiety,Depression,Stress,Sleep disorders SAS,EPDS,CPSS,PSQI Zilver SJM [ 70. ] Netherlands 1102 2021 Anxiety,Depression,Stress HADS-A,HADS-D,PSS-10 Maharlouei N [ 71. ] Iran 540 2021 Anxiety,Depression,Stress DASS21-A, DASS21-D, DASS21-S Harrison V [ 72. ] UK 205 2021 Anxiety,Depression PASS,EPDS Saadati N [ 73. ] Iran 300 2021 Anxiety HAQ Wang Q [ 74. ] China 15,428 2021 Anxiety,Depression GAD-7,PHQ-9 Behmard V [ 75. ] Iran 801 2021 Anxiety CDAS Hamzehgardeshi Z [ 201. ] Iran 318 2021 Anxiety,Depression PRAQ,EPDS Jelly P [ 78. ] India 333 2021 Anxiety GAD-7 Wang Q [ 74. ] China 19,515 2021 Anxiety,Depression GAD-7,PHQ-9 Zhang Y [ 80. ] China 1794/560 2021 Anxiety,Stress SAS,IES Masjoudi M [ 81. ] Iran 215 2021 Anxiety,Stress CDAS,PSS-14 Shangguan F [ 82. ] China 2120 2021 Anxiety,Stress GAD-7,PSS Tsakiridis I [ 83. ] Greece 505 2021 Anxiety,Depression STAI-S,STAI-T/EPDS Brik M [ 84. ] Spain 109/164 2021 Anxiety STAI-S,STAI-T/EPDS Effati-Daryani F [ 85. ] Iran 437 2021 Anxiety,Depression,Stress DASS21-A, DASS21-D, DASS21-S Lubián López DM [ 88. ] Spain 514 2021 Anxiety STAI-S,STAI-T/EPDS Maleki A [ 89. ] Iran 2336 2021 Anxiety GAD-7 Khoury JE [ 90. ] Canada 304 2021 Anxiety,Depression,Stress,Sleep disorders GAD-7,CES-D,PSS-10,ISI Suárez-Rico BV [ 91. ] Mexico 293 2021 Anxiety STAI-T Obata S [ 93. ] Japan 4798 2021 Anxiety,Depression K6,EPDS Mo PKH [ 98. ] China 4087 2021 Anxiety,Depression GAD-7,PHQ-9 Wu F [ 99. ] Shenzhen 3434 2021 Anxiety,Depression GAD-7,PHQ-9 Ding W [ 100. ] Wuhan 817 2021 Anxiety SAS Mirzaei N [ 104. ] Iran 200 2021 Anxiety,Depression HADS-A, HADS-D Ramirez Biermann C [ 110. ] US 162 2021 Anxiety,Depression self-designed questionnaire Palalioglu RM [ 111. ] Turkey 526 2021 Anxiety self-designed questionnaire Molgora S [ 112. ] Italian 389 2020 Anxiety,Depression STAI-S,STAI-T/EPDS Patabendige M [ 113. ] Sri Lanka 257 2020 Anxiety,Depression HADS-A, HADS-D Zeng X [ 116. ] China 516 2020 Anxiety,Depression,Sleep disorders GAD-7,EPDS, DSM-IV Nurrizka RH [ 77. ] Indonesia 36 2021 Anxiety DASS-21-A Wu Y [ 9. ] China 1285 2020 Depression EPDS Wang Y [ 211. ] China 72 2020 Depression,PTSD EPDS,PCL-C Medina-Jimenez V [ 29. ] Mexico 503 2020 Depression,Stress EPDS,PSS Matsushima M [ 31. ] Japan 1777 2020 Depression EPDS Gildner TE [ 33. ] US 1856 2020 Depression EPDS Shayganfard M [ 34. ] Iran 66 2020 Depression,Stress EPDS,PSS-14 Silverman ME [ 36. ] US 516 2020 Depression EPDS Muhaidat N [ 37. ] Jordan 944 2020 Depression self-designed questionnaire Thayer ZM [ 38. ] US 2099 2021 Depression EPDS Zhang CJP [ 43. ] China 1901 2020 Depression,PTSD EPDS,PCL-S Khamees RE [ 45. ] Egypt 120 2021 Depression EPDS Silverman ME [ 47. ] US 485 2020 Depression EPDS Shahid A [ 49. ] Pakistan 552 2020 Depression,Sleep disorders EPDS,self-designed questionnaire Ionio C [ 52. ] Italy 75 2021 Depression EPDS Overbeck G [ 55. ] Denmark 330 2021 Depression MDI Kachi Y [ 56. ] Japan 270 2021 Depression EPDS Smith CL [ 59. ] USA 83 2021 Depression,Stress EPDS,PSS-10 King LS [ 76. ] US 725 2021 Depression EPDS Korukcu O [ 92. ] Turkey 497 2021 Depression EDS Zhou Y [ 107. ] China 1266 2021 Depression PHQ-9 Chaves C [ 157. ] Spain 450 2021 Depression EPDS Davis JA [ 119. ] US 31 2021 Stress PSS-10 Ionio C [ 52. ] Italy 75 2021 PTSD IES-R Basu A [ 95. ] 64 countries 5712 2021 PTSD IES-6 Kara P [ 96. ] Turkey 445 2021 PTSD PCL-5 Wang J [ 115. ] China 2235 2021 Sleep disorders ISI This table outlines first author, year of publication, and geographical location for the studies. Sample size, mental health symptoms and names of measures were included Outline of all studies in the systematic review and meta-analysis p  = 0.004 (comparing scores) p  = 0.062 (comparing prevalence) This table outlines the first author, year of publication, and geographical locations for all studies. Sample size has been recorded and p-value has been included where appropriate Studies selected for the meta-analysis 1757/ 1764 DASS21-A, DASS21-D, DASS21-S DASS21-A, DASS21-D, DASS21-S HADS-A, HADS-D GAD-7,EDS, PSS-10 SAS,EDS, CPSS-14 HADS-A, HADS-D DASS21-A, DASS21-D, DASS21-S DASS21-A, DASS21-D, DASS21-S DASS21-A, DASS21-D, DASS21-S HADS-A, HADS-D HADS-A, HADS-D GAD-7,EPDS, DSM-IV This table outlines first author, year of publication, and geographical location for the studies. Sample size, mental health symptoms and names of measures were included All 217 studies used different study designs; 107 cross-sectional, 