Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis

607Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 Systematic reviews Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis Pamela J Surkan,a Caitlin E Kennedy,a Kristen M Hurleyb & Maureen M Blackb Introduction Research in developing countries suggests that poor maternal mental health, in particular maternal depression, may be a risk factor for poor growth in young children.1 In addition, the risk of depression in women is approximately twofold higher than in men2 and women are particularly prone in the postpartum period because of hormonal changes associated with childbirth and stressors associated with parenting.3,4 The combination of women’s vulnerability to depression, their responsibility for childcare and the high prevalence of maternal depression in developing countries5 means that maternal mental health in these countries could have a substantial influence on growth during childhood. Childhood growth is a key indicator of child health and nutritional status. According to recent estimates from develop- ing countries, stunting and underweight have an overall preva- lence of 32% and 20%, respectively.6 Inadequate growth during childhood can result in reduced adult stature, low educational performance, reduced economic productivity, impaired work capacity and heightened disease risk.7–12 Rapid physical growth and development occur in early life when infants are dependent on the primary caregiver for their social and nutritional needs,13 which makes young children vulnerable to the effects of their caregivers’ mental health problems. Recent research on the relationship between maternal depressive symptoms and child stunting or underweight has produced inconsistent results. Two descriptive reviews have provided a summary of research findings14,15 but, to the best of our knowledge, no quantitative synthesis of research results has been produced. Our study goals were to review systematically the literature on maternal depression and childhood growth in developing countries and to summarize and compare any associa- tions found across populations using meta-analytical techniques. Methods The study used standard methods for systematic reviews and meta-analyses in accordance with PRISMA (Preferred reporting items for systematic reviews and meta-analyses) and MOOSE (Meta-analysis of observational studies in epidemiology) state- ments.16,17 Study inclusion criteria A study was included in the meta-analysis if it: (i) quantitatively assessed the relationship between maternal depression or depres- sive symptoms (or mental disorders in which depression was a major component) and child growth using an odds ratio (OR) or included data that could be used to calculate an OR; (ii) was published in a peer-reviewed journal up until April 2010; and (iii) was not an intervention study. We restricted our search to developing countries but applied no other population or language restrictions. Maternal depression and childhood growth can both be assessed using several methods. Depression can be diagnosed through standardized diagnostic interviews, such as the Structured Clinical Interview of the Diagnostic and statistical manual of mental disorders, 4th edition18 or the interview for the Schedules for Clinical Assessment in Neuropsychiatry,19 while depressive symptoms can be assessed directly using a question- Abstracts in بيرع, 中文, Français, Pусский and Español at the end of each article. Objective To investigate the relationship between maternal depression and child growth in developing countries through a systematic literature review and meta-analysis. Methods Six databases were searched for studies from developing countries on maternal depression and child growth published up until 2010. Standard meta-analytical methods were followed and pooled odds ratios (ORs) for underweight and stunting in the children of depressed mothers were calculated using random effects models for all studies and for subsets of studies that met strict criteria on study design, exposure to maternal depression and outcome variables. The population attributable risk (PAR) was estimated for selected studies. Findings Seventeen studies including a total of 13 923 mother and child pairs from 11 countries met inclusion criteria. The children of mothers with depression or depressive symptoms were more likely to be underweight (OR: 1.5; 95% confidence interval, CI: 1.2–1.8) or stunted (OR: 1.4; 95% CI: 1.2–1.7). Subanalysis of three longitudinal studies showed a stronger effect: the OR for underweight was 2.2 (95% CI: 1.5–3.2) and for stunting, 2.0 (95% CI: 1.0–3.9). The PAR for selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms 23% to 29% fewer children would be underweight or stunted. Conclusion Maternal depression was associated with early childhood underweight and stunting. Rigorous prospective studies are needed to identify mechanisms and causes. Early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries. a Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, United States of America (USA). b Department of Pediatrics, University of Maryland School of Medicine, Baltimore, USA. Correspondence to Pamela J Surkan (e-mail: psurkan@jhsph.edu). (Submitted: 14 March 2011 – Revised version received: 14 April 2011 – Accepted: 18 April 2011 – Published online: 26 May 2011 ) Bull World Health Organ 2011287:607–615D | doi:10.2471/BLT.11.088187608 Maternal depression and child growth in developing countries Systematic reviews Pamela J Surkan et al. naire, such as the Edinburgh Postnatal Depression Scale20 or assessed as a major component of mental disorders using, for example, the World Health Organization (WHO) Self-Reporting Questionnaire.21 Childhood growth can be quantified in terms of weight-for-age or height-for-age. Underweight and stunting are commonly defined using WHO criteria: more than two standard deviations (SDs) below the mean weight-for-age and the mean height-for-age, respectively (i.e. a z-score < −2). In this analysis we also included studies with more relaxed or more strin- gent criteria. Overall, the studies included in the analysis measured maternal depres- sion or depressive symptoms and child- hood growth in a variety of ways. Search strategy and study selection The following online computer databases were searched for studies on maternal de- pression and child growth: PubMed, Psy- cINFO, CINAHL Plus, Web of Science, SCOPUS and EMBASE. Medical Subject Heading (MeSH) terms in PubMed were used to identify a string of search terms that were applied in the six data- bases: (“mother” OR “maternal”) AND (“depression” OR “depressive disorder” OR “mental health”) AND (“child” OR “infant”) AND (“nutritional disorders” OR “growth disorders” OR “nutritional status” OR “body size”). Where available, full-text searches and explosion-of-terms searches were carried out. In an explosion- of-terms search, the initial search terms are linked to a web of similar search terms provided by the database. A search of sec- ondary references was conducted by scan- ning the reference lists of relevant articles and by cross-referencing with previous reviews on the topic. In addition, experts in the field were contacted to identify ad- ditional citations. Studies that were clearly not relevant were excluded by reviewing their titles and abstracts. The remaining studies were then read in full by at least two authors of this study and selected for inclusion in the analysis by consensus. Articles identified as relevant by both authors were invariably included; those considered relevant by only one author were discussed among all au- thors to assess their suitability for inclusion. Data extraction A systematic coding form was used to record each study’s objective, location, population, design and sample size; the children’s ages; exposure and outcome measures; confounding variables; and the study’s method of analysis, results, conclu- sions and limitations. Discrepancies in coding were resolved by consensus. The rigour of each study was evaluated using an adaptation of the Newcastle–Ottawa Scale for assessing the quality of nonran- domized studies in meta-analyses.22 Each study was classified by design as either a longitudinal cohort, case–control or cross-sectional study and each was as- sessed to determine if it satisfied four criteria: (i) the women and children were representative of the community studied; (ii) the response rate (i.e. the percentage of individuals in the selected population sample who agreed to participate in the study and completed follow-up) was 80% or higher; (iii) a diagnostic measure of depression had been used; and (iv) the results had been adjusted for at least two confounding variables. Meta-analysis We converted different estimates of effect size to the common metric of an OR since most studies compared two groups and reported dichotomous outcomes. How- ever, three studies reported outcomes as continuous variables.23–25 We converted data from the first of these