Correlation between gestational diabetes and peripartum mental disorders: A meta-analysis of 1,636,131 patients .Running title :A meta-analysis about correlation between gestational diabetes and peripartum mental disorders

Correlation between gestational diabetes and peripartum mental disorders: A meta-analysis of 1,636,131 patients .Running title :A meta-analysis about correlation between gestational diabetes and peripartum mental disorders | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Correlation between gestational diabetes and peripartum mental disorders: A meta-analysis of 1,636,131 patients .Running title :A meta-analysis about correlation between gestational diabetes and peripartum mental disorders Qirong Wan, Haiying Xie, Wei Yuan, Zhenhua Chen, Yanhong Gao, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4229400/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Aim The relationship between gestational diabetes mellitus (GDM) and peripartum mental disorders is unclear. Hence, the current meta-analysis aimed to systematically evaluate the risk of mental disorders in pregnant women with or without GDM. Methods We searched the PubMed, Cochrane Library, EMBASE, and Web of Science databases for relevant articles published up to October 30, 2021. The random-effects or fixed-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the prevalence of mental disorders in GDM. Sensitivity and subgroup analyses were conducted to test the robustness of the pooled estimates. Results We analyzed 32 studies involving 1,636,131 pregnant women, and the results demonstrated that GDM significantly increased the prevalence of peripartum depression (antenatal, pooled OR: 1.57, 95% CI: 1.33–1.85, P < 0.05; postpartum, pooled OR: 1.42, 95% CI: 1.18–1.70, P < 0.05), especially in women from Asia (pooled OR: 2.71, 95% CI: 1.98–3.72, P < 0.05). Compared to pregnant women without GDM, women with GDM reported significantly higher anxiety scores (pooled OR: 4.19, 95% CI: 1.21–7.17, P = 0.006) but insignificantly on antenatal stress symptoms while this evidence still needs to be further strengthened. Conclusions GDM significantly increased the prevalence of antenatal and postpartum mental disorders. Further multi-center prospective studies with long-term follow-up are required to verify the association between GDM and mental health. Gestational diabetes mellitus depression anxiety mental disorders meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 1. INTRODUCTION Gestational diabetes mellitus (GDM) is defined as glucose intolerance that is first diagnosed during pregnancy ( 1 ). The global prevalence of GDM is estimated to be 6–13%, and has increased by approximately 30% within the last 2 decades ( 2 ). The risk factors for GDM include advanced maternal age, obesity, a family history of diabetes, and previous unexplained stillbirth. Women with GDM are at risk for preeclampsia, preterm labor, and type 2 diabetes, and their infants are at risk for significant neonatal complications including congenital anomalies, birth injury, and macrosomia ( 3 – 5 ). In addition to physical complications, GDM is associated with worse psychological outcomes, such as impaired quality of life, anxiety, stress, and peripartum depression ( 6 – 8 ). The incidence of depression has been reported to remarkably increase with pregnancy, from approximately 5% in non-pregnant women to 8–10% during pregnancy and 13% after delivery ( 9 ). Furthermore, women with GDM are 2–4 times more likely to develop antenatal or postpartum depression than women without GDM ( 10 – 11 ). Additionally, perinatal depression may itself be fueling the GDM epidemic, as GDM results from overeating and decreased physical exercise, which are commonly associated with depression; thus, women with GDM are at a higher risk for obesity and diabetes after delivery ( 10 ). The bidirectional association between depression and type 2 diabetes is well established, but the evidence for a link between depression and GDM is inconsistent ( 12 – 13 ). Three studies have reported that compared to women without diabetes in pregnancy, women with GDM did not experience a significant mood change ( 14 – 16 ). Therefore, exploring the relationship between depression and diabetes in the peripartum period may improve the care of women with GDM as well as help prevent maternal and fetal complications. The aim of the present meta-analysis is to determine the relationship between mental disorders and GDM in the peripartum period. A deeper understanding of the development of GDM and mental health problems may help improve the care of women during the perinatal and postnatal periods, and thereby result in a better quality of life. 2. METHODS The meta-analysis followed Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE) ( 17 ) and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines ( 18 ). 2.1 Literature search Two researchers searched the PubMed, Cochrane Library, EMBASE, and Web of Science databases for potentially relevant journal articles using the following search terms: “mood disorder”, “depression”, “depressive”, “melancholi”, “dysthymic disorder”, “anxiety”, “stress”, “pregnancy diabetes”, “gestational diabetes mellitus”, and “gestational diabetes”. Forward and backward citation tracking were also undertaken. The last search was run on October 31, 2021. No language or country limitations were applied. All studies reporting on the mental disorders listed above were included and screened by two authors to identify any relevant studies that met the inclusion criteria. If the article titles and abstracts were ambiguous with regard to the inclusion criteria, the full text was downloaded and carefully reviewed. 2.2 Eligibility criteria We included studies investigating the relationship between GDM and perinatal mental disorders. Studies were eligible for inclusion if they met the following criteria: (i) the study involved pregnant women diagnosed with GDM and reported any mental disorder; (ii) the study included pregnant women without GDM for comparison; and (iii) the study was designed as a prospective or retrospective cohort study. Perinatal mental disorders were categorized into antenatal (conception to delivery) or postpartum (until 1 year after delivery) disorders, and included anxiety, stress, and psychotic or mood disorders. 2.3 Exclusion criteria We excluded studies that used medication status to classify mental disorders. In addition, studies that provided only risk estimates with corresponding 95% confidence intervals (CIs) were excluded from the meta-analysis, but included in the review. 2.4 Data extraction and quality assessment Two experienced researchers independently assessed each study for the risk of bias by using the modified Newcastle–Ottawa Scale based on the current PRISMA guidelines. The researchers focused on measurement and selection biases because most studies in the present review had a cross-sectional design. Disagreements were resolved by a third person who served as an intermediary and made the final decision. According to the selection, comparability, and outcome data, each study was graded as having a high, low, or unclear risk of bias. Two reviewers independently extracted relevant data from the original studies by using standardized data-extraction forms, and clarified discrepancies via re-evaluation and discussion with the other authors. We collected the following data: first author’s name, country, year of publication, study design, study period, sample size, age, body mass index before pregnancy, timing of outcome assessment, and tests for GDM and mental disorders. Prevalence, risk estimates, and information on potential underlying mechanisms, if present, were also collected. In the case of studies with unclear or missing data, the corresponding author was contacted to request clarification. 2.5 Statistical analysis Statistical analyses were conducted in accordance with the recommendations of The Cochrane Collaboration. Differences in the prevalence of dichotomous variables were evaluated using odds ratios (ORs) and 95% CIs. Heterogeneity among studies was evaluated using the Cochran Q test (significance level, P 75%, high heterogeneity; I 2 0.05 and the I 2 statistic was < 50%; otherwise, a random-effects model was used ( P < 0.05, I 2 ≥ 50%) ( 19 ). Subgroup analyses were performed based on differences in variables such as study design, location, assessment tools, and sample size. Sensitivity analyses were performed by omitting studies one by one and combining the remaining studies to reveal the impact of individual studies on the overall risk estimate. The Begg test and Egger test were used to assess potential publication bias ( 20 ). Pooled data were analyzed using Review Manager v 5.3 (The Nordic Cochrane Center, The Cochrane Collaboration, 2014, Copenhagen, Denmark). Two-tailed P -values of < 0.05 indicated statistically significant differences. 3. RESULTS Electronic searches of the 4 databases identified 9072 potentially relevant records. After removing 8878 duplicated articles and irrelevant studies, we further excluded 47 studies by reading their titles and abstracts; the remaining 147 publications were assessed in detail. Another 115 articles were excluded for various reasons, and 32 eligible studies were ultimately included for further qualitative and quantitative analyses. The detailed screening method and results are shown in Fig. 1 . 3.1 Basic characteristics and quality assessment The primary characteristics of the included studies are listed in Tables 1 and 2 . We included 32 studies in our meta-analysis, with a total sample size of 1,636,131 pregnant women. Two of the studies were from South America; seven studies were from Asia; ten studies were from Europe; and thirteen studies were from North America. The included studies were published between 2002 and 2021. The most common study design was prospective cohort (n = 18), followed by cross-sectional design (n = 7), retrospective cohort (n = 5), and case–control studies (n = 2). Table 1 Characteristics of included studies for antenatal depression on pregnant women with or without GDM Study Country Study type Sample size Study period Age (GDM/ no-GDM) Pre-pregnancy BMI (kg/m2) GDM assessment Outcome Outcome assessment Timing of outcome assessment Risk of bias Unadjusted OR (95% CI) Rumbold et al. 2002 Australia Prospective cohort 21/95 Unavailable 30.0/28.0 30.0/27.0 WHO criteria Depression prevalence EPDS 36 weeks gestation High NA Daniells et al. 2003 Australia Prospective cohort 50/50 2000.11-2001.11 31.4/29.0 27.4/24.6 ADIPS criteria Depression prevalence; OR MHI-5 ≥ 16 30–36 weeks gestation High 3.14 (1.1–8.94) Kim et al. 2005 USA Prospective cohort 64/1,233 2001.05-2002.07 30.0/30.0 Unavailable Medical data Depression prevalence CES-D ≥ 11 12–20 weeks gestation Low NA Besser et al. 2007 Israel Prospective cohort 100/109 Unavailable 29.97/25.31 Unavailable 50 g OGTT Depression prevalence CES-D ≥ 16 in third trimester Low NA Kozhimannil et al. 2009 USA Retrospective cohort 657/10,367 2004.07.01-2006.09.30 28.4/25.0 Unavailable ICD-9 Depression prevalence ICD-9 6 months prior to delivery High NA Räisänen et al. 2014 Finland Cross-sectional study 57,858/454,080 2002–2010 Unavailable Unavailable ICD-10 Depression prevalence; OR ICD-10 during pregnancy Low 1.49 (1.37–1.62) Keskin et al. 2015 Turkey Cross-sectional cohort 44/45 Unavailable 31.4/30.6 27.6/25.1 75 g OGTT Depression prevalence BDI ≥ 17 24–28 weeks gestation High NA Natasha et al. 2015 Bangladesh Cross-sectional cohort 382/366 2011.08-2012.09 28.35/27.17 Unavailable WHO and ACOG criteria Depression prevalence MADRS ≥ 13 24–28 weeks gestation Low NA Byrn et al. 2015 USA Cross-sectional study 65/70 Unavailable 32.12/27.36 34.4/31.0 Medical data Depression prevalence; OR EPDS ≥ 12 24–40 weeks gestation Low 3.79 (1.07–13.45) Huang et al. 2015 USA Prospective cohort 130/1,982 1999–2002 Unavailable Unavailable ADA criteria Depression prevalence EPDS ≥ 13 during mid-pregnancy High NA Morrison et al. 2015 USA Prospective cohort 83/938 Unavailable 27.7/24.4 31.9/26.0 Unavailable Depression prevalence; OR CES-D ≥ 10 the first trimester prenatal interview Low 1.66 (1.21–2.86) Dahlen et al. 2015 Australia Retrospective cohort Unavailable 2012.07-2013.06 Unavailable Unavailable Medical records OR EPDS ≥ 13 the first antenatal visit High 1.75 (1.09–2.82) Miller et al. 2016 USA Prospective cohort 96/133 2012.02-2014.04 Unavailable Unavailable Medical records Depression prevalence PHQ-9 ≥ 5 the third trimester Low NA Varela et al. 2017 Greece Prospective cohort 17/100 Unavailable Unavailable Unavailable Self-report Depression prevalence EPDS ≥ 13 32–35 weeks gestation High NA Egan et al. 2017 Ireland Cross-sectional cohort 78/108 Unavailable 33.6/31.6 Unavailable Unavailable Depression prevalence DASS-21 Unavailable High NA Hassan et al. 2017 Iraq Prospective cohort 50/50 2015.07-2015.08 Unavailable 27.4/24.6 ADA criteria Depression prevalence BDI ≥ 12 36 weeks gestation High NA Pace et al. 2018 Canada Retrospective cohort 29,200/29,200 1990.04.01-2007.12.31 Unavailable Unavailable ICD-9, ICD-10 Depression prevalence; OR ICD-9, ICD-10 24 weeks gestation to delivery Low 1.81 (1.44–2.28) Beka et al. 2018 Canada Retrospective cohort 12,140/314,583 2000.04.01-2009.03.31 32.1/29.1 Unavailable Diagnostic codes Depression prevalence; OR ICD-9, ICD-10 24–28 weeks gestation Low 1.09 (1.02–1.17) Larrabure-Torrealva et al. 2018 Perú Cross-sectional study 205/1,095 2013.02-2014.06 29.83/28.68 Unavailable IADPSG