1. Introduction
Antepartum depression (APD), also referred to as prenatal or perinatal depression, denotes depressive episodes that occur during pregnancy. APD is defined as a non-psychotic mood disorder characterized by a decreased interest or pleasure in almost all activities, significant weight loss, disturbed sleep, fatigue, loss of appetite, feelings of hopelessness and inferiority, as well as a diminished ability to think or concentrate, occurring specifically during the gestational period [1].
According to the World Health Organization (WHO), APD forms part of a broader spectrum of perinatal mental health conditions, which encompass mental health disturbances experienced during pregnancy and up to one year after childbirth. These conditions commonly present with symptoms such as persistent sadness, a profound lack of energy, excessive worry, sleep disturbances, and feelings of guilt or hopelessness, reflecting clinically significant impairment in well-being during the antenatal period [2].
In comparison with postpartum depression, APD has historically gone somewhat unrecognized despite having a profound impact on maternal health, fetal development, and overall family well-being. According to the WHO, the prevalence of APD in low- and middle-income countries (LMICs) ranges from 12% to 42% [1].
It is well documented that APD is associated with adverse maternal and perinatal outcomes, which include preeclampsia, preterm delivery, low birth weight, smaller fetal head circumference, lower Apgar scores, and a higher incidence of childhood behavioral disorders later in life. Furthermore, APD is a critical risk factor for postpartum depression, which hinders healthy child development, mother-infant interaction, and family cohesion [1].
Studies suggest that hormonal fluctuations, psycho-social stressors (such as marital disharmony, domestic violence, chronic stress, and lack of social support) [1], and pre-existing mental illness contribute significantly to its occurrence. Similarities between depressive symptoms and some physiological symptoms of pregnancy may result in this mental health disorder remaining undiagnosed, as these symptoms sometimes coincide with the normal physical changes of pregnancy, thus complicating the clinical diagnosis [3].
There is a frequent neglect of maternal mental health services, especially in LMICs. Insufficient investment in maternal mental health has resulted in poor availability of services, inadequate infrastructure and workforce, and a lack of culturally appropriate approaches for identification and treatment. This consequently leads to suboptimal health-seeking behaviors among women residing in these regions [4]. Globally, there are significant gaps in knowledge regarding depression in pregnancy, accompanied by negative attitudes among both mothers and health workers towards sufferers [4].
These collective findings support the urgent need to integrate routine mental health assessments into antenatal care protocols at tertiary institutions, aligning with WHO recommendations for maternal mental health services in LMICs. This paper aims to explore antepartum depression, highlighting its clinical features, risk factors, and healthcare implications in practice, specifically within the Nigerian context.
2. Methods
Search Strategy
A comprehensive literature search was conducted utilizing electronic databases, predominantly Google Scholar and PubMed, to identify relevant studies on antepartum depression and its associated factors in Nigeria. Additional relevant articles were identified through meticulous manual searches of the reference lists of the retrieved papers.
The search terms utilized included: “antepartum depression”, “antenatal depression”, “prenatal depression”, “pregnancy”, “pregnant women”, “risk factors”, “determinants”, “maternal mental health”, and “Nigeria”.
A narrative synthesis approach was adopted for this review, and the findings were subsequently organized into relevant thematic areas.
Inclusion and Exclusion Criteria
Quantitative and observational studies that explored antepartum depression and its associated factors among pregnant women were eligible for inclusion in this review. These encompassed cross-sectional, cohort, and correlational study designs conducted specifically within Nigeria. Studies published from 2015 to the present that reported the prevalence and/or determinants of antepartum depression were included. A total of 21 core studies were included in the final qualitative synthesis based on the provided bibliography.
Studies that focused solely on postpartum depression, were conducted outside of Nigeria, were published prior to 2015, or failed to report relevant clinical outcomes were excluded from the review.
3. Results And Discussion
Overview of Antepartum Depression (APD)
Antepartum depression (APD) is a non-psychotic mood disorder that develops during pregnancy. It is characterized by a persistent low mood, anhedonia (loss of interest or pleasure), disturbed sleep architecture, significant fatigue, impaired concentration, and compromised daily functioning. The etiology commonly stems from a complex interrelationship between biological, psychosocial, and obstetric factors, and it may manifest from depressive symptoms that initially appeared during the pregnancy. APD is also a major predisposing factor for postpartum depression, a condition that can severely impede child development, mother-infant bonding, and overall family dynamics [1].