three studies to ORs using Comprehensive Meta-Analysis V2.2 software (Biostat Inc., Englewood, United States of America). For the other two studies, the original authors either re-analysed the primary data to generate ORs or provided data for us to calculate them. We used standard meta-analytical methods to estimate the standardized effect sizes using the inverse variance approach and random effects models.26 The heterogeneity of the different studies’ findings was assessed using the Q-statistic. Publication bias was assessed from funnel plots of the standard error against the log OR using both Begg and Mazumdar’s rank correlation test and Egger’s test of the intercept to determine statistical significance. Meta-analysis was conducted for the two outcomes of interest – underweight and stunting – using weight-for-age and height-for-age as variables, respectively. When different follow-up times were used in a given study, we used the longest follow-up time. If a study assessed depres- sion at several time points, we used the assessment closest to delivery. We con- ducted subanalyses of studies that used strict criteria of underweight and stunting (i.e. a weight-for-age and height-for-age z-score < −2 or a weight-for-age and height-for-age below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts27), studies that used a measure of depression or depressive symptoms but not of mental disorders of which depression was a major component, and longitudinal studies. The population attributable risk (PAR) for underweight and stunting was calculated on the basis of four studies that were selected because they reported significant findings and a prevalence of maternal depressive symptoms near the lower or higher end of the range. For each study, the overall relative risk (RR) of child underweight was calculated using the adjusted OR obtained in that study and the prevalence of underweight in children with depressed mothers. The RR for stunt- ing was similarly obtained. These RRs were then used to calculate the PARs.28 Results The computer database search yielded 312 citations and two additional records were identified through other sources. After removing duplicates, 210 citations were available for assessment. The initial screening of titles and abstracts identified 51 citations that potentially met the inclu- sion criteria. After the texts were reviewed in full, 14 articles reporting on 17 separate studies met the inclusion criteria. The studies came from several re- gions: four from Africa, six from South America and the Caribbean, six from southern Asia and one from south-eastern Asia. Although the studies covered a mix of urban and rural settings, most were carried out among participants with a low socioeconomic status (Table 1, available from: http://www.who.int/bulletin/ volumes/89/8/11-088187). Seven studies were cross-sectional, six were case–control studies and four used a longitudinal cohort design. Nine of the 17 studies were based on rep- resentative community samples, four used a diagnostic measure of depression and 15 controlled for at least two con- founding variables (Table 2, available from: http://www.who.int/bulletin/vol- umes/89/8/11-088187). In addition, 10 of the 13 studies that reported a response rate had a rate ≥ 80%. Most studies used the WHO crite- rion of a weight-for-age or height-for-age z-score < −2 to identify underweight or stunting, respectively. All 17 studies as- Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 609 Systematic reviews Maternal depression and child growth in developing countriesPamela J Surkan et al. sessed underweight. They used a variety of measures: nine used a weight-for-age z-score < −2; three used a weight-for-age below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts;27 one used a weight-for-age below the equivalent 10th percentile; one used a weight-for- age below the third percentile; one used a weight-for-age of 50% to 80% of the expected value; one used a weight-for- age < 75% of the expected value and one used the combined measure of a current weight-for-age z-score < −1.5 plus a history of a weight-for-age z-score < −2. Twelve studies assessed stunting: nine used a height-for-age z-score < −2; two used a height-for-age below the fifth per- centile given in WHO and Centers for Disease Control and Prevention growth charts; and one used a height-for-age below the 10th percentile. Studies used a wide range of indica- tors of maternal depression. Four used a diagnostic measure of depression based on either the Diagnostic and statistical manual of mental disorders18 (n = 3) or the International classification of diseas- es40 (n = 1); five used a measure of depres- sive symptoms such as the Edinburgh Postnatal Depression Scale20 (n = 2) or the Center for Epidemiologic Studies Depression Scale41 (n = 3); and eight used a measure of mental disorders such as the 20-item WHO Self-Reporting Questionnaire21 (n = 7) or the Adult Psychiatric Morbidity Questionnaire42 (n = 1). Some deviations from the standard use of these measures were ob- served: for example, one study analysed only items related to depression on the Self-Reporting Questionnaire. Overall, most studies found a null or marginally significant relationship between maternal depression and poor child growth. However, the direction of the association was always the same: the worse the depression, the greater the growth deficit. Only 6 of the 17 studies on underweight and 5 of the 12 on stunting found a statistically significant relation- ship with maternal depression. Underweight meta-analysis The meta-analysis of the relationship between maternal depression and child underweight included effect size esti- mates from 17 studies (Fig. 1),23–25,29–39 covering a combined study population of 13 923 mother and child pairs. The pooled data showed a moderate, statisti- cally significant relationship between maternal depression and underweight (OR: 1.5; 95% confidence interval, CI: 1.2–1.8). The heterogeneity of the find- ings was substantial (Q-statistic: 39.94; Table 2. Qualitya of studies included in systematic review of maternal depression and child growth in developing countries, 1996– 2010 Study design Selection Exposure Comparability Representative study sampleb Response rate ≥ 80%c Depression assessed using diagnostic testd Adjustment for 2 or more de- mographic variablese Prospective longitudinal cohort Patel et al. 200331 No Yes No No Rahman et al. 200433 Yes Yes Yes Yes Tomlinson et al. 200635 Yes No Yes No Santos et al. 201038 Yes Yes No Yes Case–control Adewuya et al. 200834 No NA Yes Yes Anoop et al. 200429 NA NA Yes Yes Baker-Henningham et al. 2003f,25 No Yes No Yes Carvalhaes et al. 200236 Yes Yes No Yes de Miranda et al. 199637 No NA No Yes Rahman et al. 200432 No NA No Yes Cross-sectional Black et al. 2009g,24 No No No Yes Harpham et al. 200530 Yes Yes No Yes Harpham et al. 200530 Yes Yes No Yes Harpham et al. 200530 Yes Yes No Yes Harpham et al. 200530 Yes No No Yes Stewart et al. 200823 No Yes No Yes Surkan et al. 200839 Yes Yes No Yes NA, not available (data were either incomplete or not reported); OR, odds ratio. a Study quality was assessed using a checklist adapted from the Newcastle–Ottawa Scale for assessing the quality of nonrandomized studies in meta-analyses. b Women and children included in the study were representative of the community. c Individuals who refused to participate and those lost to follow-up were included in calculating the response rate. d Individuals who were not assessed using a diagnostic test for depression were assessed using a measure of depressive symptoms or of common mental disorders. e The analysis of the relationship between maternal depression and child growth was adjusted for at least two demographic variables. f In this study, multivariate adjustments were made for more than two demographic variables. However, the data used in our meta-analysis were based on crude estimates because maternal depressive symptoms were not included in the final adjusted model due to the stepwise procedure. g In this study, multivariate adjustments were made for growth outcomes as continuous variables but only the crude OR was presented in the paper. For the meta- analysis, ORs were based on an adjusted analysis of data obtained from the authors of the original study. 610 Maternal depression and child growth in developing countries Systematic reviews Pamela J Surkan et al. Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 P = 0.001) across the studies. The funnel plot showed a statistically significant relationship between the standard er- ror and the log OR using both tests of significance, an indication of a publica- tion bias against small studies reporting non-significant findings. Fifteen studies used a strict defini- tion of underweight: a weight-for-age z-score < −2 or a weight-for-age at or below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts.23,24,29–34,36–39 Meta-analysis of these studies showed that the relationship between maternal depression and underweight (OR: 1.5; 95% CI: 1.2–1.8) remained similar to that in the meta-analysis of all studies and the heterogeneity persisted (Q = 37.83, P = 0.001). When the meta-analysis was restricted to the nine studies that used measures of depression or depressive symptoms,24,25,29,31,33–35,38,39 the relation- ship between maternal depression and underweight strengthened and remained statistically significant (OR: 1.7; 95% CI: 1.2–2.4), and the findings remained heterogeneous (Q = 18.70; P = 0.017). Finally, when the meta-analysis was re- stricted to the four longitudinal cohort studies,31,33,35,38 the relationship strength- ened further (OR: 2.2; 95% CI: 1.5–3.2) and high homogeneity was noted (Q: 2.47; P = 0.48). Stunting meta-analysis The meta-analysis of the relationship between maternal depression and child stunting included effect size estimates from 12 studies (Fig. 2)23,24,30,31,33–35,38,39 with a combined study population of 13 214 mother and child pairs. The pooled data showed a moderate, statisti- cally significant relationship between maternal depression and stunting (OR: 1.4; 95% CI: 1.2–1.7). Substantial heterogeneity across studies was noted (Q: 26.85; P = 0.005). The relationship between the standard error and the log OR in the funnel plot was statistically significant using both tests of significance. Eleven studies used a strict definition of stunting: a height-for-age z-score ≤ −2 or a height-for-age at or below the fifth percentile given in WHO and Centers for Disease Control and Prevention growth charts.23,24,30,31,33,34,38,39 Meta-analysis of these studies showed that the relationship between maternal depression and stunt- ing (OR: 1.4; 95% CI: 1.2–1.7) remained similar to that in the meta-analysis of all studies and the heterogeneity persisted (Q = 25.00; P = 0.005). When the meta- analysis was restricted to the seven stud- ies that used measures of depression or depressive symptoms,24,31,33–35,38,39 the relationship between maternal depres- sion and stunting strengthened (OR: 2.0; 95% CI: 1.4–2.9) and homogeneity was noted (Q: 11.55; P = 0.073). Finally, when the meta-analysis was restricted to the four longitudinal cohort stud- ies,31,33,35,38 the relationship was strength- ened slightly (OR: 2.0; 95% CI: 1.0–3.9) and modest heterogeneity was found (Q: 9.30; P = 0.026). Population attributable risk The PAR for underweight was calculated for two studies: the study of Patel et al., which reported a low prevalence of de- pressive symptoms,31 and that of Surkan et al., which reported a high prevalence of depressive symptoms and a low prevalence of underweight (Table 3).39 The PAR in these studies was 22.5% and 29.4%, respectively. Similarly, the PAR for stunting was calculated for two studies: the study of Patel et al., which reported a rela- tively low prevalence of depressive symp- toms,31 and that of Black et al., which reported a high prevalence (Table 3).24 The PAR was 27.5% and 27.0% for the two studies, respectively. Discussion Our analysis revealed a positive and significant association between maternal depression or depressive symptoms and impaired child growth in developing countries. Our meta-analysis of 17 stud- ies, based on adjusted estimates when possible, showed that the children of depressed mothers were at an increased risk of both underweight and stunting: the combined OR was approximately 1.4. This finding emerged after combining the results of studies that had very different de- signs, came from a wide range of locations and included children of different ages. Because the findings varied across studies, we conducted subanalyses to explore how they might be altered by applying stricter definitions of maternal depression and of child growth outcomes or by restricting the analysis to longitudi- nal studies alone. When strict definitions of underweight and stunting were used, the magnitude of the pooled estimate for the relationship between maternal depression and inadequate growth was almost unaffected. When a strict defini- tion of maternal depression was used, the OR for poor child growth increased. Finally, when the analysis was restricted to longitudinal studies, the pooled results showed strong associations with maternal Fig. 1. Effect of maternal depression on child underweight reported in studies from developing countries included in meta-analysis, 1996–2010 0.1 OR and 95% CI Reduced risk 0.2 0.5 1 2 5 10 Increased risk Study Location Adewuya et al. 200834 Nigeria Anoop et al. 200429 India Baker-Henningham et al. 200325 Jamaica Black et al. 200924 Bangladesh Carvalheas et al. 200236 Brazil de Miranda et al. 199637 Brazil Harpham et al. 200530 Ethiopia Harpham et al. 200530 India Harpham et al. 200530 Peru Harpham et al. 200530 Viet Nam Patel et al. 200331 India Rahman et al. 2004 (urban)32 Pakistan Rahman et al. 2004 (rural)32 Pakistan Santos et al. 201038 Brazil Stewart et al. 200823 Malawi Surkan et al. 200839 Brazil Tomlinson et al. 200635 South Africa Combined estimate CI, confidence interval; OR, odds ratio. Note: The position of the square indicates the OR for the relationship between maternal depression and child underweight for the study and its size is proportional to the weight of that study in the meta-analysis. The length of the line represents the 95% CI for the OR. The diamond shape indicates the pooled OR for all studies included in the meta-analysis. 611 Systematic reviews Maternal depression and child growth in developing countriesPamela J Surkan et al. Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 depression: the ORs for underweight and stunting were approximately 2.2 and 2.0, respectively. However, because this subanalysis was based on only four longitudinal studies, its findings must be considered preliminary and need to be confirmed by more prospective studies. Using data from four selected stud- ies, we estimated a PAR for inadequate growth in the range of 23–29%. However, this estimate is imprecise because the four studies used different measures of depressive symptoms and controlled for different confounding variables. The mechanisms responsible for the association between maternal depres- sion and inadequate child growth are not clear. Nor is it known whether these mechanisms vary between countries and regions. Cultural differences in caregiv- ing and feeding and the degree of food insecurity may all play a role. Previous research suggests that maternal depression is associated with compromised parenting behaviour,43,44 nonresponsive caregiving practices43 and a lower likelihood or shorter duration of breastfeeding.45–47 The time at which child growth is mea- sured may also influence the observed association with maternal depression: Stewart et al. hypothesized that, because caregivers other than the mother often become more involved after weaning, the effect of maternal depression may be more pronounced in the immediate post- partum period.14 Of the articles included in the meta-analysis, only two evaluated the influence of other factors on the re- lationship between maternal depressive symptoms and child growth. Black et al. found that the effect of maternal depres- sive symptoms on infant height-for-age was partially mediated by the home envi- ronment, whereas maternal perceptions of infant temperament had no effect.24 Surkan et al. found no evidence that the relationship between maternal depres- sive symptoms and stunting was medi- ated by parenting self-efficacy, which reflects the belief parents have in their ability to care for their children.39 Future research should examine the mechanisms linking maternal depressive symptoms and child growth. The review was limited by the modest number of studies included: only 17 were available overall and only four were in- cluded in the subanalysis of longitudinal studies. Additionally, the studies varied in quality, as reflected in the way they adjust- ed for potential confounding variables: one study adjusted for covariates individ- ually while another made no adjustments. In some regions, most studies were from the same country; for example, four of the five studies from South America were conducted in Brazil. As in any systematic review, publication bias may have affected our findings; significant findings may have been disproportionately reported in the literature, as suggested by the funnel plots for both underweight and stunting in the meta-analysis. Consequently, our meta-analysis may have overestimated the Fig. 2. Effect of maternal depression on child stunting reported in studies from developing countries included in meta-analysis, 1996–2010 0.1 OR and 95% CI Reduced risk 0.2 0.5 1 2 5 10 Increased risk Study Location Adewuya et al. 200834 Nigeria Black et al. 200924 Bangladesh Harpham et al. 200530 Ethiopia Harpham et al. 200530 India Harpham et al. 200530 Peru Harpham et al. 200530 Viet Nam Patel et al. 200331 India Rahman et al. 200433 Pakistan Santos et al. 201038 Brazil Stewart et al. 200823 Malawi Surkan et al. 200839 Brazil Tomlinson et al. 200635 South Africa Combined estimate CI, confidence interval; OR, odds ratio. Note: The position of the square indicates the OR for the relationship between maternal depression and child stunting for the study and its size is proportional to the weight of that study in the meta-analysis. The length of the line represents the 95% CI for the OR. The diamond shape indicates the pooled OR for all studies included in the meta-analysis. Table 3. Effect of maternal depressive symptoms on child underweight or stunting in selected studies from developing countries, 1996–2010 Study Measure of depressive symptoms Mothers with depressive symptoms (%) Underweight or stunted children (%) Underweight or stunting prevalence (%) in children of mothers with depressive symptoms Adjusted OR RRa PAR (%) Underweight Patel et al. 200331 EPDS 23.0 16.4 30.0 2.8 2.26 22.5 Surkan et al. 200839 CES-D 55.0 4.0 5.8 1.8 1.75 29.4 Stunting Patel et al. 200331 EPDS 23.0 12.3 25.0 3.2 2.65 27.5 Black et al. 200524 CES-D 52.0 36.9 45.3 2.3 1.71 27.0 CES-D, Center for Epidemiologic Studies Depression Scale; EPDS, Edinburgh Postnatal Depression Scale; OR, odds ratio; PAR, population attributable risk; RR, relative risk. a The relative risk for each study was calculated from the adjusted OR and the prevalence of underweight or stunting, as appropriate, in children of depressed mothers. 