criteria Depression prevalence; OR PHQ-9 ≥ 10 24–28 weeks gestation High 1.52 (1.09–2.12) Ruohomäki et al. 2018 Finland Prospective cohort 150/916 2012–2017 31.4/29.9 28.7/24.1 Medical records Depression prevalence; OR EPDS ≥ 10 28–44 weeks gestation High 0.89 (0.49–1.64) Miller et al. 2019 USA Prospective cohort 46/516 2013.07.01-2015.06.30 32.0/30.5 29.7/25.2 Medical records Depression prevalence PHQ-9 ≥ 5 18–28 weeks gestation Low NA Schmidt et al. 2019 Netherlands Prospective cohort 36/64 Unavailable 32.9/32.3 27.4/26.3 PAID-5 Depression prevalence PHQ-9 ≥ 12 28–32 weeks gestation Low NA Wilson et al. 2020 UK Prospective cohort 1,028/12,044 2007–2010 30.35/27.04 28.36/25.83 modified WHO criteria Depression prevalence; OR ICD-10 26–28 weeks gestation Low 0.95 (0.77–1.17) Munda et al. 2021 Slovenia Prospective cohort 77/103 Unavailable 33.0/31.3 25.54/22.92 IADPSG criteria Depression prevalence; OR BDI II ≥ 13 the 2nd trimester Low 2.55 (1.13–5.78) GDM, gestational diabetes mellitus; BMI, body mass index; OR, odds risk; CI, confidence interval; NA, not applicable; ADIPS, Australasian Diabetes in Pregnancy Society; PAID-5, the Dutch version of the 5-item Problem Areas in Diabetes Scale 5; WHO, World Health Organization; ADA: American diabetic association; IADPSG, International Association of Diabetes and Pregnancy Study Groups; ACOG, the American College of Obstetricians and Gynecologists; ICD, International Classification of Diseases; OGTT, oral glucose tolerance test; EPDS, Edinburgh Postnatal Depression Scale; MHI-5, Mental Health Inventory-5; MADRS, Montgomery-Asberg Depression Rating Scale; CES-D, Center for Epidemiologic Studies Depression Scale; BDI, Beck Depression Inventory; DASS-21, Depression, Anxiety and Stress Scale-21 Items; PHQ-9, Patient Health Questionnaire-9; STAI, State–Trait Anxiety Inventory. Table 2 Characteristics of included studies for postpartum depression on pregnant women with or without GDM Study Country Study type Sample size Study period Age (GDM/ no-GDM) Pre-pregnancy BMI (kg/m 2 ) GDM assessment Outcome Outcome assessment Timing of outcome assessment Risk of bias Unadjusted OR (95% CI) Kim et al. 2005 USA Prospective cohort 64/1,233 2001.05-2002.07 30.0/30.0 Unavailable Medical data Depression prevalence; OR CES-D ≥ 11 8–12 weeks postpartum Low 1.58 (0.73–3.41) Besser et al. 2007 Israel Prospective cohort 100/109 Unavailable 29.97/25.31 Unavailable 50 g OGTT Depression prevalence; OR CES-D ≥ 16 8 weeks postpartum Low 1.31 (0.76–2.27) * Kozhimannil et al. 2009 USA Retrospective cohort 657/10,367 2004.07.01-2006.09.30 28.4/25.0 Unavailable ICD-9 Depression prevalence ICD-9 1 year after delivery High NA Räisänen et al. 2014 Finland Cross-sectional study 57,836/453,586 2002–2010 Unavailable Unavailable ICD-10 Depression prevalence ICD-10 6 weeks postpartum Low NA Katon et al. 2014 USA Prospective cohort 294/1,129 2001.01-2011.06 Unavailable Unavailable ICD-9 Depression prevalence; OR PHQ-9 ≥ 10 6 weeks postpartum Low 1.02 (0.57–1.8) * Sundaram et al. 2014 USA Prospective cohort 10,691/49,972 2007–2008 Unavailable Unavailable Self-report Depression prevalence; OR PHQ-2 ≥ 3 Unavailable High 1.13 (0.93–1.30) Abdollahi et al. 2014 Iraq Retrospective cohort Unavailable 2009.01-2009.06 Unavailable Unavailable Self-report OR EPDS ≥ 12 12 weeks postpartum Low 2.19 (1.26–3.8) Huang et al. 2015 USA Prospective cohort 87/1,599 1999–2002 Unavailable Unavailable ADA criteria Depression prevalence EPDS ≥ 13 24 weeks postpartum High NA Hinkle et al. 2016 USA Prospective cohort 81/81 2009–2013 Unavailable Unavailable Carpenter-Coustan criteria Depression prevalence; OR EPDS ≥ 10 6 weeks postpartum High 4.00 (1.17–13.65) Miller et al. 2016 USA Prospective cohort 94/133 2012.02-2014.04 Unavailable Unavailable Medical records Depression prevalence PHQ-9 ≥ 5 the postpartum visit Low NA Varela et al. 2017 Greece Prospective cohort 14/89 Unavailable Unavailable Unavailable Self-report Depression prevalence; OR EPDS ≥ 13 1 weeks postpartum High 4.32 (1.18–15.78) * Damé et al. 2017 Brazil Cross-sectional cohort 96/724 2014–2015 Unavailable Unavailable IADPSG criteria Depression prevalence EPDS ≥ 12 Unavailable High NA Zwolińska-Kloc et al. 2017 Poland Case-control study 35/35 2012.11-2013.07 31.7/27.6 Unavailable IADPSG criteria Depression prevalence HADS 6 months postpartum High NA Silverman et al. 2017 Swedish Prospective cohort 3,289/69,8115 1997.01.01-2008.12.31 Unavailable Unavailable Medical records Depression prevalence; OR ICD-9, ICD-10 1 year postpartum High 2.3 (1.72–3.09) * Ruohomäki et al. 2018 Finland Prospective cohort 150/916 2012–2017 31.4/29.9 28.7/24.1 Medical records Depression prevalence; OR EPDS ≥ 10 8 weeks postpartum High 1.84 (1.13-3.00) Pace et al. 2018 Canada Retrospective cohort 29,200/29,200 1990.04.01-2007.12.31 Unavailable Unavailable ICD-9; ICD-10 Depression prevalence; OR ICD-9, ICD-10 1 year postpartum Low 1.10 (0.92–1.32) Beka et al. 2018 Canada Retrospective cohort 12,140/314,583 2000.04.01-2009.03.31 32.1/29.1 Unavailable Diagnostic codes Depression prevalence; OR ICD-9, ICD-10 1 year postpartum Low 0.99 (0.93–1.05) Miller et al. 2019 USA Prospective cohort 46/516 2013.07.01-2015.06.30 32.0/30.5 29.7/25.2 Medical records Depression prevalence PHQ-9 ≥ 5 6 months postpartum Low NA Schmidt et al. 2019 Netherlands Prospective cohort 36/64 Unavailable 32.9/32.3 27.4/26.3 PAID-5 Depression prevalence PHQ-9 ≥ 12 4 months postpartum Low NA Clark et al. 2019 USA Case-control cohort 384/382 1998–2017 Unavailable Unavailable ICD-9 Depression prevalence; OR ICD-9 6 months postpartum Low 0.94(0.56–1.58) * GDM, gestational diabetes mellitus; BMI, body mass index; OR, odds risk; CI, confidence interval; NA, not applicable; PAID-5, the Dutch version of the 5-item Problem Areas in Diabetes Scale 5; ADA: American diabetic association; IADPSG, International Association of Diabetes and Pregnancy Study Groups; ICD, International Classification of Diseases; OGTT, oral glucose tolerance test; EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiologic Studies Depression Scale; PHQ, Patient Health Questionnaire; HADS, Hospital Anxiety and Depression Scale. * Estimate given in paper. Most studies clearly stated the criteria used for GDM diagnosis, which included the Carpenter-Coustan criteria for the interpretation of the 100-g 3-h oral glucose tolerance test, the 2010 International Association of Diabetes and Pregnancy Study Groups criteria, the Australasian Diabetes in Pregnancy Society criteria, and the 2008 Canadian Diabetes Association criteria. Four studies used the International Classification of Diseases criteria to assess patients for GDM. Thirteen studies did not provide full information. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess peripartum depressive symptoms and antenatal anxiety in pregnant women with GDM in 9 studies, and different EPDS cut-off scores were used to differentiate severe depression from no or mild depression. The rest of the studies used the ICD-9 or ICD-10 criteria, the Center for Epidemiologic Studies Depression Scale (CES-D), Mental Health Inventory-5, Depression, Anxiety and Stress Scale-21 (DASS-21) items, Patient Health Questionnaire-9 (PHQ-9), the Beck Depression Inventory (BDI), and self-reporting. To measure anxiety, 3 studies used the State–Trait Anxiety Inventory (STAI), and 4 studies used the DASS-21, ICD-9 criteria, and Taylor Anxiety Scale. 3.2 GDM and antenatal depression In all, 23 studies with a sample size of 930,824 provided data on the prevalence of depressive symptoms during the antenatal period in pregnant women with or without GDM (Table 1 ) ( 9 , 15 , 21 – 42 ). The pooled data exhibited significant between-study heterogeneity (I 2 > 50%, P < 0.05), so the random-effects model was used (Fig. 2 ). The meta-analysis suggested that the presence of GDM significantly increased the risk of antenatal depressive symptoms in pregnant women (pooled OR: 1.57, 95% CI: 1.33–1.85, P < 0.001; Fig. 3 ). To reduce the influence of pre-gestational diabetes on the prevalence of depression, we conducted a meta-analysis of the 11 studies that reported prevalence data after excluding pre-existing diabetes. This analysis showed that pregnant women with GDM had a statistically significant 54% increase in the risk of developing antenatal depressive symptoms as compared to pregnant women without GDM (pooled OR: 1.54, 95% CI: 1.17–2.01, P = 0.002). We also conducted a meta-analysis of 11 studies ( 15 , 22 , 27 , 33 – 36 , 39 – 41 , 43 ) that reported unadjusted ORs (pooled OR: 1.44, 95% CI: 1.20–1.73, P < 0.001; Fig. 4 ). There was high heterogeneity (I 2 = 85%) among these studies, possibly due to differences in study type, locations, assessment methods, covariates, and other factors. 3.3 GDM and postpartum depression Eighteen studies involving 1,617,320 women provided data on the prevalence of postpartum depressive symptoms in women with or without GDM (Table 2 ) ( 7 , 15 , 23 – 25 , 28 , 30 – 31 , 33 – 34 , 36 – 38 , 44 – 48 ). Due to significant between-study heterogeneity (I 2 = 79%), we used the random-effects model. The pooled results indicated a high risk of postpartum depressive symptoms in women with GDM as compared to women without GDM (pooled OR: 1.42, 95% CI: 1.18–1.70, P < 0.05; Fig. 5 ). In addition, we performed a meta-analysis of 7 studies ( 15 , 33 – 34 , 36 , 45 , 49 – 50 ) that reported unadjusted ORs (pooled OR: 1.26, 95% CI: 1.04–1.54, P = 0.02, I 2 = 72%; Fig. 6 ). 3.4 GDM and antenatal anxiety and stress Three studies reported the prevalence of high levels of anxiety during the antenatal period (Table 3 ). Significant heterogeneity (I 2 = 88%, P < 0.05) was found among these studies, so the random-effects model was used. The meta-analysis showed that the pooled OR was 2.81 (95% CI: 0.84–9.42, P = 0.1; Fig. 7 A). Two studies used the STAI criteria to assess anxiety (I 2 = 37%). The pooled result indicated that GDM significantly increased the risk of antenatal anxiety symptoms (pooled OR: 4.19, 95% CI: 1.21–7.17, P = 0.006; Fig. 7 B). However, the sample sizes of the above five studies were too small to draw definitive conclusions. Table 3 Characteristics of included studies for antenatal anxiety and stress on pregnant women with or without GDM Study Country Study type Sample size Study period Age (GDM/ no-GDM) Pre-pregnancy BMI (kg/m2) GDM assessment Outcome Outcome assessment Timing of outcome assessment Risk of bias Anxiety Rumbold et al. 2002 Australia Prospective cohort 21/95 Unavailable 30.0/28.0 30.0/27.0 WHO criteria Anxiety prevalence STAI 36 weeks gestation High Daniells et al. 2003 Australia Prospective cohort 50/50 2000.11-2001.11 31.4/29.0 27.4/24.6 ADIPS criteria Anxiety prevalence STAI 30 weeks gestation High Byrn et al. 2015 USA Cross-sectional study 65/70 Unavailable 32.12/27.36 34.4/31.0 Medical data Anxiety prevalence STAI 24–40 weeks gestation Low Hassan et al. 2017 Iraq Prospective cohort 50/50 2015.07-2015.08 Unavailable 27.4/24.6 ADA criteria Anxiety prevalence Taylor anxiety scale ≥ 25 36 weeks gestation High Beka et al. 2018 Canada Retrospective cohort 12,140/314,583 2000.04.01-2009.03.31 32.1/29.1 Unavailable Diagnostic codes Anxiety prevalence ICD-9 24–28 weeks gestation Low Stress Byrn et al. 2015 USA Cross-sectional study 65/70 Unavailable 32.12/27.36 34.4/31.0 Medical data Stress score PSS 24–40 weeks gestation Low Horsch et al. 2016 Switzerland Cross-sectional study 39/164 2012.11-2013.07 32.73/29.70 25.15/22.78 IADPSG criteria Stress score PSS, DASS-21 24–30 weeks gestation Low Egan et al. 2017 Ireland Cross-sectional cohort 78/108 Unavailable 33.6/31.6 Unavailable Unavailable Stress score DASS-21 Unavailable High GDM, gestational diabetes mellitus; BMI, body mass index; OR, odds risk; CI, confidence interval; NA, not applicable; ADIPS, Australasian Diabetes in Pregnancy Society; WHO, World Health Organization; ADA: American diabetic association; IADPSG, International Association of Diabetes and Pregnancy Study Groups; ICD, International Classification of Diseases; DASS-21, Depression, Anxiety and Stress Scale-21 Items; STAI, State–Trait Anxiety Inventory. PSS, Perceived Stress Scale. Two studies used the DASS-21 and another two studies used the Perceived Stress Scale (PSS) to assess severe stress. The data were presented as continuous scores. The pooled results indicated that GDM insignificantly increased the risk of antenatal stress symptoms (DASS-21, pooled OR: 1.68, 95% CI: -0.20-3.57, P = 0.08; PSS, pooled OR: 0.25, 95% CI: -3.15-3.65, P = 0.89; Fig. 7 C and 7 D). 