7 cohort and 7 case controlled. A total of 23 qualitative studies used self-reported methods of data collection. Real-world data from hospital admissions were used in 5 studies whilst 2 extracted data from patient medical records. The 217 study-pool comprised of a sample of 638,889 pregnant women, including 6898 women who were within 90 days of delivery. The sample sizes used within the studies varied considerably; 129 studies comprised of approximately 500 women, 40 studies consisted of500–999 ladies, 18 studies had 1000–1999 women and 24 studies had ≥2000 women. A total of 99 studies reported pregnant women during their first, second and third trimester. Many studies reported that data collection took place during routine antenatal or postnatal visits in outpatient departments, tertiary/provincial hospitals, secondary level or district hospitals, and primary healthcare facility level. Sixty-four reported data on depressive symptoms, 82 on symptoms of anxiety, 20 on symptoms of stress, 7 on PTSD symptoms, and 8 on symptoms of sleep disorders. Detailed characteristics of the systematically included studies and those meta-analysed are listed in Tables  1 and 2 (see page 33 for Table  1 and page 35 for Table  2 ). Edinburgh Postnatal Depression Scale (EPDS), the Patient Health Questionnaire 9-item (PHQ-9), and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) were the commonly used data collection tools to assess symptoms of depression. The pooled prevalence of depression was 24.91% with a 95% CI of 21.37–29.02% (see Fig.  2 ). Fig. 2 Forest plot showing prevalence of depressive symptoms. Legend. The forest plot shows the first author, sample size and geographic location for the included studies. Measure of depressive symptoms, prevalence rate with confidence internal and weighting of results have also been displayed Forest plot showing prevalence of depressive symptoms. Legend. The forest plot shows the first author, sample size and geographic location for the included studies. Measure of depressive symptoms, prevalence rate with confidence internal and weighting of results have also been displayed Anxiety symptoms were commonly measured by the State-Trait Anxiety Inventory (STAI, with two subscales STAI-T and STAI-S), the General Anxiety Disorder 7-item (GAD-7), and Self-rating Anxiety Scale (SAS). Anxiety prevalence was 32.88% with a 95% CI of 29.05 to 37.21% (see Fig.  3 ). Fig. 3 Forest plot showing prevalence of anxiety symptoms. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of anxiety symptoms, prevalence rate with confidence internal and weighting of results have also been displayed Forest plot showing prevalence of anxiety symptoms. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of anxiety symptoms, prevalence rate with confidence internal and weighting of results have also been displayed Tools like the Perceived Stress Scale (PSS, with 10-item and 14-item versions), and the stress subscale of the 21-item Depression Anxiety and Stress Scale (DASS21-S) were frequently used to evaluate stress symptoms. The pooled prevalence of stress among perinatal women was 29.44% (95% CI: 18.21–47.61%) (see Fig.  4 ). Figure 4 Forest plot showing prevalence of stress symptoms. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of stress symptoms, prevalence rate with confidence internal and weighting of results have also been displayed Forest plot showing prevalence of stress symptoms. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of stress symptoms, prevalence rate with confidence internal and weighting of results have also been displayed PTSD symptoms were typically measured by the DSM-V Post-Traumatic Stress Disorder Checklist (PCL-5) and the Impact of Events Scale (IES). The studies reporting PTSD symptoms were heterogeneous resulting in a pooled prevalence of 27.93% with a 95%CI of 9.05–86.15% (see Fig.  5 ). Fig. 5 Forest plot showing symptoms of PTSD. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of PTSD symptoms, prevalence rate with confidence internal and weighting of results have also been displayed Forest plot showing symptoms of PTSD. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of PTSD symptoms, prevalence rate with confidence internal and weighting of results have also been displayed The Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI) were to assess and report symptoms associated with sleep disorders. The pooled prevalence was 24.38% with a 95% CI of 11.89–49.96% (see Fig.  6 ). Fig. 6 Forest plot showing symptoms of sleep disorders. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of sleep disorder symptoms, prevalence rate with confidence internal and weighting of results have also been displayed Forest plot showing symptoms of sleep disorders. Legend. The above forest plot shows the first author, sample size and geographic location for the included studies. Measure of sleep disorder symptoms, prevalence rate with confidence internal and weighting of results have also been displayed The I 2 evaluated for symptoms of depression, anxiety, PTSD, stress, and sleep disorders were over 98%, which demonstrates a high heterogeneity among the studies. Therefore, a subgroup analysis was conducted to further evaluate the heterogeneity. To determine the symptom prevalence, women were assessed at different stages of their pregnancy and the dataset was categorised based on the trimesters:1st trimester (< 12 weeks), 2nd trimester (13–27 weeks), 3rd trimester (28–41 weeks)] and the immediate post-partum period (immediately after childbirth and up to 6 weeks) for studies that reported follow-up details. The heterogeneity of depressive symptoms was lower in comparison to anxiety, PTSD, stress, and sleep problems. Heterogeneity within the 1st trimester was 89.47%. I 2 of the anxiety group during the 1st trimester and 2nd trimester were 88.91 and 92.35%, respectively. These appear to be similar to the I 2 values of depression. I 2 for stress associated with the 2nd and 3rd trimesters were 78.57 and 64.65%, respectively, indicating mild heterogeneity. Intuitively, Maharlouei and colleagues study reported a small prevalence, thus could be an influencing factor for the heterogeneity reported. I 2 for PTSD across three trimesters were 24.67, 89.47 and 81.62%, respectively. I 2 was 0% during the 1st trimester within the groups of participants reporting sleep disturbance. 1st trimester group showed relatively low heterogeneity across mental health symptoms, thus strictly stipulating the gestational weeks of the included pregnancy helped reduce the heterogeneity. Forest plots were generated for 1st trimester, 2nd trimester, 3rd trimester, post-partum and overall, for symptoms of depression (see Figs.  7 , 8 , 9 , 10 and 11 ), anxiety (see Figs.  12 , 13 , 14 , 15 and 16 ), stress (see Fig.  17 ), PTSD (see Fig.  18 ), sleep disorders (see Fig.  19 ). Funnel plots were also generated: depression (see Fig.  20 ), anxiety (see Fig.  21 ), stress, (see Fig.  22 ), PTSD (see Fig.  23 ), and sleep disorders (see Fig.  24 ). Fig. 7 A forest plot showing the subgroup analysis for depressive symptoms in the 1st trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 8 A forest plot showing the subgroup analysis for depressive symptoms in the 2nd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 9 A forest plot showing the subgroup analysis for depressive symptoms in the 3rd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 10 A forest plot showing the subgroup analysis for depressive symptoms postpartum. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 11 A forest plot showing the overall subgroup analysis for depressive symptoms. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 12 A forest plot showing the subgroup analysis for anxiety symptoms in the 1st trimester. Legend First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 13 A forest plot showing the subgroup analysis for anxiety symptoms in the 2nd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 14 A forest plot showing the subgroup analysis for anxiety symptoms in the 3rd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 15 A forest plot showing the subgroup analysis for anxiety symptoms postpartum. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 16 A forest plot showing the overall subgroup analysis for anxiety symptoms. Legend First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 17 A forest plot showing the subgroup analyses for stress symptoms. Legend. The forest plot shows the subgroup analyses results during the 1st, 2nd, and 3rd trimester as well as postpartum and overall. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 18 A forest plot showing the subgroup analyses for PTSD symptoms. Legend. The forest plot shows the subgroup analyses results during the 1st, 2nd, and 3rd trimester as well as postpartum and overall. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 19 A forest plot showing the subgroup analyses for sleep disorder symptoms. Legend. The forest plot shows the subgroup analyses results for sleep disorder symptoms during the 1st, 2nd, and 3rd trimester as well as postpartum and overall. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Fig. 20 Funnel plot of depressive symptoms Fig. 21 Funnel plot of anxiety symptoms Fig. 22 Funnel plot of stress symptoms Fig. 23 Funnel plot of PTSD symptoms Fig. 24 Funnel plot of sleep disorders symptoms A forest plot showing the subgroup analysis for depressive symptoms in the 1st trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analysis for depressive symptoms in the 2nd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analysis for depressive symptoms in the 3rd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analysis for depressive symptoms postpartum. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the overall subgroup analysis for depressive symptoms. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analysis for anxiety symptoms in the 1st trimester. Legend First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analysis for anxiety symptoms in the 2nd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analysis for anxiety symptoms in the 3rd trimester. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analysis for anxiety symptoms postpartum. Legend. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the overall subgroup analysis for anxiety symptoms. Legend First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analyses for stress symptoms. Legend. The forest plot shows the subgroup analyses results during the 1st, 2nd, and 3rd trimester as well as postpartum and overall. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analyses for PTSD symptoms. Legend. The forest plot shows the subgroup analyses results during the 1st, 2nd, and 3rd trimester as well as postpartum and overall. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown A forest plot showing the subgroup analyses for sleep disorder symptoms. Legend. The forest plot shows the subgroup analyses results for sleep disorder symptoms during the 1st, 2nd, and 3rd trimester as well as postpartum and overall. First author and outcomes measures have been included. Prevalence rate with confidence internal and weighting of results have been shown Funnel plot of depressive symptoms Funnel plot of anxiety symptoms Funnel plot of stress symptoms Funnel plot of PTSD symptoms Funnel plot of sleep disorders symptoms Publication bias and sensitivity analysis tests were conducted to assess the reliability of the data as some studies had large standard errors that would produce undesirable effects. Copas Selection Model was used to select studies for the sensitivity analysis. The p -values of residual selection bias were evaluated (see Fig.  25 , 26 , 27 , 28 and 29 ). Studies with a p -value of > 0.1 indicated that the residual selection had minimal bias and, the selected studies can be represented. The proportions identified were 67.84, 100 and 59.49% for depression, anxiety, and sleep disorders, respectively. For studies reporting stress and PTSD, the Copas Selection Model could not provide a decision, indicating the previous conclusions of high heterogeneity is accurate. Fig. 25 P -value for residual selection bias of depressive symptoms Fig. 26 P -value for residual selection bias of anxiety symptoms Fig. 27 P -value for residual selection bias of stress symptoms Fig. 28 P -value for residual selection bias of PTSD symptoms P -value for residual selection bias of depressive symptoms P -value for residual selection bias of anxiety symptoms P -value for residual selection bias of stress symptoms P -value for residual selection bias of PTSD symptoms A summary of studies used within the Copas Selection Model and Random Effects Model indicate that the two models have no significant difference (see Table  4 ). P -value of the changes between these conclusions were 0.1108 for depressive symptoms, 0.638 for anxiety symptoms, and 0.1042 for sleep disorder symptoms. The p -value of the Egger’s test was 0.0256 for studies of depressive symptoms, revealing the existence of publication bias (see Table  5 ). The p -values of 0.256 and 0.998 indicate that it is challenging to detect publication bias for studies associated with symptoms of anxiety and