Epidemiological studies across different regions of Nigeria demonstrate a lack of homogeneity in the prevalence of antepartum depressive symptoms, often measured using various validated screening instruments (e.g., 14.1% in Ibadan; 31.6% in Port Harcourt; 37.8% in Benin City; and a significantly increased symptom burden documented during the COVID-19 lockdown) [1, 4–6]. The most frequently cited drivers of this variation are psychosocial in nature: low socioeconomic status, unemployment, poor social and spousal support, high perceived stress, unplanned pregnancy, an adverse obstetric history, and an overall low quality of life [4-7].
APD is intricately associated with poor perinatal outcomes, particularly preterm birth, which may further contribute to the development of postpartum depression and the disruption of the maternal-infant bond [1][6]. Furthermore, it has been established that the prevalence and severity of APD are typically highest during the third trimester of pregnancy and lowest during the second trimester [8].
Collectively, these studies emphasize the critical necessity for routine perinatal mental health screening, the seamless implementation of mental-health services within maternal care frameworks, and planned postpartum follow-ups for at-risk women identified during the antenatal period. These represent the most feasible measures to prevent or mitigate APD under current healthcare conditions [1, 8].
Prevalence
Various studies conducted across several states in Nigeria illustrate that the prevalence of antepartum depression varies significantly, heavily dependent upon the methodological approach and the specific regional context. A cross-sectional survey of 320 pregnant women in Bauchi, utilizing the Edinburgh Postnatal Depression Scale (EPDS) with a cutoff score of 13, revealed that 18.4% of pregnant women were severely depressed. This study identified primigravida women, those in their third trimester, and those lacking partner support as being at a considerably higher risk [9]. Similarly, a study encompassing 500 women in Port Harcourt reported a prevalence of 31.6%, identifying predictors such as marital conflict, threats to life, and prior adverse child health outcomes.
In Ibadan, a prospective cohort study involving approximately 1,467 women in their third trimester revealed a prevalence of 14.1%, with socioeconomic disadvantage and high perceived stress emerging as principal determinants [1]. A comparative study involving secondary and tertiary healthcare facilities in Benin City indicated a high prevalence rate of 37.8% (33.1% in University of Benin Teaching Hospital [UBTH] and 39.4% in the Central Hospital). This study elucidated significant relationships between depression and factors such as low educational attainment, large family size, alcohol consumption, and comorbid medical conditions like hypertension and diabetes [4].
Furthermore, prevalence peaked dramatically in Abakaliki during the COVID-19 lockdown, where 452 out of 456 women reported experiencing depressive symptoms according to the Depression, Anxiety and Stress Scale. This highlights the severe compounding effect of acute situational stress factors during a global pandemic, work-related risks, and profound limitations in social support structures [5].
These Nigerian statistics align with, and in several instances surpass, global estimates. A comprehensive meta-analysis encompassing 26 studies (involving over 25,000 participants) calculated a combined global prevalence of 15% to 16.4% [8]. This review also confirmed that antepartum depression peaks during the third trimester (26.7%) and reaches its nadir during the second trimester (6.6%). Notably, there was a demonstrable difference in prevalence dependent on the screening tool utilized: the highest prevalence rates were generated by the EPDS (23.8%) and the Beck Depression Inventory (BDI) (25.3%), whereas lower rates were found with other instruments (14.2%). This underscores the significant effect of methodological heterogeneity, such as the choice of instrument and cutoff scores, on reported prevalence figures.
Collectively, these results highlight the marked variability of APD prevalence in Nigeria, ranging broadly from 14.1% to 45.2% depending on the specific region, the methodologies employed, and contextual circumstances. Although the global combined prevalence rate is generally lower, the Nigerian literature consistently points to a lack of social support, entrenched poverty, family discord, poor obstetric history, and situational stressors like the COVID-19 pandemic as critical variables increasing risk [10, 11]. The reliable finding of an increased prevalence in the third trimester in both Nigerian and international studies further underscores the imperative for focused screening and intervention during late pregnancy.