3.5 Subgroup analysis We performed subgroup analyses to find the sources of heterogeneity among studies reporting data on depression and GDM (Table 4 ). Subgroups were formed based on the following factors: (i) study design (prospective study, retrospective study, and cross-sectional study); (ii) location (North America, Europe, and Asia); (iii) assessment tools (EPDS, BDI, CES-D, ICD, and PHQ-9); and (iv) sample size (≥ 100 or < 100 pregnant women with GDM). The subgroup analysis based on study design included 14 prospective studies, 6 cross-sectional studies, and 3 retrospective studies, and yielded pooled ORs of 1.52 (95% CI: 1.10–2.09, P = 0.01), 1.61 (95% CI: 1.05–2.48, P = 0.03), and 1.80 (95% CI: 1.36–2.38, P < 0.05), respectively. The analysis based on assessment tools included 5 studies using the EPDS, 3 studies using the BDI, 3 studies using the CES-D, 4 studies using the PHQ-9, and 4 studies using ICD-9 or ICD-10 criteria to assess depressive symptoms. The results were as follows: EPDS (pooled OR: 1.42, 95% CI: 1.00–2.00, P = 0.05), BDI (pooled OR: 2.50, 95% CI: 1.47–4.25, P < 0.05), CES-D (pooled OR: 1.07, 95% CI: 0.60–1.90, P = 0.82), PHQ-9 (pooled OR: 1.88, 95% CI: 0.91–3.86, P = 0.09), and ICD (pooled OR: 1.55, 95% CI: 1.22–1.96, P < 0.05). The subgroup analysis based on location included 9 studies from North America, 9 studies from Europe, and 5 studies from Asia. The results were as follows: North America (pooled OR: 1.53, 95% CI: 1.15–2.03, P = 0.003), Europe (pooled OR: 1.34, 95% CI: 0.99–1.81, P = 0.05), and Asia (pooled OR: 2.71, 95% CI: 1.98–3.72, P < 0.05). These results suggested that pregnant women with GDM from Asia have a higher risk of developing depressive symptoms. Table 4 Subgroup analysis for antenatal depression on pregnant women with or without GDM. Outcomes No. of Studies OR (95% CI) Z-value P Heterogeneity I 2 (%) P Study design Prospective study 14 1.52 [1.10, 2.09] 2.57 0.01 68 < 0.001 Retrospective study 3 1.61 [1.05, 2.48] 2.18 0.03 92 < 0.001 Cross-sectional study 6 1.80 [1.36, 2.38] 4.14 < 0.001 58 0.04 Location North America 9 1.53 [1.15, 2.03] 2.95 0.003 80 < 0.001 Asia 5 2.71 [1.98, 3.72] 6.17 < 0.001 32 0.21 Europe 8 1.34 [0.99, 1.81] 1.92 0.05 75 < 0.001 Assessment tools EPDS 5 1.42 [1.00, 2.00] 1.98 0.05 28 0.24 BDI 3 2.50 [1.47,4.25] 3.39 < 0.001 38 0.20 CES-D 3 1.07 [0.60, 1.90] 0.22 0.82 60 0.08 ICD 4 1.55 [1.22, 1.96] 3.58 < 0.001 92 < 0.001 PHQ-9 4 1.88 [0.91, 3.86] 1.71 0.09 75 0.008 Sample size < 100 12 1.78 [1.21, 2.63] 2.91 0.004 53 0.02 ≥ 100 9 1.51 [1.16, 1.96] 3.10 0.002 87 < 0.001 OR, odds risk; CI, confidence interval; GDM, gestational diabetes mellitus; EPDS, Edinburgh Postnatal Depression Scale; BDI, Beck Depression Inventory; CES-D, Center for Epidemiologic Studies Depression Scale; ICD, International Classification of Diseases; PHQ-9, Patient Health Questionnaire-9. 3.6 Sensitivity analysis Considering the significant between-study heterogeneity and the results of the subgroup analyses, we performed sensitivity analysis to assess the robustness of the pooled ORs in regards to the prevalence of GDM. We excluded studies one by one, and recalculated the pooled ORs for the remaining studies to determine if there was any significant change in our findings. The results showed that the exclusion of any single study was unlikely to change our findings. 4. DISCUSSION 4.1 Main findings Women with GDM are a high-risk group for maternal and infant complications as well as mental health problems, which have attracted increasing attention from clinicians and researchers worldwide. Perinatal mental problems, such as depression, anxiety, and stress, will further exacerbate the hormone imbalance associated with GDM, resulting in poor pregnancy outcomes ( 51 – 52 ). Research on the relationship between mental health and GDM will contribute to better guidance on intervention measures and improve postpartum outcomes. The present meta-analysis comprehensively assessed the relationship between GDM and mental health problems. Our results suggest that compared to pregnant women without GDM, those with GDM had a significantly increased prevalence of antenatal and postpartum depressive symptoms, especially among Asian people. Moreover, compared to pregnant women without GDM, women with GDM reported significantly higher anxiety scores, but this evidence needs to be further strengthened. 4.2 Comparison with previous studies In 2020, Wilson et al. conducted a systematic review and meta-analysis of 62 studies on the association of GDM with mental disorders, especially depression ( 53 ), and reported increased risks of antenatal depressive symptoms, especially around the time of GDM diagnosis, as well as postnatal depressive symptoms. The authors included a large number of studies and achieved convincing results; however, they did not compare the risk of mental health problems in GDM among women with different nationalities. Our results indicated that pregnant women with GDM from Asia bear a greater risk of peripartum depression than women from North America and Europe (OR: 2.71 vs. 1.53 vs. 1.34, respectively). It is well-established that a large treatment gap for mental disorders exists between different world regions. Regional differences in culture have a great influence on the treatment and overall outcomes of mental disorders. It is estimated that 42–44% of patients in developed regions seek treatment for depressive or anxiety disorders, in contrast to as little as 5% of patients in low- and middle-income countries ( 54 – 55 ). Depressive and anxiety symptoms may be perceived as being less relevant in non-Western cultures ( 56 ). Furthermore, the stigma and shame associated with mental disorders influence positive reinforcement behaviors, resulting in greater reluctance to discuss and manage emotional problems in patients from low- and middle-income countries ( 57 – 58 ). Delanerolle et al. conducted a meta-analysis to evaluate the risk of GDM among black, Asian, and minority ethnic women who had pre-existing mental disorders; the results suggested that Hispanic women with GDM had a higher risk of depression ( 57 ). However, high between-study heterogeneity was identified in this analysis. Furthermore, only 2–4 studies were included in the subgroup analyses based on ethnicity, which greatly reduced the reliability of the evidence. 4.3 New findings within the meta-analysis Our meta-analysis involved almost 10,000 patients from 32 studies and demonstrated that pregnant women with GDM are at a greater risk for developing depressive symptoms in the antenatal and postpartum periods as well as for developing antepartum anxiety symptoms. Furthermore, this conclusion was verified by the subgroup analyses based on the assessment tools used for mental disorders. Notably, ours is the first study to evaluate the correlation between GDM and anxiety/stress symptoms by using meta-analysis rather than literature review. Nevertheless, the present evidence is still insufficient because only few studies could be included in the subgroup analyses. Anxiety is a psychological disorder with diverse manifestations, including persistent anxiety and recurring panic ( 59 ). Due to the hormone and glucose imbalance caused by GDM, pregnant women with GDM are often more vulnerable to developing psychological symptoms ( 60 ). Furthermore, GDM patients who have little social support and a low education level tend to develop more severe pregnancy-related anxiety ( 59 , 61 ). This is because pregnant women who lack access to knowledge about diabetes and adequate social support may not be able to correct their own unhealthy behaviors, which will further affect blood glucose control and aggravate their anxiety symptoms. Therefore, family members and friends should help pregnant women promote their own healthy behaviors and improve their self-management ability to relieve their anxiety. The present study has several important strengths. We included numerous studies that reported the antenatal and postpartum prevalence rates of mental disorders in pregnant women with GDM. We also included recently published meta-analyses to ensure that our results are up-to-date. To reduce the influence of pre-gestational diabetes as a confounding factor, we conducted a secondary analysis of studies that excluded pregnant women with pre-gestational diabetes, and found that the conclusions remained solid and reliable. In addition, a series of subgroup analyses based on various factors, including study design, were conducted. The results of these analyses indicated that GDM patients from Asia are more vulnerable to depressive symptoms than GDM patients from other regions. Thus, healthcare providers in Asia should be alert to negative emotions in pregnant women with GDM and take appropriate psychological and behavioral treatment measures. 4.4 Limitations Several limitations of the present meta-analysis should be noted. Although we conducted subgroup analyses based on the assessment tools used for peripartum depression, the cut-offs used for the various depression scales differed among the studies, leading to substantial between-study heterogeneity. Moreover, some studies assessed exposure and outcomes using self-reported data, and may therefore, have a high risk of information bias. Some studies had a retrospective or cross-sectional design, which may lead to selection bias in the pooled results. Furthermore, the excessive gap in the range of sample sizes among the studies may increase the weight of studies with large sample sizes in the pooled results and increase systematic biases. 5. CONCLUSION GDM significantly increased the prevalence of antenatal and postpartum depressive and anxiety symptoms. Further multi-center prospective studies with long-term follow-up are required to verify the relationship between GDM and mental health disorders. Declarations Funding None Author Contribution Conception and design: All authors ,Administrative support: Zhenhua Chen and Qirong Wan,Provision of study materials or patients: Yanhong Gao and Jing Wang ,Collection and assembly of data:Haiying Xie and Wei Yuan,Data analysis and interpretation: Qirong Wan and Haiying Xie,Manuscript writing: Qirong Wan and Haiying Xie Acknowledgments None Data Availability Data is provided within the manuscript or supplementary information files. References Metzger BE, Coustan DR. Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. The Organizing Committee. Diabetes Care. 1998;21 Suppl 2:B161-7. Zhu Y, Zhang C. Prevalence of Gestational Diabetes and Risk of Progression to Type 2 Diabetes: a Global Perspective. Curr Diab Rep. 2016;16:7. Catalano PM, McIntyre HD, Cruickshank JK, et al. The hyperglycemia and adverse pregnancy outcome study: associations of GDM and obesity with pregnancy outcomes. Diabetes Care. 2012;35:780–6. At SZZ. Maternal Obesity, Maternal Gestational Diabetes Mellitus, and Maternaland Neonatal Outcomes. J Obes Weight Loss Therapy. 2016;06. Wendland EM, Torloni MR, Falavigna M, et al. Gestational diabetes and pregnancy outcomes–a systematic review of the World Health Organization (WHO) and the International Association of Diabetes in Pregnancy Study Groups (IADPSG) diagnostic criteria. BMC Pregnancy Childbirth. 2012;12:23. Lydon K, Dunne FP, Owens L, et al. Psychological stress associated with diabetes during pregnancy: a pilot study. Ir Med J. 2012;105:26–8. Silverman ME, Reichenberg A, Savitz DA, et al. The risk factors for postpartum depression: A population-based study. 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Association between diabetes and perinatal depression among low-income mothers. JAMA. 2009;301:842–7. Raisanen S, Lehto SM, Nielsen HS, et al. Risk factors for and perinatal outcomes of major depression during pregnancy: a population-based analysis during 2002–2010 in Finland. BMJ Open. 2014;4:e4883. Keskin FE, Ozyazar M, Pala AS, et al. Evaluation of cognitive functions in gestational diabetes mellitus. Exp Clin Endocrinol Diabetes. 2015;123:246–51. Byrn M, Penckofer S. The relationship between gestational diabetes and antenatal depression. J Obstet Gynecol Neonatal Nurs. 2015;44:246–55. Huang T, Rifas-Shiman SL, Ertel KA, et al. Pregnancy Hyperglycaemia and Risk of Prenatal and Postpartum Depressive Symptoms. Paediatr Perinat Epidemiol. 2015;29:281–9. Horsch A, Kang JS, Vial Y, et al. Stress exposure and psychological stress responses are related to glucose concentrations during pregnancy. Br J Health Psychol. 2016;21:712–29. Miller ES, Peri MR, Gossett DR. The association between diabetes and postpartum depression. Arch Womens Ment Health. 2016;19:183–6. Varela P, Spyropoulou AC, Kalogerakis Z, et al. Association between gestational diabetes and perinatal depressive symptoms: evidence from a Greek cohort study. Prim Health Care Res Dev. 2017;18:441–7. Egan AM, Dunne FP, Lydon K, et al. Diabetes in pregnancy: worse medical outcomes in type 1 diabetes but worse psychological outcomes in gestational diabetes. QJM. 2017;110:721–7. Pace R, Rahme E, Da CD, et al. Association between gestational diabetes mellitus and depression in parents: a retrospective cohort study. Clin Epidemiol. 2018;10:1827–38. Beka Q, Bowker S, Savu A, et al. Development of Perinatal Mental Illness in Women With Gestational Diabetes Mellitus: A Population-Based Cohort Study. Can J Diabetes. 2018;42:350–5. Larrabure-Torrealva GT, Martinez S, Luque-Fernandez MA, et al. Prevalence and risk factors of gestational diabetes mellitus: findings from a universal screening feasibility program in Lima, Peru. BMC Pregnancy Childbirth. 2018;18:303. Ruohomaki A, Toffol E, Upadhyaya S, et al. The association between gestational diabetes mellitus and postpartum depressive symptomatology: A prospective cohort study. J Affect Disord. 2018;241:263–8. Miller NE, Curry E, Laabs SB, et al. Impact of gestational diabetes diagnosis on concurrent depression in pregnancy. J Psychosom Obstet Gynaecol. 2021;42:190–3. Schmidt CB, Voorhorst I, van de Gaar V, et al. Diabetes distress is associated with adverse pregnancy outcomes in women with gestational diabetes: a prospective cohort study. BMC Pregnancy Childbirth. 2019;19:223. Wilson CA, Santorelli G, Dickerson J, et al. Is there an association between anxiety and depression prior to and during pregnancy and gestational diabetes? An analysis of the Born in Bradford cohort. J Affect Disord. 2020;276:345–50. Munda A, Fekonja U, Pongrac BD. Prevalence of depressive and anxiety symptoms in women with gestational diabetes: a longitudinal cohort study. Acta Diabetol. 