sleep disorders (see Table  5 ). Table 4 Summary of sensitivity analysis Outcome N of study Model Probability of publishing study with largest standard error Proportion (%) lower (%) upper (%) p- value for differences between two conclusions Depression 64 copas selection model 67.84% 27.11 24.32 30.22 0.1108 random effects model 24.91 21.37 29.02 Anxiety 82 copas selection model 100.00% 32.88 29.08 37.18 0.638 random effects model 32.88 29.05 37.21 Sleep disorders 8 copas selection model 59.49% 27.11 14.94 49.21 0.1042 random effects model 24.38 11.89 49.95 This table outlines mental health outcome, number of studies and model used to check publishing biases. Statistical analysis relevant to the publication biases have also been reported Fig. 29 P -value for residual selection bias of sleep disorders symptoms Table 5 P -value of Egger Test for the five mental health symptoms Outcome N of studies p -value of Egger test Depression 64 0.0256 * Anxiety 82 0.256 Stress 20 0.069 PTSD 7 0.742 Sleep disorders 8 0.998 This table shows mental health outcomes, number of studies and test results for the Eggers test Note: (*): p  < 0.05 indicates significance Summary of sensitivity analysis This table outlines mental health outcome, number of studies and model used to check publishing biases. Statistical analysis relevant to the publication biases have also been reported P -value for residual selection bias of sleep disorders symptoms P -value of Egger Test for the five mental health symptoms This table shows mental health outcomes, number of studies and test results for the Eggers test Note: (*): p  < 0.05 indicates significance

In December 2019, SARS-CoV-2 unprecedentedly spread around the world, overwhelming global healthcare systems. On March 11, 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) global pandemic. This led to a rippling impact of the virus on healthcare systems. In order to reduce viral transmission and relieve pressure on healthcare networks, many countries, including the United Kingdom (UK), entered a national lockdown by which people were ordered by law to stay at home [ 1. ]. In many hospitals, staff were redeployed, and departments were adapted or converted to provide COVID-19 services [ 1. ]. Whilst public health emergencies explicitly effect the physical health of a population, increased levels of poor mental health can also be discovered (e.g., depression, PTSD, substance use disorder, and behavioural disorders) [ 2. ]. Influences directly related to infection, such as, the neuroinvasive potential of SARS-CoV-2, may affect brain function and in turn mental health. The treatment for COVID-19 may also have adverse effects on mental health. For example, the imposition of unfamiliar public health measures (i.e., social isolation) increases the likelihood of clinically significant depression or anxiety [ 2. , 3. ]. Whilst all individuals were urged to comply with lockdown protocols, emotional distress tempted some to consider violating the recommended public health measures [ 3. ]. One vulnerable group during the pandemic were pregnant women and women who had recently given birth. Millions of women experience mental ill-health during pregnancy and after childbirth, with maternal mental ill-health being an international public health concern, affecting up to 10% of women during pregnancy and 13% of women after childbirth [ 4. – 6. ]. Compromised mental health can cause short and long-term consequences for the mother and baby however limited data exists on the prevalence of mental ill-health in women who were pregnant and gave birth during the COVID-19 pandemic [ 6. – 8. ]. This systematic review and meta-analysis will assess the prevalence of mental ill-health in women during pregnancy and after childbirth throughout the Covid-19 pandemic. Findings with be compared to other global pandemics including SARS and MERS.

This study highlights that maternity mental ill-health was common during the Covid-19 pandemic and highlights the need to understand the complexity of factors associated with maternal mental health. Maternity mental health services need further investment and prioritisation with clear effective referral pathways and support for women who report mental health concerns during and after pregnancy. Further research is required to explore how to best provide care in a way that meets the specific needs of each woman, across different healthcare systems.