612 Maternal depression and child growth in developing countries Systematic reviews Pamela J Surkan et al. Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 association between maternal depression and inadequate child growth. However, this is unlikely because most studies re- ported null results. Although the definitions of under- weight and stunting differed between the studies, height and weight were measured, not self-reported. In contrast, the diagnosis of maternal depression and its severity may have been less precise owing to the use of depression scales that were not validated in the study popula- tions, particularly since different cultures have differing concepts of depression. In addition, there may be a reciprocal relationship between maternal mental health and child health given that a child’s poor health could generate depressive symptoms in the mother.48 Subsequent research should investigate the possibility that poor child growth increases the risk of maternal depression. Estimates of the incidence of depres- sion in women in developing countries vary widely, from 15–57%.49 Depression in these women has a complex etiology involving factors as diverse as poverty, marital conflict, domestic violence and lack of control over economic resources.50 However, recent studies suggest that depression can be affordably treated in de- veloping countries.51 Varied interventions, such as social support, group therapy or home visits, which are often delivered by lay community workers, have led to a reduction in maternal depressive symp- toms in a range of countries, including China, Jamaica, Pakistan, South Africa and Uganda.52–57 Interventions aimed at improving parenting and the mother– infant relationship have been effective in reducing depressive symptoms in post- partum women,55–57 which suggests that maternal depression is modifiable. Our findings indicate that a reduction in the incidence of maternal depressive symp- toms in developing countries would not only have a beneficial effect on mothers, but would also improve child growth sub- stantially, and this could in turn influence the children’s future health, development and socioeconomic status.7–12 ■ Acknowledgements The authors thank Laurence Magder, Bryan Shaw, Yan Wang and Virginia Ted- row for their assistance with this project. Competing interests: None declared. 摘要 发展中国家母亲抑郁和儿童早期发育:系统评价和荟萃分析 صخلم يولت ليلحتو ةيجهنم ةعجارم :ةيمانلا نادلبلا في لافطلأل ركبلما ومنلاو تاهملأا بائتكا نع ةيمانلا نادلبلا في لافطلأا ونمو تاهملأا بائتكا ينب ةقلاعلا صيقت ضرغلا .اهل يولت ليلحتو تايشرنلل ةيجهنم ةعجارم قيرط ةيمانلا نادلبلا تاسارد نع تايطعم دعاوق تس في ثحب ىرُجأ ةقيرطلا عبت .2010 رهش ىتح تَ ِرشرُن يتلاو لافطلأا ونمو تاهملأا بائتكاب ةقلعتلما صقنل ةيعماجلا ةيحجرلأا بسن تَب ِرسُحو يرايعم يولت ليلحت ءارجإ كلذ جذانم مادختساب بائتكلااب تاباصلما تاهملأا لافطأ ىدل ّمزقتلاو نزولا يتلا تاساردلل ةيعرفلا تائفللو تاساردلا عيمجل ةيئاوشعلا تايرثأتلا ةجيتنو ،يموملأا بائتكلال ّضرعتلاو ،ةساردلا ميمصتل ةمراصلا يرياعلما تّبل .ةاقتنُم تاساردل ّوزعلما نياكسلا راطتخلاا ريدقت ىرجو .تايرغتلما لافطلأاو تاهملأا نم ًاجوز 13923 تنمضت ةسارد ةشرع عبس تّبل جئاتنلا بائتكلااب تاباصلما تاهملأا لافطأ ناكو .ثحبلا في جاردلإا يرياعم ًادلب 11 نم ؛1.5 :ةيحجرلأا ةبسن( نزولا صقن نم حجرلأا في نوناعي بائتكلاا ضارعأ وأ ةقثلا ةلصاف ؛1.4 :ةيحجرلأا ةبسن( ّمزقتلا نمو )1.8-1.2 :95% ةقثلا ةلصافو :ىوقأ ًايرثأت ةينلاوط تاسارد ثلاثل يعرف ليلحت رهظأو .)1.7-1.2 :95% )3.2-1.5:95% ةقثلا ةلصاف( 2.2 نزولا صقنل ةيحجرلأا ةبسن تناك ثيح .)3.9-1.0 :95% ةقثلا ةلصاف( 2.0 ةيحجرلأا ةبسن تناكف مزقتلل ةبسنلابو لمجم ّضرعتي لم اذإ هنأ ةاقتنُلما تاساردلا في ّوزعلما نياكسلا راطتخلاا لديو لقأ ّمزقتلا وأ نزولا صقن نوكيسف تاهملأا بائتكا ضارعلأ عّضرلا روهمج .29% لىإ 23% ةبسنب .لافطلأا في نيركبلما ّمزقتلاو نزولا صقنب تاهملأا بائتكا طبترا جاتنتسلاا .بابسلأاو تايللآا فاشكتسلا ةقيقد ةيلبقتسم تاسارد لىإ ةجاح كانهو دحلا في تاهملأا بائتكا نم ةياقولاو ناركبلما جلاعلاو فاشتكلاا دعاسي دقو .ةيمانلا نادلبلا في لافطلأا ىدل نزولا صقنو ّمزقتلا نم 目的 旨在通过系统文献评价和荟萃分析调查发展中国家母 亲抑郁和儿童发育之间的关系。 方法 本研究检索了六个数据库,查找发展中国家截至2010 年发表的关于母亲抑郁和儿童发育的研究文献。运用标准 荟萃分析方法进行分析,并且运用随机效应模型计算所有研 究以及满足研究设计严格标准的研究子集中,母亲患有抑郁 症或者暴露在母亲抑郁的儿童出现体重不足和发育不良的 总体相对危险度(ORs)。同时还估计了研究所选的人群特异 危险度(PAR)。 结果 来自11个国家的17项研究满足入选标准,包括了 13923对母亲和儿童。患有抑郁症或有抑郁症状的母亲 的孩子更易出现体重不足(相对危险度OR:1.5;95%可信区 间CI:1.2-1.8)或发育不良(相对危险度OR:1.4;95%可信区间 CI:1.2-1.7)。三项纵向研究的再分析表明影响较强:体重不 足的相对危险度为2.2(95%可信区间CI:1.5-3.2),发育不良危 险度为2.0(95%可信区间CI:1.0-3.9)。研究选定的人群特异 危险度(PAR)表明:如果幼儿群体完全没有暴露在母亲抑郁 症状中,则体重不足或发育不良的儿童可减少23%–29%。 结论 母亲抑郁与早期儿童体重不足和发育不良相关。需要 进行严格的前瞻性研究以确定机制和原因。母亲抑郁的早 发现、早治疗和早预防将有助于减少发展中国家儿童发育 不良和体重不足。 613 Systematic reviews Maternal depression and child growth in developing countriesPamela J Surkan et al. Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 Résumé Dépression maternelle et croissance de la petite enfance dans les pays en développement: examen systématique et méta-analyse Objectif Étudier la relation entre dépression maternelle et croissance infantile dans les pays en développement par un examen systématique de la documentation et une méta-analyse. Méthodes Six bases de données ont été consultées pour les études sur la dépression maternelle et la croissance des enfants dans les pays en développement, publiées jusqu’en 2010. Les méthodes standard de méta-analyse ont été suivies et les odds ratios (OR, rapports des chances) mis en commun pour l’insuffisance pondérale et le retard de croissance des enfants de mères déprimées ont été calculés en utilisant des modèles à effets aléatoires pour toutes les études et pour les sous-ensembles d’études qui répondaient aux critères stricts de conception d’étude, d’exposition à la dépression maternelle et de variables de résultat. Le risque attribuable dans la population (RAP) a été estimé pour des études sélectionnées. Résultats Dix-sept études, incluant un total de 13 923 paires de mère et enfant de 11 pays, remplissaient les critères d’inclusion. Les enfants de mères souffrant de dépression ou de symptômes dépressifs étaient plus susceptibles de présenter une insuffisance pondérale (IP: 1,5; intervalle de confiance, IC, de 95%: 1,2–1,8) ou un retard de croissance (IP: 1,4; IC de 95%: 1,2–1,7). La sous-analyse de trois études longitudinales a montré un effet plus important: l’OR pour insuffisance pondérale était de 2,2 (IC de 95%: 1,5–3,2) et pour retard de croissance, de 2,0 (IC de 95%: 1,0–3,9). Le RAP des études sélectionnées a indiqué que si la population infantile était entièrement non-exposée à des symptômes dépressifs maternels, 23 à 29% d’enfants en moins souffriraient d’insuffisance pondérale ou de retard de croissance. Conclusion La dépression maternelle est associée à l’insuffisance pondérale et au retard de croissance de la petite enfance. De rigoureuses études prospectives sont nécessaires pour en identifier les mécanismes et les causes. L’identification précoce, le traitement et la prévention de la dépression maternelle peuvent aider à réduire le retard de croissance et l’insuffisance pondérale des enfants dans les pays en développement. Резюме Материнская депрессия и рост детей в раннем возрасте в развивающихся странах: систематический обзор и мета-анализ Цель Исследовать связь между материнской депрессией и ростом ребенка в развивающихся странах с помощью систематического обзора литературы и мета-анализа. Методы Проведен поиск в шести базах данных для выявления исследований из развивающихся стран по тематике материнской депрессии и роста ребенка, опубликованных за период по 2010 года. Авторы использовали стандартные методы мета-анализа и производили расчет суммарного отношения шансов (ОШ) по пониженной массе тела и задержке роста у детей, чьи матери страдали депрессией, с использованием моделей случайных эффектов