2021;58:1091–100. Morrison C, McCook JG, Bailey BA. First trimester depression scores predict development of gestational diabetes mellitus in pregnant rural Appalachian women. J Psychosom Obstet Gynaecol. 2016;37:21–5. Hassan SM, Ejerish MA, Harba U. Effect of depression and anxiety on gestational diabetes in Babylon Government. Int J Pharm Sci Res. 2017;10:4371–5. Dahlen HG, Barnett B, Kohlhoff J, et al. Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes: a population based cohort study. BMC Pregnancy Childbirth. 2015;15:292. Katon W, Russo J, Gavin A. Predictors of postpartum depression. J Womens Health (Larchmt). 2014;23:753–9. Hinkle SN, Buck LG, Rawal S, et al. A longitudinal study of depression and gestational diabetes in pregnancy and the postpartum period. Diabetologia. 2016;59:2594–602. Dame P, Cherubini K, Goveia P, et al. Depressive Symptoms in Women with Gestational Diabetes Mellitus: The LINDA-Brazil Study. J Diabetes Res. 2017;2017:7341893. Zwolińska-Kloc M, Zabel M, Czajkowski K, et al. Relations between gestational diabetes and postpartum depressive disorders and symptoms. Archives Psychiatry Psychother. 2017;19:43–6. Clark CE, Rasgon NL, Reed IIDE, et al. Depression precedes, but does not follow, gestational diabetes. Acta psychiatrica Scandinavica. 2019;4:311–21. Sundaram S, Harman JS, Cook RL. Maternal morbidities and postpartum depression: an analysis using the 2007 and 2008 Pregnancy Risk Assessment Monitoring System. Womens Health Issues. 2014;24:e381–8. Abdollahi F, Zarghami M, Azhar MZ, et al. Predictors and incidence of post-partum depression: a longitudinal cohort study. J Obstet Gynaecol Res. 2014;40:2191–200. Robinson DJ, Coons M, Haensel H, et al. Diabetes and Mental Health. Can J Diabetes. 2018;42(Suppl 1):S130–41. Azami M, Badfar G, Soleymani A, et al. The association between gestational diabetes and postpartum depression: A systematic review and meta-analysis. Diabetes Res Clin Pract. 2019;149:147–55. Wilson CA, Newham J, Rankin J, et al. Is there an increased risk of perinatal mental disorder in women with gestational diabetes? A systematic review and meta-analysis. Diabet Med. 2020;37:602–22. Kohn R, Saxena S, Levav I, et al. The treatment gap in mental health care. Bull World Health Organ. 2004;82:858–66. Wang PS, Aguilar-Gaxiola S, Alonso J, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet. 2007;370:841–50. Wang PS, Aguilargaxiola S, Alonso J, et al. Worldwide Use of Mental Health Services for Anxiety, Mood, and Substance Disorders: Results from 17 Countries in the WHO World Mental Health (WMH) Surveys. Lancet. 2007;370:841. Delanerolle G, Phiri P, Zeng Y, et al. A systematic review and meta-analysis of gestational diabetes mellitus and mental health among BAME populations. EClinicalMedicine. 2021;38:101016. Hui AL, Sevenhuysen G, Harvey D, et al. Stress and anxiety in women with gestational diabetes during dietary management. Diabetes Educ. 2014;40:668–77. Fu F, Yan P, You S, et al. The pregnancy-related anxiety characteristics in women with gestational diabetes mellitus: why should we care? BMC Pregnancy Childbirth. 2021;21:424. Zemestani M, Fazeli NZ. Effectiveness of mindfulness-based cognitive therapy for comorbid depression and anxiety in pregnancy: a randomized controlled trial. Arch Womens Ment Health. 2020;23:207–14. Abrar A, Fairbrother N, Smith AP, et al. Anxiety among women experiencing medically complicated pregnancy: A systematic review and meta-analysis. Birth. 2020;47:13–20. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4229400","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288973339,"identity":"e19655ad-d5f0-4360-88e3-0ef2bf2ec07f","order_by":0,"name":"Qirong 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3","display":"","copyAsset":false,"role":"figure","size":310473,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of the prevalence of antenatal depressive symptoms in pregnant women with or without GDM, after excluding women with pre-gestational diabetes.\u003c/p\u003e\n\u003cp\u003eGDM, gestational diabetes mellitus\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4229400/v1/070bbf8dbe99d2fd6cf43eee.png"},{"id":54864587,"identity":"c119024c-2e55-4be9-bb1e-294ce5d8769c","added_by":"auto","created_at":"2024-04-17 20:38:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":313293,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of the unadjusted ORs of antenatal depressive symptoms in pregnant women with or without GDM.\u003c/p\u003e\n\u003cp\u003eOR, odds ratio; GDM, gestational diabetes mellitus\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4229400/v1/e5dfe4951b2175f9446c7ac3.png"},{"id":54864589,"identity":"6f3f3499-9b07-47b6-b2a7-4bc1c3aa0417","added_by":"auto","created_at":"2024-04-17 20:38:42","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":436946,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of the prevalence of postpartum depressive symptoms in pregnant women with or without GDM.\u003c/p\u003e\n\u003cp\u003eGDM, gestational diabetes mellitus\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4229400/v1/def3ae1a827d6511e0f1b490.png"},{"id":54864592,"identity":"69779bc4-e775-4264-acd9-cc15a62de43d","added_by":"auto","created_at":"2024-04-17 20:38:42","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":243020,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of the unadjusted ORs of postpartum depressive symptoms in pregnant women with or without GDM.\u003c/p\u003e\n\u003cp\u003eOR, odds ratio; GDM, gestational diabetes mellitus\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-4229400/v1/b608f2bf6b14a6a1a9aeba1d.png"},{"id":54864591,"identity":"59a901cc-c974-4c51-b375-c8e032536c52","added_by":"auto","created_at":"2024-04-17 20:38:42","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":626799,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of pooled ORs for high levels of antenatal anxiety and stress symptoms in pregnant women with or without GDM. \u003cstrong\u003e(A)\u003c/strong\u003ePrevalence of anxiety. \u003cstrong\u003e(B)\u003c/strong\u003e Anxiety assessed using the STAI. \u003cstrong\u003e(C)\u003c/strong\u003e Stress assessed using the DASS-21. \u003cstrong\u003e(D)\u003c/strong\u003e Stress assessed using the Perceived Stress Scale.\u003c/p\u003e\n\u003cp\u003eOR, odds ratio; GDM, gestational diabetes mellitus; CI, confidence interval; STAI, State–Trait Anxiety Inventory; DASS-21, Depression, Anxiety and Stress Scale-21 Items\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-4229400/v1/3369d33fa8862a2fa2a2ea60.png"},{"id":65577110,"identity":"4f90de4d-3543-4751-9dda-d26aa610c79a","added_by":"auto","created_at":"2024-09-30 07:47:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3317826,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4229400/v1/22d32701-6b5f-4074-9f7f-d13f2475318a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correlation between gestational diabetes and peripartum mental disorders: A meta-analysis of 1,636,131 patients .Running title :A meta-analysis about correlation between gestational diabetes and peripartum mental disorders","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eGestational diabetes mellitus (GDM) is defined as glucose intolerance that is first diagnosed during pregnancy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The global prevalence of GDM is estimated to be 6\u0026ndash;13%, and has increased by approximately 30% within the last 2 decades (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The risk factors for GDM include advanced maternal age, obesity, a family history of diabetes, and previous unexplained stillbirth. Women with GDM are at risk for preeclampsia, preterm labor, and type 2 diabetes, and their infants are at risk for significant neonatal complications including congenital anomalies, birth injury, and macrosomia (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to physical complications, GDM is associated with worse psychological outcomes, such as impaired quality of life, anxiety, stress, and peripartum depression (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The incidence of depression has been reported to remarkably increase with pregnancy, from approximately 5% in non-pregnant women to 8\u0026ndash;10% during pregnancy and 13% after delivery (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Furthermore, women with GDM are 2\u0026ndash;4 times more likely to develop antenatal or postpartum depression than women without GDM (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Additionally, perinatal depression may itself be fueling the GDM epidemic, as GDM results from overeating and decreased physical exercise, which are commonly associated with depression; thus, women with GDM are at a higher risk for obesity and diabetes after delivery (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The bidirectional association between depression and type 2 diabetes is well established, but the evidence for a link between depression and GDM is inconsistent (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Three studies have reported that compared to women without diabetes in pregnancy, women with GDM did not experience a significant mood change (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Therefore, exploring the relationship between depression and diabetes in the peripartum period may improve the care of women with GDM as well as help prevent maternal and fetal complications.\u003c/p\u003e \u003cp\u003eThe aim of the present meta-analysis is to determine the relationship between mental disorders and GDM in the peripartum period. A deeper understanding of the development of GDM and mental health problems may help improve the care of women during the perinatal and postnatal periods, and thereby result in a better quality of life.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cp\u003eThe meta-analysis followed Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Literature search\u003c/h2\u003e \u003cp\u003eTwo researchers searched the PubMed, Cochrane Library, EMBASE, and Web of Science databases for potentially relevant journal articles using the following search terms: \u0026ldquo;mood disorder\u0026rdquo;, \u0026ldquo;depression\u0026rdquo;, \u0026ldquo;depressive\u0026rdquo;, \u0026ldquo;melancholi\u0026rdquo;, \u0026ldquo;dysthymic disorder\u0026rdquo;, \u0026ldquo;anxiety\u0026rdquo;, \u0026ldquo;stress\u0026rdquo;, \u0026ldquo;pregnancy diabetes\u0026rdquo;, \u0026ldquo;gestational diabetes mellitus\u0026rdquo;, and \u0026ldquo;gestational diabetes\u0026rdquo;. Forward and backward citation tracking were also undertaken. The last search was run on October 31, 2021. No language or country limitations were applied. All studies reporting on the mental disorders listed above were included and screened by two authors to identify any relevant studies that met the inclusion criteria. If the article titles and abstracts were ambiguous with regard to the inclusion criteria, the full text was downloaded and carefully reviewed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Eligibility criteria\u003c/h2\u003e \u003cp\u003eWe included studies investigating the relationship between GDM and perinatal mental disorders. Studies were eligible for inclusion if they met the following criteria: (i) the study involved pregnant women diagnosed with GDM and reported any mental disorder; (ii) the study included pregnant women without GDM for comparison; and (iii) the study was designed as a prospective or retrospective cohort study. Perinatal mental disorders were categorized into antenatal (conception to delivery) or postpartum (until 1 year after delivery) disorders, and included anxiety, stress, and psychotic or mood disorders.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Exclusion criteria\u003c/h2\u003e \u003cp\u003eWe excluded studies that used medication status to classify mental disorders. In addition, studies that provided only risk estimates with corresponding 95% confidence intervals (CIs) were excluded from the meta-analysis, but included in the review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data extraction and quality assessment\u003c/h2\u003e \u003cp\u003e Two experienced researchers independently assessed each study for the risk of bias by using the modified Newcastle\u0026ndash;Ottawa Scale based on the current PRISMA guidelines. The researchers focused on measurement and selection biases because most studies in the present review had a cross-sectional design. Disagreements were resolved by a third person who served as an intermediary and made the final decision. According to the selection, comparability, and outcome data, each study was graded as having a high, low, or unclear risk of bias.\u003c/p\u003e \u003cp\u003eTwo reviewers independently extracted relevant data from the original studies by using standardized data-extraction forms, and clarified discrepancies via re-evaluation and discussion with the other authors. We collected the following data: first author\u0026rsquo;s name, country, year of publication, study design, study period, sample size, age, body mass index before pregnancy, timing of outcome assessment, and tests for GDM and mental disorders. Prevalence, risk estimates, and information on potential underlying mechanisms, if present, were also collected. In the case of studies with unclear or missing data, the corresponding author was contacted to request clarification.