Our study demonstrates that symptoms of depression, anxiety, PTSD, stress, and sleep problems were common throughout the pregnancy period and after childbirth during the COVID-19 pandemic with 24.9% of women reporting symptoms of depression, 32.8% anxiety, 29.44% stress, 27.93% PTSD, and 24.38% sleep disorders. The lack of research conducted to assess the mental health impact of SARS and MERS on pregnant women is a significant limitation as such data could support preparation for similar pandemics in the future. Our meta-analyses indicate the clear impact of COVID-19 on the mental health of pregnant and post-partum mothers, with a pooled prevalence of the multiple symptomatology of depression, anxiety, PTSD, stress, and sleep disorder. To our knowledge, this is the first systematic review and meta-analysis to focus on mental health outcomes in women during pregnancy and after childbirth during the Covid-19 pandemic. The searches were not limited by geographical location or language, therefore, further increasing the chances for all relevant literature to be identified. The MESH terms used did not consider all types of obstetric or gynaecology conditions but did include the common conditions. The variety of screening tools used across the included studies must be considered when interpreting the results of this review. Direct comparisons cannot be made where the same screening tool was not used. Furthermore, most studies used self-reported questionnaires, with no clinical follow-up to confirm diagnoses. Therefore, the results cannot be interpreted as prevalence of mental illness, but rather prevalence of symptomatology. Similar to our study, other research has demonstrated that the extent and severity of mental health impacts increased in women throughout pregnancy and after childbirth during humanitarian disasters and pandemics [ 224. ]. The subgroup analysis showed that the prevalence of symptoms of depression ranged from 16.52 to 24.96% across the four time points. In terms of anxiety symptoms, prevalence ranged from 22.06 to 32.09%. Likewise, Grumi et al. (2021) found prevalence of depressive and anxious symptoms ranges between 26 and 32% amongst pregnant women through the COVID-19 pandemic [ 225. ]. Contrary to previous findings, we found that pregnant women and women who have just given birth experience higher levels of anxiety, especially in the 1st trimester and post-partum, compared to depressive symptoms [ 226. ]. In terms of symptoms of anxiety and PTSD, some research has found that these symptoms have been elevated in pregnant women throughout the COVID-19 pandemic [ 24. ]. Women who became pregnant or gave birth during the pandemic suffered from various symptoms of poor mental health across all stages of their pregnancy and postpartum. It is unclear as to the reason for this observation, and the impact of this in a real-time scenario. These findings could be due to pressure of being a first-time mother or, general stress and health anxiety regarding how and when to access care from midwives and obstetricians as part of routine and emergency maternity care due to the Covid-19 pandemic. Similar to our findings, other studies carried out during the Covid-19 pandemic reported up to 70% of pregnant women suffering from stress during the pandemic [ 8. ]. Being pregnant and giving birth are known triggers for women to develop anxiety and depression and is a known risk factor for exacerbations or decline in pre-existing mental ill-health [ 5. , 6. ]. Other possible reasons for the increase in mental ill-health in women during pregnancy or after childbirth may be because of the massive clinical changes that took place regarding how women could access maternity care during the Covid-19 pandemic. As pregnant women were at higher risk of severe illness if infected with SARS-CoV-2, they advised to be stringent with public health measures such as social distancing and self-isolation to lower their risk of COVID-19 exposure. This led to the rapid implementation of virtual access to antenatal care in order to minimising the need for travel to antenatal clinics and in-person contact with healthcare staff. Antenatal care changed immediately from face-to-face consultations to telephone or video consultation. Birth partners were limited in number, with visiting hours for partners restricted resulting in less emotional and psychological support for women during labour and after childbirth on the postnatal wards. Furthermore, once the Covid-19 vaccination was developed, there was uncertainty regarding the effectiveness and safety of the vaccine for pregnant women, which may also have contributed to and exacerbated stress and anxiety. All women should be risk assessed for maternal mental health at their initial visit with antenatal services and screened at every contact during pregnancy and after childbirth. All healthcare systems need to invest in perinatal mental health services, delivered from a multi-disciplinary team including mental health nurses, specialist midwives, obstetricians with specialist interest in mental health, and perinatal psychologists and psychiatrists. Maternity mental health services should be delivered in a way that meets the specific needs of the individual patient, including face-to-face consultations, telephone calls and/or video consultations. Up to date information regarding the impact of Covid-19 on maternity services needs to be available and accessible for women during pregnancy and after childbirth (e.g., through social media campaigns or hospital websites). Learning from this data, considerations of the special needs of the pregnant and postnatal mothers should be imperative in the implementation of strategies improve preparedness of the health service in future pandemics.