для всех исследований и подгрупп исследований, которые удовлетворяли точным критериям в отношении плана исследования, экспозиции к воздействию материнской депрессии и переменных показателей исхода. Для некоторых исследований проводилась оценка популяционного добавочного риска (ПДР). Результаты Критериям включения в обзор удовлетворяли 17 исследований, которые в сумме охватывали 13 923 пары «мать – ребенок» из 11 стран. У детей матерей с депрессией или отдельными ее симптомами была выше вероятность пониженной массы тела (ОШ: 1,5; 95% доверительный интервал, ДИ: 1,2–1,8) или задержки роста (ОШ: 1,4; 95% ДИ: 1,2–1,7). При субанализе трех лонгитюдных исследований отмечен более сильный эффект: ОШ для пониженной массы тела составляло 2,2 (95% ДИ: 1,5–3,2), а для задержки роста – 2,0 (95% ДИ: 1,0–3,9). Оценка ПДР для некоторых исследований показала, что если популяция детей в возрасте до 1 года совершенно не подвержена воздействию симптомов материнской депрессии, то в ней детей с пониженной массой тела или задержкой роста на 23–29% меньше. Вывод Отмечена корреляция между материнской депрессией и пониженной массой тела и задержкой роста детей в раннем возрасте. Для выявления механизмов и причин этого необходимо проведение строгих проспективных исследований. Помочь снизить долю детей с задержкой роста и пониженной массой тела в развивающихся странах могут ранние выявление, лечение и профилактика материнской депрессии. 614 Maternal depression and child growth in developing countries Systematic reviews Pamela J Surkan et al. Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 Resumen Depresión materna y crecimiento durante la primera infancia en los países en vías de desarrollo: revisión sistemática y metaanálisis Objetivo Investigar la relación entre la depresión materna y el crecimiento infantil en países en vías de desarrollo a través de una revisión bibliográfica sistemática y un metaanálisis. Métodos Se realizó una búsqueda en seis bases de datos para hallar estudios realizados en países en vías de desarrollo sobre la depresión materna y el crecimiento infantil que hubieran sido publicados antes de 2010. Se emplearon métodos metanalíticos y se calculó el conjunto de oportunidades relativas (OR) del bajo peso y el retraso del crecimiento infantil en los hijos de madres con depresión, empleando modelos de efectos aleatorios para todos los estudios y subconjuntos de estudios que cumplieron los estrictos criterios de diseño de estudio, exposición a la depresión materna y variables de resultados. Se calculó el riesgo atribuible a la población (RAP) en los estudios seleccionados. Resultados Los criterios de inclusión se cumplieron en 17 estudios que incluyeron a un total de 13 923 parejas de madres e hijos procedentes de 11 países. Los hijos de madres con depresión o síntomas depresivos resultaron ser más proclives a tener peso bajo (OR: 1,5; intervalo de confianza del 95%, IC: 1,2–1,8) o un retraso del crecimiento infantil (OR: 1,4; IC del 95 %: 1,2–1,7). El subanálisis de tres estudios longitudinales evidenció un efecto más contundente: la OR del peso insuficiente fue de 2,2 (IC del 95%: 1,5–3,2) y para el retraso en el crecimiento infantil, 2,0 (IC del 95%: 1,0–3,9). El RAP para los estudios seleccionados mostró que si se mantuviera la población infantil completamente al margen de los síntomas de depresión de las madres, entre un 23% y un 29% menos de niños tendría bajo peso o retraso en el crecimiento infantil. Conclusión La depresión materna se asoció al bajo peso y al retraso en el crecimiento en la primera infancia. Es necesario realizar estudios prospectivos rigurosos para identificar los diversos mecanismos y causas. La detección temprana, el tratamiento y la prevención de la depresión materna podrían ayudar a reducir el retraso en el crecimiento infantil y el peso insuficiente en los niños de los países en vías de desarrollo. References 1. Rahman A, Patel V, Maselko J, Kirkwood B. The neglected ‘m’ in MCH programmes–why mental health of mothers is important for child nutrition. Trop Med Int Health 2008;13:579–83. doi:10.1111/j.1365- 3156.2008.02036.x PMID:18318697 2. Riolo SA, Nguyen TA, Greden JF, King CA. Prevalence of depression by race/ ethnicity: findings from the National Health and Nutrition Examination Survey III. Am J Public Health 2005;95:998–1000. doi:10.2105/AJPH.2004.047225 PMID:15914823 3. Nicolson P. Understanding postnatal depression: a mother-centred approach. J Adv Nurs 1990;15:689–95. doi:10.1111/j.1365-2648.1990.tb01892.x PMID:2365909 4. Gale S, Harlow BL. Postpartum mood disorders: a review of clinical and epidemiological factors. J Psychosom Obstet Gynaecol 2003;24:257–66. doi:10.3109/01674820309074690 PMID:14702886 5. Wachs TD. Models linking nutritional deficiencies to maternal and child mental health. Am J Clin Nutr 2009;89:935S–9S. doi:10.3945/ ajcn.2008.26692B PMID:19176736 6. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M et al.; Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008;371:243–60. doi:10.1016/S0140-6736(07)61690-0 PMID:18207566 7. Haas JD, Murdoch S, Rivera J, Martorell R. Early nutrition and later physical work capacity. Nutr Rev 1996;54:S41–8. doi:10.1111/j.1753-4887.1996. tb03869.x PMID:8710235 8. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L et al.; Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008;371:340–57. doi:10.1016/S0140-6736(07)61692-4 PMID:18206223 9. Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa: Humana Press; 2001. 10. Bielicki T, Waliszko H. Stature, upward social mobility and the nature of statural differences between social classes. Ann Hum Biol 1992;19:589–93. doi:10.1080/03014469200002402 PMID:1476414 11. Cernerud L. Height and social mobility. A study of the height of 10 year olds in relation to socio-economic background and type of formal schooling. Scand J Soc Med 1995;23:28–31. PMID:7784849 12. Pollitt E, Gorman KS, Engle PL, Rivera JA, Martorell R. Nutrition in early life and the fulfillment of intellectual potential. J Nutr 1995;125(Suppl):1111S– 8S. PMID:7536831 13. Black MM, Hurley KM. Helping children develop health eating habits. In: Tremblay RE, Barr RG, Peters R, Boivin M, editors. Encyclopedia on early childhood development. Montreal: Centre of Excellence for Early Child Development, 2007. pp. 1–10. 14. Stewart RC. Maternal depression and infant growth: a review of recent evidence. Matern Child Nutr 2007;3:94–107. doi:10.1111/j.1740- 8709.2007.00088.x PMID:17355442 15. Hurley KM, Surkan PJ, Black MM. Maternal depression and child growth in developing countries: a focus on the post-natal period. In: Preedy VR, editor. Handbook of growth monitoring and health and disease. London: Springer Publications; 2011. 16. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. doi:10.1371/journal. pmed.1000097 PMID:19621072 17. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283:2008–12. doi:10.1001/jama.283.15.2008 PMID:10789670 18. American Psychiatric Association Task Force on DSM-IV. Diagnostic and statistical manual of mental disorders, 4th ed.: DSM-IV. Washington DC: American Psychiatric Association; 1994. 19. Wing JK, Babor T, Brugha T, Burke J, Cooper JE, Giel R et al.; Schedules for Clinical Assessment in Neuropsychiatry. SCAN: Schedules for clinical assessment in neuropsychiatry. Arch Gen Psychiatry 1990;47:589–93. PMID:2190539 20. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6. doi:10.1192/bjp.150.6.782 PMID:3651732 21. A user’s guide to the self-reporting questionnaire. Geneva: World Health Organization; 1994 (WHO/MNH/PSF/94.8). 22. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute; 1996. Available from: http://www.ohri.ca/programs/clinical_ epidemiology/oxford.htm [accessed 18 April 2011]. 23. Stewart RC, Umar E, Kauye F, Bunn J, Vokhiwa M, Fitzgerald M et al. Maternal common mental disorder and infant growth–a cross-sectional study from Malawi. Matern Child Nutr 2008;4:209–19. doi:10.1111/j.1740- 8709.2008.00147.x PMID:18582354 24. Black MM, Baqui AH, Zaman K, El Arifeen S, Black RE. Maternal depressive symptoms and infant growth in rural Bangladesh. Am J Clin Nutr 2009;89:951S–7S. doi:10.3945/ajcn.2008.26692E PMID:19176729 25. Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. Mothers of undernourished Jamaican children have poorer psychosocial functioning and this is associated with stimulation provided in the home. Eur J Clin Nutr 2003;57:786–92. doi:10.1038/sj.ejcn.1601611 PMID:12792663 615 Systematic reviews Maternal depression and child growth in developing countriesPamela J Surkan et al. Bull World Health Organ 2011;287:607–615D | doi:10.2471/BLT.11.088187 26. Cooper H, Hedges LV. The handbook of research synthesis. New York: Russell Sage Foundation; 1994. 27. Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0–59 months in the United States. MMWR Recomm Rep 2010;59(RR-9):1–15. PMID:20829749 28. Rothman KJ, Greenland S. Modern epidemiology. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1998. 