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e \u003cp\u003e Statistical analyses were conducted in accordance with the recommendations of The Cochrane Collaboration. Differences in the prevalence of dichotomous variables were evaluated using odds ratios (ORs) and 95% CIs. Heterogeneity among studies was evaluated using the Cochran Q test (significance level, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the I\u003csup\u003e2\u003c/sup\u003e statistic (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026gt;\u0026thinsp;75%, high heterogeneity; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026lt;\u0026thinsp;25%, low heterogeneity). Data were analyzed using a fixed-effects model when the \u003cem\u003eP\u003c/em\u003e-value was \u0026gt;\u0026thinsp;0.05 and the I\u003csup\u003e2\u003c/sup\u003e statistic was \u0026lt;\u0026thinsp;50%; otherwise, a random-effects model was used (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026ge;\u0026thinsp;50%) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Subgroup analyses were performed based on differences in variables such as study design, location, assessment tools, and sample size. Sensitivity analyses were performed by omitting studies one by one and combining the remaining studies to reveal the impact of individual studies on the overall risk estimate. The Begg test and Egger test were used to assess potential publication bias (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Pooled data were analyzed using Review Manager \u003cem\u003ev\u003c/em\u003e5.3 (The Nordic Cochrane Center, The Cochrane Collaboration, 2014, Copenhagen, Denmark). Two-tailed \u003cem\u003eP\u003c/em\u003e-values of \u0026lt;\u0026thinsp;0.05 indicated statistically significant differences.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eElectronic searches of the 4 databases identified 9072 potentially relevant records. After removing 8878 duplicated articles and irrelevant studies, we further excluded 47 studies by reading their titles and abstracts; the remaining 147 publications were assessed in detail. Another 115 articles were excluded for various reasons, and 32 eligible studies were ultimately included for further qualitative and quantitative analyses. The detailed screening method and results are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Basic characteristics and quality assessment\u003c/h2\u003e \u003cp\u003eThe primary characteristics of the included studies are listed in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. We included 32 studies in our meta-analysis, with a total sample size of 1,636,131 pregnant women. Two of the studies were from South America; seven studies were from Asia; ten studies were from Europe; and thirteen studies were from North America. The included studies were published between 2002 and 2021. The most common study design was prospective cohort (n\u0026thinsp;=\u0026thinsp;18), followed by cross-sectional design (n\u0026thinsp;=\u0026thinsp;7), retrospective cohort (n\u0026thinsp;=\u0026thinsp;5), and case\u0026ndash;control studies (n\u0026thinsp;=\u0026thinsp;2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included studies for antenatal depression on pregnant women with or without GDM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudy period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(GDM/\u003c/p\u003e \u003cp\u003eno-GDM)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePre-pregnancy BMI\u003c/p\u003e \u003cp\u003e(kg/m2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGDM assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOutcome assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eTiming of outcome assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eRisk of\u003c/p\u003e \u003cp\u003ebias\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eUnadjusted OR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRumbold et al. 2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21/95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.0/28.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30.0/27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWHO criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e36 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaniells et al. 2003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50/50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2000.11-2001.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.4/29.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.4/24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eADIPS criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMHI-5\u0026nbsp;\u0026ge; 16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e30\u0026ndash;36 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e3.14 (1.1\u0026ndash;8.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKim et al. 2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64/1,233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2001.05-2002.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.0/30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCES-D\u0026thinsp;\u0026ge;\u0026thinsp;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12\u0026ndash;20 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBesser et al. 2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsrael\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100/109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.97/25.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50 g OGTT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCES-D\u0026thinsp;\u0026ge;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ein third trimester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKozhimannil et al. 2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e657/10,367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2004.07.01-2006.09.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.4/25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 months prior to delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR\u0026auml;is\u0026auml;nen et al. 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57,858/454,080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2002\u0026ndash;2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eduring pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.49 (1.37\u0026ndash;1.62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeskin et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTurkey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44/45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.4/30.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.6/25.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e75 g OGTT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBDI\u0026thinsp;\u0026ge;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;28 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNatasha et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e382/366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2011.08-2012.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.35/27.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWHO and ACOG criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMADRS\u0026thinsp;\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;28 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eByrn et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65/70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.12/27.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34.4/31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;40 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e3.79 (1.07\u0026ndash;13.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuang et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130/1,982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1999\u0026ndash;2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eADA criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eduring mid-pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMorrison et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83/938\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.7/24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.9/26.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCES-D\u0026thinsp;\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ethe first trimester prenatal interview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.66 (1.21\u0026ndash;2.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDahlen et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2012.07-2013.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ethe first antenatal visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.75 (1.09\u0026ndash;2.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiller et al. 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96/133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2012.02-2014.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ethe third trimester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVarela et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreece\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17/100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e32\u0026ndash;35 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEgan et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIreland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78/108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.6/31.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDASS-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHassan et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIraq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50/50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2015.07-2015.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.4/24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eADA criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBDI\u0026thinsp;\u0026ge;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e36 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePace et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29,200/29,200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1990.04.01-2007.12.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-9,\u003c/p\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9,\u003c/p\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24 weeks gestation to delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.81 (1.44\u0026ndash;2.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeka et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12,140/314,583\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2000.04.01-2009.03.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.1/29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDiagnostic codes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9,\u003c/p\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;28 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.09 (1.02\u0026ndash;1.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarrabure-Torrealva et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePer\u0026uacute;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e205/1,095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2013.02-2014.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.83/28.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIADPSG criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;28 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.52 (1.09\u0026ndash;2.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRuohom\u0026auml;ki et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150/916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2012\u0026ndash;2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.4/29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.7/24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e28\u0026ndash;44 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.89 (0.49\u0026ndash;1.64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiller et al. 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46/516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2013.07.01-2015.06.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.0/30.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.7/25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e18\u0026ndash;28 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchmidt et al. 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36/64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.9/32.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.4/26.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePAID-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e28\u0026ndash;32 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWilson et al. 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,028/12,044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2007\u0026ndash;2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.35/27.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.36/25.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003emodified WHO criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e26\u0026ndash;28 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.95 (0.77\u0026ndash;1.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMunda et al. 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSlovenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77/103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.0/31.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25.54/22.