Effects of Antepartum Depression on Fetal Growth
Antepartum depression exerts a negative impact on fetal growth trajectories among pregnant women in Nigeria, particularly leading to reduced fetal growth rates during the third trimester and an increased incidence of low birth weights. Studies originating from the Jos University Teaching Hospital demonstrated statistically significant lower fetal growth rates, as well as an increased frequency of birth weights under 2500g, among depressed women when compared to non-depressed control groups [12]. APD has been associated with a spectrum of adverse perinatal outcomes, such as low birth weight, preterm births, and intrauterine growth restriction (IUGR), although it must be noted that some findings in the broader literature remain inconsistent [1].
In a specific study conducted in Nigeria, it was discovered that antepartum depression was significantly associated with an increased relative risk of preterm delivery [1]. The biologically plausible mechanisms for this association include elevated levels of circulating maternal stress hormones, specifically cortisol. High cortisol levels may interfere with normal placental function, potentially causing hypoperfusion to the fetus. Additionally, depression may compromise maternal immunity, thereby increasing the susceptibility to infections—particularly reproductive tract infections—which are known to trigger premature uterine contractions [13]. Furthermore, APD may be associated with poor self-care practices during pregnancy, including inadequate nutrition and poor personal hygiene, factors that can indirectly precipitate premature labor [1].
Cortisol acts as a key mediator between maternal depression and low birth weight. It transmits maternal physiological stress to the unborn fetus because it can directly cross the placental barrier. Elevated cortisol has also been found to adversely affect maternal vascular function, thereby decreasing placental blood flow, which subsequently restricts fetal growth due to a diminished supply of essential oxygen and nutrients [12].
In addition, antenatal depression has been linked to elevated levels of inflammatory cytokines, which may trigger premature contractions leading to prematurity. Research in Nigeria established a significant difference in the mean gestational age at birth, noting that depressed women delivered earlier compared to their non-depressed counterparts [12]. However, it is important to recognize that the broader global literature has occasionally shown an inconsistent relationship between antenatal depression and prematurity [12].
Depression during pregnancy frequently predisposes women to poor nutritional intake and poor adherence to prescribed antenatal care plans, thereby placing their fetuses at elevated risk for intrauterine growth restriction [14]. A prior Nigerian study established a significant relationship between depression and preterm births, noting that poor appetite—a hallmark symptom of depression—can lead to inadequate maternal weight gain and a lower Body Mass Index (BMI), which directly and negatively impacts fetal birth weight [15]. Collectively, these interacting factors likely contribute to the poor growth outcomes observed in the fetuses and neonates of depressed women [12]. Antenatal depression was also found to exhibit an independent association with both a low fetal growth rate and low birth weight specifically in the third trimester [12].
Determinants and Risk Factors Associated with Antepartum Depression
Antepartum depression constitutes a significant public health concern, particularly in LMICs, where pervasive psychosocial stressors and severely limited mental health resources dramatically increase population vulnerability. Major determinants associated with APD encompass socioeconomic challenges, including a lack of family support, profound financial instability, and inadequate housing [8].
Among pregnant women in Abeokuta, Nigeria, the presence of an underlying, pre-existing medical condition emerged as a highly significant risk factor for antenatal depression [7]. Although attendees at antenatal clinics are routinely screened for chronic physical disorders, psychological and psychiatric disorders are often overlooked. This is particularly concerning in developing countries where chronic medical problems, such as hypertension and diabetes mellitus, are becoming increasingly prevalent [16]. When generalizing the predictors for antenatal depression, conditions such as anemia in pregnancy and a history of pre-existing medical disorders were identified as main, statistically significant predictors of APD. This further re-emphasizes the critical importance of comprehensively addressing antenatal depression within routine obstetric care [17].
A study conducted in Nigeria highlighted a significant association between sexual satisfaction and APD among women in Akwa Ibom. The results demonstrated a significant negative correlation, indicating that higher levels of sexual satisfaction were robustly associated with lower levels of depressive symptoms during pregnancy [18]. This suggests that sexual satisfaction may function as a protective factor, mitigating the emotional and psychological strain experienced by pregnant women and thereby reducing the likelihood of developing APD [18].