29. Anoop S, Saravanan B, Joseph A, Cherian A, Jacob KS. Maternal depression and low maternal intelligence as risk factors for malnutrition in children: a community based case-control study from South India. Arch Dis Child 2004;89:325–9. doi:10.1136/adc.2002.009738 PMID:15033840 30. Harpham T, Huttly S, De Silva MJ, Abramsky T. Maternal mental health and child nutritional status in four developing countries. J Epidemiol Community Health 2005;59:1060–4. doi:10.1136/jech.2005.039180 PMID:16286495 31. Patel V, DeSouza N, Rodrigues M. Postnatal depression and infant growth and development in low income countries: a cohort study from Goa, India. Arch Dis Child 2003;88:34–7. doi:10.1136/adc.88.1.34 PMID:12495957 32. Rahman A, Lovel H, Bunn J, Iqbal Z, Harrington R. Mothers’ mental health and infant growth: a case-control study from Rawalpindi, Pakistan. Child Care Health Dev 2004;30:21–7. doi:10.1111/j.1365-2214.2004.00382.x PMID:14678308 33. Rahman A, Iqbal Z, Bunn J, Lovel H, Harrington R. Impact of maternal depression on infant nutritional status and illness: a cohort study. Arch Gen Psychiatry 2004;61:946–52. doi:10.1001/archpsyc.61.9.946 PMID:15351773 34. Adewuya AO, Ola BO, Aloba OO, Mapayi BM, Okeniyi JA. Impact of postnatal depression on infants’ growth in Nigeria. J Affect Disord 2008;108:191–3. doi:10.1016/j.jad.2007.09.013 PMID:17997163 35. Tomlinson M, Cooper PJ, Stein A, Swartz L, Molteno C. Post-partum depression and infant growth in a South African peri-urban settlement. Child Care Health Dev 2006;32:81–6. doi:10.1111/j.1365-2214.2006.00598.x PMID:16398794 36. Carvalhaes MA, Benício MH. Capacidade materna de cuidar e desnutrição infantil. Rev Saude Publica 2002;36:188–97. doi:10.1590/S0034- 89102002000200011 PMID:12045800 37. de Miranda CT, Turecki G, Mari JJ, Andreoli SB, Marcolim MA, Goihman S et al. Mental health of the mothers of malnourished children. Int J Epidemiol 1996;25:128–33. doi:10.1093/ije/25.1.128 PMID:8666480 38. Santos IS, Matijasevich A, Domingues MR, Barros AJ, Barros FC. Long- lasting maternal depression and child growth at 4 years of age: a cohort study. J Pediatr 2010;157:401–6. doi:10.1016/j.jpeds.2010.03.008 PMID:20400093 39. Surkan PJ, Kawachi I, Ryan LM, Berkman LF, Carvalho Vieira LM, Peterson KE. Maternal depressive symptoms, parenting self-efficacy, and child growth. Am J Public Health 2008;98:125–32. doi:10.2105/AJPH.2006.108332 PMID:18048782 40. International statistical classification of diseases and related health problems, 10th revision. Geneva: World Health Organization; 2007. 41. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. doi:10.1177/014662167700100306 42. Harrington R, Fudge H, Rutter M, Pickles A, Hill J. Adult outcomes of childhood and adolescent depression. I. Psychiatric status. Arch Gen Psychiatry 1990;47:465–73. PMID:2184797 43. Lovejoy MC, Graczyk PA, O’Hare E, Neuman G. Maternal depression and parenting behavior: a meta-analytic review. Clin Psychol Rev 2000;20:561– 92. doi:10.1016/S0272-7358(98)00100-7 PMID:10860167 44. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. The timing of maternal depressive symptoms and mothers’ parenting practices with young children: implications for pediatric practice. Pediatrics 2006;118:e174–82. doi:10.1542/peds.2005-1551 PMID:16818531 45. Papinczak TA, Turner CT. An analysis of personal and social factors influencing initiation and duration of breastfeeding in a large Queensland maternity hospital. Breastfeed Rev 2000;8:25–33. PMID:10842578 46. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. Maternal depressive symptoms at 2 to 4 months post partum and early parenting practices. Arch Pediatr Adolesc Med 2006;160:279–84. doi:10.1001/ archpedi.160.3.279 PMID:16520447 47. Bick DE, MacArthur C, Lancashire RJ. What influences the uptake and early cessation of breast feeding? Midwifery 1998;14:242–7. doi:10.1016/ S0266-6138(98)90096-1 PMID:10076319 48. Samaroff A. The transactional model of development: how children and contexts shape each other. Washington: American Psychological Association; 2009. 49. Husain N, Creed F, Tomenson B. Depression and social stress in Pakistan. Psychol Med 2000;30:395–402. doi:10.1017/S0033291700001707 PMID:10824659 50. Wachs TD, Black MM, Engle PL. Maternal depression: a global threat to children’s health, development, and behavior and to human rights. Child Dev Perspect 2009;3:51–9. doi:10.1111/j.1750-8606.2008.00077.x 51. Patel V, Simon G, Chowdhary N, Kaaya S, Araya R. Packages of care for depression in low- and middle-income countries. PLoS Med 2009;6:e1000159. doi:10.1371/journal.pmed.1000159 PMID:19806179 52. Ali BS, Rahbar MH, Naeem S, Gul A, Mubeen S, Iqbal A. The effectiveness of counseling on anxiety and depression by minimally trained counselors: a randomized controlled trial. Am J Psychother 2003;57:324–36. PMID:12961817 53. Bolton P, Bass J, Neugebauer R, Verdeli H, Clougherty KF, Wickramaratne P et al. Group interpersonal psychotherapy for depression in rural Uganda: a randomized controlled trial. JAMA 2003;289:3117–24. doi:10.1001/ jama.289.23.3117 PMID:12813117 54. Chen CH, Tseng YF, Chou FH, Wang SY. Effects of support group intervention in postnatally distressed women. A controlled study in Taiwan. J Psychosom Res 2000;49:395–9. doi:10.1016/S0022-3999(00)00180-X PMID:11182431 55. Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S. The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 2005;90:1230–4. doi:10.1136/adc.2005.073015 PMID:16159905 56. Cooper PJ, Tomlinson M, Swartz L, Landman M, Molteno C, Stein A et al. Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ 2009;338:b974. 57. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Lancet 2008;372:902–9. doi:10.1016/S0140-6736(08)61400-2 PMID:18790313 ASystematic reviews Maternal depression and child growth in developing countriesPamela J Surkan et al. Bull World Health Organ 2011;89:607–615D | doi:10.2471/BLT.11.088187 Ta bl e 1. S tu di es in cl ud ed in s ys te m at ic re vi ew o f m at er na l d ep re ss io n an d ch ild g ro w th in d ev el op in g co un tr ie s, 1 99 6– 20 10 Ge og ra ph ic al re gi on an d st ud y Co un tr y, st ud y de si gn an d sa m pl e si ze a De pr es si on m ea su re an d tim in g of a ss es s- m en t Gr ow th m ea su re a nd tim in g of a ss es sm en t Fi nd in gs No te s So ut he rn o r s ou th - ea st er n As ia An oo p et a l. 20 04 29 In di a, c as e– co nt ro l (m at ch ed ); n = 1 44 (7 2 m al no ur is he d ca se s an d 72 w el l n ou ris he d co nt ro ls ) M ea su re : m aj or de pr es si on d ia gn os is us in g th e DS M II I R (S CI D) . Ti m in g: p os tp ar tu m de pr es si on 1 m on th a fte r bi rth . C ur re nt d ep re ss io n du rin g th e pa st m on th – af te r g ro w th a ss es sm en t M ea su re : 5 0– 80 % v er su s > 8 0% o f e xp ec te d w ei gh t- fo r- ag e. T im in g: 6– 12 m on th s po st pa rtu m Si gn ifi ca nt fi nd in g: p os tp ar tu m de pr es si on , u nd er w ei gh t: ad ju st ed O R: 7 .4 , 9 5% C I: 1. 6– 38 .5 . N on -s ig ni fic an t fin di ng : c ur re nt m aj or de pr es si on , u nd er w ei gh t: ad ju st ed O R: 3 .1 , 9 5% C I: 0. 9– 9. 7 No te : I nt er ac tio ns b et w ee n cu rre nt m at er na l d ep re ss io n an d lo w bi rth w ei gh t a nd b et w ee n po st pa rtu m d ep re ss io n an d lo w m at er na l in te llig en ce w er e st at is tic al ly si gn ifi ca nt . T he s ev er ity o f m al nu tri tio n w as s ig ni fic an tly a ss oc ia te d w ith p os tp ar tu m d ep re ss io n an d lo w m at er na l i nt el lig en ce . C ov ar ia te s in cl ud ed m at er na l i nt el lig en ce , lo w b irt h w ei gh t, so ci oe co no m ic s ta tu s, d ur at io n of e xc lu si ve br ea st fe ed in g, d ur at io n of s up pl em en ta ry b re as tfe ed in g, im m un iza tio n st at us a nd m ot he r’s li te ra cy . Bl ac k et a l. 20 09 b, 24 Ba ng la de sh , c ro ss - se ct io na l, n = 2 21 M ea su re : C ES -D u si ng a cu t o ff of ≥ 1 6. T im in g: 1 2 m on th s po st pa rtu m M ea su re : u nd er w ei gh t, he ig ht -f or -a ge z- sc or e an d w ei gh t- fo r- he ig ht z- sc or e; s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. Ti m in g: 6 a nd 1 2 m on th s po st pa rtu m Si gn ifi ca nt fi nd in gs : 1 2- m on th he ig ht -f or -a ge z- sc or e, ad ju st ed β : – 0· 01 (P = 0 ·0 1) ; st un tin g, u na dj us te d OR : 2. 2, 9 5% C I: 1. 3– 3. 8. N on - si gn ifi ca nt fi nd in g: 1 2- m on th w ei gh t- fo r- he ig ht z- sc or e, ad ju st ed β : – 0· 01 (P > 0 .0 5) No te : T he re la tio ns hi p be tw ee n de pr es si ve s ym pt om s an d in fa nt gr ow th w as p ar tia lly m ed ia te d by c ar eg ivi ng . C ov ar ia te s at 1 2 m on th s in cl ud ed 6 -m on th w ei gh t- fo r- he ig ht z- sc or e, m at er na l ed uc at io n, p ov er ty s ta tu s, in fa nt s ex , b irt h or de r, re ce ip t o f z in c or iro n, H OM E sc or e, m at er na l p er ce pt io ns o f i nf an t t em pe ra m en t a nd m on th s of b re as tfe ed in g (m od el s w er e al so p re se nt ed w ith ou t e ith er in fa nt te m pe ra m en t o r t he H OM E sc or e or b ot h) . Ha rp ha m e t a l. 20 05 30 In di a, c ro ss -s ec tio na l, n = 1 8 23 M ea su re : S RQ -2 0 us in g a cu t o ff of 7 –8 . T im in g: 6– 18 m on th s po st pa rtu m M ea su re : u nd er w ei gh t, w ei gh t- fo r- ag e z- sc or e < − 2; s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. T im in g: 6– 18 m on th s po st pa rtu m Si gn ifi ca nt fi nd in g: s tu nt in g, ad ju st ed O R: 1 .4 , 9 5% C I: 1. 