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIADPSG criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBDI II\u0026thinsp;\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ethe 2nd trimester\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.55 (1.13\u0026ndash;5.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eGDM, gestational diabetes mellitus; BMI, body mass index; OR, odds risk; CI, confidence interval; NA, not applicable; ADIPS, Australasian Diabetes in Pregnancy Society; PAID-5, the Dutch version of the 5-item Problem Areas in Diabetes Scale 5; WHO, World Health Organization; ADA: American diabetic association; IADPSG, International Association of Diabetes and Pregnancy Study Groups; ACOG, the American College of Obstetricians and Gynecologists; ICD, International Classification of Diseases; OGTT, oral glucose tolerance test; EPDS, Edinburgh Postnatal Depression Scale; MHI-5, Mental Health Inventory-5; MADRS, Montgomery-Asberg Depression Rating Scale; CES-D, Center for Epidemiologic Studies Depression Scale; BDI, Beck Depression Inventory; DASS-21, Depression, Anxiety and Stress Scale-21 Items; PHQ-9, Patient Health Questionnaire-9; STAI, State\u0026ndash;Trait Anxiety Inventory.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included studies for postpartum depression on pregnant women with or without GDM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudy period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(GDM/\u003c/p\u003e \u003cp\u003eno-GDM)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePre-pregnancy BMI\u003c/p\u003e \u003cp\u003e(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGDM assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOutcome assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eTiming of outcome assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eRisk of\u003c/p\u003e \u003cp\u003ebias\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eUnadjusted OR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKim et al. 2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64/1,233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2001.05-2002.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.0/30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCES-D\u0026thinsp;\u0026ge;\u0026thinsp;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8\u0026ndash;12 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.58 (0.73\u0026ndash;3.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBesser et al. 2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsrael\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100/109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.97/25.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50 g OGTT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCES-D\u0026thinsp;\u0026ge;\u0026thinsp;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.31 (0.76\u0026ndash;2.27) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKozhimannil et al. 2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e657/10,367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2004.07.01-2006.09.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.4/25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1 year after delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR\u0026auml;is\u0026auml;nen et al. 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57,836/453,586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2002\u0026ndash;2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaton et al. 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e294/1,129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2001.01-2011.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.02 (0.57\u0026ndash;1.8) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSundaram et al. 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,691/49,972\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2007\u0026ndash;2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-2\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.13 (0.93\u0026ndash;1.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdollahi et al. 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIraq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2009.01-2009.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.19 (1.26\u0026ndash;3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuang et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87/1,599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1999\u0026ndash;2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eADA criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHinkle et al. 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81/81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2009\u0026ndash;2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCarpenter-Coustan criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e4.00 (1.17\u0026ndash;13.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiller et al. 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94/133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2012.02-2014.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ethe postpartum visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVarela et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreece\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14/89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e4.32 (1.18\u0026ndash;15.78) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDam\u0026eacute; et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96/724\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2014\u0026ndash;2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIADPSG criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZwolińska-Kloc et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase-control study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35/35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2012.11-2013.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.7/27.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIADPSG criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHADS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 months postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSilverman et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSwedish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,289/69,8115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1997.01.01-2008.12.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9,\u003c/p\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1 year postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.3 (1.72\u0026ndash;3.09) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRuohom\u0026auml;ki et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150/916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2012\u0026ndash;2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.4/29.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.7/24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEPDS\u0026thinsp;\u0026ge;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8 weeks postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.84 (1.13-3.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePace et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29,200/29,200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1990.04.01-2007.12.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-9;\u003c/p\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9,\u003c/p\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1 year postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.10 (0.92\u0026ndash;1.32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeka et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12,140/314,583\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2000.04.01-2009.03.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.1/29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDiagnostic codes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9,\u003c/p\u003e \u003cp\u003eICD-10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1 year postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.99 (0.93\u0026ndash;1.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiller et al. 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46/516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2013.07.01-2015.06.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.0/30.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.7/25.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 months postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchmidt et al. 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36/64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.9/32.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.4/26.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePAID-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4 months postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClark et al. 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase-control cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e384/382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1998\u0026ndash;2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDepression prevalence; OR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6 months postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.94(0.56\u0026ndash;1.58) *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eGDM, gestational diabetes mellitus; BMI, body mass index; OR, odds risk; CI, confidence interval; NA, not applicable; PAID-5, the Dutch version of the 5-item Problem Areas in Diabetes Scale 5; ADA: American diabetic association; IADPSG, International Association of Diabetes and Pregnancy Study Groups; ICD, International Classification of Diseases; OGTT, oral glucose tolerance test; EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiologic Studies Depression Scale; PHQ, Patient Health Questionnaire; HADS, Hospital Anxiety and Depression Scale. * Estimate given in paper.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost studies clearly stated the criteria used for GDM diagnosis, which included the Carpenter-Coustan criteria for the interpretation of the 100-g 3-h oral glucose tolerance test, the 2010 International Association of Diabetes and Pregnancy Study Groups criteria, the Australasian Diabetes in Pregnancy Society criteria, and the 2008 Canadian Diabetes Association criteria. Four studies used the International Classification of Diseases criteria to assess patients for GDM. Thirteen studies did not provide full information.\u003c/p\u003e \u003cp\u003eThe Edinburgh Postnatal Depression Scale (EPDS) was used to assess peripartum depressive symptoms and antenatal anxiety in pregnant women with GDM in 9 studies, and different EPDS cut-off scores were used to differentiate severe depression from no or mild depression. The rest of the studies used the ICD-9 or ICD-10 criteria, the Center for Epidemiologic Studies Depression Scale (CES-D), Mental Health Inventory-5, Depression, Anxiety and Stress Scale-21 (DASS-21) items, Patient Health Questionnaire-9 (PHQ-9), the Beck Depression Inventory (BDI), and self-reporting. To measure anxiety, 3 studies used the State\u0026ndash;Trait Anxiety Inventory (STAI), and 4 studies used the DASS-21, ICD-9 criteria, and Taylor Anxiety Scale.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 GDM and antenatal depression\u003c/h2\u003e \u003cp\u003eIn all, 23 studies with a sample size of 930,824 provided data on the prevalence of depressive symptoms during the antenatal period in pregnant women with or without GDM (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). The pooled data exhibited significant between-study heterogeneity (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;\u0026gt;\u0026thinsp;50%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), so the random-effects model was used (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The meta-analysis suggested that the presence of GDM significantly increased the risk of antenatal depressive symptoms in pregnant women (pooled OR: 1.57, 95% CI: 1.33\u0026ndash;1.85, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). To reduce the influence of pre-gestational diabetes on the prevalence of depression, we conducted a meta-analysis of the 11 studies that reported prevalence data after excluding pre-existing diabetes. This analysis showed that pregnant women with GDM had a statistically significant 54% increase in the risk of developing antenatal depressive symptoms as compared to pregnant women without GDM (pooled OR: 1.54, 95% CI: 1.17\u0026ndash;2.01, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). We also conducted a meta-analysis of 11 studies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR34 CR35\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) that reported unadjusted ORs (pooled OR: 1.44, 95% CI: 1.20\u0026ndash;1.73, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). There was high heterogeneity (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;85%) among these studies, possibly due to differences in study type, locations, assessment methods, covariates, and other factors.