Maternal age was observed to play a crucial moderating role in the relationship between domestic violence, sexual satisfaction, and antepartum depression. Younger women, particularly adolescents and those in early adulthood, may possess limited coping strategies and fewer life experiences. This makes them more susceptible to developing "learned helplessness" in response to adversity [19]. From the perspective of hopelessness theory, these younger individuals may face greater difficulty in cognitively restructuring negative thought patterns, thereby heightening their inherent risk for depressive symptoms when confronted with intimate partner violence or profound dissatisfaction in sexual relationships [20]. Conversely, older women may possess more robust psychological resilience and highly adaptive coping skills. These attributes could serve as a buffer against feelings of hopelessness and, by extension, reduce the overall likelihood of experiencing APD [6].
Conclusion
The reviewed studies conclusively demonstrate that antepartum depression constitutes a substantial and pervasive mental health challenge among pregnant women across diverse Nigerian populations. Although precise prevalence rates vary depending on geographic location and study design, depression during pregnancy remains relatively common and can manifest at any stage of gestation, with an overwhelming consensus pointing to a higher occurrence during the third trimester. The condition is not restricted to any singular socioeconomic or educational demographic, indicating its widespread and indiscriminate nature. Crucially, antenatal depression is inextricably linked to adverse maternal and neonatal outcomes, including an increased risk of preterm delivery, intrauterine growth restriction, and a diminished quality of life, thereby emphatically highlighting its profound clinical and public health significance.
Financial hardship, low socioeconomic status, limited educational attainment, ethnic disparities, and entrenched social inequality were repeatedly and consistently highlighted as vital contributors. Psychosocial stressors—most notably intimate partner violence and abuse, partner conflict, verbal aggression, and high perceived stress—emerged as some of the strongest and most reliable predictors of APD. Furthermore, obstetric and health-related factors, such as a history of pregnancy loss, coexisting chronic medical conditions, prior episodes of depression, and pregnancy-related complications, significantly amplified maternal vulnerability. Underlying psychological states, including clinical anxiety, post-traumatic stress symptoms, and severe body image dissatisfaction, were also closely correlated with depressive symptoms. This demonstrates the highly complex and synergistic interaction between emotional states and environmental stressors during pregnancy.
Overall, these findings underscore the urgent, unignorable need for routine mental health assessment and the integration of robust psychosocial support mechanisms within standard antenatal care services. While certain protective factors, such as strong social support networks and positive interpersonal relationships, may mitigate depressive risk, their protective effects appear to be heavily context-dependent. Therefore, strengthening maternal mental health programs through universal early screening, targeted health education, active social intervention, and specialized support for high-risk groups is absolutely essential. Integrating mental health services into standard, routine antenatal care will not only improve maternal psychological well-being but will also definitively enhance pregnancy outcomes, thereby promoting holistic, long-term maternal and child health.
Recommendations
Maternal healthcare services must mandate the incorporation of regular, standardized screening for antepartum depression and ensure the provision of integrated mental health care pathways for affected women. It is essential to implement integrated, holistic interventions that directly address the key social determinants of maternal mental health, which include financial hardship, food insecurity, intimate partner violence, and limited social support networks [21].
Strengthening antenatal care requires routine screening for both depression and anxiety, with a heightened focus during the third trimester, operating alongside the seamless integration of psychosocial support services. Furthermore, primary healthcare systems must be significantly enhanced through comprehensive provider training and the establishment of multidisciplinary care teams that include obstetric, psychological, and social care professionals. These systemic improvements can be effectively supported by collaborative, patient-centered care models, such as peer support groups and group-based psychological interventions [22]. Additionally, the research base must be expanded through rigorous longitudinal, randomized, qualitative, and targeted intervention studies. These studies must encompass rural populations and diverse healthcare settings, operating alongside community-based initiatives, to foster a more nuanced and accurate understanding of the true prevalence and profound impact of antepartum depression in Nigeria [8].
Declarations
Funding
This research received no internal or external funding from any commercial, public, or not-for-profit entities.
Clinical Trial Registration
This study is a comprehensive literature review and not a clinical trial; therefore, trial registration is not applicable.
Ethics Declaration
Not applicable. This study constitutes a review of existing, previously published literature and did not involve interaction with human participants, animals, or primary clinical data collection.
Competing Interests
The authors declare that they have no competing interests, financial or otherwise.
Transparency Declaration
The lead author (Olufiade P Oyerogba) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been appropriately explained.