2– 1. 6. N on -s ig ni fic an t fin di ng : u nd er w ei gh t, ad ju st ed OR : 1 .1 , 9 5% C I: 0. 9– 1. 4 No te : C ov ar ia te s in cl ud ed m at er na l a ge a nd e du ca tio n, c hi ld s ex , ag e an d bi rth w ei gh t, an d ho us eh ol d co m po si tio n, w ea lth in de x an d ge og ra ph ic al lo ca tio n. Ha rp ha m e t a l. 20 05 30 Vi et N am , c ro ss -s ec tio na l, n = 1 5 70 M ea su re : S RQ -2 0 us in g a cu t o ff of 7 –8 . T im in g: 6– 18 m on th s po st pa rtu m M ea su re : u nd er w ei gh t, w ei gh t- fo r- ag e z- sc or e < − 2; s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. T im in g: 6– 18 m on th s po st pa rtu m Si gn ifi ca nt fi nd in g: un de rw ei gh t, ad ju st ed O R: 1. 4, 9 5% C I: 1. 1– 1. 8. N on - si gn ifi ca nt fi nd in g: s tu nt in g, ad ju st ed O R: 1 .3 , 9 5% C I: 0. 9– 1. 7 No te : C ov ar ia te s in cl ud ed m at er na l a ge a nd e du ca tio n, c hi ld s ex , ag e an d bi rth w ei gh t a nd h ou se ho ld c om po si tio n, w ea lth in de x an d ge og ra ph ic al lo ca tio n Pa te l e t a l. 20 03 a, 31 In di a, h os pi ta l-b as ed co ho rt, n = 1 71 (2 3% o f in fa nt s ha d de pr es se d m ot he rs ) M ea su re : E PD S us in g a cu t o ff of 1 1– 12 . T im in g: 6– 8 w ee ks p os tp ar tu m M ea su re : u nd er w ei gh t, w ei gh t- fo r- ag e < 5 th pe rc en til e; s tu nt in g, he ig ht -f or -a ge < 5 th pe rc en til e. T im in g: 6 –8 w ee ks a nd 6 m on th s po st pa rtu m Si gn ifi ca nt fi nd in gs : un de rw ei gh t, ad ju st ed O R ra ng e: 2 .7 –3 .6 ; s tu nt in g, ad ju st ed O R ra ng e: 3 .2 –3 .8 No te : S ig ni fic an t fi nd in gs re m ai ne d af te r a dj us tin g fo r t he fo llo w in g co nf ou nd in g va ria bl es o ne b y on e: m at er na l a nd p at er na l e du ca tio n, in fa nt b irt h w ei gh t, se x an d fe ed in g pr ac tic e, in fa nt il ln es s in th e fir st 6 w ee ks o f l ife a nd p re m at ur ity . BMaternal depression and child growth in developing countries Systematic reviews Pamela J Surkan et al. Bull World Health Organ 2011;89:607–615D | doi:10.2471/BLT.11.088187 Ge og ra ph ic al re gi on an d st ud y Co un tr y, st ud y de si gn an d sa m pl e si ze a De pr es si on m ea su re an d tim in g of a ss es s- m en t Gr ow th m ea su re a nd tim in g of a ss es sm en t Fi nd in gs No te s Ra hm an e t a l. 20 04 32 Pa ki st an , c as e– co nt ro l, n = 1 72 (8 2 ca se s, 90 c on tro ls ). Ad ju st ed an al ys es : n = 1 07 (4 8 ca se s, 5 9 co nt ro ls ) d ue to m is si ng d at a M ea su re : S RQ -2 0 us in g a cu t o ff of ≥ 1 0. T im in g: in fa nt a t m ea n 9. 7 m on th s (S D: 0 .9 ) p os tp ar tu m M ea su re : u nd er w ei gh t, ca se s, w ei gh t- fo r- ag e < 3 rd p er ce nt ile ; c on tro ls , w ei gh t- fo r- ag e > 1 0t h pe rc en til e. T im in g: m ea n 9. 7 m on th s (S D: 0 .9 ) po st pa rtu m Si gn ifi ca nt fi nd in gs : un de rw ei gh t, un ad ju st ed OR : 3 .9 , 9 5% C I: 1. 9– 7. 8; ad ju st ed O R: 2 .8 , 9 5% C I: 1. 2– 6. 8 No te : C ov ar ia te s in cl ud ed in fa nt b irt h w ei gh t, nu m be r o f y ou ng ch ild re n in th e ho us eh ol d an d so ci oe co no m ic s ta tu s. Ra hm an e t a l. 20 04 33 Pa ki st an , p ro sp ec tiv e co ho rt, n = 3 20 in fa nt s (1 60 w ith d ep re ss ed m ot he rs ,1 60 w ith ps yc ho lo gi ca lly w el l m ot he rs ) M ea su re : d ia gn os is o f de pr es si ve d is or de r us in g SC AN . T im in g: th ird tri m es te r a nd 2 , 6 a nd 1 2 m on th s po st pa rtu m M ea su re : u nd er w ei gh t, w ei gh t- fo r- ag e z- sc or e < − 2; s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. T im in g: 2, 6 a nd 1 2 m on th s po st pa rtu m Si gn ifi ca nt fi nd in gs : p re na ta l de pr es si on , u nd er w ei gh t a t 6 m on th s, a dj us te d OR : 3 .5 , 95 % C I: 1. 5– 8. 6; s tu nt ed a t 6 m on th s, a dj us te d OR : 3 .2 , 95 % C I: 1. 1– 9. 9; u nd er w ei gh t at 1 2 m on th s, a dj us te d OR : 3. 0, 9 5% C I: 1. 5– 6. 0; s tu nt ed at 1 2 m on th s, a dj us te d OR : 2. 8, 9 5% C I: 1. 3– 6. 1 No te : C hr on ic d ep re ss io n ca rri ed a g re at er ri sk fo r a p oo r c hi ld gr ow th o ut co m e th an e pi so di c de pr es si on . C ov ar ia te s in cl ud ed lo w b irt h w ei gh t, ea rly b re as tfe ed in g ce ss at io n < 6 m on th s, ≥ 5 di ar rh oe al e pi so de s pe r y ea r, m ot he r’s a nd fa th er ’s e du ca tio n, m at er na l fi na nc ia l e m po w er m en t a nd re la tiv e po ve rty . O th er an al ys es in cl ud ed c al cu la tio ns o f t he re la tiv e ris ks o f s tu nt in g an d un de rw ei gh t i n ch ild re n of d ep re ss ed m ot he rs . R el at ive ri sk s w er e al so c al cu la te d fo r u nd er w ei gh t a nd s tu nt in g in c hi ld re n ag ed 6 a nd 12 m on th s of c hr on ic al ly de pr es se d m ot he rs (a t f ou r t im e po in ts ) ve rs us d ep re ss ed a t n o tim e po in t. Af ric a Ad ew uy a et a l. 20 07 34 Ni ge ria , l on gi tu di na l ca se –c on tro l, n = 2 42 (1 20 de pr es se d ca se s an d 12 2 no n- de pr es se d m at ch ed co nt ro ls ) M ea su re : m aj or de pr es si on d ia gn os is us in g th e DS M -II I-R (S CI D- NP ). Ti m in g: 6 -w ee ks po st pa rtu m M ea su re : m al nu tri tio n, < 5 th p er ce nt ile o f w ei gh t- fo r- ag e or h ei gh t- fo r- ag e. Ti m in g: 6 w ee ks a nd 3 , 6 an d 9 m on th s po st pa rtu m Si gn ifi ca nt fi nd in gs : m al nu tri tio n, w ei gh t f or a ge a t 3 m on th s, u na dj us te d OR : 3 .2 , 95 % C I: 1. 2– 8. 4; h ei gh t f or ag e at 3 m on th s, u na dj us te d OR : 3 .3 , 9 5% C I: 1. 03 –1 0. 5; w ei gh t f or a ge a t 6 m on th s, un ad ju st ed O R: 4 .2 , 9 5% C I: 1. 4– 13 .2 ; h ei gh t f or a ge a t 6 m on th s, u na dj us te d OR : 3. 3, 9 5% C I: 1. 2– 9. 6. N o st at is tic al ly si gn ifi ca nt re su lts at 6 w ee ks o r 9 m on th s No te : D ep re ss ed m ot he rs w er e m or e lik el y to s to p br ea st fe ed in g ea rly a nd th ei r i nf an ts w er e m or e lik el y to h av e ep is od es o f di ar rh oe a or o th er in fe ct io us il ln es se s. C ov ar ia te s w er e no t i nc lu de d in th e m od el s. Ha rp ha m e t a l. 20 05 30 Et hi op ia , c ro ss -s ec tio na l, n = 1 7 22 M ea su re : S RQ -2 0 us in g a cu t o ff of 7 –8 . T im in g: 6– 18 m on th s po st pa rtu m M ea su re : u nd er w ei gh t, w ei gh t- fo r- ag e z- sc or e < − 2; s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. T im in g: 6– 18 m on th s po st pa rtu m No n- si gn ifi ca nt fi nd in gs : un de rw ei gh t, ad ju st ed O R: 0. 9, 9 5% C I: 0. 6– 1. 2; st un tin g, a dj us te d OR : 1 .1 , 95 % C I: 0. 9– 1. 4 No te : U na dj us te d an d ad ju st ed a ss oc ia tio ns b et w ee n m at er na l m en ta l h ea lth a nd in fa nt g ro w th w er e no t s ig ni fic an t. Co va ria te s in cl ud ed m at er na l a ge a nd e du ca tio n, th e ch ild ’s s ex , a ge a nd b irt h w ei gh t, an d ho us eh ol d co m po si tio n, w ea lth in de x an d ge og ra ph ic al lo ca tio n. CSystematic reviews Maternal depression and child growth in developing countriesPamela J Surkan et al. Bull World Health Organ 2011;89:607–615D | doi:10.2471/BLT.11.088187 Ge og ra ph ic al re gi on an d st ud y Co un tr y, st ud y de si gn an d sa m pl e si ze a De pr es si on m ea su re an d tim in g of a ss es s- m en t Gr ow th m ea su re a nd tim in g of a ss es sm en t Fi nd in gs No te s St ew ar t e t a l. 20 08 23 M al aw i, cr os s- se ct io na l, n = 5 01 M ea su re : S RQ -2 0 us in g a cu t o ff of 7 –8 . T im in g: m ed ia n in fa nt a ge a t t im e of s ur ve y: 9 .9 m on th s po st pa rtu m M ea su re : m ea n w ei gh t- fo r- ag e z- sc or e, m ea n he ig ht -f or -a ge z- sc or e. Ti m in g: d ep en de d on c hi ld Si gn ifi ca nt fi nd in gs : h ei gh t- fo r- ag e z- sc or e: a dj us te d β: − 0. 27 (P = 0 .0 1) . N on - si gn ifi ca nt fi nd in gs : w ei gh t- fo r- ag e z- sc or e: a dj us te d β: − 0. 02 (P = 0 .8 7) No te : M ul tiv ar ia te a na lys es a dj us te d fo r m at er na l h ei gh t, m at er na l w ei gh t, w ea lth in de x, e du ca tio n to S ta nd ar d 6 or a bo ve , ≥ 4 su rv ivi ng c hi ld re n, m at er na l o cc up at io n, m ar ita l s ta tu s, p at er na l oc cu pa tio n, m ot he r a bl e to c on fid e in h us ba nd o r r el at ive , r ec en t in fa nt d ia rrh oe a, re ce nt in fa nt fe ve r, in fa nt a ge , i nf an t s ex a nd w ei gh t- fo r- ag e z- sc or e at fi rs t p os tn at al w ei gh in g. To m lin so n et a l. 20 06 35 So ut h Af ric a, p ro sp ec tiv e co ho rt, n = 1 47 a t b as el in e; n = 9 8 at 1 8 m on th s M ea su re : m aj or de pr es si on d ia gn os is us in g th e DS M -IV (S CI D) . Ti m in g: 2 a nd 1 8 m on th s po st pa rtu m M ea su re : h ei gh t- fo r- ag e z- sc or e < 1 0t h pe rc en til e; w ei gh t- fo r- ag e z- sc or e < 1 0t h pe rc en til e; h ei gh t z- sc or e an d w ei gh t z- sc or e (u si ng T an ne r sc al es ). Ti m in g: 2 a nd 1 8 m on th s po st pa rtu m No n- si gn ifi ca nt fi nd in gs : us in g de pr es si on a t 2 m on th s to p re di ct in fa nt g ro w th a t 18 m on th s, h ei gh t- fo r- ag e z- sc or e < 1 0t h pe rc en til e, un ad ju st ed O R: 2 .3 , 9 5% CI : 0 .9 –6 .0 ; w ei gh t- fo r- ag e z- sc or e < 1 0t h pe rc en til e, un ad ju st ed O R: 2 .5 , 9 5% C I: 0. 