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 GDM and postpartum depression\u003c/h2\u003e \u003cp\u003eEighteen studies involving 1,617,320 women provided data on the prevalence of postpartum depressive symptoms in women with or without GDM (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45 CR46 CR47\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Due to significant between-study heterogeneity (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;79%), we used the random-effects model. The pooled results indicated a high risk of postpartum depressive symptoms in women with GDM as compared to women without GDM (pooled OR: 1.42, 95% CI: 1.18\u0026ndash;1.70, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In addition, we performed a meta-analysis of 7 studies (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) that reported unadjusted ORs (pooled OR: 1.26, 95% CI: 1.04\u0026ndash;1.54, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;72%; Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 GDM and antenatal anxiety and stress\u003c/h2\u003e \u003cp\u003eThree studies reported the prevalence of high levels of anxiety during the antenatal period (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Significant heterogeneity (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;88%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) was found among these studies, so the random-effects model was used. The meta-analysis showed that the pooled OR was 2.81 (95% CI: 0.84\u0026ndash;9.42, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.1; Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eA). Two studies used the STAI criteria to assess anxiety (I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;37%). The pooled result indicated that GDM significantly increased the risk of antenatal anxiety symptoms (pooled OR: 4.19, 95% CI: 1.21\u0026ndash;7.17, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006; Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eB). However, the sample sizes of the above five studies were too small to draw definitive conclusions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included studies for antenatal anxiety and stress on pregnant women with or without GDM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudy period\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e(GDM/\u003c/p\u003e \u003cp\u003eno-GDM)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePre-pregnancy BMI\u003c/p\u003e \u003cp\u003e(kg/m2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGDM assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOutcome assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eTiming of outcome assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eRisk of\u003c/p\u003e \u003cp\u003ebias\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRumbold et al. 2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21/95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30.0/28.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30.0/27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWHO criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnxiety prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSTAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e36 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaniells et al. 2003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50/50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2000.11-2001.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31.4/29.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.4/24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eADIPS criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnxiety prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSTAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e30 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eByrn et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65/70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.12/27.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34.4/31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnxiety prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSTAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;40 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHassan et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIraq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50/50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2015.07-2015.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.4/24.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eADA criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnxiety prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eTaylor anxiety scale\u0026thinsp;\u0026ge;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e36 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeka et al. 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12,140/314,583\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2000.04.01-2009.03.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.1/29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDiagnostic codes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAnxiety prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eICD-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;28 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStress\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eByrn et al. 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65/70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.12/27.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34.4/31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedical data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStress score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;40 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHorsch et al. 2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSwitzerland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39/164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2012.11-2013.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.73/29.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25.15/22.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIADPSG criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStress score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePSS,\u003c/p\u003e \u003cp\u003eDASS-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e24\u0026ndash;30 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEgan et al. 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIreland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCross-sectional cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78/108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.6/31.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStress score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDASS-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eUnavailable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eGDM, gestational diabetes mellitus; BMI, body mass index; OR, odds risk; CI, confidence interval; NA, not applicable; ADIPS, Australasian Diabetes in Pregnancy Society; WHO, World Health Organization; ADA: American diabetic association; IADPSG, International Association of Diabetes and Pregnancy Study Groups; ICD, International Classification of Diseases; DASS-21, Depression, Anxiety and Stress Scale-21 Items; STAI, State\u0026ndash;Trait Anxiety Inventory. PSS, Perceived Stress Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTwo studies used the DASS-21 and another two studies used the Perceived Stress Scale (PSS) to assess severe stress. The data were presented as continuous scores. The pooled results indicated that GDM insignificantly increased the risk of antenatal stress symptoms (DASS-21, pooled OR: 1.68, 95% CI: -0.20-3.57, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08; PSS, pooled OR: 0.25, 95% CI: -3.15-3.65, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.89; Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eC and \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003eD).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Subgroup analysis\u003c/h2\u003e \u003cp\u003eWe performed subgroup analyses to find the sources of heterogeneity among studies reporting data on depression and GDM (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Subgroups were formed based on the following factors: (i) study design (prospective study, retrospective study, and cross-sectional study); (ii) location (North America, Europe, and Asia); (iii) assessment tools (EPDS, BDI, CES-D, ICD, and PHQ-9); and (iv) sample size (\u0026ge;\u0026thinsp;100 or \u0026lt;\u0026thinsp;100 pregnant women with GDM). The subgroup analysis based on study design included 14 prospective studies, 6 cross-sectional studies, and 3 retrospective studies, and yielded pooled ORs of 1.52 (95% CI: 1.10\u0026ndash;2.09, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), 1.61 (95% CI: 1.05\u0026ndash;2.48, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03), and 1.80 (95% CI: 1.36\u0026ndash;2.38, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), respectively. The analysis based on assessment tools included 5 studies using the EPDS, 3 studies using the BDI, 3 studies using the CES-D, 4 studies using the PHQ-9, and 4 studies using ICD-9 or ICD-10 criteria to assess depressive symptoms. The results were as follows: EPDS (pooled OR: 1.42, 95% CI: 1.00\u0026ndash;2.00, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05), BDI (pooled OR: 2.50, 95% CI: 1.47\u0026ndash;4.25, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), CES-D (pooled OR: 1.07, 95% CI: 0.60\u0026ndash;1.90, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.82), PHQ-9 (pooled OR: 1.88, 95% CI: 0.91\u0026ndash;3.86, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.09), and ICD (pooled OR: 1.55, 95% CI: 1.22\u0026ndash;1.96, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The subgroup analysis based on location included 9 studies from North America, 9 studies from Europe, and 5 studies from Asia. The results were as follows: North America (pooled OR: 1.53, 95% CI: 1.15\u0026ndash;2.03, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), Europe (pooled OR: 1.34, 95% CI: 0.99\u0026ndash;1.81, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05), and Asia (pooled OR: 2.71, 95% CI: 1.98\u0026ndash;3.72, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These results suggested that pregnant women with GDM from Asia have a higher risk of developing depressive symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubgroup analysis for antenatal depression on pregnant women with or without GDM.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNo. of\u003c/p\u003e \u003cp\u003eStudies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eZ-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eHeterogeneity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eI\u003csup\u003e2\u003c/sup\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProspective study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.52 [1.10, 2.09]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetrospective study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.61 [1.05, 2.48]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.80 [1.36, 2.38]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.53 [1.15, 2.03]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.71 [1.98, 3.72]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.34 [0.99, 1.81]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssessment tools\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.42 [1.00, 2.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.50 [1.47,4.25]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCES-D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.07 [0.60, 1.90]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.55 [1.22, 1.96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHQ-9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.88 [0.91, 3.86]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.78 [1.21, 2.63]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.51 [1.16, 1.96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eOR, odds risk; CI, confidence interval; GDM, gestational diabetes mellitus; EPDS, Edinburgh Postnatal Depression Scale; BDI, Beck Depression Inventory; CES-D, Center for Epidemiologic Studies Depression Scale; ICD, International Classification of Diseases; PHQ-9, Patient Health Questionnaire-9.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Sensitivity analysis\u003c/h2\u003e \u003cp\u003eConsidering the significant between-study heterogeneity and the results of the subgroup analyses, we performed sensitivity analysis to assess the robustness of the pooled ORs in regards to the prevalence of GDM. We excluded studies one by one, and recalculated the pooled ORs for the remaining studies to determine if there was any significant change in our findings. The results showed that the exclusion of any single study was unlikely to change our findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Main findings\u003c/h2\u003e \u003cp\u003eWomen with GDM are a high-risk group for maternal and infant complications as well as mental health problems, which have attracted increasing attention from clinicians and researchers worldwide. Perinatal mental problems, such as depression, anxiety, and stress, will further exacerbate the hormone imbalance associated with GDM, resulting in poor pregnancy outcomes (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Research on the relationship between mental health and GDM will contribute to better guidance on intervention measures and improve postpartum outcomes. The present meta-analysis comprehensively assessed the relationship between GDM and mental health problems. Our results suggest that compared to pregnant women without GDM, those with GDM had a significantly increased prevalence of antenatal and postpartum depressive symptoms, especially among Asian people. Moreover, compared to pregnant women without GDM, women with GDM reported significantly higher anxiety scores, but this evidence needs to be further strengthened.