98 –6 .5 ; w ei gh t- fo r- ag e z- sc or e ad ju st ed fo r b irt h w ei gh t, β: 0 .2 , 9 5% C I: − 0. 21 to 0 .7 8; h ei gh t- fo r- ag e z- sc or e, u na dj us te d β: 0 ·5 6, 95 % C I: − 0· 16 to 1 ·3 No te : T he a ttr iti on ra te w as 3 3% . B irt h w ei gh t w as a c ov ar ia te in on e m od el . So ut h Am er ic a an d th e Ca rib be an Ba ke r- He nn in gh am e t a l. 20 03 25 Ja m ai ca , c as e– co nt ro l (m at ch ed ), n = 2 10 (1 39 m al no ur is he d ca se s an d 71 w el l n ou ris he d co nt ro ls ) M ea su re : C ES -D (a da pt ed ) us ed a s a co nt in uo us va ria bl e. T im in g: a fte r in iti al g ro w th a ss es sm en t M ea su re : u nd er w ei gh t, ca se s, h is to ry o f w ei gh t- fo r- ag e z- sc or e < − 2 pl us cu rre nt w ei gh t- fo r- ag e z- sc or e < − 1. 5; c on tro ls , w ei gh t- fo r- ag e z- sc or e > − 1 pl us n o hi st or y of un de rn ut rit io n. T im in g: 9– 30 m on th s po st pa rtu m No n- si gn ifi ca nt a dj us te d fin di ng s: u nd er w ei gh t, m ea n = 2 6; n or m al w ei gh t, m ea n = 1 6. 5; u na dj us te d co m pa ris on , P < 0 .0 1 No te : I n cr ud e an al ys es , m at er na l d ep re ss io n w as re la te d to un de rw ei gh t. Th e re la tio ns hi p be ca m e no n- si gn ifi ca nt a fte r ad ju st in g fo r c on fo un di ng v ar ia bl es . C ov ar ia te s in cl ud ed m at er na l he ig ht , e co no m ic s tre ss , w or k sk ill le ve l, ab se nt fa th er a nd po ss es si on s. Ca rv al ha es a nd B en íc io 20 02 36 Br az il, c as e– co nt ro l, n = 3 01 (1 01 c as es a nd 20 0 co nt ro ls ) M ea su re : s el ec te d SR Q- 20 s ub se t o f i te m s: (i ) th re e de pr es se d m oo d ite m s (s co re d 0/ 1– 2/ 3) , an d (ii ) f ou r d ep re ss ive sy m pt om s (s co re d 0/ 1– 2/ 3– 4) . T im in g: s om et im e af te r i ni tia l s cr ee ni ng o f ch ild re n at 1 2– 23 m on th s po st pa rtu m M ea su re : u nd er w ei gh t, ca se s, < 5 th p er ce nt ile o f w ei gh t- fo r- ag e; c on tro ls , > 2 5t h pe rc en til e of w ei gh t- fo r- ag e. T im in g: so m et im e af te r i ni tia l sc re en in g of c hi ld re n at 1 2– 23 m on th s po st pa rtu m Un de rw ei gh t, si gn ifi ca nt or m ar gi na lly s ig ni fic an t fin di ng s: m at er na l d ep re ss ive sy m pt om s, u na dj us te d OR : 4. 1 (P < 0 .0 1) , a dj us te d OR : 3. 1, 9 5% C I: 1. 0– 10 .3 . N on - si gn ifi ca nt fi nd in gs : m at er na l de pr es se d m oo d, u na dj us te d OR ra ng e: 1 .8 –1 .9 (P = 0 .3 ); ad ju st ed re su lts n ot s ho w n No te : M od el s w er e ad ju st ed fo r p er c ap ita h ou se ho ld in co m e, m at er na l e du ca tio n, p re se nc e of th e pa rtn er , c hi ld ’s a ge w he n th e m ot he r r et ur ne d to w or k, h os pi ta liz at io n du rin g ge st at io n an d al co ho lis m in th e fa m ily . DMaternal depression and child growth in developing countries Systematic reviews Pamela J Surkan et al. Bull World Health Organ 2011;89:607–615D | doi:10.2471/BLT.11.088187 Ge og ra ph ic al re gi on an d st ud y Co un tr y, st ud y de si gn an d sa m pl e si ze a De pr es si on m ea su re an d tim in g of a ss es s- m en t Gr ow th m ea su re a nd tim in g of a ss es sm en t Fi nd in gs No te s De M ira nd a et a l. 19 96 37 Br az il, c as e– co nt ro l, n = 1 39 fo r u na dj us te d an al ys es ; n = 1 05 fo r ad ju st ed a na lys es (6 0 co nt ro ls a nd 4 5 ca se s) M ea su re : Q M PA s co re > 6 . T im in g: c as es , m ea n: 10 .9 m on th s (S D: 6 .9 ) po st pa rtu m ; c on tro ls , m ea n: 8 .4 m on th s (S D: 4. 8) p os tp ar tu m M ea su re : u nd er w ei gh t, ca se s < 7 5% e xp ec te d w ei gh t f or a ge . Ti m in g: c as es , m ea n: 10 .9 m on th s (S D: 6. 9) ; c on tro ls , m ea n: 8. 4 m on th s (S D: 4 .8 ) po st pa rtu m Si gn ifi ca nt fi nd in gs : un de rw ei gh t, un ad ju st ed OR : 2 .8 , 9 5% C I: 1. 2– 6. 9; ad ju st ed O R: 2 .9 , 9 5% C I: 1. 3– 6. 8 No te : I nd ivi du al a dj us tm en ts w er e m ad e fo r t he n um be r o f s ib lin gs , m at er na l a ge , i nf an t b irt h w ei gh t, in co m e an d m at er na l e du ca tio n. Th e nu m be r o f s ib lin gs , m at er na l a ge a nd in fa nt b irt h w ei gh t w er e in cl ud ed in m ul tiv ar ia te m od el s. Ha rp ha m e t a l. 20 05 30 Pe ru , c ro ss -s ec tio na l, n = 1 94 9 M ea su re : S RQ -2 0 us in g a cu t o ff of 7 –8 . T im in g: 6– 18 m on th s po st pa rtu m M ea su re : u nd er w ei gh t, w ei gh t- fo r- ag e z- sc or e < − 2; s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. T im in g: 6– 18 m on th s po st pa rtu m No n- si gn ifi ca nt fi nd in gs : un de rw ei gh t, ad ju st ed O R: 0. 9, 9 5% C I: 0. 6– 1. 2; st un tin g, a dj us te d OR : 1 .1 , 95 % C I: 0. 9– 1. 4 No te : U na dj us te d an d ad ju st ed a ss oc ia tio ns b et w ee n m at er na l m en ta l h ea lth a nd in fa nt g ro w th w er e no t s ig ni fic an t. Co va ria te s in cl ud ed m at er na l a ge a nd e du ca tio n, th e ch ild ’s s ex , a ge a nd b irt h w ei gh t a nd h ou se ho ld c om po si tio n, w ea lth in de x an d ge og ra ph ic al lo ca tio n. Sa nt os e t a l. 20 10 38 Br az il, lo ng itu di na l, n = 4 2 87 in iti al ly en ro lle d (3 7 48 re m ai ne d at th e 48 -m on th fo llo w -u p) M ea su re : E PD S us in g a cu t o ff of ≥ 1 3. Ti m in g: 1 2, 2 4 an d 48 m on th s po st pa rtu m . (M et a- an al ys is in cl ud ed de pr es si on a t 1 –2 ti m e po in ts in re la tio n to an th ro po m et ry a t 4 8 m on th s) M ea su re : u nd er w ei gh t, w ei gh t- fo r- ag e z- sc or e < − 2; s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. T im in g: 48 m on th s po st pa rtu m No n- si gn ifi ca nt fi nd in gs : un de rw ei gh t, ad ju st ed O R: 1. 5, 9 5% C I: 0. 8– 2. 8; st un tin g, a dj us te d OR : 1 .0 , 95 % C I: 0. 6- 1 .5 No te : M od el s ad ju st ed fo r f am ily in co m e, m at er na l s ki n co lo ur , m at er na l s ch oo lin g, p ar ity , p re -p re ga nc y bo dy m as s in de x, s m ok in g du rin g pr eg na nc y, pr et er m b irt h an d ho sp ita liz at io n in th e fir st y ea r of li fe . T he u nd er w ei gh t a na lys is a ls o ad ju st ed fo r t he d ur at io n of br ea st fe ed in g an d th e st un tin g an al ys is a dj us te d fo r a ge . Su rk an e t a l. 20 08 39 Br az il, c ro ss -s ec tio na l, n = 5 95 M ea su re : C ES -D u si ng a cu t o ff of ≥ 1 6. T im in g: 6– 24 m on th s po st pa rtu m M ea su re : s tu nt in g, h ei gh t- fo r- ag e z- sc or e < − 2. Ti m in g: 6 –2 4 m on th s po st pa rtu m Si gn ifi ca nt fi nd in gs : s tu nt in g, ad ju st ed O R: 1 .8 , 9 5% C I: 1. 1– 2. 9 No te : C ov ar ia te s in cl ud ed th e ch ild ’s g en de r, bi rth w ei gh t a nd ag e, b re as tfe ed in g du ra tio n, m at er na l e du ca tio n, s an ita tio n sc or e, so ci oe co no m ic s ta tu s, li vin g co nd iti on s, th e nu m be r o f c hi ld re n liv in g in th e ho us eh ol d an d pa rti ci pa tio n in th e Fa m ily H ea lth Pr og ra m m e. CE S- D, C en te r f or E pi de m io lo gi c St ud ie s De pr es si on S ca le ; C I, co nfi de nc e in te rv al ; D SM -II I-R (S CI D) , D ia gn os tic a nd s ta tis tic al m an ua l o f m en ta l d iso rd er s, th ird e di tio n, re vis ed S tru ct ur ed C lin ic al In te rv ie w ; D M S- III- R (S CI D- NP ), Di ag no st ic an d st at ist ica l m an ua l o f m en ta l d iso rd er s, th ird e di tio n, re vis ed S tru ct ur ed C lin ic al In te rv ie w – n on -p at ie nt v er si on ; D SM -IV (S CI D) , D ia gn os tic a nd s ta tis tic al m an ua l o f m en ta l d iso rd er s, fo ur th e di tio n, S tru ct ur ed C lin ic al In te rv ie w ; E PD S, E di nb ur gh Po st -n at al D ep re ss io n Sc al e; H OM E, H om e Ob se rv at io n fo r M ea su re m en t o f t he E nv iro nm en t; OR , o dd s ra tio ; Q M PA , A du lt Ps yc hi at ric M or bi di ty Q ue st io nn ai re ; S CA N, S ch ed ul es fo r C lin ic al A ss es sm en t i n Ne ur op sy ch ia try ; S D, s ta nd ar d de via tio n; SR Q- 20 , 2 0- ite m S el f- Re po rti ng Q ue st io nn ai re . a E ac h sa m pl e co m pr is ed a m ot he r a nd c hi ld p ai r. b A lth ou gh th e pa pe r p re se nt ed c on tin uo us o ut co m es a nd d id n ot re po rt ad ju st ed re su lts fo r u nd er w ei gh t o r s tu nt in g, w e ob ta in ed th e da ta fr om th e au th or s an d re -a na lys ed it u si ng m ul tiv ar ia te lo gi st ic m od el s to o bt ai n th e ad ju st ed O Rs fo r st un tin g an d un de rw ei gh t i nc lu de d in th e m et a- an al ys is .