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Comparison with previous studies\u003c/h2\u003e \u003cp\u003eIn 2020, Wilson et al. conducted a systematic review and meta-analysis of 62 studies on the association of GDM with mental disorders, especially depression (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e), and reported increased risks of antenatal depressive symptoms, especially around the time of GDM diagnosis, as well as postnatal depressive symptoms. The authors included a large number of studies and achieved convincing results; however, they did not compare the risk of mental health problems in GDM among women with different nationalities. Our results indicated that pregnant women with GDM from Asia bear a greater risk of peripartum depression than women from North America and Europe (OR: 2.71 \u003cem\u003evs.\u003c/em\u003e 1.53 \u003cem\u003evs.\u003c/em\u003e 1.34, respectively). It is well-established that a large treatment gap for mental disorders exists between different world regions. Regional differences in culture have a great influence on the treatment and overall outcomes of mental disorders. It is estimated that 42\u0026ndash;44% of patients in developed regions seek treatment for depressive or anxiety disorders, in contrast to as little as 5% of patients in low- and middle-income countries (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Depressive and anxiety symptoms may be perceived as being less relevant in non-Western cultures (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Furthermore, the stigma and shame associated with mental disorders influence positive reinforcement behaviors, resulting in greater reluctance to discuss and manage emotional problems in patients from low- and middle-income countries (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Delanerolle et al. conducted a meta-analysis to evaluate the risk of GDM among black, Asian, and minority ethnic women who had pre-existing mental disorders; the results suggested that Hispanic women with GDM had a higher risk of depression (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). However, high between-study heterogeneity was identified in this analysis. Furthermore, only 2\u0026ndash;4 studies were included in the subgroup analyses based on ethnicity, which greatly reduced the reliability of the evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.3 New findings within the meta-analysis\u003c/h2\u003e \u003cp\u003eOur meta-analysis involved almost 10,000 patients from 32 studies and demonstrated that pregnant women with GDM are at a greater risk for developing depressive symptoms in the antenatal and postpartum periods as well as for developing antepartum anxiety symptoms. Furthermore, this conclusion was verified by the subgroup analyses based on the assessment tools used for mental disorders. Notably, ours is the first study to evaluate the correlation between GDM and anxiety/stress symptoms by using meta-analysis rather than literature review. Nevertheless, the present evidence is still insufficient because only few studies could be included in the subgroup analyses. Anxiety is a psychological disorder with diverse manifestations, including persistent anxiety and recurring panic (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Due to the hormone and glucose imbalance caused by GDM, pregnant women with GDM are often more vulnerable to developing psychological symptoms (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Furthermore, GDM patients who have little social support and a low education level tend to develop more severe pregnancy-related anxiety (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). This is because pregnant women who lack access to knowledge about diabetes and adequate social support may not be able to correct their own unhealthy behaviors, which will further affect blood glucose control and aggravate their anxiety symptoms. Therefore, family members and friends should help pregnant women promote their own healthy behaviors and improve their self-management ability to relieve their anxiety.\u003c/p\u003e \u003cp\u003eThe present study has several important strengths. We included numerous studies that reported the antenatal and postpartum prevalence rates of mental disorders in pregnant women with GDM. We also included recently published meta-analyses to ensure that our results are up-to-date. To reduce the influence of pre-gestational diabetes as a confounding factor, we conducted a secondary analysis of studies that excluded pregnant women with pre-gestational diabetes, and found that the conclusions remained solid and reliable. In addition, a series of subgroup analyses based on various factors, including study design, were conducted. The results of these analyses indicated that GDM patients from Asia are more vulnerable to depressive symptoms than GDM patients from other regions. Thus, healthcare providers in Asia should be alert to negative emotions in pregnant women with GDM and take appropriate psychological and behavioral treatment measures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Limitations\u003c/h2\u003e \u003cp\u003eSeveral limitations of the present meta-analysis should be noted. Although we conducted subgroup analyses based on the assessment tools used for peripartum depression, the cut-offs used for the various depression scales differed among the studies, leading to substantial between-study heterogeneity. Moreover, some studies assessed exposure and outcomes using self-reported data, and may therefore, have a high risk of information bias. Some studies had a retrospective or cross-sectional design, which may lead to selection bias in the pooled results. Furthermore, the excessive gap in the range of sample sizes among the studies may increase the weight of studies with large sample sizes in the pooled results and increase systematic biases.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. CONCLUSION","content":"\u003cp\u003eGDM significantly increased the prevalence of antenatal and postpartum depressive and anxiety symptoms. Further multi-center prospective studies with long-term follow-up are required to verify the relationship between GDM and mental health disorders.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception and design: All authors ,Administrative support: Zhenhua Chen and Qirong Wan,Provision of study materials or patients: Yanhong Gao and Jing Wang ,Collection and assembly of data:Haiying Xie and Wei Yuan,Data analysis and interpretation: Qirong Wan and Haiying Xie,Manuscript writing: Qirong Wan and Haiying Xie\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMetzger BE, Coustan DR. 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Int J Pharm Sci Res. 2017;10:4371\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahlen HG, Barnett B, Kohlhoff J, et al. Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes: a population based cohort study. BMC Pregnancy Childbirth. 2015;15:292.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaton W, Russo J, Gavin A. Predictors of postpartum depression. J Womens Health (Larchmt). 2014;23:753\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHinkle SN, Buck LG, Rawal S, et al. A longitudinal study of depression and gestational diabetes in pregnancy and the postpartum period. Diabetologia. 2016;59:2594\u0026ndash;602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDame P, Cherubini K, Goveia P, et al. Depressive Symptoms in Women with Gestational Diabetes Mellitus: The LINDA-Brazil Study. J Diabetes Res. 2017;2017:7341893.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZwolińska-Kloc M, Zabel M, Czajkowski K, et al. Relations between gestational diabetes and postpartum depressive disorders and symptoms. Archives Psychiatry Psychother. 2017;19:43\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark CE, Rasgon NL, Reed IIDE, et al. Depression precedes, but does not follow, gestational diabetes. Acta psychiatrica Scandinavica. 2019;4:311\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSundaram S, Harman JS, Cook RL. Maternal morbidities and postpartum depression: an analysis using the 2007 and 2008 Pregnancy Risk Assessment Monitoring System. Womens Health Issues. 2014;24:e381\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdollahi F, Zarghami M, Azhar MZ, et al. Predictors and incidence of post-partum depression: a longitudinal cohort study. J Obstet Gynaecol Res. 2014;40:2191\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson DJ, Coons M, Haensel H, et al. Diabetes and Mental Health. Can J Diabetes. 2018;42(Suppl 1):S130\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzami M, Badfar G, Soleymani A, et al. The association between gestational diabetes and postpartum depression: A systematic review and meta-analysis. Diabetes Res Clin Pract. 2019;149:147\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson CA, Newham J, Rankin J, et al. Is there an increased risk of perinatal mental disorder in women with gestational diabetes? A systematic review and meta-analysis. Diabet Med. 2020;37:602\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKohn R, Saxena S, Levav I, et al. The treatment gap in mental health care. 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Stress and anxiety in women with gestational diabetes during dietary management. Diabetes Educ. 2014;40:668\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu F, Yan P, You S, et al. The pregnancy-related anxiety characteristics in women with gestational diabetes mellitus: why should we care? BMC Pregnancy Childbirth. 2021;21:424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZemestani M, Fazeli NZ. Effectiveness of mindfulness-based cognitive therapy for comorbid depression and anxiety in pregnancy: a randomized controlled trial. Arch Womens Ment Health. 2020;23:207\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbrar A, Fairbrother N, Smith AP, et al. Anxiety among women experiencing medically complicated pregnancy: A systematic review and meta-analysis. Birth. 2020;47:13\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gestational diabetes mellitus, depression, anxiety, mental disorders, meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-4229400/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4229400/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Aim\u003c/h2\u003e \u003cp\u003eThe relationship between gestational diabetes mellitus (GDM) and peripartum mental disorders is unclear. Hence, the current meta-analysis aimed to systematically evaluate the risk of mental disorders in pregnant women with or without GDM.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe searched the PubMed, Cochrane Library, EMBASE, and Web of Science databases for relevant articles published up to October 30, 2021. The random-effects or fixed-effects model was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the prevalence of mental disorders in GDM. Sensitivity and subgroup analyses were conducted to test the robustness of the pooled estimates.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe analyzed 32 studies involving 1,636,131 pregnant women, and the results demonstrated that GDM significantly increased the prevalence of peripartum depression (antenatal, pooled OR: 1.57, 95% CI: 1.33\u0026ndash;1.85, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; postpartum, pooled OR: 1.42, 95% CI: 1.18\u0026ndash;1.70, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), especially in women from Asia (pooled OR: 2.71, 95% CI: 1.98\u0026ndash;3.72, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Compared to pregnant women without GDM, women with GDM reported significantly higher anxiety scores (pooled OR: 4.19, 95% CI: 1.21\u0026ndash;7.17, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006) but insignificantly on antenatal stress symptoms while this evidence still needs to be further strengthened.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eGDM significantly increased the prevalence of antenatal and postpartum mental disorders. Further multi-center prospective studies with long-term follow-up are required to verify the association between GDM and mental health.\u003c/p\u003e","manuscriptTitle":"Correlation between gestational diabetes and peripartum mental disorders: A meta-analysis of 1,636,131 patients .Running title :A meta-analysis about correlation between gestational diabetes and peripartum mental disorders","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-17 20:38:37","doi":"10.21203/rs.3.rs-4229400/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb0dde3c-b377-4be7-be8c-7276acd46e2c","owner":[],"postedDate":"April 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T07:39:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-17 20:38:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4229400","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4229400","identity":"rs-4229400","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}